HomeMy WebLinkAbout02-1347PINNACLE HEALTH SYSTEMS, INC.
Plaintiff
V.
MICHAELLA N. BOSTWICK
Defendant
CUMBERLAND
CIVIL ACTION - LAW
NO. - J3q7
IN THE COURT OF COMMON PLEAS
COUNTY PENNSYLVANIA
NOTICE
You have been sued in court. If you wish to defend
against the claims set forth in the following Dages, 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 ob3ect]ons
to the claims set forth against you. You are warned that if you
fail to do so, the case may proceed without you and 3udgment may
be entered against you by the court without further notice for any
money claimed in the Complaint 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 OR CANNOT AFFORD ONE, GO TO OR TELEPNONE
THE OFFICE SET FORTH BELOW TO FIND OUT WNERE YOU CAN GET LEGAL
HELP.
Lawyer Referral Service
Court Administrator
Cumberland County Courthouse
one Courthouse Square, 4th Floor
Carlisle, PA 17013
(717) 240-6200
Respectfully submitted:
Post Office Box 67015
Harrisburg, PA 17112
(717) 540-5610
SUPREME COURT NO, 07207
ATTORNEY FOR PLAINTIFF
Dated:
PINNACLE HEALLTH SYSTEMS, INC.
Plaintiff
V.
MICHAELLA N. BOSTWICK
Defendant
IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY PENNSYLVANIA
CIVIL ACTION - LAW
Le han demandado a usted en la corte. Si usted quiere
defenderse de estas demandas expuestas en ]as paginas siguientes,
usted tiene viente (20) dias de p]azo al partir presentar una
apariencia escrita o en persona o pot abogado y archivar en la
corte en forma escrita sus defensas o sus objeciones a ]as demandas
en contra de su persona. Sea avisado que si usted no se defiende,
la corte tomara medidas y puede entrar una orden contra usted sin
previo aviso o notificacion y pot cua]quier queja o a]ivio que es
pedido en la peticion de demanda. Usted puede perder dinero o sus
propiedades o otros derechos importantes para usted.
LLEVE ESTA DEMANDA A UN ABOGADO INMEDIATAMENTE. SI NO
TIENE ABOGADO O SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL
SERVIClO, VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA
DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SU PUEDE
CONSEGUIR ASISTENCIA LEGAL:
LAWYER REFERRAL SERVICE
Court Administrator
Cumberladn County Courthouse
One Courthouse Square, 4th Floor
Carlisle, PA 17013
(717) 240-6200
Respectfully submitted:
Post Office Box 67015
Harrisbur9, PA 17112
(717) 540-5610
SUPREME COURT NO. 07207
ATTORNEY FOR PLAINTIFF
Dated:
PINNACLE HEALTH
SYSTEMS, INC.,
Plaintiff
MICHAELLA N. BOSTWICK,
Defendant
*IN THE COURT OF COMMON PLEAS
*CUMBERLAND COUNTY, PENNSYLVANIA
COMP~NT
AND NOW comes P1~_intiff by and through its attorney Arthur A.
Kusic, Esquire and respectfully makes its Compl-int as follows:
1. Plaintiff, Pinnacle Health Systems, Inc. is a health care facility
organized and existing under the laws of the Commonwealth of
Pennsylvania with hospit~! facilities in both Dauphin and Cumberland
Counties and with a mailing address of P.O. Box 2353, Harrisburg,
Dauphin County, Pennsylvania 17105.
2. Defendant, Michaella N. Bostwick, is an adult individual
residing at 155 Salem Church Road, Lot 2, Mechanicsburg, Cumberland
County, Pennsylvania 17050.
3. From on or about June 12, 2000 and continuing from time to
time through to or about September 7, 2000, Plaintiff, at the Defendant's
request, provided health care services to the Defendant.
4. Plaintiff in good faith provided the health care services to the
Defendant and thereafter billed the Defendant its usual and custom~ry
charges for the services rendered. Copies of Plaintiffs billing statements
in the amount of $9,840.50 are attached hereto, made a part hereof and
marked Exhibit "A~.
5. Plaintiff did render the health care services to the Defendant
with the reasonable expectation that payment for such services would be
made by the party benefited.
6. Should Defendant not be required to pay for the services
rendered, Defendant would be unjustly enriched at P]9intiff's expense by
having received services without paying for the services rendered.
7. Plaintiff has credited Defendant's account with all monies
received on the account leaving a balance due and owing of $9,840.50.
8. Plnintiff has made demands upon the Defendant for the
balance due and owing of $9,840.50, which demands remain unheeded.
9. Plaintiff avers that the amount c]~imed due does not excc¢cl
the jurisdictional amount requiring referral to arbitrators under local
WHEREFORE, Plaintiff prays your Honorable Court to enter
Judr, went in its favor and against Defendant in the amount of $9,840.50
Harrisburg, PA 17112
(717) 540-5610
Supreme Court No. 07207
Attorney for p]~iut/ff
EXHIBIT "A"
PINNACLE HEALTH
SYSTEMS, INC,,
Plaintiff
Vo
MICHAELLA N. BOSTWICK,
Defendant
* IN THE COURT OF COMMON PLEAS
* CUMBERLAND COUNTY, PENSYLVANIA
*
* CIVIL ACTION - LAW
* NO,
VERIFICATION
HE ' ~ ' ' ~'/~'
ALTH SYSTEMS,INC.verify that the statements made in the Complaint
are true and correct to the best of my knowledge, infoi-x.ation and belief
and that I am authorized to make this Verification on behalf of
PINNCACLE HEALTH SYSTEMS, INC. I understand that false
statements made herein are subject to the penalties of 18 Pa.C.S.A.
