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Home My WebLink About06-5363 THIS IS AN ARBITRATION MATTER ASSESSMENT OF DAMAGES HEARING NOT REQUIRED TABAS & ROSEN, P.C. BY: LEWIS C. TRAUFFER, ESQUIRE Attorney LD. #60267 1845 Walnut Street, 22nd Floor Philadelphia, PA 19103 (215) 569-5050 Attorney for Plaintiff THE MILTON S. HERSHEY MEDICAL CENTER P.O. Box 853 Hershey, PA 17033 VS LILLIE ANN BROWN 42 West Baltimore Street Carlisle, PA 17013 AND RUTH B. DANIELS 2700 Double Churches Road Apt. 306 Columbus, GA 31909 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO 0(.. -53/.3 Ciutt lea..""\.. CIVIL ACTION 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 OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMA nON ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717)249-3166 or (800)990-9108 COMPLAINT - CIVIL ACTION THE MILTON S. HERSHEY MEDICAL CENTER VS RUTH B. DANIELS AND LILLIE A. BROWN, ADMINISTRATORS OF THE ESTATE OF RALIEGH BROWN, JR., DECEASED 1. Plaintiff is a non-profit corporation located at the address indicated in the caption hereof. 2. Defendants are individuals who reside at the addresses indicated in the caption hereof. 3. At all times material hereto, defendants were the Administrators of the Estate of Raliegh Brown, Jr., Deceased. 4. As a result of a certain medical condition, defendants' decedent was admitted to the plaintiff hospital for medical care on January 19, 2003 thru January 22, 2003. 5. The amounts, quantities and nature of said medical care rendered, the dates on which said medical care was rendered, and the charges therefore are set forth in Exhibit "A' which is incorporated herein as if set forth at length. 6. Said medical care was commensurate with the condition of defendants' decedent and was necessary for the health and welfare of defendants' decedent. 7. At or about the time of defendants' decedent's admission to the plaintiff hospital, implied, constructive and oral con- tracts arose between defendants' decedent and plaintiff by the terms of which defendants' decedent became obligated to pay plaintiff's charges for the medical care rendered by plaintiff to defendants' decedent. 9. Defendants are liable for the medical care rendered to defendants' decedent. 10. As a result of the foregoing, there is due and owing from defendants to plaintiff the sum indicated in Exhibit "A". WHEREFORE, plaintiff demands judgment against defendants for the sum of $14,360.75 plus six percent (6%) interest per annum from the date of discharge to the date of judgment, record costs and non-record costs. TABAS & ROSEN, P.C. ~~~ 1LEWIS C. UFFER, ESQURIE Attorney for Plaintiff MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/18/04 at 07:18 AM Guarantor: BROWN RALIEGH J 604 N BALTIMORE AVE BGA MOUNT HOLLY S, PA 17065-0000 Date I Svc Code I 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/20/03 01/21/03 01/21/03 01/21/03 01/21/03 10348 11078 11081 104042 104060 104065 104398 105052 105059 105657 245555 245814 246086 246582 246836 249415 250856 251225 251959 272425 272852 273136 273392 521211 531223 531233 531412 532262 680009 680041 680050 680052 680064 680066 680106 680107 680108 10234 11078 104106 104129 Description T INTERMEDIATE CARE U IV FLUIDS 501-1000 IV TUBING 10 DROPS ML CREATININE, BLOOD GLUCOSE, BLOOD UREA NITROGEN (BUN), ELECTROLYTES PARTIAL THROMBOPLAS T PROTHROMBIN TIME CBC W/PLT/DIFF AUTO LIDOCAINE 1 ML DILTIAZEM 60 MG ACETAMINOPHEN/CODEINE METOPROLOL 50 MG FENTANYL CITRATE 2 ML DIAZEPAM 10MGL 2ML SD NIFEDIPINE 60MG KDUR 