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Home My WebLink About95-00885 ]1 - t.;.. -j '> < :] 11 r ~ .~ j -..;,; j I , ~ I j p:- I c:1 I d i ! ~'/ ::' '. ",' J' if """:" ,. " ,! ) i ) ~ ! \ I \j .. . 'Ii~, i: "1 \1' . ~ N THE COURT OF COMMON PLEAS 'UMBERLAND COUNTY, PENNSYLVAN 'IVIL ACTION - [,AW O. lARRISBURG HOSPITAL 'LA I N'rI FF 'HIRLEY FLOOD EFENDANT ~~(:) . '"'b ~ 4- ' ~ ' .,t>. \-: ~ C 0 M P L A I N T u.l VV y -. 'v\J \-' ~ -'. 'A) ~ " ,-..~:' .~, ~.. i1);;,~_ ,,' ' ,<~~ .' ,.: ~~:nl ~.~~ i 0-,0 -. ~ J.. I hereby errti',! the;! the within ., ,,-, ." 1 . .. :'.,<;J\. .'.- ; .;-;!,_~ ',FF c;)~r~~d copy l t~ w; ;,(' t i':"m, , ; :: l'~-.l , iO , ; . 'J'_: IVS . ;t>:ill...:fll lllay ;'1"; ',;L iir~. it..'U. ; '! i r i ,l tjun~:ndcd. ...A.- .. ,,,''If:Y I.lJ. No. {\ 7 1 (j 7 ARTHUR A. KUSIC ATTORNEY AT LAW 4201 CRUMS MILL ROAD P.O. Box 67015 HARRIS8URG, PENNSYLVANIA 17106.7015 (717) 540,5610 , ...., m = -.I 'w N W -0 -= - <<D ...", HARRISBURG HOSPITAL, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY PENNSYLVANIA V. SHIRLEY FLOOD, Defendant CIVIL ACTION - LAW NO. 70- 8f S- [}-L~JiA.M-- !,!QUC_~ 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 jUdgment may be entered against you by the court without further notice for any money claimed in the Complaint for any other claim or rel ief requested by the PIa i nt iff. 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 CAr4 GET LEGAL HELP. Lawyer Referral Cumberland Co. Court Administrator Fourth Floor 1 Courthouse Square Carlisle, PA 17013 (717) 240-6200 Respectfully submitted: ~IRE 4201 Crums Mill Road Post Office Boy 67015 Harrisb~r9. PA 17112 (717) 540-5610 SUPREME COURT NO. 07207 ATTORNEY FOR PLAINTIFF Dated: ~lIdq) HARRISBURG HOSPITAL, Plaintiff V. : : : ".: : : I IN THE COURT OF COHKON PLEAS CUKBERLANDCOUNTY, PENNSYLVANIA CIVIL ACTION - LAW SHIRLEY FLOOD, Defendant NO. COM P L A I N T AND NOW comes Plaintiff by and through its attorney, Arthur A. Kusic, Esquire, and respectfully represents the following: 1. Plaintiff, HARRISBURG HOSPITAL, is a hospital facility organized and existing under the laws of the Commonwealth of Pennsylvania located at South Front street, Harrisburg, Dauphin County, Pennsylvania. 2. Defendant, SHIRLEY FLOOD is an adult individual residing at 3600 Chestnut street, Camp Hill, Cumberland County, Pennsylvania. 3. On or about June 22, 1993 through June 25, 1993, Defendant was admitted to Plaintiff's facility for treatment. 4. Plaintiff in good fai th provided the necessary medical services to Defendant, and thereafter billed the Defendant for those services and expenses incurred. As evidence whereof, copies of the billing for services rendered to the Defendant are attached hereto, made a part hereof and marked Exhibit "A". 