HomeMy WebLinkAbout01-23-06
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Claim Against Decedent's Estate
Estate Of: Dorothy Swain ~ S .~ \ ~
Case #717-240-6345
The undersigned hereby presents for filing against the above estate this statement of
claim and alleges:
Beverly Enterprises/West Shore Health & Rehab Center
P.O. Box 180970 Fort Smith, AR. 72918
The basis of claim is: See Attached
The amount of the claim is $4371.50
Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true to the best
of my knowledge and belief.
Signed on: January 19, 2006
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Claimant Sandra Burnett
I Swear this statement is correct
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TWYLA LENSING
Sebastian County
My Commission Expires
June 17, 2015
My Commission EXPires~15
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P.o. Box 180970
Fon Smith, AR 729] 8.0970
479.201.2000.877.82,.8375
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BEVERLY ENTERPRISES
POBOX 180970
FORT SMITH ARKANSAS 72918
Itemized Resident Statement
RESIDENT ACCOUNT#:
69343-00285-40055
Dorthy Swain 01/19/06
DATES OF SERVICE DESCRIPTION DAYS I QTY CHARGES CREDITS
01/03/05 Beautician 1 $12.00
01/12/05-01/31/05 Part A Coinsurance 20 $1,630.00
02/01/05 Part A Coinsurance 1 $81.50
04/18/05-04/21/05 Room CharQe 4 $300.00
04/01/05-04/30/05 Part A Coinsurance 26 $2,119.00
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05/18/05 Beautician 1 $40.00
OS/27/05 Beautician 1 $12.00
05/01/05-05/27/05 Part A Coinsurance 27 $489.00
02/18/05 Payment $12.00
05/13/05 Payment $300.00
An add itional $1141.00 will be due
I privately should insurance not pay.
CHARGES CREDITS TOTAL AMOUNT DUE ' ,
$4,683.50 $312.00 $4,371.50
Dorothy Swain
C\O William Yeingst
Old William Mill Road
Mechanicsburg, PA 17005
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January 19,2006
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, P A 17013
Whom It May Concern
Enclosed please find an itemized statement and a claim form to be used to file a claim
against the estate of Dorothy Swain. Mrs. Swain incurred these charges while a resident
in our facility, West Shore Health & Rehab Center. Enclosed please find a check for the
amount of $1 0.00 and a self addressed stamped envelope.
If you should need additional information or have questions regarding this please feel
free to contact me at 877-823-8375 ext 2270 Monday thru Friday from 8:00 to 5:00 PM
Central Time.
Sincerely,
Rita Donnelly
Healthcare Collection
Beverly Enterprises Inc
PO Box 180970
Ft. Smith, AR 72918
RDC
encl:
cc: Client's File
69343
P.O. Box I X0970
Fort Smith, AI{ 7291X-0970
479.201.2000. X77.xn.X.17S
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