Section 4904, relating to unswom falsification to authorities.
PINNACLE HEALTHSYSTEMS, INC.
Date:
CK
PATIENT NUMBER
200740159
ADMIBS,ON DATE DISCHARGE DATE
06/ 12/00 DAYS
GUARANTOR
NAME
AND
ADDRESS
MICHAELLA N BOSTWICK
1201 OAK STREET
NEW PROVIDENCE PA 17560
INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER
TNA US HEALTHCA 0 WQGF5010
-PHYSIC IAN-SPEC'I F IED '
I DESCRIPTION OF I ' SERVI~E TOTAL EST. COVERAGE E~T. COVERAGE EST. COVERAGE EST. COVERAGE PATIENT
I
DATE HOSPITAL SERVICESI CODE CHARGES INS, CO. NO. 1 INS. CO, NO, 2 INS, CO. NO. 3 INS. CO. NO. 4 AMOUNT
DETAIL OF CURRENT CHARGES, PAYMENTS AND ADJUSTMENTS
6/12 1105889 001 196.50 196.50
PT E~AL - FULL 97001
'7/15 3036802 001 68.77- 68.77-
AETNA USHC DISCOUNT
9/05 3012350 001 196.50 196.50
PATIENT RESPONSIBILITY
9/05 3012350 001 196.50- 196.50-
PATIENT RESPONSIBILITY
9/05 3036801 001 68.77 68.77
AETNA USHC DISCOUNT
BALANCE FORWARD 0.00
SUMMARY OF CURRENT PAY/ADJ 196.50- 196.50
SUMMARY OF CURRENT CHARGES
60 PHYSICAL THRPY 196.50 196.50
SUB-TOTAL OF CURR. CHARGES 196.50 196.50
GUAR RELATIONSHIP S SEX F ~UAR NO 162583~23
ACC DATE TYPE B Tiff-' PLACE EMPL REL
DIAGNOSIS 724.4
:'19~0 :::::::::::::::::::::::::::::::::::
I
~00740iS~ IAND CORRESPONDENCE' .,~.WAS PREPARED OR IF INSURANCE CARRIERS DO..v *~v ..~. ^~ .ut ...^,,.,....,~,,,., PAY THIS AMOUNT 196.50
PINNACLE HLTH HOSP
HARRISBURG, PA
NOT PAY ANY PART OF THE AMOUNTS SHOWN
UNDER ESTIMATED INSURANCE COVERAGE.
TYPE OF DATE OF SILL DATE OF
SILL PREV, SILL
05/18/01
18 A U D D
L PATIENT NAME
PATIENT NUMBER SEX AGE DISCHARGE DATE
F 36 ADMISSION DATE
210008613 07/ 10/00
BOSTWICK ,MICHAELLA
GUARANTOR MICHAELLA N BOSTWICK
NAME 1201 OAK STREET
AND NEW PROVIDENCE PA 17560
ADDRESS
INSURANCE COMPANY NAME GROUP NUMBERwQGPOL~CY NUMBER
AETNA US HEALTHC^ 0 F5010
PEPPELMAN UALTER
I DESCRIPTION OF I SERVICE TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE PATIENT
DATE HOSPITAL SERVICES CODE CHARGES INS. CO, NO 1 INS. CO. NO. 2 INS. CO. NO. 3 INS. CO. NO. 4 AMOUNT
DETAIL OF CURRENT CHARGES, PAYMENTS AND ADJUSTMENTS
17/10 1103291 001 80.00 80.00
GAIT TRAINING 97116
~7/10 1103292 007 280.00 280.00
EXERCISE - 15M 97110
i7/10 1105043 001 15.00 15.00
THERAPUTTY 20Z 00000
17/10 1105052 001 40.00 40.00
GROUP TX - 15M 97150
~7/12 1103291 001 80.00 80.00
GAIT TRAINING 97116
~7/12 1103292 007 280.00 280.00
EXERCISE - 15M 97110
17/12 1105052 001 40.00 40.00
GROUP TX - 15M 97150
17/12 1105053 001 119.00 119.00
AQUATIC THERAPY 97113
17/14 1103291 001 80.00 80.00
GAIT TRAINING 97116
17/14 1103292 008 320.00 320.00
EXERCISE - 15M 97110
t7/14 1105052 001 40.00 40.00
GROUP TX - 15M 97150
17/14 1105053 001 119.00 119.00
AQUATIC THERAPY 97113
17/17 1103291 001 80.00 80.00
GAIT TRAINING 97116
17/17 1103292 011 440.00 440.00
EXERCISE - 15M 97110
~7/17 1105052 001 40.00 40.00
GROU3 TX - 15M 97150
'7/18 1105052 001 40.00 40.00
GROU3 TX - 15M 97150
'7/21 1103291 001 80.00 80.00
GAIT TRAINING 97116
!iii?i~ ~::i~i ................. !!ii:!ii!?i:iiiill PLEASE REFER TO PATENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY I
:!:!:!:i:!: i:~ ~:i~Ei~i:i:!i!:!i!!!!!ii!i:!:!i NUMBER ON ALL INQUIRIES FOR ANY CHARGES NOT POSTED WHEN THIS BILL
AND CORRESPONDENCE.
WAS PREPARED OR IF INSURANCE CARRIERS DO
UNDER ESTIMATED INSURANCE COVERAGE.
