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I~ THE aOURTO' COMMON '~.A'
~VMIIltLAND ~ ~yNm
CIVIL ACTION - ..kw ' "
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ARTHUR A, KUSIC
ATTORNEY At LAW
4201 CIlllM~ MILL A~D
P,O, IIOx &1016 ,
HAAftISlUiIG, PlNNSYLVAN'" 1?IOHOla
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OHANB.R.IURO ARIA LIr. 'U'PORT I
IIRVIC., ,
'laintiff ,
V. ,
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rRAIIO.' ROO.WILL, I
I
Defendant I
1M TH. OOURT or CONHOI 'Lla.
OUNIIRL~DCOU.TY, '....YLVANIA
OIVIL ACTION - LAW
MO.
COM P L A I N T
AND NOW comes Plaintiff by and through its attorney,
Arthur A. Kusic, Esquire, and respectfully represents the
followingl
1. Plaintiff, CHAMBERSaURG AREA LIFE SUPPORT SERVICE,
ia an ambulance service organized and existing under the laws of
the Commonwealth of Pennsylvania with its facilities located at
P.O. Box 427, chambersburg, Franklin county, Pennsylvania.
2. Defendant, FRANCIS ROCKWELL is an adult individual
residing at 93 Walnut Bottom Road, Shippensburg, Cumberland county,
pennsyl vania.
3. On or about January 29, 1990 through March 30, 1993,
Defendant, was given necessary emergency medical treatment and
emergency ambulance tranaportation to the chambersburg Hospital.
Plaintiff in good faith provided the necessary emergency medical
services to the Defendant and thereafter billed the Defendants for
those services and expenses incurred, which are its usual and
customary charges for these mervices.
4. Copies of the billing for services rendered to
Defendant by Plaintiff is attaohed hereto, made a part hereof and
marked Exhibit "A".
5. Defendant ie indebted to Plaintiff in the amount of
Eight Hundred and Thirty and 00/100 ($830.00) Dollars. A. evi~enae
Whereof, a copy of the Defendant's summary of Accounts 11 attaahed
hereto, made a part hereof and marked Exhibit "B".
6. Demand has been made upon Defendant for prompt
payment amount due, which demand hae gOI,e unheoded.
WHEREFORE, Plaintiff praye your Honorable Court to enter
JUdgment in its favQr and against: Defendant in the amount of
$830.00, along with interest at the rate of 6% per annum and the
aoate of this proceeding.
R~~
Art ur ,.'. !<ue c, - :re-
4201 Crums Mill Road '
Post Office Box 11585
Harrisburg, PA 17108
(717) 540-5610
Supreme Court No. 07207
Attorney for the Plaintiff
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OHAH.I.,.UIG ARIA L~r. SUPPOIT I IN Tal OOURT or ooMMol 'LIA.
...VIOI, I OUM.I.LAlD OOuny, 'InlYLVUIA
plaintiff I
V. I OIVIL AOTIol - LA.
I
rUJrol. .OO..ILL, I
I HO.
Defendant I
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,ot CHAMBERS BURG AREA LIFE SUPPORT SERVICE
verify that the statements made in the COMPLAIN'l' are true and
correct and that I am authorized to make this Verification on
behalf ot CHAMBERS BURG AREA LIFE SUPPORT SERVICE. I understand
that talse statements herein are subject to the penalties ot 18 Pa.
C. S. section 4904/ relating to unsworn falsification to authority.
CHAMBERSBURG AREA LIFE SUPPORT SERVICE
By~
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TITLEI
OATE I
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NAMI
_~HAMBERSBURG'
ALS SERVICE, INC.
ACCOUNTS; PAYABLE
>'
patient ,IJ)fo
~~&r~AS
~ms'l: W'l'
A.OORlss-J012S~' Iii I "'''Iqg 'I",'..~'l
~OCKWELL. FRAnCES F
CITY ~ J :: L ,\ t: IJ r n. 0 rr r" ~ n STAT I " .11
S::!'p,Il::"I)"'" P,\ I7ZS7
INI.INJIO (',":,:;", J,'( ;,7 532-'.l2\)~
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LW.Ho.1UJ .t ~ S~e
DATI Oll SlAVIC! / / ~- -; f U .'
