The URL can be used to link to this page

Home My WebLink About95-04904 ~ (f)~ .- j dJl I -JI ~ 'Q. Jl -fJ - '\.. - ~ 7- - '~. :f ~ f. ... ~ J -:t' o 0- -r I \fJ i 0-: ) f / / , . . j' .' HOLY SPIRIT HOEPITAL, IN THE COURT OF COMMON PLEAS ~ COUNTY PENNSYLVANIA Plaintiff V. ARTHUR G. BIGGS and FRANCES I. BIGGS, Defendant CIVIL ACTION - LAW (I ( t':' ( ")f t NO.1)' 9q(,4 NOTICE You have been sued ln court. If you wlsh to defend agalnst the clalms set forth in the followlng pages, you must take action withln twenty (20) days after this Complaint and Notlce are served. by entering a wrltten appearance personally or bv attorney and fl1ing ln wrltlng with the court your defenses or obJectlons to the claims set forth against you. You are warned that if you fail to do so, the case may proceed wlthout you and Judgment may be entered agalnst vou bv the court wlthout further notice for any money clalmed ln the Complalnt for any other clalm or rellef requested by the Plalntlff. You may lose money or prooertv or other rlghts lmportant to you. YOU SHOULD TM,E THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAwvER OR CANNOT AFi=ORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO F I NO OUT WHERE YOU CAli GE T LEGA L HELP. LAWYER REFERRAL Cumberland Co. Court Admin. Fourth Floor One Courthouse Square Carlisle, PA 17013-3387 (717) 240-6200 Resnectflll;y s"bm,.ted: , ~~~~:C'U:R~ 4201 Cru~s MIll Roaa Post Offlce 80- 670'5 Harr' sb Irq. PA . 7112 1717) ~4(1-56'1l SUPREME COURT NO. 07207 ATTORr.E, FOR Pt,AIIIT I FI Dateo: ~~'..... HOLY SPIRIT HOSPITAL, . IN THE COURT OF COMMON PLEAS . plaintiff . CUMBERLAND COUNTY, PENNSYLVANIA . : V. . CIVIL ACTION - LAW . . . ARTHUR G. BIGGS and . NO. . FRAlfCBS I. BIGGS, . . Defendants . . 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, HOLY SPIRIT 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. Defendants, ARTHUR G. BIGGS and FRANCES 1. BIGGS are adult married individuals residing at 222 East Main street, Shiremanstown, Cumberland County, Pennsylvania 17011. 3. On or about January 24, 1993 through February 10, 1993, Plaintiff, at the request of the Defendants, did provide health care services to Defendant, Frances I. Biggs. 4. Plaintiff in good faith provided the necessary health care services to the Defendant, Frances I. Biggs and thereafter billed Defendants its usual and customary charges for the services rendered. As evidence thereof, a copies of the billing for services rendered to Defendant, Frances I. Biggs are attached hereto, made a part hereof and marked Exhibit "AM. 5. Plaintiff did credit Defendants' account with all payments made on the account and there now remains a balance due and owing of $19,616.09. 