N L PATIENT NAME
BOSTWICK ,MICHAELLA
PATIENT NUMBER
210008613
GUARANTOR
NAME
AND
ADDRESS
MICHAELLA N BOSTWICK
1201 OAK STREET
NEW PROVIDENCE PA 17560
INSURANCE COMPANY NAME A ~,ou, ,UMEE~, W Q GPOLICYF 50 NUMBER
AETNA US HEALTHC 0 10
PEPPELMAN WALTER
37/21 1103292 015 600.00 600.00
EXERCISE - 15M 97110
)7/21 1105052 001 40.00 40.00
GROU~ TX - 15M 97150
)7/24 1103291 001 80.00 80.00
GAIT TRAINING 97116
)7/24 1103292 016 640.00 640.00
EXEI~;ISE- 15M 97110
)7/24 105052 001 40.00 40.00
GROU ~ TX - 15M 97150
)7/25 103291 001 80.00 80.00
GAIT TRAINING 97116
)7/25 11103292 003 120.00 120.00
EXERCISE- 15M 97110
)7/25 1105052 001 40.00 40.00
GROUP TX - 15M 97150
)7/26 1103291 001 80.00 80.00
GAIT TRAINING 97116
)7/26 1103292 008 320.00 320.00
EXERCISE- 15M 97110
)7/26 1105052 001 40.00 40.00
GROUP TX - 15M 97150
)7/26 1105053 001 119.00 119.00
AQUATIC THERAPY 97113
)7/27 1103291 001 80.00 80.00
GAIT TRAINING 97116
~7/27 1103292 010 400.00 400.00
EXERCISE- 15M 97110
17/27 1105052 001 40.00 40.00
GROUP TX - 15M 97150
17/28 1103291 001 80.00 80.00
GAIT TRAINING 97116
t7/28 1103292 005 200.00 200.00
EXERCISE- 15M 97110
NUMBER ON ALL INQUIRIES
1
AND CORRESPONDENCE, FOR ANY CHARGES NOT POSTED WHEN THIS BILL
WAS PREPARED OR IF IN~:URANCE CARRIERS DO
NOT PAY ANY PART OF THF AMOtlNTR
UNDER ESTIMATED INSURANCE COVERAGE,
N L PATIENT RAMB
BOSTWICK ~MICHAELLA
210008613PATIENT NUMBER SEXF 36AGE ADMISSION07/10/00DATE DISCHARGE DATE DAYS
GUARANTOR
NAME
AND
ADDRESS
MICHAELLA N BOSTWICK
1201 OAK STREET
NEW PROVIDENCE PA 17560
INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER
AETNA US HEALTHCA 0 WQGF5010
PEPPELMAN WALTER
DESCRIPTION OF SERVI~ TOTAL EST. COVERAGE EST, COVERAGE EST. COVERAGE EST, COVERAGE PATIENT
DATE HOSPITAL SERVICESI CODE CHARGES INS, CO, NO. 1 INS. CO. NO, 2 INS. CO. NO, 3 ~N$, CO. NO. 4 AMOUNT
)7/28 105052 001 40.00 40.00
GROL" TX - 15M 97150
)7/28 105053 001 119.00 119.00
AQU~ FIC THERAPY 97113
)7/31 ,1103291 001 80.00 80.00
GAIT TRAINING 97116
)7/31 1103292 005 200.00 200.00
EXERCISE- 15M 97110
)7/31 1105052 001 40.00 40.00
GROUP TX - 15M 97150
)8/13 0036802 001 1977.85- 1977.85-
AETNA USHC DISCOUNT
)9/12 0011041 001 15.75- 15.75-
PMT-AETNA US HEALTHCARE
)9/14 0011041 001 6.00- 6.00-
PMT-AETNA US HEALTHCARE
)9/14 0011041 001 12.00- 12.00-
PMT-AETNA US HEALTHCARE
)9/14 0011041 001 402.00- 402.00-
PMT-AETNA US HEALTHCARE
~9/14 0011041 001 156.00- 156.00-
PMT-AETNA US HEALTHCARE
)9/14 0011041 001 115.35- 115.35-
PMT-AETNA US HEALTHCARE
~9/14 0011041 001 32.00- 32.00-
PMT-AETNA US HEALTHCARE
~9/14 0011041 001 6.00- 6.00-
PMT-AETNA US HEALTHCARE
0/09 ~012350 001 320.00 320.00
PATIENT RESPONSIBILITY
0/09 D012350 001 320.00- 320.00-
PATIENT RESPONSIBILITY
0/18 3012348 001 20.00 20.00
COINSURANCE/COPAY
UNDER ESTIMATED INSURANCE COVERAGE,
BOSTWICK MICHAELLA I 210008613 I F 36 07/10/00
GUARANTOR
NAME
AND
ADDRESS
MICHAELLA N BOSTWICK
1201 OAK STREET
NEW PROVIDENCE PA 17560
INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER
AETNA US HEALTHCA 0 WQGF5010
PEPPELMAN WALTER
PAYMENT
10/18 0012348 001 20.00- 20.O0-
COI~SURANCE/COPAY
11/28 0012348 001 180.00 180.00
COII~SURANCE/COPAY
11/28 0012348 001 20.00 20.00
COINSURANCE/COPAY
11/28 0012348 001 180.00- 180.00-
COINSURANCE/COPAY
11/28 0012348 001 20.00- 20.00-
COINSURANCE/COPAY
11/28 0036801 001 1889.05- 1889.05-
AETNA USHC DISCOUNT
11/28 0036801 001 499.00- 499.00-
AETNA USHC DISCOUNT
BALANCE FORWARD 0.00
SUMMARY OF CURRENT PAY/ADJ 5111.00- 5651.00- 540.00
SUMMARY OF CURRENT CHARGES
60 PHYSICAL THRPY 5651.00 5651.00
SUB-TOTAL OF CURR. CHARGES 5651.00 5651.00
GUAR RELATIONSHIP S SEX F GUAR NO 162583~23
ACC DATE TYPE B TIME PLACE EMPL REL
DIAGNOSIS 724.4
NUMBER ON ALL INQUIRIES
210008613 I POR ANY C,A.GES NOT POSTED W.EN
AND CORRESPONDENCE. WAS PREPARED OR ~F INSURANCE CARRIERS DO PAY THIS AMOUNT 540.00
I
PINNACLE HLTH HOSP
HARRISBURG, PA
UNDER ESTIMATED INSURANCE COVERAGE.
