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HomeMy WebLinkAbout05-2357TABAS & ROSEN, P.C. BY: LEWIS C. TRAUFFER I.D.#60267 22nd F1.,1845 Walnut Street Phila. PA 19103 (215) X69-5050 ATTORNEYFOR Plaintiff Plaintiff(s) T THE MILTON S. HERSHEY MEDICAL CENTER P.O. Box 853 Hershey, PA 17033 vs Del' ndanis(s) JAMES SALISBURY 737 Bloserville Newville, PA 17241 COURT OF COMMON PLEAS DIVISION CUMBERLAND COUNTY No. ()S -a3S7 e CJL??U`- 1.y COMPLAINT - CIVIL ACTION NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOC 2 Liberty Avenue Carlisle, PA 17013 (800)990-9108 (717)249-3166 AVI SO Le han demandado a usted en la corte. Si usted quiere defenderse de estas demandas expuestas en Las paginas siguientes, usted tiene veinte (20) dias de plazo at partir de La fecha de la demandanda y La notificacion. Hace falta asentar una comparencia escrita o en persona o con un abogado y entregar a la corte en for escrita sus defenses o sus objeciones a Las demandas en contra de su persona. Sea avisado que si usted no se defiende, la corte tomara medidas y puede continuer la demandanda en contra suya sin previo aviso o notif icacion. Ademas, la corte puede decidir a favor del demandante y requiere que usted cumpla con todas Las provisiones de esta demanda. Usted puede perder dinero o sus propiedades u otros derechos importantes pars usted. LLEVE ESTA DEMANDA A UN ABOGADO INMEDIATAMENTE. SI USTED NO TIENE ABOGADO, VAYA PERSONALMENTE 0 LLAME POR TELEFONO A LA OFICINA MENCIONADA A CONTINUACION. ESTA OFICINA LE PUEDE PROVEER LA INFORMACION NECESARIA PARA CONTRATAR A UN ABOGADO. SI USTED CARECE DE LOS MEDICS NECESARIGS PARA CONTRATAR A UN ABOGADO, DICHA OFICINA LE PUEDE SUMINISTRAR LA INFORMACION NECESARIA ACERCA DE AOUELLAS AGENCIAS OUE OFRECEN SERVICIOS LEGALES A LAS PERSONAS OUE TIENEN DERECHO A RECIBIR TAL AYUDA GRATIS O A UNA CUOTA REDUCIDA. CUMBERLAND COUNTY BAR ASSOC. 2 Liberty Avenue Carlisle, PA 17013 (800)990-9108 (717)249-3166 COMPLAINT - CIVIL ACTION THE MILTON S. HERSHEY MEDICAL CENTER VS. JAMES SALISBURY 1. Plaintiff is a non-profit corporation located at the address indicated in the caption hereof. 2. Defendant is an individual who resides at the address indicated in the caption hereof. 3. As the result of a certain medical condition, defendant was treated by the plaintiff on Dec. 4, 2003 thru April 26, 2004. 4. The amounts, quantities and nature of said medical care, the dates on which said medical care was rendered, and the charges therefore are set forth in Exhibit "A" which is incor- porated herein as if set forth at length. S. Said medical care was commensurate with the condition of defendant and was necessary for the health and welfare of defendant. 6. At or about the time of defendant's treatment by plain- tiff, implied, constructive and oral contracts arose between defendant and plaintiff by the terms of which defendant became obligated to pay plaintiff the charges for the medical care rendered by plaintiff to defendant. 7. Defendant refuses to pay the balance due although plaintiff has made demand that defendant do so. THIS DOCUMENT IS BEING USED IN CONNECTION WITH THE COLLECTION OF A DEBT; ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. 8. As a result of the foregoing, there is due and owing from defendant to plaintiff the sum indicated in Exhibit "A" WHEREFORE, plaintiff demands judgment against defendant for the sum of $49,209.51 plus six percent (6s) interest per annum from the date of discharge to the date of judgment, record costs and non-record costs. TABAS & ROSEN, P.C. WI C. TRNrJ FFER, ESQUIRE Attorney for Plaintiff THIS DOCUMENT IS BEING USED IN CONNECTION WITH THE COLLECTION OF A DEBT; ANY INFORMATION OBTAINED MAY BE USED FOR THAT PURPOSE. MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/01/04 at 02:15 PM Guarantor: SALISBURY JAMES A 737 BLOSERVILLE NEWVILLE, PA 17241-0000 Patient: SALISBURY JAMES A Visit #: 25525 ------------------------------------------------------------ - ----------- Date Svc Code Description Units Debits Credits 12/04/03 10376 T INTERMEDIATE CARE U 1 1345.00 12/04/03 16502 ADULT LEVEL IT TRAUMA 1 2544.00 12/04/03 46122 HEMOCCULT, STOOL 1 7.00 12/04/03 46473 ER,CRITICL CARE,30-75 1 1013.00 12/04/03 46620 ROUTINE VENIPUNCTURE 1 14.00 12/04/03 46696 IV INFUSION TX 0-1 HR 2 358.00 12/04/03 46794 IV PUMP, SINGLE LINE 2 6.00 12/04/03 101003 ABO BLOOD GROUP 1 18.00 12/04/03 101004 ANTIBODY SCREEN 1 32.00 12/04/03 101005 RE TYPE 1 17.00 12/04/03 104002 ALCOHOL (ETOH), BLOOD 1 45.00 12/04/03 104009 AMYLASE, BLOOD 1 38.00 12/04/03 104042 CREATININE, BLOOD 1 11.00 12/04/03 104060 GLUCOSE, BLOOD 1 10.00 12/04/03 104131 POTASSIUM (K), BLOOD 1 11.00 12/04/03 104145 SODIUM (NA), BLOOD 1 11.00 12/04/03 104156 SGPT (ALT) 1 12.00 12/04/03 105052 PARTIAL THROMBOPLAS T 1 32.00 12/04/03 105059 PROTHROMBIN TIME 1 20,00 12/04/03 105656 CBC W/PLT AUTO 1 27.00 12/04/03 111001 GLUCOSE BEDSIDE MONIT 1 25.00 12/04/03 245208 LIDOCAINE 1 ML 1 2.10 12/04/03 245465 WATER FOR INJ.BACT. 1 2 4.20 12/04/03 245482 DEXTROSE 5% IN WATER 1 2.10 12/04/03 246182 GLYCOPYRROLATE 0.2 MG 3 6.30 12/04/03 246273 METHYLPRED. SOD. SUCC 2 18,70 12/04/03 246316 NEOSTIGMINE 10 ML 1 2.10 12/04/03 246400 PROMETHAZINE 25 MG/ML 1 3.30 12/04/03 246487 SUCCINYL CHOLINE 200 1 2.10 12/04/03 246874 PROMETHAZINE HCL 50 M 1 4.55 12/04/03 247786 MORPHINE SULFATE 10 M 1 2.50 12/04/03 248225 SENNA SYRUP 1ML 1 26.10 12/04/03 248390 METHYLPREDNISOLONE 1M 3 655.70 12/04/03 274347 PANTOPRAZOLE INJ 2 28.30 12/04/03 307205 C-SPINE 2-3 VIEWS 1 133.00 12/04/03 307551 FLUORO MORE THAN ONE 1 260.00 12/04/03 307841 ORBITS MRI F13 XPAY 1 133.00 12/04/03 310501 CT HEAD UNENHANCED 1 649.00 12/04/03 310515 CT THORAX UNENHANCED ]. 620.00 12/04/03 310518 CT ABDOMEN UNENHANCED 1 761,00 12/04/03 310534 CT MULTIPLANAR 3D 1 490.00 12/04/03 310560 CT C-SPINE UNENHANCED 1 719,00 Continue R - ? MS HERSHEY MEDICAL CENTER PAGE: 2 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/01/04 at 02:15 PM Guarantor: SALISBURY JAMES A 737 BLOSERVILLE NEWVILLE, PA 17241-0000 Patient: SALISBURY JAMES A Visit #: 25525 --------------- - ---------------------------------------------------- --- Date Svc Code Description Units Debits credits 12/04/03 310566 CT PELVIS UNENHANCED 1 700.00 12/04/03 310694 CT TRAUMA SPINE RECON 1 490.00 12/04/03 347038 MRI L SPINE UNENHANCE 1 1409.00 12/04/03 600510 PULSE OXIMETER SNSR A 1 13.00 12/04/03 621054 IV LACTATED RINGERS 1 1 6.00 12/04/03 626081 IV DILUENT NML SALINE 1 8.00 12/04/03 667765 SCD SLEEVES, KNEE LEN 1 75,00 12/04/03 670334 IV INFUSION SET, UNIV 1 8.00 12/05/03 601 INITIAL EVALUATION-PT 1 137.00 12/05/03 674 THER EXERCISE 15 MIN 1 46.00 12/05/03 10376 T INTERMEDIATE CARE U 1 1345.00 12/05/03 111001 GLUCOSE BEDSIDE MONIT 5 125.00 12/05/03 246037 BISACODYL 10 MG 1 2.10 12/05/03 246400 PROMETHAZINE 25 MG/ML 1 3.30 12/05/03 246706 MORPHINE SULFATE 2 MG 1 2.30 12/05/03 274347 PANTOPRAZOLE INJ 1 14,15 12/05/03 600520 SPIRO INCENTIVE ADULT 1 7,00 12/05/03 621044 I V SODIUM CHLORIDE 0 1 6.00 12/05/03 621054 IV LACTATED RINGERS 1 1 6,00 12/05/03 626081 IV DILUENT NML SALINE 1 8.00 12/05/03 670832 COLLAR RPLMT PAD ASPE 1 30.00 12/06/03 10376 T INTERMEDIATE CARE U 1 1345.00 12106103 274347 PANTOPRAZOLE INJ 1 14.15 12/06/03 621044 I V SODIUM CHLORIDE 0 2 12,00 12/06/03 621274 IV DEXTROSE 5s-0.9 SO 1 6,00 12/06/03 626081 IV DILUENT NML SALINE 1 8.00 12/07/03 10376 T INTERMEDIATE CARE U 1 1345.00 12/07/03 250092 OXYCODONE APAP 1TAB 2 4.20 12/07/03 272987 CEFAZOLIN 1 GM PRE-MI 1 8.55 12/07/03 274347 PANTOPRAZOLE INJ 1 14.15 12/07/03 621044 I V SODIUM CHLORIDE 0 3 18.00 12/07/03 626081 IV DILUENT NML SALINE 1 8.00 12/07/03 670330 IV INFUSION SET, UNIV 1 16.00 12/08/03 10144 I CRITICAL CARE UNIT 1 2535.00 12/08/03 101003 ABO BLOOD GROUP 1 18,00 12/08/03 101004 ANTIBODY SCREEN 1 32.00 12/08/03 101005 RH TYPE 1 17.00 12/08/03 101021 COMPAT, IMMED SPIN 2 122.00 12/08/03 104028 IONIZED CALCIUM 2 150,00 1.2/08/03 104060 GLUCOSE, BLOOD 1 10.00 12/08/03 104110 BLOOD GAS PANEL 1 110.00 12/08/03 104111 BLOOD GAS PANEL W/02 2 262.00 Continue MS HERSHEY MEDICAL CENTER PAGE: 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/01/04 at 02:15 PM Guarantor: SALISBURY JAMES A 737 BLOSERVILLE NEWVILLE, PA 1-7241-0000 Patient: SALISBURY JAMES A Visit #: 25525 --------- - -- Date - -- - ----- Svc Code ---------------- Description - -- - ------I Units ---- ------------? Debits ---I Credits ------------- 12/08/03 ----------- 104131 ----------- POTASSIUM (K), BLOOD 2 22.00 12/06/03 104145 SODIUM (NA), BLOOD 2 22.00 12/08/03 104398 ELECTROLYTES 1 27.00 12/08/03 104433 BASIC METABOLIC PANEL 1 36.00 12/08/03 105029 FIBRINOGEN 1 29.00 12/08/03 105037 HEMOGLOBIN 2 30.00 12/08/03 105052 PARTIAL THROMBOPLAS T 1 32.00 12/08/03 105059 PROTHROMBIN TIME 1 20.00 12/08/03 105656 CBC W/PLT AUTO 2 54.00 12/08/03 245208 LIDOCAINE 1 ML 1 2.10 12/08/03 245717 DEXAMETHASONE 4 MG/ML 1 2.10 12/08/03 246020 BACITRACIN 50000 U 1 29.70 12/08/03 246037 BISACODYL 10 MG 1 2.1D 12/08/03 246057 CEFAZOLIN 1 GM/5 ML 1 6.75 12/08/03 246162 FENTANYL CITRATE 5 ML 3 2.10 12/08/03 246182 GLYCOPYRROLATE 0.2 MG 2 4.20 12/08/03 246478 SODIUM CHLORIDE 30 ML 2 4.20 12/08/03 246487 SUCCINYL CHOLINE 200 1 2.10 12/08/03 246708 MEPERIDINE HCL 25 MG 1 2.10 12/08/03 246831 FENTANYL CITRATE 20 M 7 4.27 12/08/03 250577 PROPOFOL 20ML 3 71.55 12/08/03 273028 REMIFENTANIL 2MG/5ML 6 368.70 12/08/03 273532 PROPOFOL IOMG/ML 100M 5 596.00 12/08/03 273724 DEXMEDETOMIDINE 200MC 4 734.60 12/08/03 274157 THROMBIN 5000U VIAL 1 153.70 12/08/03 274347 PANTOPRAZOLE INJ 2 28.30 12/08/03 307101 CHEST 1 VIEW 1 104.00 12/08/03 307201 SPINE 1 VIEW ANY LEVE 1 118.00 12/08/03 307211 T-L SPINE AP/LAT-2 EX 1 133.00 12/08/03 390584 CROSSLINK 2 3710.00 12/08/03 391182 SCREW 4 7120.00 12/08/03 392131 PLATE 2 4532.00 12/08/03 394190 CAGE 4 14405.00 12/08/03 410032 O.R. TIME @ 15MIN INC 30 6750.00 12/08/03 410054 COMPLEX SET-UP 1 1894.00 12/08/03 410060 ELECTROCAUTERY 1 28.00 12/08/03 410061 BIPOLAR CAUTERY 1 39.00 12/08/03 410075 PLATING SYSTEM 1 36.00 12/08/03 410079 NEURO DRILLS 1 163.00 12/08/03 462689 BUR 1 187.00 12/06/03 464105 SPINE ROD 70 MM 1 463.00 12/08/03 464443 ROD 1 672.00 - Continue - J? -3 MS HERSHEY MEDICAL CENTER PAGE: 4 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/01/04 at 02:15 PM Guarantor: SALISBURY JAMES A 737 BLOSERVILLE NEWVILLE, PA 17241-0000 Patient: SALISBURY JAMES A Visit #: 25525 ----------------- - -----------------------?