6. The purpose of this communication is to collect a debt and any information obtained will be used for that purpose. COUNT I. (Plaintiff v. Frances I. Biggs) (Quantum meruit) 7. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 6. 8. Plaintiff did render health care services to Defendant with the reasonable expectation that payment for such services would be made by the party benefitted. 9. Should Defendant not be required to pay for the balance due for the services rendered, Defendant would be unjustly enriched at Plaintiff's expense. WHEREFORE, Plaintiff pray your Honorable Court to enter Judgment in its favor and against Defendant Frances I. Biggs in the amount of $19.616.09, along with interest at the rate of 6\ per annum and the costs of this proceeding. COUNT II. (Plaintiff v. Arthur G. Biggs) (Doctrine of necessaries) 10. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 9. 11. Plaintiff believes and therefore avers that the health care services rendered, upon request, to Defendant Frances I. Biggs, wife of the Defendant Arthur G. Biggs, were necessary for her benefit and welfare. 12. Plaintiff believes and therefore avers that pursuant to the "doctrine of necessaries", Defendant Arthur G. Biggs, as spouse of the recipient of health care services, is liable to plaintiff for the balance due. 13. Should Defendant Arthur G. Biggs not be held liable to Plaintiff for payment of services rendered his wife, he would be unjustly enriched as the services were necessary to benefit the health and welfare of his spouse and their marital union. 14. plaintiff has made demands for payment upon Defendant, which demands remain unheeded. WHEREFORE, Plaintiff prays your Honorable Court to enter Judgment in its favor and against Defendant Arthur G. Biggs in the amount of $19,616.09 along with interest at the rate of 6\ per annum and the costs of this proceeding. COUNT III. (Plaintiff v. Arthur G. Biggs) (statute) 15. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 14. 16. Pursuant to 23 Pa.C.S.A. 4321, married persons are liable for the support of each other. 17. Pursuant to 23 Pa.C.S.A. 4102, where debts are contracted for necessaries by either spouse, a creditor may institute suit against the husband and wife for the price of the necessaries. 18. Plaintiff did render necessary health care services to Defendant Frances I. Biggs with the reasonable expectation that such services would be paid for by the persons benefitted, which in the instant case include said Defendant and her spouse, Defendant Arthur G. Biggs as partner in the marital union. 