,
procedure codes
j 100
~105
---LL110
---1-.115
120
125
~130
1040
1045
150
ApT
ZIP
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Bn.n.7VnlIA
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RUN "NUMW 27 ~)
!IU.OO GUIDE
CARDIAC MONITORING
OXYGIN THERAPY
PT ASSESS
I V THERAPY
I T TUBE
OIlF'.
MAST
MIDS
VITALS
MID CMND
$123,00 (CLASS 3)
Monitor
Oxygen (or any caDbo of the..)
Msessment
Vitals
~200.00 (CLASS 2)
Monitor HId CQImand
OxyJ.n ~Q.tick
Aues8llllnt Draw Blood
IV
Mad. (or any canbo of the..)
Vital.
$230.00 (CLASS 1 tlWW. CR CARDIAC)
Monitor IV ~ Ccmwld
Oxygen HId.s mil or
As.essment Vital. ET Tube
llIUb
H.."t
Of charge Info
CHARGI - - 12~ ~ 250 c::ircle
DATI IILLID /l13rt:
IILLID IV J/ '-
Re"'oI.W~J I\,s-'-)o/+dr
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C".",lItrtllur8 Alt.
Mv.noM Life 'uppoJ1 '11'11..
1I,Q, 'o~ fIT" 'I II
Chamberlburg, PA 17201
Phone: (717) ~lr1 '} (, I I I 1\'"
I,
8TAUMINT PAT,I
, ~ATIINT NUM"R
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STATlMINT DATI
I ,
PATIINT NUMBER
r ro..'vc.....uJ R (lr. k""..d..R.."
R, D (., 1\<.1.. },l
S IoJ"f1' ~>'(> Lv.,.' 'j I r II I-'), S 1
TO INSURE PRopeR CREDIT,
PLEASE RETURN THIS PORTION
O~ THE STATlMEN r WITH YOUR
PAYMENT
THAN~ YOU CAALSS
-----.
RUN NO, DATE Of SERVICE - DIBeRIPTION
t---.--__.I.--.
ClO -1,0', " :l..'l,') 0 ~ I)..,'j, () ()
'10 ' g Lj 1.. It, '},1-'1 () 11"l). ()l)
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CI 0, J,U 5 II OJ-'} () , ), tJ (), () (J
93, ()~ () 'i :J :,0 ,Il :-" II 3() 5, (l 0
I CHMGI
BALANCE RUN NO.
CODE
CHARGE
I I
"'00 Cerdlac Monllorlng
.,0& a.yo.n Therapy/Airway Malnt,nlnCI
.,10 Pall.nl "'''lIlmlnl
., I~ Inlra~.nou. Th,rapy,'Blood O"lIwlng
.'20 Endolrach'81lnluballon
,., ~e Oellbrlllatlon
HlOO Malt Trou.., Appllcallon
H'..o M'lllcellon Adtnlnhllrnllon
ItU~ Monitoring 01 VllalS!gna
HIM MedlcRI Cotllmllnd COn1rtlunICa'llonl
PLEA" !lAME CHECMI PAVAILE TO' CAALII
CURRENT
G,.eo DAVS
81.90 DAVS
PLEASE PAV
AMOUNT DUE
OVER 00 DAVS
AMOUNT DUI
OHaHal.S8URQ ARIA ~IrM suppoa, I 1M THI OOURT or OONHOM '~IA'
...VIOI, , OUKBlRUMD OOUIITY, '.IfIIIY~VMlIA
PldntUf I
V. I OIVIL AOTION ~ LAW
I
rauol. ROOJUf.~~, I
I NO.
Defendant I
COMPj,J\INT
AND NOW comes plaintiff by and through its attorney,
Arthur A. Rusic, Enquire, and respectfully represents the
t'ollowinyl
t. Plaintiff, CHAMBERSBURG AREA LIFE SUPPORT SERVICE,
i8 an ambulanoe service organized and existing under the laws of
the commonwealth of Pennsylvania with its facilities looated at
P.O. Box 427, Chambersburg, Franklin county, Pennsylvania.