---- --- ---------- Date I Svc Code I Description Unitsi Debits Credits 12/08/03 464947 LOCKING SCREW 1 934.00 12/08/03 469016 STRAIGHT THORACIC CAT 1 29.00 12/08/03 469040 ANGLED THORACIC CATH- 1 35.00 12/08/03 469277 CLIP APPLIER 1 146.00 12/08/03 469837 PROXIMATE SKIN STAPLE 1 48.00 12/08/03 469973 NEURO PACK 1 155.00 12/08/03 479001 SOMATOSENSORY;UPPER L 1 631.00 12/08/03 479003 MOTOR EVOKED RESP/POT 1 812.00 12/08/03 479007 INTRAOP MONITORING EA 6 9258.00 12/08/03 479009 DISPOSABLE RECORDING 45 630.00 12/08/03 479019 SOMATOSENSORY;LOWER L 1 631.00 12/08/03 480017 CELL SAV (AUTOTRANSFU 1 744.00 12/08/03 502000 ANESTHESIA TIME-HOSP 30 1882.00 12/08/03 503036 DOUBLE TRANSDUCER SET 1 213.00 12/08/03 503071 BRONCHOSCOPY ANESTHES 1 66.00 12/08/03 503123 ADULT A-LINE KIT 1 29.00 12/08/03 503145 ARROW PERC SHEATH INT 1 6B.00 12/08/03 515502 ADD-ON KIT 1 57.00 12/08/03 600510 PULSE OXIMETER SNSR A 1 13.00 12/08/03 6210,13 I V SODIUM CHLORIDE 0 1 6.00 12/08/03 621044 I V SODIUM CHLORIDE 0 2 12.00 12/08/03 621054 IV LACTATED RINGERS 1 1 6.00 12/08/03 621386 IV KCL 20MEQ+D5 NACL 1 9.00 12/08/03 622023 IRRIGATION SOD CHL 0_ 5 30.00 12/08/03 623017 ADAPTOR, VENTED SPIKE 1 9.00 12/08/03 626080 IV DILUENT NML SALINE 1 8.00 12/08/03 626081 IV DILUENT NML SALINE 1 8.00 12/08/03 661514 CHEST DRAIN SYSTEM DR 1 66.00 12/08/03 667765 SCD SLEEVES, KNEE LEN 2 150.00 12/08/03 670330 IV INFUSION SET, UNIV 3 48.00 12/08/03 670334 IV INFUSION SET, UNIV 1 8.00 12/09/03 10144 I CRITICAL CARE UNIT 1 2535.00 12/09/03 104110 BLOOD GAS PANEL 2 220.00 12/09/03 104433 BASIC METABOLIC PANEL 1 36.00 12/09/03 104434 HEPATIC FUNCTION PANE 1 31.00 12/09/03 105052 PARTIAL THROMBOPLAS T 1 32.00 12/09/03 105059 PROTHROMBIN TIME 1 20.00 12/09/03 105656 CBC W/PLT AUTO 1 27.00 12/09/03 246706 MORPHINE SULFATE 2 MG 1 2.30 12/09/03 246708 MEPERIDINE HCL 25 MG 4 8.40 12/09/03 247788 MEPERIDINE HCLROCHLOR 3 6.30 1.2/09/03 2,28225 SENNA SYRUP 1ML 1 26.10 ----- - - --- ----------- --------- - Continue - MS HERSHEY MEDICAL CENTER PAGE: 5 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/01/04 at 02:15 PM Guarantor: SALISBURY JAMES A 737 BLOSERVILLE NEWVILLE, PA 17241-0000 Patient: SALISBURY JAMES A Visit #: 25525 ------------------- - ---------------------------------------------------- Date I Svc Code I Description I Units Debits Credits 2/09'03 250092 OXYCODONE APAP 1TAB 3 6.30 1 2/09103 272199 ONDANSETRON 2MG/ML 2M 4 53.64 12/09/03 272987 CEFAZOLIN 1 GM PRE-MI 3 25.65 12/09/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/09/03 307101 CHEST 1 VIEW 1 104.00 12/09/03 310534 CT MULTIPLANAR 3D 1 490.00 12/09/03 310562 CT T-SPINE UNENHANCED 1 670.00 12/09/03 516201 STERILE WATER UP TO 5 400 4.00 12/09/03 516202 VENTILATOR DAY INITIA 1 441.00 12/09/03 516203 VENTILATOR DAY SUBSEQ 1 441.00 12/09/03 516803 VENTILATOR CIRCUIT 1 20.00 12/09/03 621386 IV KCL 20MEQ+D5 NACL 2 18.00 12/09/03 626080 IV DILUENT NML SALINE 1 8.00 12/09/03 670334 IV INFUSION SET, UNIV 1 8.00 12/10/03 680 THERAPEUTIC EXERCISE 2 92.00 12/10/03 10145 T INTERMEDIATE CARE U 1 1345.00 12/10/03 104433 BASIC METABOLIC PANEL 1 36.00 12/10/03 105656 CBC W/PLT AUTO 1 27.00 12/10/03 246621 DOCUSATE SODIUM 100 M 2 4.20 12/10/03 246706 MEPERIDINE HCL 25 MG 8 16.80 12/10/03 247788 MEPERIDINE HCLROCHLOR 1 2.10 12/10/03 250092 OXYCODONE APAP 1TAB 5 10.50 12/10/03 272987 CEFAZOLIN 1 GM PRE-MI 3 25.65 12/10/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/10/03 307101 CHEST 1 VIEW 1 104.00 12/10/03 621386 IV KCL 20MEQ+D5 NACL 2 18.00 12/11/03 308 INITIAL EVALUATION-OT 1 137.00 12/11/03 10223 P PRIVATE MED/SURG RM 1 1015.00 12/11/03 246621 DOCUSATE SODIUM 100 M 2 4.20 12/11/03 246708 MEPERIDINE HCL 25 MG 2 4.20 12/11/03 247788 MEPERIDINE HCLROCHLOR 4 8.40 12/11/03 250092 OXYCODONE APAP 1TAB 6 12.60 12/11/03 272967 CEFAZOLIN 1 GM PRE-MI 1 8.55 12/11/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/11/03 307101 CHEST 1 VIEW 2 206.00 12/11/03 307102 CHEST 2 VIEW A/P LAT 1 125.00 12/12/03 434 THERAPEUT ACTIVITIES 1 46.00 12/12/03 435 ACT DAILY LIVING 15 M 1 46.00 12/12/03 680 THERAPEUTIC EXERCISE 2 92.00 12/12/03 245985 ACETAMINOPHEN 600 MG 1 2.10 12/12/03 246299 MEPERIDINE HCL 100 MG 1 2.20 12/12/03 246621 DOCUSATE SODIUM 100 M 1 2.10 Continue MS HERSHEY MEDICAL CENTER PAGE: 6 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/01/04 at 02:15 PM Guarantor : SALISBURY JAMES A 737 BLOSERVILLE NEWVILLE, PA 17241-0000 Patient: SALISBURY JAMES A Visit #: 25525 - - ------ Date -------------- I Svc Code ---------------------- Description ----- --- I Units ---- ----- Debits -- --------- I Credits --------- 12/12/03 -------------- 246708 ----------- MEPERIDINE HCL 25 MG 2 4.20 12/12/03 250092 OXYCODONE APAP 1TA13 2 4.20 12/12/03 307213 L-SPINE 2-3 VIEWS 1 188.00 12/23/03 503128 BAIR HUGGER UPPER BOD 1 32.00 04/06/04 902040 AUTO/WORK COMP PAYMEN -1 ------ --- ---------- 85747.99- -------------- --------- * - Not ----------- - posted ------ - --------------- - -- Balance: ---------- 3111.52 -------------- MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/01/04 at 02:15 PM Guarantor: SALISBURY JAMES A 737 BLOSERVILLE NEWVILLE, PA 17241-0000 Patient: SALISBURY JAMES A Visit #: 4013374 ------------------- ---------P--- -?------------I------ --- Date I Svc Code I Description j Units Debits Credits 12/12/03 10200 G 3-4 BED REHAB RM 1 895.00 12/12/03 250092 OXYCODONE APAP 1TAB 1 2.10 12/12/03 251170 MORPHINE SULFATE 15MG 2 4.20 12/12/03 272176 ZOLIPIDEM 5MG TAB 1 11.80 12/12/03 272811 DALTEPARIN 2500U/0.2M 1 26.00 12/12/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/12/03 667732 STOCKINGS THIGH MED R 2 28.00 12/13/03 308 INITIAL EVALUATION-OT 1 137.00 12/13/03 1401 INITIAL EVALUATION-PT 1 137.00 12/13/03 10200 G 3-4 BED REHAB RM 1 895.00 12/13/03 102214 CULTURE, URINE QUANT 1 34.00 12/13/03 104042 CREATININE, BLOOD 1 11.00 12/13/03 104060 GLUCOSE, BLOOD 1 10.00 12/13/03 104065 UREA NITROGEN (BUN), 1 10.00 12/13/03 104398 ELECTROLYTES 1 27.00 12/13/03 105656 CSC W/PLT AUTO 1 27.00 12/13/03 106011 URINALYSIS-BASIC & MI 1 19.00 12/13/03 246037 BISACODYL 10 MG 1 2.10 12/13/03 246124 DOCUSATE NA/CASANTHR 2 4.20 12/13/03 246470 SENNA CONCENTRATE TAB 1 2.10 12/13/03 246644 BACLOFEN 10 MG 2 4.20 12/13/03 250092 OXYCODONE APAP 1TAB 5 10.50 12/3-3/03 250580 MORPHINE SULFATE 30MG 2 4.30 12/13/03 272176 ZOLIPIDEM 5MG TAB 1 11.80 12/13/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 12/13/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/14/03 10200 G 3-4 BED REHAB RM 1 895.00 12/14/03 246037 BISACODYL 10 MG 1 2.10 12/14/03 246124 DOCUSATE NA/CASANTHR 2 4.20 12/14/03 246470 SENNA CONCENTRATE TAB 1 2.10 12/14/03 246644 BACLOFEN 10 MG 2 4.20 12/14/03 250092 OXYCODONE APAP 1TAB 3 6.30 12/14/03 250580 MORPHINE SULFATE 30MG 2 4.30 12/14/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 12/14/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/14/03 274244 POLYETHYLENE GLYCOL-E 1 3.75 12/15/03 434 THERAPEUT ACTIVITIES 2 92.00 12/15/03 674 THER EXERCISE 15 MIN 1 46.00 12/15/03 675 NEUROMUSCULAR RE ED 1 1 46.00 12/15/03 684 GA7:1' TRAINING 15 MIN 2 92.00 EEV B `72/15/03 48229 SCAN -COMPLE DUPLEX - - 1 ------- 400.00 ------------- -------------- ------------ ----------- --------------- ------ - Continue - MS HERSHEY MEDICAL CENTER PAGE: 2 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/01/04 at 02:15 PM Guarantor: SALISBURY JAMES A 737 BLOSERVILLE NEWVILLE, PA 17241-0000 Patient: SALISBURY JAMES A Visit #: 4013374 ------------ -----------P----------------------------- Date I Svc Code Description I Units Debits Credits 12/15/03 246124 DOCUSATE NA/CASANTHR 2 4.20 12/15/03 246644 BACLOFEN 10 MG 2 4.20 12/15/03 250092 OXYCODONE APAP 1TAB 1 2.10 12/15/03 250580 MORPHINE SULFATE 30MG 2 4.30 12/15/03 272176 ZOLIPIDEM 5MG TAB 1 11.80 12/15/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 12/15/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/15/03 274244 POLYETHYLENE GLYCOL-9 1 3.75 12/16/03 434 THERAPEUT ACTIVITIES 2 92.00 12/16/03 435 ACT DAILY LIVING 15 M 2 92.00 12/16/03 674 THER EXERCISE 15 MIN 2 92.00 12/16/03 675 NEUROMUSCULAR RE ED 1 1 46.00 12/16/03 684 GAIT TRAINING 15 MIN 3 138.00 12/16/03 10200 G 3-4 BED REHAB RM 1 895.00 12/16/03 246124 DOCUSATE NA/CASANTHR 2 4.20 12/16/03 246470 SENNA CONCENTRATE TAB 1 2.10 12/16/03 246644 BACLOFEN 10 MG 3 6.30 12/16/03 251170 MORPHINE SULFATE 15MG 2 4.20 12/16/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 12/16/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/16/03 274244 POLYETHYLENE GLYCOL-E 1 5.30 12/17/03 434 THERAPEUT ACTIVITIES 2 92.00 12/17/03 435 ACT DAILY LIVING 15 M 2 92.00 12/17/03 674 THER EXERCISE 15 MIN 2 92.00 12/17/03 675 NEUROMUSCULAR RE ED 1 1 46.00 12/17/03 684 GAIT TRAINING 15 MIN 3 138.00 12/17/03 10200 G 3-4 BED REHAB RM 1 895.00 12/17/03 11618 THERAPEUT ACTIV-RT 15 2 92.00 12/17/03 246037 BISACODYL 10 MG 1 2.10 12/17/03 246124 DOCUSATE NA/CASANTHR 3 6.30 12/17/03 246470 SENNA CONCENTRATE TAB 1 2.10 12/17/03 24664,1 BACLOFEN 10 MG 3 6.30 12/17/03 250092 OXYCODONE APAP 1TAB 2 4.20 12/17/03 251170 MORPHINE SULFATE 15MG 2 4.20 12/17/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 12/17/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/17/03 274244 POLYETHYLENE GLYCOL-E 1 5.30 12/18/03 434 THERAPEUT ACTIVITIES 2 92.00 12/18/03 435 ACT DAILY LIVING 15 M 2 92.00 7.2' /18/03 674 THER EXERCISE 15 MIN 3 138.00 12/18/03 675 NEUROMUSCULAR RE ED 1 1 46.00 12/18/03 6,84 GAIT TRAINING 15 MIN I 46.00 ------- - -- --- - ------ -- -- - Continue - i MS HERSHEY MEDICAL CENTER PAGE: 3 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/01/04 at 02:15 PM Guarantor: SALISBURY JAMES A 737 BLOSERVILLE NEWVILLE, PA 17241-0000 Patient: SALISBURY JAMES A Visit #: 4013374 ----------------------------------- ------------------------------- Date Svc Code Description I Unitsj Debits Credits 12/18/03 10200 G 3-4 BED REHAB RM 1 895.00 12/18/03 11618 THERAPEUT ACTIV-RT 15 2 92.00 12/18/03 246037 BISACODYL 10 MG 1 2.10 12/18/03 246124 DOCUSATE NA/CASANPHR 2 4.20 12/18/03 246470 SENNA CONCENTRATE TAB 1 2.10 12/18/03 246644 BACLOFEN 10 MG 3 6.30 12/18/03 250092 OXYCODONE APAP 1TAB 1 2.10 12/18/03 251170 MORPHINE SULFATE 15MG 2 4.20 12/18/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 12/18/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/18/03 274244 POLYETHYLENE GLYCOL-E 1 5.30 12/19/03 434 THERAPEUT ACTIVITIES 2 92.00 12/19/03 435 ACT DAILY LIVING 15 M 2 92.00 12/19/03 674 THER EXERCISE 15 MIN 2 92.00 12/19/03 684 GAIT TRAINING 1S MIN 3 138.00 12/19/03 10200 G 3-4 BED REHAB RM 1 895.00 12/19/03 11618 THERAPEUT ACTIV-RT 15 2 92.00 12/19/03 246037 BISACODYL 10 MG 1 2.10 12/19/03 246124 DOCUSATE NA/CASANTHR 2 4.20 12/19/03 246470 SENNA CONCENTRATE TAB 1 2.10 12/19/03 246644 BACLOFEN 10 MG 3 6.30 12/19/03 246838 LOPERAMIDE 2 MG 1 2.10 12/19/03 247831 ACETAMINOPHEN 325 MG 1 2.10 12/19/03 250092 OXYCODONE APAP 1TAB 1 2.10 12/19/03 251170 MORPHINE SULFATE 15MG 2 4.20 12/19/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 12/19/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/19/03 274244 POLYETHYLENE GLYCOL-E 1 5.30 12/19/03 622023 IRRIGATION SOD CHL 0. 