19. Plaintiff has made demands for payment upon Defendant, which demands remain unheeded. WHEREFORE, Plaintiff prays your Honorable Court to enter Judgment in its favor and against Defendant Arthur G. Biggs in the amount of $19,616.09 along with interest at the rate of 6% per annum and the costs of this proceeding. COUNT IV. (Plaintiff v. Arthur G. Biggs & Frances I. Biggs) (Total) 20. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 19. 21. Plaintiff has made demands for payment upon the Defendants for the balance due of $19,616.09, which demands remain unheeded. 22. 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 Defendants in the amount of $19,616.09 along with interest at the rate of 6% per annum and the costs of this proceeding. RESPECTfULLY /~,''-' ~ Art ur A. Kusic, Esquire 4201 Crums Hill Road Post Office Box 11585 Harrisburg, PA 17108 (717) 540-5610 Supreme Court No. 07207 Attorney for the Plaintiff DATED: HOLY SPIRIT HOSPITAL, plaintiff . . IN THE COURT OF COMMON PLEAS CUMBERLAHDCOUNTY, PENNSYLVANIA . . : CIVIL ACTION - LAW V. . . . . ARTHUR G. BIGGS and FRANCES I. BIGGS, Defendants . . NO. . . . . V E R I F I CAT I 0 N I, MR. GEORGE BOWERS , the CREOIT OFFICE MANAGER of HOLY SPIRIT HOSPITAL verify that the statements made in the COMPLAINT are true and correct and that I am authorized to make this Verification on behalf of HOLY SPIRIT HOSPITAL. I understand that false statements herein are subject to the penalties of 18 Pa. C. S. section 4904, relating to unsworn falsification to authority. HOLY SPIRIT HOSPITAL ~c-~ By: TITLE: C~-r "rF;,~ ..._.f'" DATE: 811.,-/,S- ~::'. .lj ," '-;'-j ~ HOLY SPIRIT'~~~~'I~~t".'1jlll.'l ""7717 [~.'~-J ' N =r" 'I' '9' - 003 NORIH ;>151 51REL1 IHRTH-D^TE [J' ',".' F-l A ~. ~. ~ CAI.lP HILI PENNSYLVANIA 11011,221)8 FEI. e3-1512741 03/30/43 ~'S S ~F~:~~~j~;'~-=--=-]~.;~_~~~~'~J'l~~Jo~/2~;;'31~~~,;-~Li,J I ~ --~---~~:-._--~] ,."'"'' .,_,1.'1;(" Pl.lUf' '11.",11\1 II ---------- _..._-~._.-._~_. _._< COR 1;'.11"",_" ','I""",l,_,,'," 195320 NAM[ ARTHUR G BIGGS 222 EAST "AIN STREET SHIRE"ANSTOWN,PA 17011 I 361 AND 86 AZIZKHAN REZA "D --------- ----.---- ADORess PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I '~',;'y~:~r,,7' I $ Of. C,Cfl'prIOt~5 OJ HO'iPITAl SERVI(f:'; SEltvlCI: CODE !UrAL (HAHnl ~; Io.,r ,r,,,plA.,! I (<,1 '-,l.V1...~.t .' l' ~ r-' -' ~l') , ' '.',' I I f j1 1 : I , DETAIIL OF CURRENT CHARGES. PA~"ENTS ANd ADJUST"ENTS 01/23 GLUCOSE 012520109 20.00 i 20.00l 01/23 [RENAL PROFILE 012520155 62,OO! 62.00! 01/23 ;A"YLASE, BLOOD 012520340 I 53.00! 53.00! 