2. Defendant, FRANCIS ROCRWELL is an adult individual
residing at 93 Walnut Bottom noad, shippensburg, Cumberland county,
Pennsylvania.
3. On or about January 29,1990 through March 30,1993,
Defendant, was given necessary emergency medical treatlTlent and
emergency ambulance transportation to the Chambersburg Hospital.
Plaintiff in good faith provided the necessary emer.gency medical
services to the Defendant and thereafter billed the Defendants for
those services and expenses incurred, which are its usual and
customary charges for these services.
4. copies of the billing for services rendered to
Defendant by Plaintiff is attached hereto, made a part hereof and
marked Exhibit "A".
SERVICE, INC.
PAYABLE
CHAMBERSBURG ALS
ACCOUNTS
F rM ~~ oS;' pat lent ' !11.f9
~ Ru".weL.':r
Ij~N' m~K""/~
F~'L LAST
ADORIII--l1~ l.I ~(:J" 2. $
CITY '5 k'PP'tJ~~t.I"'f
NAMI
LnT
APT
ZIP
STATI
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INI. INPft
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La1floN '"
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PNMP7VnllIQ. .-J- g".,
RUN NUMiiR ---.:IIiiiiI1iLDs'
DATI 0' SIRVICE
h;;~. ro
procedure codes
BILLING GUIDE
- -
AOo
~~5
/110
115
.120
125
1GO
~
~50
$125.0Q (CLASS 3)
Monitor
Oxygen (or any carbo of these)
As sesIlUlllnt
Vitals
CARDIAC MONITORING
OXYGEN THERAPY
PT ASSESS
I V THERAPY
I T TUBE
DI'IB
MAST
MEDS
VITALS
MID CMND
$200.00 (CLASS 2)
Monitor Med Cannard
Oxygen Dextrostick
AssesllUlllnt Draw Blood
IV
Meds (or any canbo of these)
Vitals
$250.00 (CLASS 1 'IllAUMA (]I. CARDIAC)
Monitor IV MIld CoIIJlImI
Oxygen Meds so%r
AssesllUlllnt Vitsls ET Tube
Defib
M.sst
,
charge Info
..
CHAROI - ~oo 250 circle
DATI IILLID /-,39 ~ ~tJ
IILLlD IV /$;f
R,v.t"'~I,,1 \"~G.'v'l t,\'-
-
~HAM8ERSBURG'
ALS SERVICE, INC.
ACCOUNTS: PAYABLE
"
patient ,1019
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-
LW,f,'o.lUl,t ~ S~e
DATE Of' SIRVICE / / ~..) f tJ .-
,
procedure codes BULIN; GUID~
$125.00 (CLASS 3)
loI.onitor
Oxygen (or any canbo of the..)
.~sessment
Vitals
,WM.9. (CLASS 2)
Monitor Mad C'.aImIn:l
Oxygen DextT.ostick
Aasessmenc Draw Blood
IV
Meds (or any caDbo of the..)
Vitals
$250.00 (CLASS 1 'IRAUiA CP. CARDIAC)
Monitor IV MIld o,-.~
Oxygen Mtds ard/or
Aasessmenc Vitals ET '1\Jbe
IlIfib
Hal"t
HAMI
~IRST L.AS!
AI)ORII8~ I~ I' I,' ',"10 :1", I.~dll
:\OCKIHLL. FH/lCES F
CITY 'll ~I L.\ ti I) T n. Q TT 0 ~ ~ n STATI \ I,. - II
5 f : P P [II ~ E IF :, P A 17 25 7
INI.I~ C'/!U:', F( 7,7 !H2-S2<)1)
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ZIP
B,Nrn:7VnlIA
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RUN NUMBER -2 rz g-5
J 100
~I 10e
110
lIe
120
lU
~'30
140
145
1110
CARDIAC MONITORING
OXYGEN THERAPY
PT ASSESS
I V THERAPY
I T TUBE
DUf'IB
MAST
MIDS
VITAL.S
MID CMND
charse Info
..
CHARGI- - 12~ ~ 250 circle
DATI BIL.L.ED / / /3rt:
BILL.ID BV J / L
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