1 6.00 12/20/03 674 THER EXERCISE 15 MIN 1 46.00 12/20/03 684 GAIT TRAINING 15 MIN 1 46.00 12/20/03 10200 G 3-4 BED REHAB RM 1 895.00 12/20/03 246127 DIPHENHYDRAMINE 25 MG 1 2.10 12/20/03 246644 BACLOFEN 10 MG 1 2.10 12/20/03 248402 SILVER SULFADIAZINE 5 1 11.85 12/20/03 250092 OXYCODONE APAP 1TAB 2 4.20 12/20/03 251170 MORPHINE, SULFATE 15MG 2 4.20 12/20/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 12/20/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/20/03 274244 POLYETHYLENE GLYCOL-E 1 5.30 12/21/03 674 THER EXERCISE 15 MIN 1 46.00 12/21/03 684 GAIT TRAINING 15 MIN 1 46.00 __ - ----- - Continue - --- - -------------- MS HERSHEY MEDICAL CENTER PAGE: 4 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/01/04 at 02:15 PM Guarantor: SALISBURY JAMES A 737 BLOSERVILLE NEWVILLE, PA 17241-0000 Patient: SALISBURY JAMES A Visit #: 4013374 ------------------------------------------------------------------------- Date Svc Code Description Units Debits I Credits 12/21/03 10200 G 3-4 BED REHAB RM 1 895.00 12/21/03 246037 BISACODYL 10 MG 1 2.10 12/21/03 246124 DOCUSATE NA/CASANTHR 1 2.10 12/21/03 246470 SENNA CONCENTRATE TAB 1 2.10 12/21/03 246644 BACLOFEN 10 MG 3 6.30 12/21/03 250092 OXYCODONE APAP 1TAB 2 4.20 12/21/03 251170 MORPHINE SULFATE 15MG 2 4.20 12/21/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 12/21/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/21/D3 274244 POLYETHYLENE GLYCOL-E 1 5.30 12/22/03 428 THER EXERCISES 15 MIN 2 92.00 12/22/03 435 ACT DAILY LIVING 15 M 2 92.00 12/22/03 674 THER EXERCISE 15 MIN 4 184.00 12/22/03 684 GAIT TRAINING 15 MIN 1 46.00 12/22/03 10200 G 3-4 BED REHAB RM 1 895.00 12/22/03 11618 THERAPEUT ACTIV-RT 15 2 92.00 12/22/03 246124 DOCUSATE NA/CASANTHR 2 4.20 12/22/03 246470 SENNA CONCENTRATE TAB 1 2.10 12/22/03 246644 BACLOFEN 10 MG 2 4.20 12/22/03 250092 OXYCODONE APAP 1TAB 1 2.10 12/22/03 251170 MORPHINE SULFATE 15MG 2 4.20 12/22/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 12/22/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/22/03 274244 POLYETHYLENE GLYCOL-E 1 5.30 12/23/03 674 THER EXERCISE 15 MIN 2 92.00 12/23/03 684 GAIT TRAINING 15 MIN 2 92.00 12/23/03 10200 G 3-4 BED REHAB RM 1 895.00 12/23/03 246124 DOCUSATE NA/CASANTHR 2 4.20 12/23/03 246470 SENNA CONCENTRATE TAB 1 2.10 12/23/03 246644 BACLOFEN 10 MG 6 12.60 12/23/D3 250092 OXYCODONE APAP 1TAB 1 2.10 12/23/03 251170 MORPHINE SULFATE 15MG 1 2.10 12/23/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 12/23/03 273509 BOOST EN CHOC DRINK 1 2.60 12/23/03 273737 PANTOPRAZOLE 40 MG TA 2 4.20 12/23/03 274197 BOOST BREEZE NUTRIT D 1 3.25 12/23/03 274244 POLYETHYLENE GLYCOL-E 2 10.60 12/24/03 674 THER EXERCISE 15 MIN 1 46.00 1.2/24/03 684 GAIT TRAINING 15 MIN 1 46.00 12/24/03 246644 BACLOFEN 10 MG 1 2.10 12/24/03 250092 OXYCODONE APAP 1TAB 3 6.30 12/24/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 Continue /L MS HERSHEY MEDICAL CENTER PAGE: 5 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/01/04 at 02:15 PM Guarantor: SALISBURY JAMES A 737 BLOSERVILLE NEWVILLE, PA 17241-0000 Patient: SALISBURY JAMES A Visit #: 4013374 ------------ - ----------------------------------------------------------- Date I Svc Code I Description Units Debits Credits 12/25/03 10200 G 3-4 BED REHAB RM 1 895.00 12/25/03 246644 BACLOFEN 10 MG 1 2.10 12/25/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/26/03 428 THER EXERCISES 15 MIN 1 46.00 12/26/03 434 THERAPEUT ACTIVITIES 1 46.00 12/26/03 674 THER EXERCISE 15 MIN 2 92.00 12/26/03 684 GAIT TRAINING 15 MIN 3 138.00 12/26/03 10199 F SEMI PRIV REHAB RM 1 895.00 12/26/03 246470 SENNA CONCENTRATE TAB 1 2.10 12/26/03 246644 BACLOFEN 10 MG 3 6.30 12/26/03 250092 OXYCODONE APAP 1TAB 1 2.10 12/26/03 272811 DALTEPARIN 2500U/0.2M 2 52.00 12/26/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/26/03 274244 POLYETHYLENE GLYCOL-E 1 5.30 12/27/03 674 THER EXERCISE 15 MIN 2 92.00 12/27/03 684 GAIT TRAINING 15 MIN 1 46.00 12/27/03 10199 F SEMI PRIV REHAB RM 1 895.00 12/27/03 104433 BASIC METABOLIC PANEL 1 36.00 12/27/03 105656 CBC W/PLT AUTO 1 27.00 12/27/03 246644 BACLOFEN 10 MG 3 6.30 12/27/03 250092 OXYCODONE APAP 1TAB 2 4.20 12/27/03 272238 GABAPENTIN 400MG 1 2.25 12/27/03 272441 TRAMADOL 50MG 1 2.10 12/27/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/27/03 274244 POLYETHYLENE GLYCOL-E 1 5.30 12/28/03 674 THER EXERCISE 15 MIN 2 92.00 12/28/03 684 GAIT TRAINING 15 MIN 2 92.00 12/28/03 10199 F SEMI PRIV REHAB RM 1 895.00 12/28/03 246644 BACLOFEN 10 MG 3 6.30 12/28/03 272238 GABAPENTTN 400MG 1 2.25 12/28/03 272441 TRAMADOL 50MG 1 2.10 12/28/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/29/03 428 THER EXERCISES 15 MIN 2 92.00 12/29/03 435 ACT DAILY LIVING 15 M 1 46.00 12/29/03 674 THER EXERCISE 15 MIN 1 46.00 12/29/03 680 THERAPEUTIC EXERCISE 2 92.00 12/29/03 684 GAIT TRAINING 15 MIN 3 138.00 12/29/03 10199 F SEMI PRIV REHAB RM 1 895.00 12/29/03 11618 THERAPEUT ACTIV-RT 15 1 46.00 12/29/03 246644 BACLOFEN 10 MG 3 6.30 12/29/03 272238 GABAPENTIN 400MG 1 2.25 12/29/03 272441 TRAMADOL 50MG 1 2.10 Continue I"-f/ MS HERSHEY MEDICAL CENTER PAGE: 6 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/01/04 at 02:15 PM Guarantor: SALISBURY JAMES A 737 BLOSERVILLE NEWVILLE. PA 17241-0000 Patient: SALISBURY JAMES A Visit #: 4013374 ------------------------------------------------------------------------- Date I Svc Code Description Units Debits Credits 12/29/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/30/03 684 GAIT TRAINING 15 MIN 2 92.00 12/30/03 10199 F SEMI PRIV REHAB RM 1 B95.00 12/30/03 11618 THERAPEUT ACTIV-RT 15 2 92.00 12/30/03 11620 COMMUNITY/WORK TRN 15 6 276.00 12/30/03 246644 BACLOFEN 10 MG 4 8.40 12/30/03 272238 GABAPENTIN 400MG 2 4.50 12/30/03 272441 TRAMADOL 50MG 1 2.10 12/30/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 12/31/03 674 THER EXERCISE 15 MIN 2 92.00 12/31/03 684 GAIT TRAINING 15 MIN 1 46.00 12/31/03 10199 F SEMI PRIV REHAB RM 1 895.00 12/31/03 11618 THERAPEUT ACTIV-RT 15 2 92.00 12/31/03 246644 BACLOFEN 10 MG 4 8.40 12/31/03 273737 PANTOPRAZOLE 40 MG TA 1 2.10 01/01/04 10199 F SEMI PRIV REHAB RM 1 895.00 01/01/04 246644 BACLOFEN 10 MG 1 2.10 01/01/04 272176 ZOLIPIDEM 5MG TAB 1 11.80 01/01/04 272238 GABAPENTIN 400MG 1 2.25 01/01/04 273737 PANTOPRAZOLE 40 MG TA 1 2.10 01/02/04 436 COMMUNITY/WORK TRN 15 1 46.00 01/02/04 11618 THERAPEUT ACTIV-RT 15 1 46.00 01/02/04 11620 COMMUNITY/WORK TRN 15 1 46.00 01/02/04 246644 BACLOFEN 10 MG 1 2.10 01/02/04 273509 BOOST EN CHOC DRINK 18 46.80 01/02/04 274197 BOOST BREEZE NUTRIT D 19 60.80 03/29/04 902040 AUTO/WORK COMP PAYMEN -1 5335.24- 03/29/04 930032 ACT 6 AUTO INSURANCE -1 19976.56- 04/12/04 930032 ACT 6 AUTO INSURANCE 1 1693.99 * - Not posted Balance: 1693.99 ------------------------ IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX 10 # 251857035 DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR CODE CODE ADJUSTMENT BALANCE >>> PATIENT: JAMES A SALISBURY 1266320 366917 25525 PERFORMED BY: TRAUMA SURGERY DIV PLACE OF SVC: EMERGENCY ROOM 12/04/03 9924521 959.8 TRAUMA TEAM DIAG EVAL INT 2836.00 04/15/04 84563571 AUTO MAX PERFORMED BY: DIV OF DIAG RADIOLOGY PLACE OF SVC: INPATIENT 12/04/03 7125026 805.2 CT THORAX UNENHANCED 326.00 04115/04 89563571 AUTO MAX 12/04/03 7219226 789.9 CT PELVIS UNENHANCED 306.00 04/15/04 04563571 AUTO MAX 12/04103 7415026 789.9 C T ABDOMEN UNENHAWCED 334.DD 04/15/04 04563571 AUTO MAX 12/04/03 7214826 805.2 MRI SPINE LUMBAR UNENH 373.00 04/15/04 84563571 AUTO MAX 12/04/03 7003026 376.9 ORBIT MRI F.B. 49.00 04/15/04 84563571 AUTO MAX 12/04/03 7204026 723.1 SPINE CERVIC ANT/POS LAT 63.00 04/15/04 84563571 AUTO MAX 12/04/03 721Z526 723.1 CT CERVICAL SPINE UNENHAN 326.00 04/15/04 94563571 AUTO MAX 12104/03 7045026 959.01 CT MEAD UNENHANCEO 240.00 04/15/04 B4563571 AUTO MAX 12/04/03 7637526 723.1 CT CORONAL SAGITTAL OBLIQ 47.00 04115104 @4563571 AUTO MAX PERFORMED BY: DIV OF EMERG ROOM PLACE OF SVC: EMERGENCY ROOM 12/04/03 99291 959.01 CRITICAL CARE FIRST HR 466.00 04/15/04 B4563571 AUTO MAX PERFORMED BY: DIVISION OF NEUROSURGERY PLACE OF SVC: INPATIENT 12/04/03 99253 806.20 INITIAL INPT CONSULTATION 212.00 04/15104 84563571 AUTO MAX PERFORMED BY: DIY OF DIAL RADIOLOGY 12/04/05 7637526 805.2 CT CORONAL SAGITTAL OBLIQ 47.00 01/21/04 WC OR AUTO PAYMENT PERFORMED BY; TRAUMA SURGERY DIV 12/O5103 99231 959.8 DAILY HOSPITAL CARE 74.00 04/15/04 84563571 AUTO MAX PERFORMED BY: DIVISION OF NEUROSURGERY 12105103 99232 806.20 DAILY HOSPITAL CARE 124.00 04/15/04 84563571 AUTO MAX 12/06/03 99232 806.20 DAILY HOSPITAL CARE 124.00 04/15/04 84563571 AUTO MAX PERFORMED BY; DIV OF DIAG RADIOLOGY 12/08/03 7101026 V58181 CHEST 1 VIEW 51.00 04/15/04 84563571 AUTO MAX PERFORMED BY: DIVISION OF NEUROSURGERY 12/08/03 63085.62 806.25 VERT CORPECTOMY 1 LVL THO 8561.00 04/15/04 04563571 AUTO MAX 2836.00 326.00 306.00 334.00 373.00 49.00 63.00 326.00 240.00 47.00 466.00 212.00 0.00 47.00 74.00 124.00 124.00 51.00 8561.00 CHECK BOX AND ENTER ANY ADDRESS OR PENNSTATE JAMES A SALISBURY 1 or 5 737 BLOSERVILLE The Milton S. Hershey Medical Center NEWVILL.E PA 17241-9710 STATEMENT ® The College of Medicine DATE: 08106104 LAST STATEMENT ACCOUNT # 1266320 DATE: 08105104 The Milton S. Hershey Medical Center NEVVVILLE PA 17241.9710 STATEMENT The College 19 of Medicine DATE: 08106104 LAST TATEMENT $ ACCOUNT # 1266320 DATE 08105104 lF ANY QUESTIONS, PLEASE CONTACT : MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 2 51 8 5703 5 DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENT/ GUAR OR CODE CODE ADJUSTMENT BALANCE 12/08/03 22556.51 806.25 THORAX SPINE FUSION 7460.00 04/15/04 8#563571 AUTO MAX 7460.00 12/08/03 22845 806.25 INS SPINE FIXATION DEVICE 3803.00 04/15/04 04563571 AUTO MAX 3803,00 12/08/03 22851 806.25 APP OF PROSTHETIC DEVICE 2134.00 04/15/04 0#563571 AUTO MAX 2134.00 12/08/03 22585 806.25 ADDITIONAL SPINE FUSION 1759,00 04115/04 0#563571 AUTO MAX 1759.06 12/06/03 20936 806.25 SPINAL BONE AUTOGRAFT 563.00 04/15/04 8#563571 AUTO MAX 563.00 PERFORMED BY: DIV CARDIOTHORACIC SURG 12/08/03 63085.62 806,25 VERT CORPECTONY 1 LVL THO 8561.00 04/15/04 8#563571 AUTO MAX 8561.00 PERFORMED BY: DIV OF ANESTHESIA 12/08/03 00670.QK 806.25 41 ARE/EXTEN SPINE&SPINE CAD 3440.00 04/15/04 8#563571 AUTO MAX 3440.00 12/08/03 36489 806,25 CVP CATH PERC OVER 2 YRS 597.00 04/15/04 5#563571 AUTO MAX 597.00 12/08/03 36620 806.25 ART CATH PERCUTAN 275.00 04/15/04 8#563571 AUTO MAX 275.00 PERFORMED BYt DIV OF DIAG RADIOLOGY 12/08/03 7208026.76 805.2 SPINE THORAC ANT/POST LAT 65.00 04/15/04 B#563571 AUTO MAX 65.00 12/08/03 7202026 805.2 SPINE SING VIEW ANY LVL 42,00 04/15/04 B#563571 AUTO MAX 42.00 12/09/03 7101026 V58.81 CHEST 1 VIEW 51.00 04/15/04 B4563571 AUTO MAX 51.00 PERFORMED BY: TRAUMA SURGERY DIV 12/09/03 99232 518.5 DAILY HOSPITAL CARE 124.00 04/15/04 B#563571 AUTO MAX 124.00 PERFORMED BY: DIV OF DIAG RADIOLOGY 12/09/03 7212826 805.2 CT THORACIC SPINE UNENHAN 326.00 04/15/04 B#563571 AUTO MAX 326.00 12/09/03 7637526 805.2 CT CORONAL SAGITTAL OBLIQ 47,00 04/15,104 B#563571 AUTO MAX 47.00 PERFORMED BY: REHABILITATION CENTER DIV 12/09/03 99253 806.20 INITIAL INPT CONSULTATION 212.00 04/15/04 B4563571 AUTO MAX 212,00 PERFORMED BY: DIY OF DIAG RADIOLOGY 12/10/03 7101026 518.89 CHEST 1 VIEW 51.00 04/15/04 B#563571 AUTO MAX 51.00 12/11/03 7101026 786.09 CHEST 1 VIEW 51,00 04/15/04 8#563571 AUTO MAX 51.00 12/11/03 