01/23 lCBC ~/3 PART DIOl2530120li 29.00 Ii 29.00 I 01123 ,SPEC COLLECT FE0125101031i 7,00 i 7.00 \ 01123 STAT HANDLING F012510368~ 10.00 i 10.00 i 01/23 STAT HANDLING F0125103711 10.00' 10.00 I 01/23 STAT HANDLING FOI2510J73~ 10,00: 10.00 i 01/23 STAT HANDLING F012510374~ 10.00 10,00 I 01/23 "BD/OBST SERIESOI3610196 158.00 158.00 i 01/23 GALL8LADDER US 013611406 364.00 364,00 I 01/2~ "EP 75"G INJ VIOl440el20a 1.75 1,75 \' 01/2~ "EP 75"' INJ VI014402120~ 1,75 1.75 01/24 "5 10"G VIAL 0144021251: 2,00 2,00 I 01/2~ CFX lG" IVPB FR02440B045 64.50 64.50 \ D1/2~ CFX 2'" IVPB 014408046 214.14 214.14, 01/2~ BENTYL 10"G A"P024412033 81.34 81.34 I 01/2~ HYDROXY 50"G/"LOI44280691 1.00 1.00 I )1/2~ HYDROXY SO"G/"LOI44280691 1,00 1.00 ) llC~ TOR "DOL 30"CO/"L034428089~ 7S. 00, 75.00 )112~ ANES CHARGE 034499990 18.75 ' 18,75 )1/2~ NACL 0,9 1000 011613063 8.50 8,50 )I/2~ LRS 1000 01161J068~ 9.50 I 9.50 )1/2~ "NESTHESIA SET 011613103' 16.50 1650 )1/2~ D5/0,45NS/IOK10011613J14~ 12.00' 12.00 01/24 D5/0.45NS/IOKI00116133'4~ 12.00 12,00 )1/2~ D5/04SNS/IOK1001161J3142 12.00 12.00 01/2~ D5/045NS/IOKI00el6133142 24,00 2~.00 )1/2~ D5/0.~5NS/IOKI0011613314~ 12.00 12,00 )1/24 D5/0.45NS/'OKI00116'3314~ 1200~ le.oo~ )l/e~ SECONDARY SET 10116133167 725 7.25 )1/24 ""5K OXYGEN ADU011410621~ 2.50 2.50 l1/2~ EXERCISER VOLU"01141078S8 17 75 17.75 , ."-----..--- -----..---.,. .,.., I: -- ',' h_h~T~ ....i.-___..___.. ., .:-::;;:,-~-'T i )' II c: ~" 1! ;"" 1.:, .; ,I I' I l . I .\ t- ;t"" \ ' "\ \' ~_ \, r. \ 1 i_ " - ~ t t 'i. :\ ~ . '.\ HOL V SPIRIT HOSPITAL .... .,(\; '",HIIH , c,l ",;HI! . '". .\' ,', . ~ I " , ' .\ l '~, rovfRACtr \ _ ,',', co tlO 1 , i i I I t.<;l cOvERAGE ,filS en NO" PA,TllNl AMOUN.T '-r ", ,-,.t.,. ; -'., .."1\1 'FP , ;,<:,: COB ___d__~::~:"~I\.:jll ,''''I.'f-'V., :Io\"'~___~_ _,~;~,~, P()IY~Y Nut.lHfll [,' ~'1"] ~ , j HOl VSPIAIT' ~~~~,; ~t'""''''' """. [.C;;~ F".l~ FE' '~'-1 51 .,'W ,~::', "~!:~~;;:;,~::'~~~" ".. .:~~~;~:~E ["I r;---. "^",,,,,,,,., -f~_-"'"'''''''''''''' I,-.j '"'' . ','- ,_.'J'" \ ..",\,.,.! -..j ! ...., < ] t:lli.t-'f:~'.':' ;=---=r~ ~~:=~~-<,_hlJ"I..':~.'-lliiii;F~==~~~ PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ \,~~,c;;'El,,~. I $ t+A"r ARTHUR (; 81"8 2ee EA8T "AIM 8TREET 8HIRE"AM8TOUM,PA 11011 .~o AOOR[5f; :'tSClliPlIONS Of 1,('SP,1 Al SfRI,'IC[5 ,,>[RVICE CODE , Ot/2~ IAM(;IOCATH 20 01/P.~ IANlllOCATH eo 01t~12168 01/2~ I,TOOTHETTE8 DENTOt t ~t 2el3 Ol/2~ ISTATMASTER Oll~I22~6 01/2~iTRANS-DRESS IV 011~t22S1 01/2~ ADMISSION ~IT Oll~I260S o "2~ 'IRR IGAT10N SET 011 ~12676 01/2~ llASTROGRAPHIN 013620896 01/2~ CONT OPTIRAY 10013622332 01/2~ ,CONT OPTIRAY 50013622333 01/2~ ,CHEMISTRY PROFI01252010S 01/2~ ELECTROLYTES 012520200 01/2~ AMYLASE. BLOOD Ot2S203~0 1 01/2~ LIPASE Ot2520350~ o 112~ UR IN. (NO MICROOI 25221 I O~ O1l2~ URIN. (NO "ICROOI2522\10~ 01/2~ MICROSCOPIC. UR012522190~ OI/2~MICROSCOPIC. UR012522190~ 01/2~ CBC U/3 PART DI012530120~ 01/2~ CBC U/3 PART DIOt2SJOI201\ 01/2~ DIFFERENTIAL 012530180~ )1/2~ APTT 012530310. )1/2~ PROTHRO"BIN TIM012530320~ )1/2~ URINE CULTURE 0125~0210. )1/2~ URINE CULTURE 0125~02108 )1/2~ TYPE/SCREEN 012580107~ )1/2~ CELL PANEL 0125801~08 )1/2~ ANTIGEN SCREEN 0225801~5~ )1/24 CROSSHATCH. 