TYPE OF DATE OF BILL DATE OF
BILL PREV, BILL
05/18/01i
1 S A U D D :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
N L PATIENT NAME PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE
BOSTWICK .MICHAELLA 210027453 F 36 08/01/00
INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER
GUARANTORADDRESSNAMEAND MECHANICSBuRGMICHAELLALoT155 2SALEM CHURcHN BOSTWICKpA RD 17050 AETNA US HEALTHCA 0 WQGF5010
PEPPELMAN WALTER
AMOUNT OF
PAYMENT
J
EV E CHARGES NS CO NO INS. CO.NO.2 NS.CO.NO.3 NS,CO,NO, 4DATE H AMOUNT
DETAIL OF CURRENT CHARGES, PAYMENTS AND ADJUSTME ~TS
~8/04 1103291 001 80.00 80.00
GAIT TRAINING 97116
~8/04 1103292 005 200.00 200.00
EXERCISE - 15M 97110
18/04 1105052 001 40.00 40.00
GROU3 TX - 15M 97150
18/04 1105053 001 119.00 119.00
AQUATIC THERAPY 97113
8/07 1103291 001 80.00 80.00
GAIT TRAINING 97116
'8/07 1103292 005 200.00 200.00
EXERCISE- 15M 97110
'8/07 1105050 001 68.00 68.00
RE -, EVAL 97002
8/07 1105052 001 40.00 40.00
GROII3 TX - 15M 97150
8/08 103291 001 80.00 80.00
GAIl TRAINING 97116
08/08 1103292 005 200.00 200.00
EXER~'ISE- 15M 97110
8/08 1105052 001 40.00 40.00
GROU ~ TX - 15M 97150
8/09 1103291 001 80.00 80.00
GAIT, TRAINING 97116
8/09 i1103292 006 240.00 240.00
EXERCISE- 15M 97110
8/09 1105052 001 40.00 40.00
GROUP TX - 15M 97150
8/10 1103291 001 80.00 80.00
GAI'r TRAINING 97116
8/10 1103292 006 240.00 240.00
EXERCISE- 15M 97110
8/10 1105052 001 40.00 40.00
GROUP TX - 15M 97150
::!~?:: ::':~: PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY~
I
UNDER ESTIMATED iNSURANCE COVERAGE.
TYPE OF DATE OF BiLL DATE OF
BILL PREV, BILL
05/18/01
8 A u D D
BOSTWICK MICHAELLA
PATIENT NUMBER
21
GUARANTOR
NAME
AND
ADDRESS
MICHAELLA N BOSTWICK
155 SALEM CHURCH RD
LOT 2
MECHANICSBURG PA 17050
ADMISSION DATE DISCHARGE DATE
08/01/00
INSU~NCE COMPANY NAME CAOROUP NUMBERwQGPO£1CY NUMBER
AETNA US HEALTH 0 F5010
PEPPELMAN WALTER
DATE HOSPITAL SERVICES CODE CHARGES INS, CO, NO. 1 INS. CO. NO. 2 INS. CO. NO. 3 INS, CO. NO. 4 AMOUNT
)8/11 1103291 001 80.00 80.00
GAIT TRAINING 97116
)8/11 1103292 005 200.00 200.00
EXERCISE - 15M 97110
)8/11 1105052 001 40.00 40.00
GROU= TX - 15M 97150
)8/11 1105053 001 119.00 119.00
AQUATIC THERAPY 97113
)8/14 1103291 001 80.00 80.00
GAIT TRAINING 97116
)8/14 1103292 005 200.00 200.00
EXER!;ISE- 15M 97110
)8/14 1105052 001 40.00 40.00
GROL = TX - 15M 97150
)8/16 103291 001 80.00 80.00
GAIl TRAINING 97116
)8/16 103292 006 240.00 240.00
EXER;ISE- 15M 97110
)8/16 105052 001 40.00 40.00
GROU ~ TX - 15M 97150
)8/17 ;1103291 001 80.00 80.00
GAIl TRAINING 97116
)8/17 1103292 009 360.00 360.00
EXERCISE- 15M 97110
)8/17 1105052 001 40.00 40.00
GROUP TX - 15M 97150
)8/18 1103291 001 80.00 80.00
GAIT TRAINING 97116
)8/18 1103292 008 320.00 320.00
EXERCISE- 15M 97110
)8/18 1105052 001 40.00 40.00
GROUP TX - 15M 97150
)8/18 1105053 001 119.00 119.00
AQUATIC THERAPY 97113
FOR ANY CHARGES NOT POSTED WHEN THIS BILL
AND CORRESPONDENCE
· WAS PREPARED OR IF iNSURANCE CARRIERS DO
UNDER ESTIMATED iNSURANCE COVERAGE.