7101026 512.8 CHEST I VIEW 51,00 04/15/04 8#563571 AUTO MAX 51.00 12/11/03 7102026 518.0 CHEST 2 VIEWS FRONT/LAT 63,00 01/15/04 WC OR AUTO PAYMENT 0.00 63,00 12/12/03 7210026 V54.89 SPINE LUMBOS ANT/POST LAT 65.00 01/15/04 WC OR AUTO PAYMENT 0.00 65.00 4013374 AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK YDe Mt1TOn 5. peCSttC}' MetI1C81 L:eDter NEVJVILLE PA 17241.9710 STATEMENT The College of Medicine DATE: 08/06104 LAST STATEMENT ACCOUNT # 1208320 DATE: 06105104 y IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 2 518 5703 5 DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR CODE CODE ADJUSTMENT B ALANCE PERFORMED BY: REHABILITATION CENTER DIV PLACE OF SVCe INPATIENT * 12/12/03 99223 V57.89 INITIAL HOSPITAL CARE 349,00 * 03/30/04 WKC OR AUTO PAYMENT 161.89- * 03/30/04 ACT 6 AUTO ALLOWANCE 187.11- 0.00 * 12/13/03 99232 V57.89 DAILY HOSPITAL CARE 124.00 * 03/30/04 WKC OR AUTO PAYMENT 57.64- * 03/30/04 ACT 6 AUTO ALLOWANCE 66.36- 0.00 PERFORMED BY: DIV VASCULAR INSTITUTE * 12/15/03 9397026 729.5 DUPLEX SCAN EV - COMPLETE 209.00 * 03/26/04 WC OR AUTO PAYMENT 191.36- * 03/26/04 ACT 6 AUTO ALLOWANCE 17.64- 0.00 PERFORMED BY; REHABILITATION CENTER DIV * 12115/03 99232 V57.89 DAILY HOSPITAL CARE 124.00 * 03/30/04 WC OR AUTO PAYMENT 57.64- * 03/30/04 ACT 6 AUTO ALLOWANCE 66.36- 0.00 * 12/16/03 99232 V57.89 DAILY HOSPITAL CARE 124.00 * 03/30/04 NCC OR AUTO PAYMENT 57.64- * 03/30/04 ACT 6 AUTO ALLOWANCE 66.36- 0.00 * 12/17/03 99232 V57.89 DAILY HOSPITAL CARE 124.00 * 03/30/04 WKC OR AUTO PAYMENT 57.64- * 03/30/04 ACT 6 AUTO ALLOWANCE 66.36- 0.00 * 12/18/03 99232 V57.84 DAILY HOSPITAL CARE 124.00 * 03/30/04 WC DR AUTO PAYMENT 57.64- * 03/30/04 ACT 6 AUTO ALLOWANCE 66.36- 0.00 * 12/19/03 99232 V57.89 DAILY HOSPITAL CARE 124.00 * 03/30/04 WC OR AUTO PAYMENT 57.64- * 03/30/04 ACT 6 AUTO ALLOWANCE 66.36- 0.00 * 12/20/03 99232 V57.89 DAILY HOSPITAL CARE 124.00 * 03/26/04 WKC OR AUTO PAYMENT 57.64- * 03/26/04 ACT 6 AUTO ALLOWANCE 66,36- 0.00 * 12/22/03 99232 V57,89 DAILY HOSPITAL CARE 124.00 * 03/30/04 WC OR AUTO PAYMENT 57.64- * 03/30/04 ACT 6 AUTO ALLOWANCE 66.36- 0100 * 12/23/03 99232 V57.89 DAILY HOSPITAL CARE 124.00 * 03/30/04 WC OR AUTO PAYMENT 57.64- * 03/30/04 ACT 6 AUTO ALLOWANCE 66.36- 0,00 * 12/24/03 99232 V57.89 DAILY HOSPITAL CARE 124.00 * 03/30/04 WC OR AUTO PAYMENT 57.64- * 03/30/04 ACT 6 AUTO ALLOWANCE 66.36- 0.00 * 12/26/03 99231 V57.89 DAILY HOSPITAL CARE 74.00 * 03/26/04 WC OR AUTO PAYMENT 34.88- * 03/26/04 ACT 6 AUTO ALLOWANCE 39.12- 0.00 * 12/29/D3 99231 V57.89 DAILY HOSPITAL CARE 74.00 * 03/26/04 WC OR AUTO PAYMENT 34.88- * 03/26/04 ACT 6 AUTO ALLOWANCE 39.12- 0.00 * 01/02/04 99238 Y57.89 HOSPITAL DISC DAY 149.00 * 03/26/04 WC OR AUTO PAYMENT 73.52- * 03/26/04 ACT 6 AUTO ALLOWANCE 75.48- 0.00 4078769 BOX AND PENNSTATE JAMES A SALISBURY 4 of 5 737 BLOSERVILLE MOM The Milton S. Hershey Medical Center NEINVILLE PA 17241-9710 STATEMENT The College of Medicine DATE: 08/06104 LAST STATEMENT ACCOUNT # 1266320 DATE: 08!05104 p T IF ANY QUESTIONS, PLEASE CONTACT : MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG CODE CODE QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR ADJUSTMENT BALANCE PERFORMED BY: REHABILITATION CENTER DIV PLACE OF SVC: OP PHYSICIAN 02/04/04 99214 957,9 OUTPATIENT VISIT EST 105.00 * 03/30/04 WE OR AUTO PAYMENT 84.00- 03/30/04 ACT 6 AUTO ALLOWANCE 21,00- 0.00 4084505 PERFORMED BY: DIVISION OF NEUROSURGERY PLACE OF SVC; SATELLITE CLINIC * 01/08104 99024 806.20 POST-OP FOL-UP VISIT 0.00 0.00 PERFORMED BY: DIV OF DIAG RADIOLOGY * 01/08/04 72100 733.13 SPINE LIABOS ANT/POST LAT 197.00 02/20/04 WC OR AUTO PAYMENT 38,57- 02/20/04 ACT 6 AUTO ALLOWANCE 158.43- 0.00 4165590 PERFORMED BY: DIVISION OF NEUROSURGERY PLACE OF SVC; SATELLITE CLINIC * 02/05/04 99024 805.2 POST-OP FOL-UP VISIT 0.00 0.00 PERFORMED BY; DIV OF DIAG RADIOLOGY * 02105/04 72080 724.9 SPINE THORAC ANT/POST LAT 197.00 * 03/30/04 WC OR AUTO PAYMENT 38.57- * 03/30/04 ACT 6 AUTO ALLOWANCE 158.43- 0.00 4169503 PERFORMED BY: ORTHOPAEDICS DIVISION PLACE OF SVC: OP PHYSICIAN 03/05/04 99243 719.46 OFFICE OR ER CONSULTATION 169.00 06/04/04 MA CHARITY ADJUSTMENT 169.00- 0.00 PERFORMED BY: DIV OF DIAG RADIOLOGY 03/05/04 7356226 719.46 KNEE MINIMUN 3 VIEWS 52.00 03/26/04 WC OR AUTO PAYMENT 10.09- 03/26104 ACT 6 AUTO ALLOWANCE 41.91- 0.00 4233154 PERFORMED BYs REHABILITATION CENTER DIV PLACE OF SVC: OP PHYSICIAN 04/26/04 99214 957.9 OUTPATIENT VISIT EST 105.00 07/22/04 B41563571 AUTO MAX 105.00 4268667 PERFORMED BY: DIVISION OF NEUROSURGERY PLACE OF SVC: SATELLITE CLINIC * 03/11/04 99024 80512 POST-OP FOL-UP VISIT 0.00 0.00 4450357 PERFORMED BY: DIVISION OF NEUROSURGERY PLACE OF SVC: SATELLITE CLINIC * 06/10/04 99212 805.2 OUTPATIENT VISIT EST 53.00 * 07/15/04 GATEWAY PAYMENT 25.00- * 07/15104 GATEWAY CONT ALLOW 28.00- 0.00 H IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 281857035 DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR CODE CODE ADJUSTMENT BALANCE PERFORMED BY: DIV OF DIAG RADIOLOGY * 06/10/04 72100 724,2 SPINE LUMBOS ANT/POST LAT 197.00 * G6/29/04 GATEWAY PAYMENT 46.88- 06/29/04 GATEWAY CONT ALLOW 150.12- 0100 BALANCES JAMES A SALISBURY 444404.00 * INDICATES NEW FINANCIAL ACTIVITY SINCE LAST BILL. IF YOU HAVE ANY QUESTIONS ABOUT THE AMOUNT YOUR INSURANCE COMPANY PAID, CONTACT THEM DIRECTLY, FOR ANY OTHER QUESTIONS REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE, IF PAYMENT HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL. PBG6 THANK YOU FOR USING MSHMC PHYSICIANS GROUP FOR YOUR PHYSICIAN SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE CONTACT US AT 717-531-5069 OR 800-254-2619, BETWEEN Bs00AM AND 5:30PM MONDAY THROUGH WEDNESDAY OR BETWEEN B:OOAM AND 4:30PM THURSDAY AND FRIDAY, BALANCE SUMMARY RESPONSIBLE PARTY POLICY # TOTAL *** GUARANTOR RESPONSIBILITY 4 44404.00 ------------------------------ i/MPORTANT_PLEA3E DETACH AND RETURN BOTTOM PORT/ON OF STATEMENT WITH YOUN PAYMENT_?_______________,_____,________ BF6 MSHMC PHYSICIANS GROUP BILLING SERVICES P O BOX 654 HERSHEY PA 17033.0054 Malt MSHMC PHYSICIANS GROUP To. STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT 08106104 $ 44404.00 $ 44404.00 00001266320 UP 0000000004440400080604 L„111,,, L.1, h h d..,11 {, I„I I„h,, I I I h, ,,,11 d,„p„h I PO BOX 643313 PITTSBURGH PA 15264-3313 JAMES A SALISBURY 737 BLOSERVILLE NEWVILLE PA 17241-9710 OFFICE USE ONLY CHECK ONE FOR CREOIT CARD PAYMENT, PLEASE FILL IN INFORMATION BELOW M7C I ARDINUMBER I I I I I I I I I I EXP DATE VISA HC: F6B0 CARDHOLDER NAME (PRINT) TYP: DMND CREDIT CARD SIGNATURE MSHMC AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK PENNSTATE JAMES A SALISBURY 5 at 5 737 BLOSERVILLE 19 The Milton S. Hershey Medical Center NEWVILLE PA 17241-9710 STATEMENT The College of Medicine DATE 08106104 LAST STATEMENT ACCOUNT # 1266320 DATE: 08105104 03/09/2005 09153 TABRS & ROSEN, P.C. 4 17175310223 SALISBURY, JAMES #1266320 $4,805.51 (Hose) 44,404.00 (Phys) VERIFICATION LISA BROWN hereby states that she is the Team Manager, Customer Service of the Milton S. Hershey Medical center and verifies that the statements made in the foregoing pleading are true and correct to the best of her N0.885 Pe4 knowledge, information and belief. The undersigned understands that the statements therein are made subject to the penalties of IS Pa. C.S. §4904 relating to unworn falsification to authorities. LISA BROWN I DATE : y k`J 1 J ? N /?J ? \ co CJ1 f ?h V •` ?/ G? ^? t pw ? ^ J ?, p ? ? ? LJ ?'j ? ????, Lj? ? (^J T1 -i T_? ?.? 1'? `?? )? ,; "'> i SHERIFF'S RETURN - REGULAR CASE NO: 2005-02357 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND MILTON S HERSHEY MEDICAL CENTE VS SALISBURY JAMES RICHARD SMITH Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon SALISBURY JAMES the DEFENDANT , at 2008:00 HOURS, on the 10th day of May , 2005 at UPPER FRANKFORD FIRE CO 4080 ENOLA ROAD NEWVILLE, PA 17241 by handing to JAMES SALISBURY a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs Docketing 18.00 Service 7.40 Affidavit .00 Surcharge 10.00 .00 35.40 Sworn and Subscribed to before me this /-3 day of 0200,5 A. D. ?Irothonotary So Answers: R. Thomas Kline 05/11/2005 TABAS & ROSEN By: Deputy Sheriff SALZMANN HUGHES, P.C. BY: E. Ralph Godfrey, Esquire Attorney for Defendant Attorney I.D. No. 77052 95 Alexander Spring Road Carlisle, PA 17013 (717) 249-6333 - THE MILTON S. HERSHEY MEDICAL CENTER Plaintiff V. JAMES SALISBURY Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-2357 JURY TRIAL DEMANDED NOTICE TO PLEAD TO: The Milton S. Hershey Medical Center c/o Lewis C. Trauffer, Esquire Tabas & Rosen, P.C. 1845 Walnut Street 22nd Floor Philadelphia, PA 19103 You are hereby notified to plead to the enclosed New Matter within twenty (20) days from service hereof or a default judgment may be entered against you. Dated: S tG? SALZMANN t1L;GHE,9,P.C. By E"lZalphj3odfrey, squire Attorney I.D. No. 2 95 Alexander Spring Road Carlisle, PA 17013 (717) 249-6333 Attorneys for Defendant THE MILTON S. HERSHEY MEDICAL CENTER Plaintiff V. JAMES SALISBURY Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-2357 JURY TRIAL DEMANDED DEFENDANT'S ANSWER AND NEW MATTER TO PLAINTIFF'S COMPLAINT Defendant, James Salisbury, by and through his attorneys, Salzmann Hughes, P.C., answers the corresponding numbered paragraphs of Plaintiff's Complaint as follows: Denied. After reasonable investigation, Defendant is without sufficient knowledge to either admit or deny the allegations contained in paragraph 1. Strict proof thereof is demanded at the time of trial. 2. Admitted. Admitted. 4. Admitted in part; denied in part. It is admitted that Defendant had medical care at the Plaintiffs facility. It is denied that the amounts contained in Exhibit "A" are the actual charges or the reasonable and customary fee for the services. Strict proof is demanded at the time of trial Denied as stated. It is admitted that Defendant required medical care. The remaining allegations are denied. Strict proof is demanded at the time of trial. 6. Denied. Paragraph 6 is denied as a conclusion of law. To the extent that an answer may be required, it is denied that any expressed and/or implied obligation or contract -2- arose between the Plaintiff and Defendant requiring him to pay the amount indicated in Exhibit "A" attached to Plaintiff s Complaint. Strict proof is demanded at the time of trial. Denied as stated. Plaintiff has over inflated its fees requiring an uninsured person to pay more than a person covered by insurance. WHEREFORE, Defendant, James Salisbury, avers that he is not liable to Plaintiff in any amount whatsoever and prays that the Complaint against him be dismissed and that he be awarded costs of defense, including attorney fees, and that he may have such other and further relief as may be just and appropriate. NEW MATTER By way of further answer and defense, Defendant avers the following New Matter in accordance with Pennsylvania Rule of Civil Procedure 1030: Paragraphs 1 through 7 of Defendant's Answer are incorporated herein by reference as if set forth more fully at length. 