'looe2S802000 )1/24 SPEC COLLECT FEOleSI01031 )1/24 SPEC COLLECT FE0125101011 )1/24 STAT HANDlINll FOl25103680 )1/24 STAT HANDLIN' F012510171~ )1/24 STAT HANDLIN; FOl25103730 .,,-'!'.,' - . r' , .; j 101f\L CH/lJ~(',[S 2.50 2.50 3.00 \ I I. 00 \ 1.00 6.00 3.50 \ 28.75 15'3.25 77.00 I' 63.00 53.00 I 53.00 \ 53.00, 11.00 \ I 1.00 \ , \1 .00 i I 1.00 I I 29.00 : 29 .00 i \1 .00 \ 31.00 '. 20.00 26.00 26.00 5~.00 74 00 52.00 106.00 700 7.00 10.00 10 .00 10.00 1 361 86 195'320 --- _.-..._._-_.._------~-~ AZIZKHAN REZA MD (ST (J".'ffltoC,t E.Sl I.O\'fHAOL [>;1 CO..-[IMGf [51 COIIEnAGE ,t.Si})N,)' :~~<:;cnh02 IN~,(nNO') INS CO N()4 pAPfNT A.M()\:NT 2.50 2.50 3.00 i I 1.00 I 1.00 \ 6.00 3.50 I 28.75 I 153.25 \ 77.00 63.00 I 53.00 ! 53.00 i 53.00 \ 1 1.00 \ \1 .00 I \1.00 ! I 11.00 I 29.00 \ 29.00 I 11.00 I 31. 00 \ 20.00 . 26.00 i , 26.00 . 5~.00 74.00 52.00 106.00 . 7.00 7.00 10.00 to.OO 10,00 \ \ \ I \ ; ;_/!< ({l"P! I; .j< ' , t.;! I ~ - > 'j. v,v "1';' . ',of '- ,"<.\'; . 6C..L....-- -.7.' -. '---.J ,,' I", -F IN_~~tOfU-I-~ Cli [J --------~--. J L' j HOLY SPIRIT '~8~'~II~~~H".HJI" :>11,12717 It' 503 NORTH 21ST STRELT BIRTH-DATE 23-151 2m' HILL. PENNSYLVANIA 1'-011 ;'288 03/30/"3 ~_ ______n_________ .____.5_ I'At<I'll rjAl,l1 L..FRANCES I FEI . t=;~-;-.:-;-I-;;~-l..,l-;"-i ""'; ", j'. :,~",' '.l-:'~:j ----------,.---.--.-, -.--- L ..- -- 'IT---.r 3S~6 I I ~,__ !!l.I~'J __OJ~LHa 1 HUll_ ARTHUR II 81'IlS 222 EAST "~IN STREET SHIRE"ANSTOYN,PA 17011 'NO AOOA(SS COR '.';I_FIA',fll(I,'I>MI""U,AI .,W," pt.,NIl! n f'0lIC- rl:J',I{1fH I 361 86 ~ZIZKHAN REZ~ "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7ia'" ~(Ut I '~~~.:'.'Il~f I $ DrSCR!PHONS OF HO<;1'11Al SERVICE.S SU1VtCE COO[ 1/2~ ISTAT H~NDLING F01251037.. 1/2~ ~8D/08ST SERIESOl3610196 1/2~ iCT ABD U CONTRA013613602 II2~ tCRNA 8ASE UN IT 084910301 1/2.. ICRNA TI"E UNITS05~91 03021 1/2~ i'Nl III INTUBAT 01~911100 1/24 INCENTIVE SPIROOl5010020 1/2~ ~RE-EXERC/RETRAOIS01002~ 1/2~ ~XYGEN HALF HOUOISOI0501 01/2~ ED VISIT LEVEL 011710..01 01/24 ~R-BASE R~TE 011210300 01/24 RR-BASE RATE 1/021210301 01/24 ~Kll 012711100 o I /2~TELEPHONES 018911100 OI/2~SALES TAX TELE Ol8911~00 01/2~ TELEVISION 018912200 OI/2~ SALES TAX TV 018912500 01/2~ ~OO" 626 01901]318 01/25 CFX IGH IVP8 FR02....080..5 )1/25 TORADOL ]0"G/"LOIo4~2'08' )1/25 TORADOL 30"G/"L03"~28089 )1/25 CHLORASEPTIC SPOI"~8~086~ )1/25 LRS 1000 01l613068~ )1/25 D5/04SNS/IOKI0021613314~ )1/25 DS/O~5NS/10~1002161331~~ )1/25 05/0 45NS/IOK10021613314a )1/25 D5/0.4SNS/IOKI001161331~~ )1/25 EXPLORATORY LAPOll0030138 )1/25 POP, COUNT OlI020~2~~ )1/25 SPON~E COUNT 10011020~25~ )1/25 PENCILET "~ IIAOII024281e )1/25 STPLS SKIN 15U 01102~406' )1/25 TUBE SUCT CV REOII024~~6S )1/25 TIPOLISHER "EO 011050265' TOTAL ! [;,1 (('I',r[flAGF l<;l (O...fAA(;E 1 lSI r.OllfRAGF. ESf COvERAG[ CHAnGE <; I',S co M) 1 !tjr) (0 tlO 1 ; '~S CO ~#O 1 JUS co NO. I 10.00 I 158.00 I 685.00 I 296.00 I 315.00 290.00 I "8.00 19.00 9.00 I 20~. 