MICHAELLA N BOSTWICK
155 SALEM CHURCH RD
LOT 2
MECHANICSBURG PA 17050
INSURANCE COMPANY NAME GROUP NUM"ER W Q G F 50 I 0
AETNA US HEALTHCA 0 : POLICY NUMBER
PEPPELMAN WALTER
$
J L SER ICES I CODE CHARGES INS. CO. NO. 1 INS, CO, NO. 2 INS. CO, NO. 3 INS, CO. NO, 4 AMOUNT
38/21 1103291 001 80.00 80.00
GAIT TRAINING 97116
38/21 1103292 013 520.00 520.00
EXERCISE - 15M 97110
38/21 1105052 001 40.00 40.00
GROUP TX - 15M 97150
)8/22 1103291 001 80.00 80.00
GAIT TRAINING 97116
)8/22 1103292 015 600.00 600.00
EXERCISE - 15M 97110
)8/22 1105052 001 40.00 40.00
GROUP TX - 15M 97150
)8/23 1103291 001 80.00 80.00
GAIT TRAINING 97116
)8/23 1103292 006 240.00 240.00
EXERCISE - 15M 97110
)8/23 1105052 001 40.00 40.00
GROUP TX - 15M 97150
)8/24 1103291 001 80.00 80.00
GAIT TRAINING 97116
)8/24 1103292 004 160.00 160.00
EXERCISE - 15M 97110
)8/24 105052 001 40.00 40.00
GROU~ TX - 15M 97150
)8/25 1103291 001 80.00 80.00
GAIT TRAINING 97116
)8/25 1103292 006 240.00 240.00
EXERCISE - 15M 97110
18/25 1105052 001 40.00 40.00
GROUP TX - 15M 97150
~8/28 1103291 001 80.00 80.00
GAIT TRAINING 97116
)8/28 1103292 006 240.00 240.00
EXERCISE - 15M 97110
iiii!!i!!!ii~A~iii~iii!!i!iiiiitPLEASEREFERTOPAT'ENT ADDITIONALPATIENTBtLLiNGMAYBENECESSARYI
· NUMBER ON ALL INQUIRIES
AND CORRESPONDENCE, FOR ANY CHARGES NOT POSTED WHEN THIS BILL
WAS PREPARED OR IF INSURANCE CARRIERS DO
NOT PAY ANY PART OF THE AMOUNTS SHOWN
UNDER ESTIMATED INSURANCE COVERAGE.
TYPE OF DATE OF BILL DATE OF
BILL PREV, BILL
05/18/01
18 A U D D
~ PATIENT NAME PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE
BOSTWICK tMICHAELLA 210027453 F 36 08/01/00
MICHAELLA N BOSTWICK
155 SALEM CHURCH RD
LOT 2
MECHANICSBURG PA 17050
INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER
AETNA US HEALTHCA 0 WQGF5010
PEPPELMAN WALTER '
8/28 1105052 001 40.00 40.00
GROIJ!P TX - 15M 97150
8/29 i1103291 001 80.00 80.00
GAI1 1TRAINING 97116
8/29 103292 006 240.00 240.00
EXER.'ISE- 15M 97110
8/29 105052 001 40.00 40.00
GROU 3 TX - 15M 97150
8/30 103291 001 80.00 80.00
GAI1 TRAINING 97116
8/30 103292 006 240.00 240.00
EXER~'ISE - 15M 97110
8/30 105052 001 40.00 40.00
GROU 3 TX - 15M 97150
8/31 103291 001 80.00 80.00
GAI3 TRAINING 97116
8/31 103292 006 240.00 240.00
EXE~'ISE- 15M 97110
8/31 105052 001 40.00 40.00
GRO~ 3 TX - 15M 97150
9/13 )036802 001 2738.75- 2738.75-
AETh ~ USHC DISCOUNT
9/21 )012350 001 7825.00 7825.00
PATII:.NT RESPONSIBILITY
9/21 I)012350 001 7825.00- 7825.00-
PATII-'NT RESPONSIBILITY
9/21 )036801 001 2738.75 2738.75
AETNI[ USHC DISCOUNT
BALANi:E FORWARD 0.00
SUMMARY OF CURRENT PAY/ADJ 7825.00- 7825.00
ii::: ............... ............... ::::ii ! I PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY 1
I
THE SHOWN
UNDER ESTIMATED ~NSURANCE COVERAGE.