9 Plaintiff s cause of action is barred by the applicable statute of limitations. 10. Plaintiff has failed to state a cause of action upon which relief can be granted. 11 Plaintiff's claim is barred or limited by the doctrine of resjudicata and/or collateral estoppel. 12 Plaintiff's claim is barred or limited by the doctrine of accord and satisfaction. 13. Plaintiff s counsel has failed to verify the accuracy of the debt prior to filing this action and is in violation the Fair Debt Collection Practices Act. 14 Plaintiff has violated its tax emption status because of its aggressive debt collection techniques. - 3 - 15. The charges set forth in Plaintiff's complaint are inflated over the actual cost incurred by it and are not the ordinary and reasonable value for such services. 16. Plaintiff's pricing is discriminatory and/or variable in that it is charging more than it would charge a third-party payor such as an HMO, private insurer or Medicare. 17. Plaintiff has failed to bill Defendant in good faith and fair dealings by only requesting reasonable charges. 18. Plaintiff has violated the Pennsylvania Motor Vehicle Financial Responsibility Law by billing Defendant in amounts that exceed the limitations set forth in this statute. WHEREFORE, Defendant avers that he is not liable to Plaintiff in any amount whatsoever and prays that the Complaint against him be dismissed and that he be awarded costs of defense, including attorney fees, and that he may have such other and further relief as may be just and appropriate. Dated: i • t5% 0 SALZMANN HUGHES, P.C. By Ralph Godfrey, Esqui Attorney I.D. No. 77 2 95 Alexander Sprin Carlisle, PA 17013 (717) 249-6333 Attorneys for Defendant -4- Ste 3 VERIFICATION I, SoL ?1SOJ M hereby certify that the facts set forth in the foregoing Defendant's Answer and New Matter to Plaintiff's Complaint are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Defendant's Answer and New Matter to Plaintiff's Complaint is that of counsel and not my own. I have read the Defendant's Answer and New Matter to Plaintiff's Complaint, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Defendant's Answer and New Matter to Plaintiffs Complaint is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Defendant's Answer and New Matter to Plaintiffs Complaint are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unworn falsification to authorities. Date: fi-^o?5`cJ^ Document 9. 160979.1 CERTIFICATE OF SERVICE AND NOW, this A day of , 2005, I, E. Ralph Godfrey, Esquire, of Salzmann Hughes, P.C., attorneys for Defendant, hereby certify that I served a copy of the within Defendant's Answer and New Matter to Plaintiff's Complaint this day by depositing the same in the United States mail, postage prepaid, at Carlisle, Pennsylvania, addressed to: Lewis C. Trauffer, Esquire Tabas & Rosen, P.C. 1845 Walnut Street 22"d Floor Philadelphia, PA 19103 E. Ralph Godfrey ? r> C i r_s C) ? ` ? -ii ? c ._.a t ;: _? ., r.a °:_i `-i C TABAS & ROSEN, P.C. BY: LEWIS C. TRAUFFER Attorney I.D. 60267 1845 Walnut Street, 22nd Floor Philadelphia, PA 19103 (215) 569-5050 THE MILTON S. HERSHEY MEDICAL CENTER V. JAMES SALISBURY Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, 'ENNSYLVANIA NO. 05-02357 CIVIL ACTION PLAINTIFF'S REPLY TO NEW MATTER 8 - 18. The averments contained in paragraph 8 through 18 are conclusions of law requiring no response. To the extent a response is required, the same are denied and proof demanded thereof at trial. WHEREFORE, for all the foregoing reasons, plaintiff requests judgment be entered in its favor and against defendant James Salisbury in the amount of $49,209.51 plus 6% interest per annum from the date of discharge to judgment, plus its costs. TABAS & ROSEN, P.C. LEWIS C. TRAUFFER, ESQUIRE ATTORNEY FOR PLAINTIFF CERTIFICATE OF SERVICE I, Lewis C. Trauffer, Esquire, certify that on June 13, 2005 a true and correct copy of plaintiffs Reply to New Matter was served on the following individual(s) via United States mail, first class, postage pre-paid, and addressed as follows: E. Ralph Godfrey, Esquire Salzman & Hughes, P.C. 95 Alexander Spring Road Carlisle, PA 17013 LEWIS C. TRAUFFER Attorney for Plaintiff c? ? o ? i _Ji37 IT, -" Cs N ?3 N ;U rw SALZMANN HUGHES, P.C. BY: E. Ralph Godfrey, Esquire Attorney I.D. No. 77052 95 Alexander Spring Road Carlisle, PA 17013 THE MILTON S. HERSHEY MEDICAL CENTER Plaintiff V. JAMES SALISBURY Defendant Attorney for Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-2357 JURY TRIAL DEMANDED DEFENDANT'S MOTION TO COMPEL PLAINTIFF'S ANSWERS TO INTERROGATORIES AND REQUEST FOR PRODUCTION OF AND NOW, comes the Defendant, James Salisbury, by and through his counsel, Salzmann Hughes, P.C., and files this Motion to Compel as follows: On or about June 20, 2005, Defendant served Interrogatories and a Request for Production of Documents on Plaintiff. A copy of Defendant's Interrogatories and Request for Production of Documents is attached hereto and incorporated herein as Exhibits "A" and "B". Plaintiff has failed to provide its answers to the Interrogatories and documents to the Request for Production of Documents in a timely manner. 3. Defendant's discovery requests are relevant to the within action. 4. Defendant's discovery requests are within the scope of discovery and pursuant to the Pennsylvania Rule of Civil Procedure 4003. 1, et seq., in that they seek discovery regarding matters which are not privileged and are relevant to the subject matter involved in the pending action and relate to the claims of the parties. A review of Defendant's discovery requests reveals that they do not exceed the scope of permissible discovery under the Pennsylvania Rules of Civil Procedure. 6. In accordance with Pennsylvania Rule of Civil Procedure 4006, Defendant moves to compel Plaintiff to adequately and fully provide responses to his Interrogatories and Request for Production of Documents. WHEREFORE, it is respectfully requested that this Honorable Court enter an Order compelling Plaintiff's to provide full and adequate responses to Defendant's discovery requests. Respectfully submitted, By GE. Ralph Godfrey, quire Attorney I.D. No. 770 - 95 Alexander Spring Road, Ste 3 Carlisle, PA 17013 (717) 249-6333 ?j Dated: Attorneys for Defendant -2- SALZiMANN HUGHES, P.C. BY: E. Ralph Godfrey, Esquire Attorney for Defendant Attorney I.D. No. 77052 95 Alexander Spring Road Carlisle, PA 17013 (717) 249-6333 THE MILTON S. HERSHEY MEDICAL CENTER Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA V. JAMES SALISBURY Defendant CIVIL ACTION - LAW NO. 05-2357 JURY TRIAL DEMANDED DEFENDANT'S INTERROGATORIES DIRECTED TO PLAINTIFF - FIRST SET TO: The Milton S. Hershey Medical Center PURSUANT TO THE PROVISIONS of Pennsylvania Rules of Civil Procedure 4005 and 4006, as amended, you are required to file the original, and serve a copy on the undersigned, of your answers and objections, if any, in writing and under oath, to the following Interrogatories within thirty (30) days after service of the Interrogatories. The answers shall be inserted in the spaces provided following each Interrogatory. If there is insufficient space to answer an Interrogatory, the remainder of the answer shall follow on a supplemental sheet. These Interrogatories shall be deemed to be continuing in nature pursuant to Pennsylvania Rules of Civil Procedure 4005 and 4006. If between the time of filing your original answers to these Interrogatories and the time of trial of this matter, you or anyone acting in your behalf learns the identity and location of additional persons having knowledge of discoverable facts and the identity of persons expected to be called as an expert witness at trial not disclosed in your answers, or if you or an expert witness obtains information upon the basis of which you or he knows that an answer was incorrect when made, or know that an answer though correct when made is no longer true, promptly supplement your original answers under oath to include such information thereafter acquired, and promptly furnish such a supplemental answer on the undersigned. Respectfully submitted, SALZMANN HUGHES, P.C. Gam, %?" By E. Ralph Godfrey Ire Attorney I.D. No. 77052 95 Alexander Spring Road Suite 3 Carlisle, PA 17013 (717) 249-6333 Attorneys for Defednant Dated: 6 z°-6J -2- DEFINITIONS Definitions. -- The following definitions are applicable to these interrogatories: A. The words "you" or "your" when used herein refer to all ** (s), their officers, representatives, attorneys, agents, servants and/or employees or any person working for such person. B. "Identity" when used herein with respect to an individual means to state: (I) the person's full name and present or last known address; and (2) the persons position, employer and employer's address at the time of the events referred to in the Interrogatory. C. "Identity" when used herein with respect to an entity other than an individual (e.g., a corporation, partnership, unincorporated association, governmental agency, etc.), or a division or subdivision thereof, means to state the full name and present or last known address of the entity, and, if applicable, the full name and present or last known address of the entity's division or subdivision. D. "Identity" when used with references to a document or writing, the word "identify" shall mean to include the date it was written; identify each person to how it was addressed and identify each person to whom a copy was identified as being directed, identify each person who received a copy of the document or writing with a description of the document or writing as for instance, "letter", "memorandum"; include the present location and identify its custodian. If any document or writing is no longer in your possession or subject to your control, state what disposition was made of it, the reason for such disposition, the date thereof, and identify its current or last known location and custodian. Whenever you are asked to "identify" an oral communication, the following information should be given as to each oral communication or which you are aware, whether or not you or others were present or participated therein. This information includes the means of communication (e.g. telephone, personal conversation, etc.); where it took place; its date; the names, addresses, employers and positions of all persons who participated in, or who were involved in the communication, all other persons who were present during or who overheard that communication, the substance of who said what to whom and the order in which it was said, and whether that communication, or any part thereof, was recorded or referred to in any document. E. "Document" when used herein means any record, including any object containing written, printed, or magnetically recorded information, a graphic or photographic representation, or sound. "Document" includes the original or any copy of any statement, report, letter, memorandum, book, article, note, blueprint, drawing, sketch, photograph, motion picture, videotape, sound recording. "Document" also includes any card, disc, tape, printout or any other article designed for use with a computer or other word or data processing system. F. "Identify" when used herein with respect to a document means to state: (l) the nature of the document (i.e., whether it is a statement, report, etc.); (2) the title of the document, or, if the document has no title, a description of the document; (3) the identity of the person or persons - 3 - who prepared the document; (4) the identity of the person or persons for whom the document was prepared or to whom the document was directed; (5) the date the document was prepared; and, (6) the identity of the present custodian of the document or any copy of the document. G. When the word "incident" is used in these Interrogatories it is to refer to those occurrences alleged in Plaintiff" Complaint. H. CONCERN, CONCERNED, OR CONCERNING - means referring or relating to, pertaining to, commenting on, or connected with, in any manner whatsoever. 