5. Plaintiff's charges for services rendered to the Defendant are its usual and customary charges. .- 6. Should the Defendant not be held liable for the necessary medical services provided, she would be unjustly enriched and the Plaintiff unjustly impoverished. 7. Any and all monies received have been credited to the account of the Defendant. 8. The Defendant is indebted to Plaintiff in the amount of Four Thousand Five Hundred and Twenty-Two and 64/100 ($4,522.64) Dollars. 9. Demand has been made upon Defendant for prompt payment amount due, which demand has gone unheeded. 10. Plaintiff avers that the amount due and owing does not exceed the jurisdictional amount requiring arbitration referral by local rule. WHEREFORE, Plaintiff prays your Honorable Court to enter Judgment in its favor and against Defendant in the amount of $4,522.64 along with interest at the rate of 6% per annum and the costs of this proceeding. si, uire 4201 Crums Mill Road Post Office Box 11585 Harrisburg, PA 17108 (717) 540-5610 Supreme Court No. 07207 Attorney for the Plaintiff DATED: V. I I I I I I I IN THB COURT OF COMMON PLEAS CUMBBRLANDCOUNTY, PBNNSYLVANIA CIVIL ACTION - LAW HARRISBURG HOSPITAL, plaintiff SHIRLI!IY FLOOD, Defendant NO, V I!I R I F I CAT ION I, HARRY PARK , the SUPERVISOR, OF of HARRISBURG HOSPITAL verify that the CREDIT & COLLECTION statements made in the COMPLAINT are true and correct and that I am authorized to make this Verification on behalf of HARRISBURG HOSPITAL. I understand that false statements herein are subject to the penalties of 18 Pal C. S. Section 4904, relating to unsworn falsification to authority. HARRISBURG By: HO:~ TJ:frLE: SUP RVISOR DATE: 12/29/94 , -: - , " '. " '. I.o:.JUi I t<IT "1\" ,.---- \__TYPE OF B~ I I DISCH I I INP. ' BENEFiTS ASQ'C vES NO vEl NO vEl NO Fie 5 B!LL.I~G CA"!'E f2'13 94 . , B;!.lING IIER:OC 00 00 , INSURANCE COveRAGE I B , . . T o SHIRLEY FLOOD 3600 CHESTNUT ST CAMP HILL PA 17011 L I PATIENT NuMBER I PATIENT NAVE 932543251 FLOOD. SHIRLEY DATE DESCRIPTION 06,21 06:21 06'21 06 :21 06'21 06 :21 06'21 , 06,21 06:21 06,21 06:21 06'21 06 :21 06'21 , 06,21 06:21 06,21 06 :21 06121 06 :21 06'21 06 :21 06'21 , 06,21 06:21 06,21 06:21 06'21 06 :21 06'21 , 06,21 06:21 06,21 06'21 , PRE-CERTIFICATION EMER MED VISIT III IV CATHETER IV ADM-ED ED VISIT I II CBC PROF MAN DIFF SED RATE - WSTRGREN CBC AUTO DIFF STAT BLOOD CULTURE BLOOD CULTURE URINEICYSTO CULT URINEICYSTO CULT MONOSPOT STAT URINALYSIS ROUTINE AMYLASE STAT BUN STAT CREATININE STAT ELECTROLYTES STAT