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,
KENNETII G. SMALL
PH. D. & ASSOCIATES,
Plaintiffs
vs.
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNfY, PENNSYLVANIA
.
.
.
.
: CIVIL ACTION - LAW
: qJ' 4jS7 (t~t.:....L .J(-c~t--
: NO. CV 132-95-
DANIEL P. CAMPBELL,
Defendant
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 an 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 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 HA VB A LAWYER OR CANNOT AFFORD ONE, 00 TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
ALSO BE FOREWARNED AND NOTIFIED THAT 1HIS IS AN ATI'EMPT TO
mI.l.RM' A DEBT. AND ANY INFORMATION OBTAINED WILL BE USED FOR 1HAT
PURPOSE.
Court Administrator - Third Roor
Cumberland County Coun House
Carlisle, PA 17013
Tele: (717) 240-6200
r:fM& F Jlll~
Charles E. Shields, III
Anorney for Plaintiff
" .'~".'...'.'."'.".~"""-~_.......,..,"""._,,,,"~.~ - ,."-'
.
KENNETH G. SHALL,
Ph.D. & ASSOCIATES,
Plaintiff
: IN TIlE COURT OF C<HtON PLEAS OF
;CUHBERLAND COUNTY, PENNSYLVANIA
.
.
;CIVIL TERM 95-4387
v.
DANIEL P. CAMPBELL,
Defendant
.
.
:NO. CV-132-95 CIVIL 1995
TO TIlE HONORABLE JUDGES OF SAID COURT;
AND NOW cOIIes the Plaintiff, KENNETH G. SHALL, Ph.D. AND ASSOCIATES, by
his attorney, Charles E. Shields, III, Esquire, and files the following
complaint, respectfully representing as follows;
CGlPLAINT
1. The plaintiff is Kenneth G. Small, an adult individual, who
operates as a sole proprietorship, Kenneth G. Small, Ph.D. & Associates, having
an address at and conducting his practice at 410 E. Main Street, in the Borough
of Mechanicsburg, County of Cumberland, Commonwealth of Pennsylvania.
2. The Defendant is an adult individual, who resides at 3203
Schoolhouse Lane, Harrisburg, PA 17109, County of Dauphin, Commonwealth of
Pennsylvania.
3. Defendant was admitted a6 an inpatient to Seidle Memorial Hospital
under the care of doctor Jay Cho, M.D., on August 26, 1994.
4. Defendant signed a consent to: "routine examination, diagnostic
procedures, and medical treatment as ordered by Dr. Cho and his/her assistants
or designees..." on August 26, 1994.
5. Dr. Cho wrote an order on September 15, 1994, for a diagnostic
examination by Plaintiff.
6. Plaintiff is a licensed psychologist in and for the Commonwealth of
Pennsylvania.
7. Plaintiff provided to Defendant, a diagnostic examination at Seidle
Melorial Hospital on September 18, 1994.
8. At no time during the performance of the diagnostic examination by
Plaintiff to the Defendant did the Defendant revoke orally or in writing his
consent for the diagnostic examination.
9. At the time of the diagnostic examination, the Defendant agreed to
a follow-up appointment in which he would receive a cassette tape provided by
the Plaintiff for the purposes of regular listening to the tape.
10. Plaintiff provided said cassette tape to the Defendant on September
20, 1994. The Defendant received the cassette tape.
11. Following receiving the cassette tape, the Defendant orally
notified the Plaintiff that he was declining further services by the Plaintiff.
12. The Plaintiff did not charge the Defendant for the cassette tape or
this brief visit on September 20, 1994.
13. The Plaintiff provided a report of his diagnostic examination at
Seidle Memorial Hospital team conference on September 20, 1994, to Dr. Cho,
nursing, physical therapy staff, occupational therapy staff, and the rehab
program manager.
14. Plaintiff submitted a statement for services rendered on the
diagnostic examination and the report at team conference to the Defendant's
automobile insurance. The diagnostic code for these services are 90801 and
90887 respectfully.
15. Plaintiff received a letter dated January 11. 1995, from
Defendant's automobile insurance indicating that the Defendant's medical
benefits had been exhausted, and that "all bills not covered due to exhausted
policy limits are the responsibility of the injured party." The letter further
stated that "Medical providers can bill the patient or secondary insurance
carrier directly once auto insurance benefits are exhausted."
16. Plaintiff's office sent Defendant a letter dated January 18, 1995,
notifying him of his exhausted auto policy medical limits, and requested
information on his secondary health insurance for billing purposes. The letter
also indicated that Plaintiff's office would await payment pending a lawsuit if
a letter was submitted by his attorney protecting Plaintiff's fees.
17. As of March 17, 1995, Plaintiff did not receive any communication
from Defendant.