1. As used herein, the term "STATEMENT" means a written statement signed or otherwise adopted or approved by the person making it, or a stenographic, mechanical, electrical or other recording, or a transcription thereof, which is substantially verbatim recital of an oral statement by the person making it and contemporaneously recorded. J. If you claim that the subject matter of a document or oral communication is privileged, you need not set forth the brief statement of the subject matter of the document, or the substance of any oral communication called for above. You shall, however, otherwise "identify" such document or oral communication and shall state each ground on which you claim that such document or oral communication is privileged. INTERROGATORIES I. Factual basis for all claims. -- State with particularity the factual basis for each claim you are asserting in this case. ANSWER: 4- 2. Witnesses. (a) Identify each person who (1) Was a witness to the incident through sight or hearing and/or (2) Has knowledge of facts concerning the happening of the incident or conditions or circumstances at the scene of the incident prior to, at the time of, or after the incident. (b) With respect to each person so identified, state that person's exact location and activity at the time of the incident. ANSWER: 3. Statements. -- If you know of anyone that has given any statement (as defined by the Rules of Civil Procedure) concerning this action or its subject matter, state: (a) The identity of such person; (b) When, where, by whom, and to whom each statement was made, and whether it was reduced to writing or otherwise recorded; and (e) The identity of any person who has custody of any such statement that was reduced to writing or otherwise recorded. ANSWER: -5- 4. Reports of incident. -- Identify documents (except reports of experts subject to Pa. R.C.P. No. 4003.5) which describe the incident or the cause thereof. ANSWER: 5. Demonstrative evidence. -- If you know of the existence of any photographs, motion pictures, video recordings, maps, diagrams, or models relevant to the incident, state: (a) The nature or type of such item; (b) The date when such item was made; (e) The identity of the person that prepared or made each item; and (d) The subject that each item represents or portrays. ANSWER: 6. Trial preparation material. -- If you, or someone not an expert subject to Pa. R.C.P. No. 4003.5, conducted any investigations of the incident, identify: (a) Each person, and the employer of each person, who conducted any investigation(s); and (b) All notes, reports or other documents prepared during or as a result Of the investigation(s) and the persons who have custody thereof. ANSWER: -6- 7. Trial witnesses. -- Identify each person you intend to call as a non-expert witness at the trial of this case, and for each person identified state your relationship with the witness and the substance of the facts to which the witness is expected to testify. ANSWER: 8. Expert witnesses. -- Identify each expert you intend to call as a witness at the trial of this matter, and for each expert state: (a) The subject matter about which the expert is expected to testify; and (b) The substance of the facts and opinions to which the expert is expected to testify and a summary of the grounds for each opinion. (You may file as your answer to this interrogatory the report of the expert or have the interrogatory answered by your expert.) ANSWER: -7- 9. Trial exhibits. (D.C.S.I. 114) -- Identify all exhibits that you intend to use at the trial of this matter and state whether they will be used during the liability or damages portions of the trial. ANSWER: 10. Books, magazines, etc. (D.C.S.I. 115) -- If you intend to use any book, magazine, or other such writing at trial, state: (a) The name of the writing; (b) The author of the writing; (c) The publisher of the writing; (d) The date of publication of the writing; and (e) The identity of the custodian of the writing. ANSWER: - 8 - 11. Admissions. (D.C.S.I. 116) -- If you intend to use any admission(s) of a party at trial, identify such admission(s). ANSWER: SALZMANN HUGHES, P.C. By E. Ralph Godfrey, Esquire Attorney I.D. No. 77052 95 Alexander Spring Road Suite 3 Carlisle, PA 17013 (717) 249-6333 Attorneys for Defendant Dated: ? 2 0 -6 S 9- SALZMANN HUGHES, P.C. BY: E. Ralph Godfrey, Esquire Attorney for Defendant Attorney I.D. No. 77052 95 Alexander Spring Road Carlisle, PA 17013 (717) 249-6333 THE MILTON S. HERSHEY MEDICAL CENTER Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY. PENNSYLVANIA V. JAMES SALISBURY Defendant CIVIL ACTION - LAW NO. 05-2357 JURY TRIAL DEMANDED DEFENDANT'S INTERROGATORIES DIRECTED TO PLAINTIFF - SECOND SET TO: The Milton S. Hershey Medical Center PURSUANT TO THE PROVISIONS of Pennsylvania Rules of Civil Procedure 4005 and 4006, as amended, you are required to file the original, and serve a copy on the undersigned, of your answers and objections, if any, in writing and under oath, to the following Interrogatories within thirty (30) days after service of the Interrogatories. The answers shall be inserted in the spaces provided following each Interrogatory. If there is insufficient space to answer an Interrogatory, the remainder of the answer shall follow on a supplemental sheet. These Interrogatories shall be deemed to be continuing in nature pursuant to Pennsylvania Rules of Civil Procedure 4005 and 4006. If between the time of filing your original answers to these Interrogatories and the time of trial of this matter, you or anyone acting in your behalf learns the identity and location of additional persons having knowledge of EXHIBIT a {? a discoverable facts and the identity of persons expected to be called as an expert witness at trial not disclosed in your answers, or if you or an expert witness obtains information upon the basis of which you or he knows that an answer was incorrect when made, or know that an answer though correct when made is no longer true, promptly supplement your original answers under oath to include such information thereafter acquired, and promptly furnish such a supplemental answer on the undersigned. Respectfully submitted, SALZMANN HUGHES, P.C. By alph Godfrey, quire Attorney I.D. No. 77052 95 Alexander Spring Road Suite 3 Carlisle, PA 17013 (717) 249-6333 Attorneys for Defendant Dated: -2- A. The words "you" or "your" when used herein refer to Plaintiff, The Milton S. Hershey Medical Center, its representatives, attorneys, or agents. B. "Identity" when used herein with respect to an individual means to state: (1) the person's full name and present or last known address; and (2) the person's position, employer and employer's address at the time of the events referred to in the Interrogatory. C. "Identity" when used herein with respect to an entity other than an individual (e.g., a corporation, partnership, unincorporated association, governmental agency, etc.), or a division or subdivision thereof, means to state the full name and present or last known address of the entity, and, if applicable, the full name and present or last known address of the entity's division or subdivision. D. "Identity" when used with references to a document or writing, the word "identify" shall mean to include the date it was written; identify each person to how it was addressed and identify each person to whom a copy was identified as being directed, identity each person who received a copy of the document or writing with a description of the document or writing as for instance, "letter", "memorandum"; include the present location and identify its custodian. If any document or writing is no longer in your possession or subject to your control, state what disposition was made of it, the reason for such disposition, the date thereof, and identify its current or last known location and custodian. Whenever you are asked to "identify" an oral communication, the following information should be given as to each oral communication or which you are aware, whether or not you or others were present or participated therein. This information includes the means of communication (e.g. telephone, personal conversation, etc.); where it took place; its date; the names, addresses, employers and positions of all persons who participated in, or who were involved in the communication, all other persons who were present during or who overheard that communication, the substance of who said what to whom and the order in which it was said, and whether that communication, or any part thereof, was recorded or referred to in any document. E. "Document" when used herein means any record, including any object containing written, printed, or magnetically recorded information, a graphic or photographic representation, or sound. "Document" includes the original or any copy of any statement, report, letter, memorandum, book, article, note, blueprint, drawing, sketch, photograph, motion picture, videotape, sound recording. "Document" also includes any card, disc, tape, print-out or any other article designed for use with a computer or other word or data processing system. F. "Identify" when used herein with respect to a document means to state: (1) the nature of the document (i.e., whether it is a statement, report, etc.); (2) the title of the document, or, if the document has no title, a description of the document; (3) the identity of the person or persons who prepared the document; (4) the identity of the person or persons for whom the document was prepared or to whom the document was directed; (5) the date the document was prepared; and, (6) the identity of the present custodian of the document or any copy of the document. -3- G. When the word "incident" is used in these Interrogatories it is to refer to those occurrences alleged in Plaintiffs Complaint. H. CONCERN, CONCERNED, OR CONCERNING - means referring or relating to, pertaining to, commenting on, or connected with, in an manner whatsoever. 