GLUCOSE STAT URINALYSIS STAT ORAL MEDS ORAL MEDS INJECTABLE MED PHARMACY-EMER DEPT IV SOL GENERAL 0931 IV SOL GENERAL 0931 IV SOL GENERAL 0931 IV SOL GENERAL 0931 IV SOL GENERAL 0931 IV SOL GENERAL 0931 IV SOL GENERAL 0931 IV ADMINISTRATION ANGIOCAT-IV THPY OBS PT 1ST HR I;' l,.A TE CHARon FOR SERVICES FlENOEREO OCCUR, YOU W~ cECi::.VE A:ClT10NA~ e'L.WNG 12 13 GROUP NO 00 02 02 02 02 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 40 40 41 41 70 70 70 70 70 70 70 80 80 82 GARMA.NS ~ . CLJ POl-tCV NO I HARRISBURG HOSPITAL HARRISBURG. PA. 17101 717 - 782-3680 ~ I.R.S. 23.0675-330N AoumEO 06,22,93 PATIENT ....OUNT <..EEP ,:,... 5 cCl:if:O~ ;'01:1 vO...;; RECCROS _ _ ~ _ _ _ _ _ _ - - - - - - . - - - - - - - - - - . - ~:i'iic~ :.-~5 f::~I:i... r...is pcq,.tO~ ';;,,:,-;" PA';I.JE'~ - - - - - - - - - - - - - - - - - - - - - - -- - - 0'"""" I OH,'," "'" II B....MOA'E 1.,,,'s:,e,sE:"CE \ ", ,."OUNTCM MAKE CHECKS i "S"",ROE 'HE 1~~"~~ PAYABLE TO: 'I I I L ~ L____J CO;;".' _01&AA 2NO COVERAGe 3RO COVERAGE 25,00 80: 00 7' 00 12: 00 90' 00 28: 50 21' 00 , 28, 00 68: 00 68, 00 29: 00 29' 00 23: 50 19' 00 37: 00 25: 00 32,00 44: 00 25' 00 24: 00 4' 00 2: 64 3' 00 , 4,00 41: 00 41,00 41: 00 41' 00 41: 00 41' 00 82: 00 39: 00 8, 00 147' 00 , 25,00 80: 00 7' 00 12: 00 90' 00 28: 50 21' 00 , 28, 00 68: 00 68,00 29: 00 29' 00 23: 50 19' 00 37: 00 25: 00 32,00 44: 00 25' 00 24: 00 4' 00 2: 64 3' 00 , 4, 00 41: 00 41, 00 41: 00 41' 00 41: 00 41' 00 82: 00 39: 00 8, 00 147' 00 , TOTALS ~ SEEJ,AST PAGE See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms ~";:E C~ B..~ GARHA.NS ~ , c::=:r=l 811.LI~Q PERle:J ! 00 'QOTTf'ir1 . i ' I " a.ou~,o r-~~,o __I B~.."3 OA.~E 12"13'94 DISCH INP. ; e-E~E-C;~~IINSURANC:f: COvERAGE r~;-;~I---- VES NO vES NO '10 5 I . , L L T o L SHIRLEY FLOOD 3600 CHESTNUT ST CAMP HILL PA 17011 PATIENT Nu~BeR I PArle,..r ,..AlJE 932543251 FLOOD. SHIRLEY CATE OESCRIPTlON 10 10 10 41 41 41 70 70 I HARRISBURG HOSPITAL HARRISBURG, PA. 17101 717 - 782-3680 ~ I.R.S. 23.0875-330N OISCI1ARQEC 06,25,93 2ND COVEFU.QE 3RC COVEAAQE PATIENT AMOUNT 06,22 06:22 06'22 06:22 06'22 06:22 06'22 , 06,22 06:23 06,23 06:23 06'23 06:23 06'23 06:23 06 :23 06,24 06:24 06'24 06:24 06'24 06:24 06'24 , 06,24 06:24 06,24 06:24 06'24 06;24 06'24 06:25 06'25 , 06,25 06'25 , CBC PROF AUTO DIFF BLOOD CULTURE CHEM 18-PROFILE 1 INJECTABLE MED INJECTABLE MED INJECTABLE MED CATHETER TRAYS BABY POWDER ROOM 1117 M CBC PROF AUTO DIFF SMEAR ONLY STOOL CULTURE OVA & PARASITES TRICHROME STAIN CHEM 18-PROFILE 1 MICROBIOLOGY RF LAB ROOM 1117 M CBC PROF AUTO DIFF ANA ANTINUC AB QUAL CMV TOTAL C IGM ABDY CHEST PA & LATERAL ABDOMEN B MODE