10 MEQ ZOCOR 20MG MIDAZOLAM 1MG/ML 2ML MUCOMYST 20% 30ML VIA ISOSORBIDE MONONITRAT TIROFIBAN INJ 12.5MG 12 LEAD ELECTROCARDIO LT HEART CATH-PERCUTA INJ PROC CATH-SEL COR IMAGE/INJ PUL, AO, CO SEDATION IV/IM/INHALA COOK SHEATH/DILATOR ACS HI TORQUE GUIDEWI NON-IONIC CONTRAST 20 IONIC CONTRAST 200CC INTRODUCER/SHEATH CCL S & D SUPPLIES AVE GUIDE AVE GUIDEWIRE AVE INDEFLATOR T INTERMEDIATE CARE U IV FLUIDS 501-1000 MAGNESIUM PHOSPHORUS, BLOOD - Continue - IJ - f PAGE: 1 Patient: BROWN RALIEGH J Visit #: 3095083 I Unitsl 1 2 1 1 1 1 1 1 1 1 1 1 2 1 2 1 2 1 1 2 3 1 1 1 1 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1 Debits Credits 1155.00 20.00 14.00 10.00 9.00 9.00 25.00 30.00 19.00 30.00 2.10 2.10 4.20 2.10 11. 40 4.70 11.60 2.10 2.10 4.20 10.50 2.10 1157.85 95.00 2761.00 281.00 246.00 328.00 S8.GO 199.00 610.00 46.00 40.00 274.00 194.00 141.00 '71.00 1155.00 10.00 40.00 10.00 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/18/04 at 07:18 AM PAGE: 2 Guarantor: BROWN RALIEGH J 604 N BALTIMORE AVE BGA MOUNT HOLLY S, PA 17065-0000 Patient: BROWN RALIEGH J Visit #; 3095083 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 01/21/03 104433 BASIC METABOLIC PANEL 1 34.00 01/21/03 105656 CBC W/PLT AUTO 1 25.00 01/21/03 245706 ASPIRIN 325 MG 1 2.10 01/21/03 246582 METOPROLOL 50 MG 2 4.20 01/21/03 250856 NIFEDIPINE 60MG 1 5.80 01/21/03 251959 ZOCOR 20MG 1 2.10 01/21/03 273136 ISOSORBIDE MONONITRAT 1 2.10 01/21/03 273301 CLOPIDOGREL 75MG TAB 1 10.60 01/21/03 500900 ECHO 2D+M MODE 1 428.00 01/21/03 500904 CARDIAC DOPPLER 1 264.00 01/21/03 500905 COLOR FLOW DOPPLER 1 264.00 01/21/03 521211 12 LEAD ELECTROCARDIO 1 95.00 01/22/03 104106 MAGNESIUM 1 40.00 01/22/03 104433 BASIC METABOLIC PANEL 1 34.00 01/22/03 245706 ASPIRIN 325 MG 1 2.10 01/22/03 246582 METOPROLOL 50 MG 1 2.10 01/22/03 250856 NIFEDIPINE 60MG 1 5.80 01/22/03 273136 ISOSORBIDE MONONITRAT 2 4.20 01/22/03 273301 CLOPIDOGREL 75MG TAB 1 10.60 01/22/03 521211 12 LEAD ELECTROCARDIO 1 95.00 01/22/03 521213 EXERCISE OR PHARM STR 1 259.00 04/30/04 980090 HOSPITAL BAD DEBT W/O -1 10686.75- 04/30/04 980091 HOSPITAL BAD DEBT PLA 1 10686.75 -------------------------------------------------------------------------------- * - Not posted Balance: 10686.75 I It'd- RALlEGH J BROWN 604 N BALTIMORE AVE BGA MOUNT HOllY SPA 17065-1925 PAGE ~. ENNSTATE !!$I The Milton S. Hershey Medical Center . The College of Medicme 1 of 2 STATEMENT DATE: 05/11/04 LAST STATEMENT DATE: OS/27/03 ACCOUNT # 531856 i IF ANY QUESTIONS PLEASE CONTACT: M~J.fM~ PATII=NT I=INANCIAl ~fRVICE~ PROCEDURE DIAG QTY DATE CODE CODE .>> PATIENT: RALIEGH J BROHN 531856 01/20/03 9351026.GC 01/20/03 93545.GC 01/20/03 93S5&26.GC 01/20/03 93010 01/Zl/03 99223 01/21/03 9330726 01/21/03 9332026 01121/03 9332526 Olln/03 93010 01122103 99238 o l/Z 2103 93018 01/22/03 93010,59 414.01 414.01 414.01 V7Z.81 410.71 429.3 429.3 429.3 414.01 410.71 786..59 414.00 DESCRIPTION FFn TAX In '# '518570~5 CHARGE PAYMENTI GUARANTOR ADJUSTMENT BALANCE INS 3095083 PERFORMED BV: DIV OF CARDIOLOGY PLACE OF SVC: INPATIENT LEFT HRT - PERC ANGlO - CORONARY INTERP - ANGlO ECG ELECTROCARD INTERP INITIAL HOSPITAL CARE 201M-MODE ECHO) COMP DOPPLER) CeMP DOPPLER COLOR FL VEL HAP ECG ELECTROCARD INTERP HasP DISC. DAY I1GT <30 "IN CARDIAC STRESS TEST ECG ELECTROCARD INTERP BALANCE: RALIEGH J BRDMN $3674.00 952.00 656.00 386.00 56.00 329.00 364.00 243.00 174.00 56,00 141.00 261.00 .56;00 952.00 656.00 386.00 .56.00 329.00 364.00 243.00 174.00 56.00 141.00 261. 