00 I 251. 00 ' I ~6. 00 ! 1.00 ! .06 ' 2.00 .12 430 . 00 6~.SO 25.00 75.00 13.00 9.50 ! 24.00 . 2~. 00 ; 2".00"'; 1200 I 14 00 5.50 225 7.50 20.75 2,75 150 10.00 I 158.00 I 685.00 I 296.00 ! 315.00 ! 290.00 I ~8.00 , 19.00 I 9.00 1 20~ . 00 ! , 251.00 i "6. 00 i , I I 1 I , i ~30 .00 i 64.50 I' 25.00 75.00 ; 13.00 l 9.50 i 2~. 00 ; 2".00 I 2~.00~ 12.00 . I 1~. 00 550 2.25 7.50 20.75. 2.7S 1.50 ,t., ' _ _ _ -" --- -...-.-- ---'-'-'-~"----"-'f"- ___'''"~'''__~,'_'M "r'. -1- ---.-------. ____1___. ---"--- - ----------- i!'!" "I',."" .', -i '..I "". r_\ t .,....' , , ;"f .- ,,,':':1,'. ( -,~ i ;\ ' . 1-\:,::-.----1 T---: I ! ~ _________._.._______. __. 1 , ,'., ,,' ,~ 'I. ','" ~ 'I '.,) ! ,';"1' ....'.1' -r -- - -.- '-'Il'.: HOl Y SPIRIT HOSP1T AL '.. \ !. ; ~ '.1. ; , .. , , t \"" '. 195320 ,,~ f,[ljf AI,'OJ'/! 1 .00 .06 2.00 .12 I::: 0" 'J' ~'j HOl Y SPIRIT '~~~~'I~~tf.'1'1 H,' 11;12/47' [,~~,-] .,...~ WI_,L~- FE' 0 ~'-1 5 ..~'W ,;:'C,"~?~;:';~[:;.~,;:\\,:" ".. · :~~~;~: ~E LJ ~:-i:~'i/';~~~~~:~;~---=:[ '~"'I':~~~UJ'JA;JnO~~/_~'JLo2;;'iillLd--'=~-~=--=~---=-~~1 Gu.nANHiR NAUE ARTHUR , 81';8 222 EAST "AIM STREET 8HIRE"AN8TOYN.PA 11011 ,"0 ADDRESS COB 1'1',' ./(.o\'j'. , ,'I,'p,";i 'IA'.'f ,.f". l ,.., ,...,-,11' POI I'-~', rllll.1I1111 .-..------ - - --.--, .------.-..--,,- -_.--- 1 361 86 I 195320 AZIZKHAN REZA MO PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I A~~~\~r"ti' I $ Qf,SOWTlON" Of ~1U';PITAl SEIl....IC[S srr-.VJC( CODE I ~1/25 I;ROUND PAD AOULOll~10314 31/25ISPONGE LAP 17X3011~107031 31/25 iSPONGE LAP 17X2021~I0704 31/25 :GRADUATES DISP 011~11598 31/25 'TED THIGH LGE-OI I~I2162 31/25 PAD CO"P 8X7 Oll~I2302 31/25 SPONGE OVER 4X~Oll~I2303 )1/25 ADAPT DRESS 3X8011412~5~ )1/25 CATH-SET FOL 16011412536 31/25 TAPE DERHCEL I.OII~I2766 )1/~5 ELECTROLYTES 012520200 )1/25 CBC U/3 PART 010125301201 )1/25 ROUT SENS (KIC1012540110 31/25 ROUTINE 10 012S~0112 31/25.SPEC COLLECT FEOl251OI031 )1/25 OR-LEVEL II 011010300 )1/25 OR-lVL II AODI/0310l0301 )1/25 BRE-EXERC/RETRAOl501002~ )1/25 BRE-EXERC/RETRAOI5010024 31/25 BRE-EXERC/RETRAOISOI0024 31/25 BRE-EXERC/RETRAOI501002~ 31/25 TELEPHONES 0189111009 11/25 SALES TAX TELE 018911~00j 31/25 TELEVISION Ol8912200~ )\ 125 SALES TAX TV 01 8912500CJ! 31/25 ROOM 626 019013318~ 11/26 CFX IGM VIAL 0244080~71 11/26 TEHAZEPA" 30"; 014~I~041. 