RETROPERITONEAL COMP IV SOL GENERAL 0931 IV SOL GENERAL 0931 IV SOL GENERAL 0931 IV SOL GENERAL 0931 IVAC 60DRP 3706 IV CONTROLLER-RENTAL SET UP CONTROLLER IV CONTROLLER-RENTAL IV SOL GENERAL 0931 IV SOL GENERAL 0931 IV SOL GENERAL 0931 23, 00 68: 00 50' 00 12: 00 30' 60 3: 00 42' 50 , 7,50 525: 00 23, 00 14: 00 53' 50 32: 00 21' 00 50: 00 82: 00 525, 00 23: 00 45' 00 55: 00 99' 90 312: 00 271' 00 , 41,00 41: 00 41' 00 41: 00 4' 50 29: 50 16' 00 29: 50 41' 00 , 41,00 41' 00 , 10 10 10 10 10 10 10 10 10 10 20 24 24 70 70 70 70 70 70 70 70 70 70 70 23, 00 68: 00 50' 00 12: 00 30' 60 3: 00 42' 50 , 7,50 525: 00 23, 00 14: 00 53' 50 32: 00 21' 00 , 50, 00 82: 00 525, 00 23: 00 45, 00 55: 00 99' 90 312: 00 271' 00 , 41,00 41: 00 41, 00 41: 00 4' 50 29: 50 16' 00 29: 50 41: 00 41,00 41' 00 , It: LATE CMARGES !:OR SERVICES I RE~OEREO OCCUR, VOu WILl. OECE"IEAn0oT10,^,.'",'a TOTALS ~ !;F:F: 1 >\SLfAGF: ! See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms o<fe:l:l ~..'s eol:"!' C" J::Qj:l vC..;R ca::cc:s - - - - - - ., - - - - - - - - - - - - - - - - - - - - - -::::iric= A-,,5 ClEr~a", T...~S poi::r'rI'C~ ...j.;" O:"V'/E';' - - - - - - ~ - - ~ - - - - - - - - - - - - . "A"'. '0 """" ","' I-':"'M CA"' . AC," 55 O'5E"'eE! ',C ""OU'.OCE! MAKE CHECKS _C-"e"A~-'_CA"-L ~""":::~ 'co', ."" PAYABLE TO: PATIENT.S BIRTHDATE BLUE CROSS GROUP NO. KEYSTONE HEALTH NO. BLUE CROSS CONTRACT NO. SUBSCRIBER GROUP NO. I I (ENCLOSE AUTHORIZATION) MEDICARE PATIENTS: PLEASE COMPLETE QUESTIONS BELOW AND SIGN. ANY QUESTIONS CONTACT HOSPITAL AT 782.3880. MEDICAL ASST. PATIENTS: YOU MUST BRING YOUR CARD WHICH RELATES TO THE DATE OF SERVICE TO HARRISBURG HOSPITAL CUSTOMER SERVICE OFFICE. COMMERCIAL INS. FORWARD A SIGNED INSURANCE CLAIM FORM FOR PROCESSING. CHAMPUS: RETURN COMPLETED AND SIGNED FORM ALONG WITH COPY OF CARDS. MEDICARE .... MEDICARE SECONDARY PAYOR ..... COMPLETE # 1. IS THE PATIENT OR PATIENT'S SPOUSE EMPLOYED? EFFECTIVE DATE PART A HOSPITAL PART B MEDICAL _YES _NO IF YES, COMPLETE A. ~ IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE? _ YES IF YES, COMPLETE C. IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? _ YES _ NO IF YES, NAME OF GROUP PLAN: 2. DOES PATIENT HAVE RENAL DISEASE OR HAD A KIDNEY TRANSPLANT? _ YES _ NO IF YES, COMPLETE C. @: IS PATIENT ENTITLED TO MEDICARE SOLELY ON THE BASIS OF RENAL DISEASE? _ YES - NO IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? _ YES _ NO IF YES, NAME OF GROUP PLAN: HAS PATIENT COMPLETED THE TWELVE (12) MONTH COORDINATION PERIOD? _ YES, STOP MEDICARE PRIMARY _ NO, SEE ABOVE GROUP INS. PLAN _NO 3. ARE SERVICES RELATED TO OR DUE TO AN AUTO ACCIDENT OR OTHER LIABILITY