1. As used herein, the term "STATEMENT" means a written statement signed or otherwise adopted or approved by the person making it, or a stenographic, mechanical, electrical or other recording, or a transcription thereof, which is substantially verbatim recital of an oral statement by the person making it and contemporaneously recorded. J. If you claim that the subject matter of a document or oral communication is privileged, you need not set forth the brief statement of the subject matter of the document, or the substance of any oral communication called for above. You shall, however, otherwise "identify" such document or oral communication and shall state each ground on which you claim that such document or oral communication is privileged. INTERROGATORIES 1. State in detail all facts that support your contention that your medical bills are not subject to the cap provided by the Pennsylvania Motor Vehicle Financial Responsibility Law, and provide the name and address of each witness who will testify in support thereof. ANSWER: 2. State in detail all facts that support your contention that there was an implied, constructive and/or an oral contract between Plaintiff and Defendant, and provide the name and address of each witness who will testify in support thereof. ANSWER: -4- 3. State in detail all facts that support your contention that Defendant refused to pay the balance as provided for by the Pennsylvania Motor Vehicle Financial Responsibility Law, and provide the name and address of each witness who will testify in support thereof. ANSWER: 4. State in detail all facts that support your contention that Plaintiff's counsel properly verified the accuracy of the debt prior to filing this action, and provide the name and address of each witness who will testify in support thereof. ANSWER: 5. State in detail all facts that support your contention that the medical bills attached as Exhibit "A" to Plaintiffs Complaint was the actual cost incurred and is the ordinary and reasonable value for such services, and provide the name and address of each witness who will testify in support thereof. ANSWER: 5- 6. State in detail all facts that support your contention that the medical bills are not discriminatory and/or variable in that it is charging more than it would charge a third-party payor such as an HMO, private insurer or Medicare, and provide the name and address of each witness who will testify in support thereof. ANSWER: Respectfully submitted, SALZMANN HUGHES, P.C. By E. Ralph Godfrey, E ire Attorney I.D. No. 77052 95 Alexander Spring Road Suite 3 Carlisle, PA 17013 (717) 238-8187 i Attorneys for Defendant Dated: Z'C' -d J -6- CERTIFICATE OF SERVICE I, E. Ralph Godfrey, Esquire, of the law firm of Salzmann Hughes, P.C., hereby certify that I served a true and correct copy of Defendant's Interrogatories Directed to Plaintiff - Second Set with reference to the foregoing action by first class mail, postage prepaid, this day of 2005, on the following: Lewis C. Trauffer, Esquire Tabas & Rosen, P.C. 1845 Walnut Street 22°d Floor Philadelphia, PA 19103 E. Ralph Godfrey SALZMANN HUGHES, P.C. BY: E. Ralph Godfrey, Esquire Attorney for Defendant Attorney I.D. No. 77052 95 Alexander Spring Road Carlisle, PA 17013 (717) 249.6333 THE MILTON S. HERSHEY MEDICAL CENTER IN THE COURT OP COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. JAMES SALISBURY Defendant CIVIL ACTION- LAW NO. 05-2357 JURY TRIAL DEMANDED REQUEST FOR PRODUCTION OF DOCUMENTS AND THINGS OF DEFENDANT ADDRESSED TO PLAINTIFF With respect to the matters referred to in Plaintiff's Complaint, please note that you are directed to produce for purposes of inspection and/or copying, the following items, all of which relate to the matter referred to in Plaintiff's Complaint. These items must be produced no later than thirty days from the date of the filing of this request. Same may be provided by forwarding copies to the office of the undersigned, 95 Alexander Spring Road, Suite 3, Carlisle, PA 17013. These requests are not directed merely to the person or party whose name appears above, but are meant to include that person's or party's agents, servants, insurers, employers, employees, investigators, attorneys, and others similarly situated to the named party or person. In addition, although the request seeks these documents within the next thirty days, the request should also be deemed continuing, in that if there are further materials which come under the purview of any of these requests which are obtained after the time of their production presently, said materials should also be furnished in accord with this request. EXHIBIT Please produce the following: 1. All written statements (signed or unsigned), descriptions, statements, records, and written accounts of the alleged debt and the collection thereof related to the matter set forth in Plaintiff's Complaint. 2. All bills, reports, and records from any and all hospitals, physicians, or other providers of medical and health care, relating directly or indirectly to the alleged debt and the collection thereof as described by Plaintiff's in the Complaint. 3. All other writings, memoranda, data, and/or tangible things which relate directly or indirectly to the alleged debt of Defendant and the collection thereof as set forth in Plaintiff's Complaint. 4. All documents relating to the Plaintiff's activities to collect debts such as Defendants. 5. An organizational chart of the Plaintiff. 6. All documents between Plaintiff, Plaintiff's attorney, Plaintiff's collection agencies and Defendant and the collection of this alleged debt. 7. A list of all employees of Plaintiff engaged in the collection of debts such as the debt Defendant allegedly owes, their positions and responsibilities. 8. All financial reports and statements concerning the collection of debt from patients for the past three years. 9. All documents relating to the Plaintiffs procedures to provide verification of the alleged debt. -2- 10. The Plaintiffs Federal and State non-profit exemption documentation showing that it is a non-profit corporation. 11. Any and all reports compiled by an individual who has been retained as an expert in this matter as well as all documents and reports utilized by said expert. 12. Any and all memoranda, notes, summaries, items of correspondence, records, documents, or other form of data retention, not included in the foregoing requests made by you or obtained by you or your representative or any witness, contained in your files or other collections of records which pertain to the incident and damages alleged in Plaintiff s Complaint. 13. Any and all reports of governmental or quasi-governmental agencies, which investigated and determine the appropriate charges for bills sent to uninsured people. 14. All contracts and rate charts for the past five years with third party insurance carriers that provide for capitation or limitation of rates for medical charges accessed against insureds including but not limited to HMOs, PPOs, Medicare, etc. 15. All exhibits which Plaintiff proposes to introduce at trial. 16. Any and all reports, documentation, memorandums showing how Plaintiff determined the amount of charges accessed against Defendant and how they determined that the price was the ordinary and reasonable value for such services. 17. Any and all reports, documentation, memorandums showing that Plaintiffs pricing is not discriminatory and/or variable in that it is charging more than it would charge a third-party payor such as an HMO, private insurer or Medicare. -3- 18. Any and all reports, documentation, memorandums showing that Plaintiff has violated the Pennsylvania Motor Vehicle Financial Responsibility Law by billing Defendant in amounts that exceed the limitations set forth in this statute. SALZMANN HUGHES, P.C. By E. IEfph 6drey, Esquire Attorney I.D. No. 7705 95 Alexander Spring Roast Suite 3 Carlisle, PA 17013 (717) 249-6333 Attorneys for Defendant Dated: 6 -Z0-o3' -4- CERTIFICATE OF SERVICE -kA- AND NOW, this 76 day of June, 2005, I, E. Ralph Godfrey, Esquire, of Salzmann Hughes, P.C., attorneys for Defendant, hereby certify that I served a copy of the within Request for Production of Documents and Things of Defendant Addressed to Plaintiff this day by depositing the same in the United States mail, postage prepaid, at Harrisburg, Pennsylvania, addressed to: Lewis C. Trauffer, Esquire Tabas & Rosen, P.C. 1845 Walnut Street 22"d Floor Philadelphia, PA 19103 E. Ralph Godfrey X" / L---- AND NOW, this '20day of o o , 2006, I, E. Ralph Godfrey, of Salzmann Hughes, P.C., counsel for the Defendant, hereby certify that I served a copy of the within otion to Compel this day by depositing the same in the United States mail, postage prepaid, at Carlisle, Pennsylvania, addressed to: E. Ralph Godfrey, squire s? ,i y n % ?; ;uLm THE MILTON S. HERSHEY MEDICAL CENTER Plaintiff V. JAMES SALISBURY Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-2357 JURY TRIAL DEMANDED AND NOW, this I S ? day of f?- _? , 2006, upon consideration of Defendant's Motion to Compel Plaintiff's Answers to Interrogatories and Request for Production of Document, Plaintiff is hereby ordered to show cause within 2-0 days of service of this Rule why the relief requested in the attached Motion should not be granted. BY THE COURT: o t.?. ? `;'r1J Z. 4 Cl',!3 Z- 3j 95oz THE MILTON S. HERSHEY MEDICAL CENTER PENNSYLVANIA Plaintiff V. JAMES SALISBURY Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, CIVIL ACTION - LAW NO. 05-2357 CERTIFICATE OF SERVICE AND NOW, this 62 day of February, 2006, I, E. Ralph Godfrey, Esquire, of Salzmann Hughes, P.C., attorney for Defendant, hereby certifies that I served a copy of the Rule to Show Cause dated February 1, 2006 this day by depositing the same in the United States mail, postage prepaid, at Carlisle, Pennsylvania, addressed to: Lewis C. Trauffer, Esquire Tabas & Rosen, P.C. 84 Walnut Street, 22°d Floor Phildaelphia, PA 19103 L ? ? C" ? ?^` :?_°? ,• ? l7 ? -rt ?. T--r: ,_. ? fir} ..:.. ttia, s:. y G"` = - = . i . ^} (`j -,Yt .. ?? r :< G . THE MILTON S. HERSHEY MEDICAL CENTER Plaintiff V. JAMES SALISBURY Defendant IN THE COURT OF COMMON p?NNSYLV ?? CUMBERLAND COUNTY, CIVIL ACTION - LAW NO. 05-2357 JURY TRIAL DEMANDED AND NOW, comes petitioner, Salzmann Hughes, P.C. and E. Ralph Godfrey, Esquire, d hereb respectfully petitions this Honorable Court pursuant to Pennsylvania Rule of Civil any Procedure 1012(b) for leave to withdraw as counsel for Defendant and, in support thereof, avers as follows: Petitioner was retained to represent Defendant. 2. At this time, discovery is still in its initial stages and there has been no notice from the Court regarding the listing of this matter for trial. 