11/26 BISACOOYL 10M; Ol4~560100 )1/26 D5/0.~SNS/I0~IOOI161331~~ 11/26 D5/0.~5NS/IOKIOOll613314~ )1/26 SPECI PAN 0114122261 )1/26 SALEM SUMP 16FROII~12e28~ )1/26 CATH RUBBER ISF011412S1~e .t '1";" ,I',' "', .' TOTAl CHAHCit:S 8,25 7.25 18.50 1.00 23.75 2.50 1 .00 S.OO 31.25 1.75 53.00 29.00 I 25.00 19.00 7.00 384.00 I 6~2.00 I 19.00 I 19.00 ".00 I 19.00 I 1.00 I .06 I 2.00 : .12 430.00 50.50 I 1,00 100 12.00 12.00 2.00 5.50 7.50 rSl [;nv[HA(i[ I';! r.(1',fll,v,( !<;T cOvfRAGF lsr COVFR.&OE ttJ', (f) NO I I.~~, r.J) !jO ~ ,OJ',, CO NO J ,NS CO NO" PIoHENf AMOUP-lf 8.25 i 7.25 18.50 1.00 23.75 2.50 I 1. 00 5.00 I 31.25 1.75 I 53.00 I 29.00 I 25.00 I 19.00 I 7.00 384.00 I '~2.00i 19.00 19 .00 1'.00 ".00 1,00 .06 2.00 .12 430. 00 I 50.50 i 1.00 . 1.00 12.00 12.00 2.00 5.50 7.S0 ~_:.,;~;:- "-~"'~=r ..... .~"I ~_;~ A. ~ ,Jut -',1.. ,,' . ";';( ,~:' l~ t I, . , ',I,"~ ''I'; ~ j'. "! t--- I I , .__~_-L__l..._ r'dJ.'~:t 'S1~,U;'A~.,tt!f TiJ , ; ~'" ',u. -. !'; ';1 ~ '.,--, . ,', ~..~ ,"'1', '" ""I,.",ri') l . ,\ ' ; , ,~ .; . " ',' l ~,~ I , I.;, HOl Y SPIRIT HOSPITAL ,n;. 'jl ll11 H ,,~ 1 ':;. H~~ ! I , . .', ' " 1 ~, - , ,'.! .....f..:- ., , 'A\';' 'Ie,' \ ,\ ", .., ..1'- ! [:~ o ~ , j HOL V SPIAIT '~;;~;;,~ ~~C""''''' ",," . ... 503 NOH1H 21ST STHEEl BIRTH-DATE FEI' 23_1512m'HILLI'ENNSYLVANIAI7011.2288 01/30/~3 ,,,;:,~,,,,~~]'l'" f,;; .:.~,...;~G.;;;:;.O;~.:.,:r;"'! -~-~1 ---- "354-- =jr!itliiLlli-7ilijillillC'~-'-- _=------=J PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~tUt I A~~~;;'i,iI' l $ eLL,-------'---, ~ -l--'-]", T ,j \,' \ : , " ". ' ' . !," ~! ' , 'I '~AL~aI-\319~\ ",'-'" k~s l'.'"'''' '''''' ; IG s .FR N.....E ARTHUR , BlllllS 222 EAST "AIN STREET SHIRE"ANSTOWN,PA 17011 AND AOORESl' DE5C~\pnONS Of HOSPITAL SERVICES 5ER....ICE CODE 1/26 IADMISSION ~1T 01 1~12605 1/26 \IRRlGATlON SET 011 41 2676 1/26 !TUBE CONNCT 3/101\412786 1/26 ~LECTROLYTES 012520200 1/26 'CBC un PART 010125301201 1/26 ',SPEC COLLECT FE01251 01 031 1/26 ',BRE_EXERC/RETRAOIS010024i 1/26 ~ELEPHONES 018911100 1/26 SALES TAX TELE 018911~00 1/26 TELEVISION 018912200 1/26 SALES TAX TV 0189125009 01/26 ROO" 626 019013318~ 01/27 TE"AZEPA" 10"1l 01~~1~0~1~ 01/27 HYDROXY 25"e/"LO~4~28068j 01/27 HYDROXY 25Mll/HLO~~428068 ' 01/27 ANESTHE81A SET 011613103 01/27 D5/0.~5NS/IO~1001161331~ 01/27 D5/0,~5NS/l0Kl0011613314 01/27 D5/0,~5NS/IO~10011613314 01/27 ANGIOCATH eo 011~121'8 01/27 J-LOOP 011412231~ 01/27 STATHASTER 011~1e2~6. 01/27 TRANS-DRESS IV 011~12~51~ )1/27 ELECTROLYTES 012520200~ 01/27 VRIN, INO "ICR00125e2110a )"27 "ICROSCOPIC. UROleS22190. ,,/27 CBC un PART DI012S3012H )\127 SPEC COLLECT FE0125101 011" )'/27 TELiPHONES 018'11100' )1/27 SALES TAX TELE 018911400~ )1/27 TELEVISION 0,8.,2200' )1/21 SALES TAX TV 018912500' "/27 ROO" 626 01901131te )1/28 "EP 75"' INJ VI02~~02120e " ) i.,'.', "l',' "j' ----_.