INCIDENT? _ YES _ NO IF YES, COMPLETE B. ~ WHAT TYPE OF ACCIDENT CAUSED THE ILLNESSilNJURY? _ AUTOMOBILE: INSURANCE COMPANY AND CLAIM NO, _ OTHER: SPECIFY WAS ANOTHER PARTY RESPONSIBLE FOR THIS ACCIDENT? _ YES NAME/ADDRESS OF RESPONSIBLE PARTY/LIABILITY INSURER: _NO 4. IS THIS ILLNESS OR INJURY WORK RELATED/BLACK LUNG? _YES _NO IF YES, EMPLOYER NAME AND ADDRESS AND TELEPHONE NO. 5. DOES THE PATIENT HAVE VA HEALTH BENEFITS THRU CARD #10.1174? 6. IS THE PATIENT A DISABLED MEDICARE BENEFICIARY UNDER AGE 85? _YES _NO YES NO MEDICARE ASSIGNMENT FORM I REQUEST PAYMENT OF AUTHORIZED MEDICARE BENEFITS TO ME, OR ON MY BEHALF FOR ANY SERVICES FURNISHED TO ME BY OR IN HARRISBURG HOSPITAL. INCLUDING PHYSICIAN SERVICES. I AUTHORIZE ANY HOLDER OF MEDICAL AND OTHER INFORMATION ABOUT ME TO MEDICARE AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR BENEFITS FOR RELATED SERVICE. SIGNED DATE PATIENT'S BIRTHDATE I BLUE CROSS GROUP NO, KEYSTONE HEALTH NO, BLUE CROSS CONTRACT NO SUBSCRIBER, GROUP NO (ENCLOSE AUTHORIZATION) MEDICARE PATIENTS: PLEASE COMPLETE QUESTIONS BELOW AND SIGN, ANY QUESTIONS CONTACT HOSPITAL AT 782.3880, MEDICAL ASST. PATIENTS: YOU MUST BRING YOUR CARD WHICH RELATES TO THE DATE OF SERVICE TO HARRISBURG HOSPITAL CUSTOMER SERVICE OFFICE, COMMERCIAL INS. FORWARD A SIGNED INSURANCE CLAIM FORM FOR PROCESSING. CHAMPUS: RETURN COMPLETED AND SIGNED FORM ALONG WITH COPY OF CARDS. MEDICARE .... MEDICARE SECONDARY PAYOR ., COMPLETE # EFFECTIVE DATE PART A HOSPITAL PART B MEDICAL 1. IS THE PATIENT OR PATIENT'S SPOUSE EMPLOYED? _YES _NO IF YES. COMPLETE A. ~ IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE? _ YES IF YES, COMPLETE C. IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? _ YES _ NO IF YES, NAME OF GROUP PLAN: _NO 2. DOES PATIENT HAVE RENAL DISEASE OR HAD A KIDNEY TRANSPLANT? _YES _NO IF YES. COMPLETE C. @: IS PATIENT ENTITLED TO MEDICARE SOLELY ON THE BASIS OF RENAL DISEASE? IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? _ YES IF YES. NAME OF GROUP PLAN: HAS PATIENT COMPLETED THE TWELVE (12) MONTH COORDINATION PERIOD? _ YES. STOP MEDICARE PRIMARY _ NO, SEE ABOVE GROUP INS. PLAN _YES _NO _NO 3. ARE SERVICES RELATED TO OR DUE TO AN AUTO ACCIDENT OR OTHER LIABILITY INCIDENT? _ YES _ NO IF YES, COMPLETE B. ~ WHAT TYPE OF ACCIDENT CAUSED THE ILLNESSIINJURY? _ AUTOMOBILE: INSURANCE COMPANY AND CLAIM NO. _ OTHER: SPECIFY WAS ANOTHER PARTY RESPONSIBLE FOR THIS ACCIDENT? _ YES NAME/ADDRESS OF RESPONSIBLE PARTY/LIABILITY INSURER: _NO 4. IS THIS ILLNESS OR INJURY WORK RELATED/BLACK LUNG? _YES _NO IF YES, EMPLOYER NAME AND ADDRESS AND TELEPHONE NO. 5. DOES THE PATIENT HAVE VA HEALTH BENEFITS