TYPE OF DATE OF BILL DATE OF
BILL PREV, BiLL
05/18/01
8 A U D D
BOSTWICK ~MICHAELLA
PATIENT NUMBER SEX AGE
210027453 F 36
ADMISSION08/01/00 DATE DISCHARGE DATE DAYS
GUARANTOR
NAME
AND
ADDRESS
MICHAELLA N BOSTWICK
155 SALEM CHURCH RD
LOT 2
MECHANICSBURG PA 17050
iNSURANCE COMPANY NAME GROUP .UMB~P WQG F 5 0
PEPPELMAN WALTER ' I POL'CYNUMSER
o
AETNA US HEALTHCA 10
I DESCRIPTION OF I SERVICE TOTAL EST. COVERAGE EST, COVERAGE EST, COVERAGE EST. COVERAGE PATIENT
DATE HOSPITAL SERVICES CODE CHARGES INS. CO. NO, 1 INS, CO. NO. 2 INS. CO. NO. 3 INS. CO. NO. 4 AMOUNT
SUMMARY OF CURRENT CHARGES
60 PHYSICAL THRPY 7825.00 7825.00
SUB-TOTAL OF CURR. CHARGES 7825.00 7825.00
GUAR RELATIONSHIP S SEX F ~UAR NO 162583923
ACC DATE TYPE B TIME PLACE EMPL REL
DIAGNOSIS 724.4
I PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY
NUMBER ON ALL INQUIRIES FOR ANY CHARGES NOT POSTED WHEN THIS BILL
210027453 lAND CORRESPONDENCE. WAS PREPARED OR IF INSURANCE CARRIERS DOI PAY THIS AMOUNT 7825.00
PINNACLE HLTH HOSP
HARRISBURG, PA
SHOWN
UNDER ESTIMATED INSURANCE COVERAGE.
IN L PAT'ERT NAME
I BOSTWICK ~,MICHAELLA
PATIENT NUMBER
210063114
GUARANTOR
NAME
AND
ADDRESS
MICHAELLA N BOSTWICK
155 SALEM CHURCH RD
LOT 2
MECHANICSBURG PA 17050
INSURANCE COMPANY NAME GROUP ~UMBE. wQGF5010
ETNA US HEALTHCA : POUC~NUMBER
A 0
PEPPELMAN WALTER
DESCRIPTION OFI SERVICE TOTAL EST, COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE PATIENT
DETAIL OF CURRENT CHARGES, PAYMENTS AND ADJUSTMENTS
09/01 1103291 001 80.00 80.00
GAIT TRAINING 97116
99/01 1103292 006 240.00 240.00
EXERCISE - 15M 97110
]9/01 1105052 001 40.00 40.00
GROUP TX - 15M 97150
39/05 1103291 001 80.00 80.00
GAIT TRAINING 97116
]9/05 1103292 005 200.00 200.00
EXERCISE - 15M 97110
]9/05 1105052 001 40.00 40.00
GROUP TX - 15M 97150
)9/06 1103291 001 80.00 80.00
GAIT TRAINING 97116
)9/06 1103292 004 160.00 160.00
EXERCISE - 15M 97110
)9/06 105052 001 40.00 40.00
GROU~ TX - 15M 97150
)9/06 ,1105053 001 119.00 119.00
AQUA'TIC THERAPY 97113
)9/07 1103292 004 160.00 160.00
EXERCISE - 15M 97110
)9/07 1105052 001 40.00 40.00
GROUP TX - 15M 97150
10/13 0036802 001 447.65- 447.65-
AETNA USHC DISCOUNT
10/23 0012350 001 1279.00 1279.00
PATIENT RESPONSIBILITY
10/23 0012350 001 1279.00- 1279.00-
PATIENT RESPONSIBILITY
10/23 0036801 001 447.65 447.65
AETNA USHC DISCOUNT
BALANCE FORWARD 0.00
WAS PREPARED OR IF INSURANCE CARRIERS DO
UNDER ESTIMATED iNSURANCE COVERAGE,
TYPE OF DATE OF BILL DATE OF
BILL PREV, BILL
05/18/01
18 A U D D ::
L PATIENT NAME PATIENT NUMBER ADMISSION DATE ~
BOSTWICK MICHAELLA 210063114 09/01/00 ~
~i0'~;t1 INSURANCE COMPANY NAME GROUP NUMBERwQGPOLIEY NUMBER
PEPPELMAN ~ALTER
SUMMARY OF CURRENT PAY/ADJ 1279.00- 1279.00
SUMMARY OF CURRENT CHARGES
60 PHYSICAL THRPY 1279.00 1279.00
SUB-T3TAL OF CURR. CHARGES 1279.00 1279.00
GUAR RELATIONSHIP S SEX F ~UAR NO 162583~23
ACC [:)ATE TYPE B TIME PL ~,CE EMPL EEL
DIAGNOSIS 724.4
NUMBER ON ALL INQUIRIES ADDITIONAL PATIENT BILLING MAY BE NECESSARY
1AND CORRESPONDENCE. FOR ANY CHARGES NOT POBTED WHEN THIS BILL
2
1
0063
1
1
4
I
I
WAS PREPARED OR IF INSURANCE CARRIERS DO PAY THIS AMOUNT 1279.00
PINNACLE HLTH HOSP
HARRISBURG, PA
UNDER ESTIMATED INSURANCE COVERAGE.
SHERIFF'S RETURN - REGULAR
CASE NO: 2002-01347 P
COMMONWEALTH OF PENNSYLVA/qIA:
COUNTY OF CUMBERLAND
PINNACLE HEALTH SYSTEMS INC
VS
BOSTWICK MICHAELLA N
BRYAN WARD , Sheriff or Deputy Sheriff of
Cumberland County, Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE was served upon
BOSTWICK MICHAELLA N the
DEFENDANT , at 1849:00 HOURS,
at 155 SALEM CHURCH ROAD
MECHANICSBURG, PA 17050
on the 20th day of March
LOT 2
by handing to
, 2002
MICHAELLA BOSTWICK
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing 18.00
Service 7.59
Affidavit .00
Surcharge 10.00
.00
35.59
Sworn and Subscribed to before
me this 2~ day of
~ ~o ~-~ A.D.