00 56.00 IF YOU HAVE ANY QUESTIDNSA80UT THE AMOUNT YOUR INSURANCE COHPANYPAID J 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. RPCl THANK YOU fOR USING MSHHC 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, BETHEEN 8:00AM AND 5:30PM MONDAY THROUGH WEDNESDAY OR BETHEEN 8:00AM AND 4:30PM THURSDAY AND FRIDAY. o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK 3 F' NNSTATE !Sa The Milton S. Hershey Medical Center .., The College of Medicme PAGE RAlIEGH J BROWN 604 N BALTIMORE AVE BGA MOUNT HOllY S PA 17065-1925 ACCOUNT # 531856 2 of 2 I:l IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES lATE PROCEDURE DIAG QTY DESCRIPTION CODe CODE STATEMENT DATE: 05/11/04 LAST STATEMENT DATE: OS/27/03 FED TAX ID # 251857035 INS CHARGE PAYMENTI GUARANTOR ADJUSTMENT BALANCE BkANCE SlfttARY RESPONSI8LE PARTY *** GUARANTOR RESPONSIBILITY POLICY . TOTAL ~ 3674.00 ____ _______________________LL'!!...Q!3J:.~#_r.'_!g~~_'u!~T_~r;ltAItP_ftUYJ!.1Lfl-'1.rTQM..f..Qf.l]"JJ~.rL9L~_r.~T.!€l#~H(LTJ!._'tPJ!.f.lJ!A'tM~!.(LL______u_u____________________ STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT: 05/11/04 $ 3674.00 $ 3674.00 BF6 MSHMC PHYSICIANS GROUP BILLING SERVICES POBOX 854 HERSHEY PA 17033-0854 00000531856 UP 0000000000367400051104 111.11.1.1..,1.1.11...1"1..11.,, 11'11I111111'11,11..11.1..1.1 Mil MSHMC PHYSICIANS GROUP ) ,: PO BOX 643313 PITTSBURGH PA 15264-3313 1",11I11I111"..11,"1.1"..11I.1'11I1,1.1.1.1.1,,1.1 ",/I" I RALIEGH J BROWN 604 N BALTIMORE AVE BGA MOUNT HOLLY S PA 17065-1925 He: F6BO TYP DMND .; CHECK ONE FOR CREDIT CARD PAYMENT, PLEASE FILL IN INFORMATION BELOW m\i:Eb~{ :~%t0.~:.\ IFFIC'. USE ONLY 531856 M/C _VISA EXP DATE Etwi.~~~~~ : :::~f",*';:::; '~-:_~~.: $ 3674.00 06101/04 CARDHOLDER NAME (PRINT) o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK fJ-L( . . BROWN, RALIEGH f,l531856 $10,686.75 (Hosp) 3,674.00 (Phys) VERIFICATION LINDA SCHLADER hereby states that she is the Team Manager I 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 knowledge, information and belief. The undersigned understands that the statements therein are made subject to the penalties of 18 Pa. C.S. ~4904 relating to unsworn falsification to authorities. DATE: 1\~ I ,- 0 ~ (1 ~ - {Q. , B i -- ~ ~ (.,J \--: - --. \) U'\ "- D :- ,", ~ -t: \.-D "" -U ~ p: l-J 0" $- TABAS & ROSEN, P.C. BY: LEWIS C. TRAUFFER I.D. No. 60267 22nd Fl.,1845 Walnut Street Philadelphia, PA 19103 (215)569-5050 Attorney for Plaintiff THE MILTON S. HERSHEY MEDICAL CENTER COURT OF COMMON PLEAS CUMBERLAND COUNTY VS LILLIE ANN BROWN AND RUTH B. DANIELS NO. 06-5363 Civil Term P RAE C I P E TO THE PROTHONOTARY: Please withdraw the above matter without prejudice. '-- ~ ~ ~ '--=:> LEWIS C. TRAUFFER, ESQUIRE Attorney for Plaintiff o s; r-.~ c..:> c;..? 0"' Cl n -! I cJ1 -0 ~ t,) SHERIFF'S RETURN - NOT FOUND CASE NO: 2006-05363 P COMMONTWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND MILTON S HERSHEY MEDICAL CENTE VS BROWN LILLIE ANN ET AL R. Thomas Kline ,Sheriff or Deputy Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named DEFENDANT BROWN LILLIE ANN but was unable to locate Her in his bailiwick. He therefore returns the COMPLAINT & NOTICE , NOT FOUND , as to the within named DEFENDANT , BROWN LILLIE ANN 42 WEST BALTIMORE STREEET CARLISLE, PA 17013 PER NEICE, DEFENDANT IS IN THE MILITARY IN IRAQ. Sheriff's Costs: Docketing Service Not Found Surcharge Postage 18.00 4.40 5.00 10.00 .39 37.79./ ;oJ()-~/o(, ~ Subscribed to before ~ R. Thomas Kline Sheriff of Cumberland County TABAS & ROSEN 09/19/2006 Sworn and me this day of A.D.