THRU CARD #10.1174? _YES _NO 6. IS THE PATIENT A DISABLED MEDICARE BENEFICIARY UNDER AGE 65? YES NO MEDICARE ASSIGNMENT FORM I REOUEST PAYMENT OF AUTHORIZED MEDICARE BENEFITS TO ME, OR ON MY BEHALF FOR ANY SERVICES FURNISHED TO ME BY OR IN HARRISBURG HOSPITAL, INCLUDING PHYSICIAN SERVICES. I AUTHORIZE ANY HOLDER OF MEDICAL AND OTHER INFORMATION ABOUT ME TO MEDICARE AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR BENEFITS FOR RELATED SERVICE. SIGNED DATE -'- ._-------. -- ~--.----._. -_._---~..-.----.-_.._.._^.---.., Ty:lE Cl: B~.. B ..i.'~:J OArE i 8'w.lt.;O PEII:O::> : ~DlscH--rTnj-g41-oO'ooTT2~3j INP. I , . : , i , ..---.---' -I t BEP\EFITS ASIJ'O I~SuRAP\CE COVERAGE I QROuP",O >-- YES NO YES NO VES NO FlC 5 I B , L L T o SHIRLEY FLOOD 3600 CHESTNUT ST CAMP HILL PA 17011 L PATIENT NuMBER I PATIENT NA.VE 932543251 FLOOD, SHIRLEY DATE DESCRIPTION SOGIAL SECURITY NO. - 207-44-09 1 BlijTH ATE - 08/22/41 SEX - ~ITA STATUS - S RA(!E - W , ADIIITT NG DOCTOR - AT1END NG DOCTOR - DRG CO E - 421 DI4GNO IS - P DIAGNO IS - 5 DI,4,GNO IS - S DIAGNO IS - 5 DIAGNO IS - S DlAGNO IS - S , DIAGNO IS - S 275.3 PRQCED RE - NOT ENTERED. PRINCI AL PROCEDURE DATE - NOT PR1NCI AL SURGEON - NOT ENTERED ADIIINI TRATION CLASS - 2-URGEN DI~CH GE STATUS - ROUTINE POt ICY HOLDER EIIPLOYER - TENDER , POLICY HOLDER - NOT ENTERED. GRACE AYS - 0 COVERE DAYS - 000 TR~ATH NT AUTHORITY - APPROV 0 FROH - AP~ROV 0 THRU - POuCY NO. I .-J GARIW!S ~ . c::::::LJ HARRISBURG HOSPITAL HARRISBURG, PA. 17101 717 - 782-3680 39920 PRES-L~G-GINN 39058 GERACI ASPERE C , , , , I I , I , , , I , I I TERED 078.5 276.8 276.5 287.4 724.2 346.90 LOVING' C , , I I I I I I , I I , I I , I I , , , , E , I I I I I , I I I /999 I I I I I I I I I , I I , I I I I I I , , I.R.S. 23-0675-330N PATIENT AMOUNT 2ND COVERAOE 3RO COVERA~E , I I , I I I I I 02526'4E I il= L.loTE CMAROES FOR SERVlCES I:lE~CEREO OCCUR. VOU WIl.:. TOTALS .... cECEvE Acomo", a~'G ...- , See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms r "'4. .......... _, _ _ _ ,7JJ, -: ]!l2-:39!lQ _ _ _ _ _ _ _ _ _ _"'-E~T~~.~"''''.'O'!C,C~.~C,C~O~ - - - -, - - - - - -, - - - - - - - - - - - - -, - , -- :::~AC- :....0 j:;;Ei..C'" ~...s "'Olr 0... \'11'1',.. PAVPJE...... =:....... N4Vl: 9'~i"'O O.r.~E I AC'l:SSC~!SEI:l',:C!:! l=iC 1 AMOuNT C\,;E I 12 13 ,94 I 06 ' 22 ,93 l:CC'J _2lJ,a.:. 932543251 FLOOD MAKE CHECKS PAYABLE TO: SHIRLEY HARRISBURG HOSPITAL 5 4772.61+ AtlOV..-r P..