? Prothonotary'
So Answers:
R. Thomas Kline
03/21/2002
ARTHUR KUSIC
By:
heriff
Arthur A. Kusic, Esquire
Supreme Court Number 07207
4201 Crams Mill Road
Harrisburg, PA 17112
(717) 540-5610
PINNACLE HEALTH
SYSTEMS, INC.
Plaintiff
V.
MICHAELLA N. BOSTWICK
Defendant
Attorney for Plaintiff
: IN THE COURT OF COMMON PLEAS
:CUMBERLAND COUNTY, PENNSYLVANIA
:
: CIVIL ACTION - LAW
: NO: 02-1347 CMLTERM
;
:
IMPORTANT NOTICE
TO: MICHAELLA N. BOSTWICK
DATE OF NOTICE: MAY 21, 2002
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A
WRITTEN APPEARANCE PERSONALLY OR BY ATrORNEY AND FILE IN
WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE
CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN
DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE
ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE
YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE
THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A
LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL
HELP.
Lawyer Referral Service
Court Administrator
Cumberland County Courthouse
One Courthouse Squarg 4th Floor
Carlisle, PA 17013
(771) 240-6200
RESPECTFULLY SUBMITTED:
A~RE
Arthur A. Kusic, Esquire
Supreme Court Number 07207
4201 Crums Mill Road
Harrisburg, PA 17112
(717) 540-5610
Attorney for Plaintiff
PINNACLE HEALTH
SYSTEMS, INC.
Plaintiff
Vo
MICHAELLA N. BOSTWICK,
Defendant
: IN THE COURT OF COMMON PLEAS
:CUMBERLAND COUNTY, PENNSYLVANIA
:
: CML ACTION - LAW
:
: NO: 02-134 CMLTERM
:
:
NOTICIA IMPORTANTE
A: MICHAELLA N. BOSTWICK
FECHE DE NOTICIA: 21 de Mayo, 2002
USTED NO HA COMPLIDO CON EL AVISO ANTERIOR PORQUE HA
FALTADO EN TOMAR MEDIDAS REQUERIDAS RESPECTO A ESTE
CASO. SI USTED NO ACTUA DENTRO DE DIEZ (10} DIAS DESDE LA
FECHE DE ESTA NOTICIA, ES POSIBLE QUE UN FALLO SERIA
RECISTRADO CONTRA USTED SIN UNA AUDIENCE Y USTED PODIA
PERDER SU PROPIEDAD O OSTROS DERECHOS IMPORTANTES USTED
DEBE LLEBAR ESTA NOTICIA A SU ABOGADO EN SEQUIDA. SI USTED
NO TIENE ABOGADO O NO TIENE CAN QUE PAGAR LOS SERVIDIOS DE
UN ABOGADO. VAYA O LLAME A LA OFICIAN ESCRITA ABAJO PARA
AVERICUAR A DONDE USTED PUEDE OBTENER LA AYUDA LEGAL.
Lawyer Referral Service
Court Administrator
Cumberland County Courthouse
One Courthouse Square, 4th Floor
Carlisle, PA 17013
(717) 240-6200
RESPECTFULLY SUBMITTED:
ARTHUR/~ KUSIC, ESQUIRE
PINNACLE HEALTH
SYSTEMS, INC.,
Plaintiff
Vo
MICHAELLA N. BOSTWICK,
Defendant
* IN THE COURT OF COMMON PLEAS
*CUMBERLAND COUNTY, PENNSYLVANIA
.
* CIVIL ACTION - LAW
* NO. 02-1347 CIVIL TERM
CERTIFICATE OF SERVICE
I, Catherine St. Pierre, paralegal for Arthur A. Kusic, Esquire, do
hereby certify that on this 21st day of May, 2002, at Mr. Kusic's request,
I placed in the United States mail true and correct copies of the Plaintiff's
Important Ten Day Notice with first class postage affixed and addressed
to the following:
Michaella N. Bostwick
155 Salem Church Road
Mechanicsburg, PA 17050
Catherine St. Pierre, Paralegal
ARTHUR A. KUSIC, P.C.
4201 Crums Mill Road
Harrisburg, PA 17112
{717) 540-5610
PINNACLE HEALTH SYSTEMS,
Plaintiff
¥.
MICHAELLA N. BOSTWICK
Defendants
INC.
IN 1HE COURT OF COMMON PLEAS
COUNTY PENNSYLVANIA
.CUMBERLAND
: CIVIL ACTION - LAW
NO'02-1347 CIVIL TERM
P R A E C ! P E
TO THE PROTHONOTARY:
Pursuant to Rule 237,1 of the Pennsylvania Rules of Civil
Procedure, Notice of Praecipe
been given to the Defendants;
hereto.
Please enter Judgment
against Defendants in the amount
for Entry
a copy of
interest at the rate of 6% per ann6m.
of Default Judgment has
said notice is attached
in favor of the Plaintiff and
of $9~4~l. 50 ........ along with
: and the
costs of this proceeding for failure to enter a defense or
otherwise file a responsive pleading in the above captioned matter.
DATE:
RESPECTFULLY SUBMITTED:
~RE
4201Crums Mill Road
P.O, Box 67015
Harrisburg , PA 17106
(717) 540-5610
ATTORNEY FOR PLAINTIFF
SUPREME COURT NO. 07207
PINNACLE HEALTH SYSTEMS,
Plaintiff
V.
MICHAELLA N. BOSTWICK
Defendants
INC.
: IN THE COURT OF COHMON PLEAS
:CUMBERLAND COUNTY PENNSYLVANIA
: CIVIL ACTION - LAW
: NO.