3. Due to recent events, communications have broken down between Defendant and Petitioner making Petitioner's representation unreasonably difficult, and because of Defendant's inability to further finance this litigation. 4. Petitioner, in accordance with their ethical obligations, have performed the required legal services on behalf of Defendant. 5. Pennsylvania Rule of Professional Conduct 1.16 provides, in pertinent part, that a lawyer may withdraw if the client has rendered the representation unreasonably difficult. 6. A withdrawal of counsel at this point will not delay the litigation. 7. There will be no prejudice to Defendant under the circumstances since he will have adequate time to retain new counsel to represent him. WHEREFORE, Petitioner respectfully requests that this Court grant its Petition for Leave to Withdraw. By Respectfully submitted, E- Ralph Godfr*, Esquire Attorney I.D. No. 77052 354 Alexander Spring Road, Suite 1 Carlisle, PA 17015 (717) 249-6333 Dated: / " (e - 0 (,' VERIFICATION I, E. Ralph Godfrey, Esquire, hereby certify that the facts set forth in the foregoing Petition to Withdraw as Counsel are true and correct to the best of my knowledge, information and belief, that this Motion is not interposed for the purpose of delay, and that false statements herein are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. Date: - G CERTIFICATE OF SERVICE I, E. Ralph Godfrey, Esquire, hereby certify that I served a copy of the foregoing Order and Petition for Leave to Withdraw as Counsel upon all parties to this action, by mailing a copy thereof on this ?o day of Attgmt, 2006, to: Lewis C. Trauffer, Esquire Tabas & Rosen, P.C. 1845 Walnut Street 22nd Floor Philadelphia, PA 19103 James Salisbury 3 Woodland Drive Newville, PA 17241 SALZMANN HUGHES, P.C. By E. alph Godfrey, Esqui Attorney I.D. No. 77052 354 Alexander Spring Road, Suite 1 Carlisle, PA 17015 (717) 249-6333 r-, ?• ?: ? c' ?? ??- _ -? ?,., T - 1 ` ?j' 7 ?' :" ? .ti' ? y 1 ?T ? "` THE MILTON S. HERSHEY MEDICAL CENTER Plaintiff V. JAMES SALISBURY Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-2357 JURY TRIAL DEMANDED RULE AND NOW, this day of , 2006, upon consideration of the forego' Petition for Leave to Withdraw, a Rule to Show Cause is issued upon t to show cause why the Petition should not be granted. Rule returnable can the r An.i ^f t,-?( © d S S? VIeL BY THE COURT: 3 ?`? ?'.??? ,?•?? ,'?? ? 1 ' ;;? 4, ('} i? ,'?v ,-.. ., 113 ?.? i 1 ?"1 ?w 3 ?-'? ? _.1 v THE MILTON S. HERSHEY MEDICAL CENTER PENNSYLVANIA Plaintiff V. JAMES SALISBURY IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, CIVIL ACTION - LAW NO. 05-2357 Defendants CERTIFICATE OF SERVICE 1? AND NOW, this I/ day of September 18, 2006, I, E. Ralph Godfrey, Esquire, of Salzmann Hughes, P.C., attorney for Defendant, hereby certifies that I served a copy of the Rule to Show Cause dated September 8, 2006 this day by depositing the same in the United States mail, postage prepaid, at Carlisle, Pennsylvania, addressed to: Lewis C. Trauffer, Esquire Tabas & Rosen, P.C. 84 Walnut Street, 22nd Floor Philadelphia, PA 19103 James Salisbury 3 Woodland Drive Newville, PA 17241 E. Ralph odfrey L:6 Ti SALZMANN HUGHES, P.C. BY: E. Ralph Godfrey, Esquire Attorney for Defendants Attorney I.D. No. 77052 354 Alexander Spring Road, Suite 1 Carlisle, PA 17013 x»»49-633 THE MILTON S. HERSHEY MEDICAL IN THE COURT OF COMMON PLEAS CENTER CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. CIVIL ACTION - LAW JAMES SALISBURY NO. 05-2357 Defendant JURY TRIAL DEMANDED AND NOW, TO WIT, this 12th day of October, 2006, come E. Ralph Godfrey, Esquire and the law firm of Salzmann Hughes, P.C. and file the within Motion stating in support thereof as follows: 1. On or about September 6, 2006, Movant filed a Motion to Withdraw as Counsel. 2. Pursuant to the above Motion to Withdraw as Counsel, a Rule was issued by the Court on all parties to show cause why Movant should not be allowed to withdraw as counsel. A true and correct copy of the Rule is hereto attached as Exhibit "A". 3. On September 18, 2006, Movant caused a copy of the Rule to be served on Defendant, James Salisbury, by United States First Class Mail, and a copy of the Rule was also served on Lewis C. Trauffer, Esquire, counsel for Plaintiff by United States First Class Mail. A true and correct copy of the "Proof of Service" is hereto attached as Exhibit "B". 4. The Rule was returnable in twenty (10) from the date of service. 5. Neither Defendants nor Plaintiffs have filed a response to Movant's Motion to Withdraw as their counsel. WHEREFORE, Movant respectfully requests this Honorable Court to make a Rule issued absolute and enter an Order granting Movant's Motion to Withdraw as Counsel. Respectfully submitted, Salzma a-ijughes, P.C. By: Attorney I.D. #X052 354 Alexan r S oad Carlisle, Pennsylvania 17013 717.249.6333 Mzodf re v(i?salzmannhudes_com Date: &444 12, 9006 Exh+b?+ A THE MILTON S. HERSHEY MEDICAL CENTER Plaintiff V. JAMES SALISBURY Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-2357 JURY TRIAL DEMANDED RULE AND NOW - this 6TA day A 2006; upon consideration of jh fore of - ( - pj(-m?t' an ? an }? a Petition for Leave to Withdraw, a Rule to Show Cause is issued uPdh the ResPe s to show r cause why the Petition should not be granted. Rule retuinabl ?tj LIS (3 F S eev icem BY THE COURT: IQJ -tcA 10AL -io 0 J. Exhib?f 8 THE MILTON S. Hr-,RSHEY MEDICAL CENTER PENNSYLVANIA Plaintiff V. TAMES SALISBURY pq Z`H_E COURT OF X0'\41 ION PLEAS CUMBERLAND COUNT', CIVIL, ACTION - LAW : NO. 05-2357 n c? De.3endants -... .?, tF,?` , ` t FT"; CE1F;.fIFICAT E OF SER`VICE AND NOW, this --?- day of September 18, 2006, I, E. Ralph Godfrey, quire; 7-1 j of Salzmann Hughes, P. C., attoricy for De fe-nda:rrt, hereby certifies that I served a copy of the Rule to Show Cause dated September 8, 2006 this day by depositing the same in the United States mail, postage prepaid, at Carlisle, Pennsylvania, addressed to: Lewis C. Trauffer. Esquire Tabas & Rosen, P.C. 84 Walnut Street, 22nd Floor Philadelphia, PA 19103 James Salisbury 3 Woodland Drive Newville, PA 17241 E. Ralph adfrey f THE MILTON S. HERSHEY MEDICAL CENTER Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - LAW JAMES SALISBURY NO. 05-2357 Defendant JURY TRIAL DEMANDED I, E. Ralph Godfrey, Esquire, hereby certify that the facts set forth in the foregoing Motion to Make Rule to Show Cause Absolute are true and correct to the best of my knowledge, information and belief, and that false statements herein are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. Date: deter lg, g006 THE MILTON S. HERSHEY MEDICAL CENTER Plaintiff V. JAMES SALISBURY Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-2357 JURY TRIAL DEMANDED I, E. Ralph Godfrey, Esquire, hereby certify that on October 12, 2006 I served a copy of the foregoing Order and Motion to Make Rule to Show Cause Absolute upon all parties to this action, by United States First Class Mail, postage pre-paid, addressed to: Lewis C. Trauffer, Esquire Tabas & Rosen, P.C. 84 Walnut Street, 22nd Floor Philadelphia, Pennsylvania 19103 James Salisbury 3 Woodland Drive Newville, Pennsylvania 17241 na ?.., r -TI _71 -) CJ v OCT 1 3 1006 A THE MILTON S. HERSHEY MEDICAL CENTER Plaintiff V. JAMES SALISBURY Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-2357 JURY TRIAL DEMANDED ORDER AND NOW, TO WIT, this __[&Lday of Q tj • 2006, it is ORDERED, ADJUDGED, and DECREED that: 1. The Rule to Show Cause is made ahsolute; and 2. E. Ralph Godfrey, Esquire. and the law firm of Salzmann Hughes, P.C., are hereby permitted to withdraw as counsel for James Salisbury. BY THE COURT: t. Ii ? a SALZMANN HUGHES, P.C. BY: E. Ralph Godfrey, Esquire Attorney for Defendant Attorney I.D. No. 77052 354 Alexander Spring Road, Suite 1 Carlisle, PA 17013 (717) 249-6333 THE MILTON S. HERSHEY MEDICAL IN THE COURT OF COMMON PLEAS CENTER CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff v. CIVIL ACTION - LAW JAMES SALISBURY NO. 05-2357 Defendant JURY TRIAL DEMANDED PRAECIPE TO WITHDRAW APPEARANCE Kindly withdraw my appearance as counsel for Defendant in the above-referenced matter. Respectfully submitted, Dated' SALZMANN HUGHES, P.C. Attorney I.D. N . 77 354 Alexander pring Road, Suite 1 Carlisle, PA 17013 (717) 249-6333 Attorneys for Defendant .i t CERTIFICATE OF SERVICE I, E. Ralph Godfrey, Esquire, hereby certify that on October 19, 2006 I served a copy of the foregoing Praecipe to Withdraw upon all parties to this action, by United States First Class Mail, postage pre-paid, addressed to: Lewis C. Trauffer, Esquire Tabas & Rosen, P.C. 84 Walnut Street, 22'd Floor Philadelphia, Pennsylvania 19103 James Salisbury 3 Woodland Drive Newville, Pennsylvania 17241 ,Z-R4hf26 dfrey ire -n i ca - m m c a C'- ?U TABAS & ROSEN, P.C. BY: LEWIS C. TRAUFFER Attorney I.D. 60267 1601 Market Street, Suite 2300 Philadelphia, PA 19103 (215) 569-5050 THE MILTON S. HERSHEY MEDICAL CENTER V. JAMES SALISBURY Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 05-02357 CIVIL ACTION PRAECIPE TO SUBSTITUTE VERIFICATION Please substitute the attached Verification of Linda Schlader, representative of The Milton S. Hershey Medical Center, for that of Lewis C. Trauffer, Esquire, in Plaintiffs Answer to Defendant's First and Second Sets of Interrogatories and Requests for Production of Documents, which were served on defendant's counsel on February 20, 2006 in the above captioned matter. TABAS & ROSEN, P.C. BY: LEWIS C. TRA FFER, ESQUIRE Attorney for Plaintiff DATE: March 29, 2007 VERIFICATION I hereby verify that the statements made in the foregoing Answers to Defendant's First and Second Sets of Interrogatories and Requests for Production are true and correct to the best of my knowledge, information, and belief. This verification is made subject to the penalties of 18 Pa. Cons. Stat. § 4904 relating to unsworn falsification to authorities. C me Service Milton S. Hershey Medical Center in M. Schlader, Team Leader sto r CERTIFICATE OF SERVICE I, Lewis C. Trauffer, Esquire, certify that on June 13, 2005 a true and correct copy of plaintiff s Reply to New Matter was served on the following individual(s) via United States mail, first class, postage pre-paid, and addressed as follows: Mr. James Salisbury 737 Bloserville Newville, PA 17241 LEWIS C. T FFER Attorney for Plaintiff i; w LO TABAS & ROSEN, P.C. BY: LEWIS C. TRAUFFER, ESQUIRE I.D. No. 60267 1601 Market Street, Suite 2300 Philadelphia, PA 19103 (215) 569-5050 THE MILTON S. HERSHEY MEDICAL CENTER P.O. BOX 853 HERSHEY, PA 17033 VS. JAMES SALISBURY 737 BLOSERVILLE NEWVILLE, PA 17241 PRAECIPE TO THE PROTHONOTARY: : COURT OF COMMON PLEAS : CUMBERLAND COUNTY : NO.: 05-2357 Please mark the above matter settled, discontinued and ended upon payment of your costs only. E' IS C. T FFER, ESQUIRE Attorney for Plaintiff c'? ?, t:?; ?.? .: ?'?-? f"s t.,„ ?„? ? ^ w , 7-, ?, ? ^?.. ? :: _ .? ; ? `.. ? +^k Z, ? r +.? C p', Y