-o I I ::::sc...r.Fl3e CArE 06 ' 25,93 V. CIVIL ACTION - LAW NO. 95 - 885 Civil Term . ~ HARRISBURG HOSPITAL, Plaintiff IN THE COURT OF COMMON PLEAS ~ COUNTY PENNSYLVANIA SH:rRLEY FLOOD, Defendant P RAE C I P E TO THE PROTHONOTARY: Pursuant to Rule 237.1 of the Pennsylvania Rules of Civi 1 Procedure. Notice of Praecipe for Entry of Default Judgment has been given to the Defendant: a copy of said notice is attached hereto. P1 ease enter Judgment in favor of the P I a i nt i ff and interest at the rate of 6.00% from !H~ 5.;!;!--.9~______ 2/17/95 --.--.- along with against Defendant. in the amount of . and the costs of this proceeding for fai lure to enter a defense or otherwise file a responsive pleading in the above captioned matter. DATE: 'b\2f:I\q( / /~ C.-AR 420 P.O. Box 67015 Harrisburg. PA 17106 (717) 540-5610 ATTORNEY FOR PLAINTIFF SUPREME COURT NO. 07207 HARRISBURG HOSPITAL, Plaintiff IN THE COURT OF COMMON PLEAS ~ COUNTY PENNSYLVANIA : V. SH:rRLEY FLOOD, : CIVIL ACTION - LAW NO. 95 - 885 Civil Term Defendant . . TO: Shirley Flood Defendant You are hereby notified that on ~ .3/, /'lr;1' the following Judgment has been entered against you -~.the above- captioned case. Amount: In the amoWlt of $4,522.64 along with interest at the rate of 6.00% fran 2/17/95. Date: _~ -Y.LL.t"!L__ j;'~".~u' P. Iu~ Prothonotary T' I hereby certify that the name and address of the proper person(s) to receive this Notice under Pa.R.Civ.P. Section 236 is: Shirley Flood 3600 Chestnut street Camp Hill, PA 17011 Defendant Arthur A. Kusic, Esquire Supreme Court No: 07207 4201 Crums Hill Road Harrisburg, PA 17112 (7 I 7) 540-5610 Attorney for Plaintiff HARRISBURG HOSPITAL, Plaintiff : IN THE COURT OF COHHON PLEAS CUMBERLANoCOUNTY, PENNSYLVANIA : v. : CIVIL' ACTION - LAW : NO. 95 - 885 Civil Term SHIRLEY FLOOD, : : : Defendant : IHPQRTANT NQTICE TO: Shirley Flood DATE OF NOTICE: March 15,1995 YOU ARE IN DEFAUL T BECAUSE YOU HA VE FAILED TO TAKE ACTION REQUIRED OF YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MA Y 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: RESPECTFULLY SUBHITTED: , ESQUIRE v. : : : : : : : : : : : IN THE CUURr OF COMMON PLEAS CUMBERLA~UNTY. PENNSYLVANIA CIVIL ACTION - LAW NO. 95 - 885 civil Term HARRISBURG HOSPITAL, Plaintiff SHIRLEY FLOOD, Defendant CERTIFICATE OF SERVICE I. Arthur A. KUSIC. Esquire. do hereby certify that on this. __IS.to._ _ _h. da.Y of Marc_h__.... , 19..J!.5, r placed in the United States Mail true and correct copIes of 1 0 D~Y._Ifo1~QR_'!'l\.N.~__.____ ~<!TICE!> '-_. ... addressed to following: ., Shirley Flood 3600 Chestnut st. Camp Hill, PA 17011 . ,~ 17112 <,.,0 -::I: ~~, .~ :Jg~;~ ~ .., : r..u - ;;l'" ~!LI '-~ ~.. tn' 'r' ~ -:~...-. cs r-...... ....f~ .~;~f;~ '" 'iL N J !;c; ~ J'f"! ~ ...."'. -- ~i> """," - '" ..., u:o .." C -l r ~ ..tl , f. 2- ~ t 'l:\ ft. l.u C" "" ~ ~ . .., "\