02-1347 CIVIL TERM
TO: MICHAELLA N. BOSTWICK Defendants
the fo]lowing gudgment has been entered against you in the above-
captioned case.
Date: _ ~_~_~.._ ....
I hereby certify
person(s) to receive
Amount: $9,840.50 along with interest at the rate of
6% per annum and court costs
that the name and address of the proper
this Notice under Pa,R.Oiv. P, Section 236 is:
Michaella N. Bostwick
155 Salem Church Road
M~chanissburg, PA 17050
Defendants
Arthur A. Kusic, Esquire
Supreme Court Number 07207
4201 Crums Mill Road
Harrisburg, PA 17112
(717) 540-5610
PINNACLE HEALTH
SYSTEMS, INC.
Plaintiff
V.
MICHAELLA N. BOSTWICK
Defendant
Attorney for Plaintiff
: IN THE COURT OF COMMON PLEAS
:CUMBERLAND COUNTY, PENNSYLVANIA
:
: CML ACTION - LAW cO__
NO: 02-1347 CML TERM
IMPORTANT NOTICE
TO: MICHAELLA N. BOSTWICK
DATE OF NOTICE: MAY 21, 2002
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A
WRITTEN APPEARANCE PERSONALLY OR BY ATrORNEY AND FILE IN
WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE
CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN
DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE
ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE
YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE
THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A
LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL
HELP.
Lawyer Referral Service
Court Administrator
Cumberland County Courthouse
One Courthouse Squar9 4th Floor
Carlisle, PA 17013
(771) 240-6200
RESPECTFULLY SUBMITTED:
rHU 0SIC, SQU RE
Arthur A. Kusic, Esquire
Supreme Court Number 07207
4201 Crums Mill Road
Harrisburg, PA 17112
(717) 540-5610
Attorney for Plaintiff
PINNACLE HEALTH
SYSTEMS, INC.
Plaintiff
MICHAELLA N. BOSTWICK,
Defendant
: IN THE COURT OF COMMON PLEAS
:CUMBERLAND COUNTY, PENNSYLVANIA
:
: CML ACTION - LAW
:
: NO: 02-134 CIVILTERM
:
;
NOTICIA IMPORTANTE
A: MICHAELLA N. BOSTWICK
FECHE DE NOTICIA: 21 de Mayo, 2002
USTED NO HA COMPLIDO CON EL AVISO ANTERIOR PORQUE HA
FALTADO EN TOMAR MEDIDAS REQUERIDAS RESPECTO.A ESTE
CASO. SI USTED NO ACTUA DENTRO DE DIEZ (10) DIAS DESDE LA
FECHE DE ESTA NOTICIA, ES POSIBLE QUE UN FALLO SERIA
RECISTRADO CONTRA USTED SIN UNA AUDIENCE Y USTED PODIA
PERDER SU PROPIEDAD 0 OSTROS DERECHOS IMPORTANTES USTED
DEBE LLEBAR ESTA NOTICIA A SU ABOGADO EN SEQUIDA. SI USTED
NO TIENE ABOGADO O NO TIENE CAN QUE PAGAR LOS SERVIDIOS DE
UN ABOGADO. VAYA O LLAME A LA OFICIAN ESCRITA ABAJO PARA
AVERICUAR A DONDE USTED PUEDE OBTENER LA AYUDA LEGAL.
Lawyer Referral Service
Court Administrator
Cumberland County Courthouse
One Courthouse Square, 4th Floor
Carlisle, PA 17013
(717) 240-6200
RESPECTFULLY SUBMITTED:
A~
PINNACLE HEALTH
SYSTEMS, INC.,
Plaintiff
Vo
MICHAELLA N. BOSTWlCK,
Defendant
* IN THE COURT OF COMMON PLEAS
*CUMBERLAND COUNTY, PENNSYLVANIA
* CIVIL ACTION - LAW
* NO. 02-1347 CIVIL TERM
CERTIFICATE OF SERVICE
I, Catherine St. Pierre, paralegal for Arthur A. Kusic, Esquire, do
hereby certify that on this 21st day of May, 2002, at Mr. Kusic's request,
I placed in the United States mail true and correct copies of the Plaintiff's
Important Ten Day Notice with first class postage affixed and addressed
to the following:
Michaella N. Bostwick
155 Salem Church Road
Mechanicsburg, PA 17050
Catherine St. Pierre, Paralegal
ARTHUR A. KUSIC, P.C.
4201 Crums Mill Road
Harrisburg, PA 17112
(717) 540-5610
PINNACLE HEALTH
SYSTEMS, INC.,
Plaintiff
MICHAELLA N. BOSTWICK,
Defendant
* IN THE COURT OF COMMON PLEAS
* CUMBERLAND COUNTY, PENNSYLVANIA
CML ACTION - LAW
NO. 02-1347 Civil Term
PRAECIPE TO ENTER SUGGESTION OF BANKRUPTCY
DICHARG~
TO THE PROTHONOTARY:
Please enter of record the within Suggestion of Bankruptcy
Discharge with regard to the above captioned matter. Plaintiff has actual
or constructive notice that Defendant received a discharge under Chapter
7 in the United States Bankruptcy Court in the Middle District of
Pennsylvania under docket no. 02-06859-JJT-1.
RESPECTFU S D:
ARTHUR ~f~~UIRE
4201 Cnirffs Mill Roa~ ......
Harrisburg, PA 17112
(717) 540-5610
Supreme Court No. 07207
Attorney for Plaintiff