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NOTICE OF CLAIM � 'J � "
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(Filed Pursuant to 20 Pa.C.S. § 3532) rv �
COURT OF COMMON PLEAS OF
Cumberland COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE OF June Tate , �Fr-�r�;�F�
No. 21-20 i4-00042
`I'o the Clerk of the Orphans' Court Division:
Enter the claim oi� Guardian Elder Care dba Forest Park IIealth Center in the
(Claima�st)
amount of$ ���12.50 , against the above entitled Estate.
The Decedent, who resided at 219 Chestnut Street I�lount Holly Springs, PA 17065
(Sn�eet AddressJ
, died on 11/23/2013 . Written notice of
(Date oJ Death)
said claim was given to Darvl Tate and Steven D. Guinter
(Personal Represe�rtatrve or his/her counsel)
at 11 Mt. Allen Drive Mechanicsbur� PA 17055 aud 480 Cabin Hollow Road Dillsburg,PA 17019
- (Address)
on January 15, 2015
(Da�e)
Guardian Elder Care Forest Park Health Center
(Clnimant)
8796 Route 213
(Street Address)
Brockway, PA 15824
jCity,State,Zip)
Steven D. Guulter, J.D.
(Clai�nant's Counse!) (Supremte Coi�rt/.D.No.)
480 Cabin Hollow Road
(Address)
Dillsburg, PA 17019
717-397-4397
(Telephone)
7
Form OC-07 rev. 10.13.06
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STATEMENT
Forest Park Health Center Resident: Tate, June (23149)
700 Walnut Bottom Road Location: -
Carlisle, PA 17013-3699 Statement Date: 1/1/2015
(888) 880-7090
ALL TRANSACTIONS PROCESSED AFTER Dec 31, 2014
WILL APPEAR ON YOUR NEXT STATEMENT
Darryl Tate
11 Mt. Allen Drive
Mechanicsburg, PA 17055
Amount Due $3,212.50
PLEASE DETACH ANL� RETt�RN WITH YOUR PAYMEN i Amount Enclosed $
Forest Park Health Center Resident: Tate, June (23149)
700 Walnut Bottom Road Location: -
Carlisle, PA 17013-3699 Statement Date: 1/1/2015
(888) 880-7090
Effective Description
Date Units Unit Amount Amount
BALANCE FORWARD $3,212.50
BALANCE DUE $3,212.50
STATEMENT
Forest Park Health Center Resident: Tate, June (23149)
700 Walnut Bottom Road Location: -
Carlisle, PA 17013-3699 Statement Date: 11/1/2013
(888) 880-7090
ALL TRANSACTIONS PROCESSED AFTER Oct 31, 2013
WILL APPEAR ON YOUR NEXT STATEMENT
Darryl Tate
11 Mt. Allen Drive
Mechanicsburg, PA 17055
Amount Due $1,975.00
PLEASC DEl'ACH ANC RETURN WITi� YOUR PAYMENT Amount Enclosed $
Forest Park Health Center Resident: Tate, June (23149)
700 Walnut Bottom Road Location: -
Carlisle, PA 17013-3699 Statement Date: 11/1/2013
(888) 880-7090
Effective Description
Date Units Unit Amount Amount
BALANCE FORWARD $0.00
9/30/2013 Private Pay Copay from Highmark for September 2013 1 $425.00 $425.00
dates of service
1011/2013 Managed Care Copay Oct 1-9 2013 9 $50.00 $450.00
10/10/2013 Managed Care Copay Oct 10-13 2013 4 $50.00 $200.00
10l14/2013 *` Managed Care Copay Oct 14-31 2013 "" 18 $50.00 $900.00
BALANCE DUE $1,975.00
STATEMENT
Forest Park Health Center Resident: Tate, June (23149)
700 Walnut Bottom Road Location: -
Carlisle, PA 17013-3699 Statement Date: 12/1/2013
(888) 880-7090
ALL TRANSACTIONS PROCESSED AFTER Nov 30, 2013
WILL APPEAR ON YOUR NEXT STATEMENT
Darryl Tate
11 Mt. Allen Drive
Mechanicsburg, PA 17055
Amount Due $2,980.00
PLEASE DETACH AND RETURN WITH YOUR PAYMENT Amount Enclosed $
Forest Park Health Center Resident: Tate, June (23149)
700 Walnut Bottom Road Location: -
Carlisle, PA 17013-3699 Statement Date: 12/1/2013
(888) 880-7090
Effective Description
Date Units Unit Amount Amount
BALANCE FORWARD $1,975.00
11/15/2013 Payment-#005090 ($425.00)
11/18/2013 Room & Board charges Nov 18-22 2013 (STD) 5 $286.00 $1,430.00
10/14/2013 *' Managed Care Copay Oct 14-31 2013 "" -18 $50.00 ($900.00)
10/14/2013 Managed Care Copay Oct 14-27 2013 14 $50.00 $700.00
10/28/2013 Managed Care Copay Oct 28-31 2013 4 $50.00 $200.00
BALANCE DUE $2,980.00
STATEMENT
Forest Park Health Center Resident: Tate, June (23149)
700 Walnut Bottom Road Location: -
Carlisle, PA 17013-3699 Statement Date: 1/1/2014
(888) 880-7090
ALL TRANSACTIONS PROCESSED AFTEft Dec 31, 2013
WILL APPEAR ON YOUR NEXT STATEMENT
Darryl Tate
11 Mt. Allen Drive
Mechanicsburg, PA 17055
Amaunt Due $3,212.50
PLEASE DETACH ANG RETURN WITH YOUR PAYMENT Amount Enclosed $
Forest Park Health Center Resident: Tate, June (23149)
700 Walnut Bottom Road Location: -
Carlisle, PA 17013-3699 Statement Date: 1/1/2014
(888) 880-7090
Effective Description
Date Units Unit Amount Amount
BALANCE FORWARD $2,980.00
12/31/2013 Payment-#0105 ($650.00)
11/18/2013 Specialty Beds 5 $26.50 $132.50
11/30/2013 Private Pay copay from Freedom Blue/Highmark for 1 $750.00 $750.00
November 2013
BALANCE DUE $3,212.50
Guardian Eldercare dba
Forest Parl< Health Center
8796 Route 219
Brockway, PA 15824
January 15, 2015
Cumberland County
Register of Wills and Orphans Court
One Courthouse Square Room 102
Carlisle, PA 17013
To whom it may concern:
Enclosed is a copy of the most recent bill with charges of$3,212.50 to be filed against
the Estate of June Tate, number: 21-2014-00042. Additional bills were also included to
show the detail of the charges. If there are any questions I have included my contact
information below.
Sincerely,
�
.('� ,��_,e�,�
Dana
Privat�Pay Account Specialist
dana.ppbi I lin�(a��uardianeldercare.net
888-880-7090 EXT 818
814-265-7818