18. Plaintiff sent a second letter dated March 17, 1995. to Defendant
requesting that Defendant address his delinquent account. Said letter notified
Defendant of a 15 working day limit prior to submitting to Small Claims Court.
19. Plaintiff did not receive any communication from Defendant through
April 24, 1995.
20. Plaintiff filed a civil complaint against Defendant on April 25.
1995.
21. Despite Plaintiff's repeated demands for payment, Defendant has
failed and continues to fail to make payment.
WHEREFORE Plaintiff prays this Honorable Court for judgaent against Defendant
in the total amount of Two Hundred, Ten and 00/100 ($210.00) dollars plus costs
and interest sec. leg.
atAf~
CHARLES E. SHIELDS, III
Attorney for Plaintiff
.' ..
I, Kenneth G. ~11. Ph.D. & Associates verify that the facts set forth in this
coeplaint are true and correct to the best of my knowledge, information, and
belief. This statement is made subject to the penalties of Section 4904 of the
Crimes Code (18PA.S.C.A. & 4904) related to unsworn falsification to
author! ties.
( ~ ~s;..,J-P fI--
(Signature of Plaintiff or Authorized Agent
"'..... ,0..'-....".""."',
'.'
Daniel P. Campbl1l:.
I'.'.
II" eGG.
NOTICE OF APPEAL
llOMMOrJ\vEALTH OF PENNSVLVANIA
COURT OF COMMON PLEAS
FROM
JUDICIAL DISTRICT
DISTRICT JUSTICE JUDGMENT
95-4387 Civil Term
COMMON PLEAS No, OU U 001 J:! 9i.
NOllce " given thaI thil~APllellantha' "'cd in Ihe ahove Courl 01 COlllmon Plea, an app"al frolll Ihe judgment rend",,,d by Iho Di'trict Justice
on the date and In the case muntionod hulow.
NOTICE OF APPEAL
\),
........ G,I'. ",0:-0-" "'....... u" D.'.
09-3-05 Ronald E. Klair
CIT"
APD.... D" ......""."',
,<-
3203 Schoolhouse La~.; Harrisburg, PA 17109
D.'. 0.. '...D....."" ~ I'" ,H. e..... 0," ,,,..'~, ",
'1....-1..."
7/28/95
Kenneth G. Small, PHD & Associates
VI,
..,,"'.'.....0'" ......""..., o. HII ""0""'." 0" .....n
Daniel P. Campbell
This hlock will be signed ONL V when this notation is required under Pa.
R,C,P,J,P, No, 1008B.
Thts Notice of Apllcal. when ,eceived by the Oisuict Justjct.!. will operate as
a SUPERSEDEAS to the judgment lor possession in this case.
CV-132-95
TA 19
LT 19
~2-'h'lt
Terrence J, McGow"'cm, Esq,
1:".1'" "'0.
If appel/alll was C/ailllarlt (see Pa, R,C,P,J.P,
No. 100/(61 ill actioll be(ore District Jus rice. 110
MUST FILE A COMPLAINT withill twelltV (20)
tlays a(rer (ilillg llis NOTICE o( APPEAL.
s,gNdrure 0' Pro,hullOf,1ry or DcpIJ'Y
PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE
(This sectioll o( (orlll to be IIsccl ONL Y whell appel/am was DEFENDANT (see Pa. R.C.P.J,P. No, 1001(7) ill actioll be(ore District Jllstice,
IF NOT USED. tletach (rolll copy o( 1I0tice o( appeal to be serveel IIpOIl appel/ee).
PRAECIPE: To Prothonotary
En'", rul" upon Kenneth G. Small. PHD & Associates . appelleo(.I, 10 file a COlllplaint ill this appoal
Qo;_4387 ,Cj.yil T&i\Y' 01 JPpo/lee'sJ
(Com111011 PI "a' No, ~ I wilhin twenty (201 day' alter service of rule or .ulfer en" of of judgmenl of non pros.
s .,uorney or dgf!lIt
RULE: To
Kenneth G. Snall. A1D & JlSSOC'iRtes II (I
. appc cc s
N.1I'w 01 iJ/Jpelllw(d
111 Vou are notified thaI a rule is hereby entorell UIIOII you to file a COl11lllaint in this allll.al wilhin twenlY 1201 days alter the dale of
SClvicl! ul this ,ule upon you by personal service OJ hy cl!uilicd or registered mail.
(2) "you do not file a COl11lllainl within tl".lil11e, a JUDGMENT OF NON PROS WILL BE ENTERED AGAINST VOU.
(3) Tim date ot service of this rule if service was by mail is the date 01 mailiny.
;-g)'
or;
Date:.-AJ.lq. 16, .19-2?
AOPC 312.84
COURT FILE TO BE FILED WITH PROTHONOTARY
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