-----~..,..... '=-;;-;7';;-:;:~lf'[f' r---:~:':'; :-,;:' :::-' -- ',',.\ '1.' ' "\ ," I>\!!',', ~IH l \..' ( "j ,~t i<\ I\. i -.:,:'1' '. TOTAt CHARGE S 6.00 3.50 1.50 \ 53.00 ' 29.00 \ 7.00 19.00 1.00 I .06 1 2.00 \ . t2 I ~30 . 00 \ 1.00 ! 4.00 i ~. 00 \ 16.50 I 12.00 i 12.00 i 12.00"; 2.50 i 3.25 ! 11.00 : \. 00 51.00 11.00 I 1,00 29.00 7.00 1,00 .06 2.00 12 430,00 1.S0 C 08 _~~~~~jU' (fWP~t.'t 'lM"I, 'h_,f' n,I,IN R l'OUr;Y'.U!.II<IH ~- ---'.------ rATiErH A'vlOUNl 1.00 .06 2.00 ,12 '-"1 , i _..i .--T-~:---.----t-----F---- r -- l ' 1 361 86 I 195320 AZIZ~HAN REZA "D EST C-OVEPMa r~;1 co.'UIAr,[ EST CO\i(RAlJl EST COVERAGE iNS co flQ 1 ~N<; Ct1 NI) l 'NS CO NO 1 IN"> co NO" 6.00 3.50 I. 50 53.00 \ 29.00 \ 7.00 , 19.00 I \ 1 \ ! I ~30 . 00 \ ~. ::1 \ ~.OO 16.50 12.00 i le.Ool' 12.00 e.SO :S.2S: 11 .00 ! 1.00 \ 53.00 i I 11.00 , 11 .00 : 29.00 7.00 \ \ \ \ , \ \ \ \ I , \ \ I \ \ \ I \ \ \ I \ 430 . 00 3 SO , ~ h ," HOl Y SPIRIT HOSPIT Al " 'ii'" (CI 1- -; ,(~::-1 ~,.,w"O Ft~i~~':~~'~'~v~~- ~,~ HOl V SPIRITI~~~~~.;.~tIJMBllnll"127~r ' It' 503 NORTH 21ST STREU BI RTH-DATE FEI. 23_15121WHILL.PENNSYLVANIA170,'.2288 03/30/~3 1--;:;"" ""'~~~r~q:~,-;p;,.-u-.~--:';;'T--:::;;::::" r;.. i -- 1=.-3-5~ - "--.P -iilii /24i9il o2iio/9-jr- -l~-----'--------P [~] LJ ] "'A...' ARTHUR , 81GG8 222 EA8T "AIN STREET SHIRE"ANSTOUN.PA 17011 "0 ADORESS COB ,',f"'lj" "', ....II!'~ POI ~ tH;'.~Ef II ,1J'...,~lq.j'-r I , t.1f'.\N" "M"'! 1 361 86 I AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I '~.?,';"'.',R' I $ (1/o1l I POSH:' i)[5CHIPliONS Of HOSP,TA.L SER\i!C[S sm....!Cf: CODE' 01/28 "EP 75"' INJ VI01~~02120 DI/28ITE"AZEPA" 30"' 014414041 01/28 iELECTROLYTES 012520200 01/28 iCBC U/3 PART DI0125301201 01/28 iSPEC COLLECT FE0125101031 01/28 iTELEPHONES 018911100 01/28 ,SALES TAX TELE 018911400 01/28 TELEVISION 018912200 01/28 SALES TAX TV 018912500 01/2S ROO" 626 019013318 01/29 "EP 75"G INJ V101~402120 01/29KCl INJ 20"EQ 05~4~004~ 01/29 ,KCL INJ 20HEQ 1 0~44004~ 01/29 .TRI"ETHOB 200H'Ol~456088 01/29 TRI"ETHOB 200"'014~56088 01/29 ,0510. 9N8 10000" 613061 01/29 05/0.9NS 1000011613061 01/29 05/0.9"8 1000021613061 01/29 05/0.9"S 1000021613061 01/29 D5/0.9M8 1000021613061 01/29 05/0.9NS 1000011613061 01/29 D5/0.9NS 1000011613061~ 01/29 D5/0.9N8 100001161]061~ 01/29 05/0.9M8 1000011611061' )1/29 ANESTHESIA SET 011613103' )1/29 llASTRIC SUCTIOMOI1412002_ )1/29 AN'IOCATH 22 011412169l )1/29 ADAPTOR PAN 011~121719 )1/29 SPECI PAN 011~122261 )1/29 SALEH SUMP 16FR011412228~ )1/29 J-LOOP 0114122]11 )1/2' STAT"ASTEA 0114122469 )1/29 TRANS-DRESS IV 011412251' )1/29 IRRIGATION SET 0114126761 ,I,." 'I", '" '" -.-;--" '-.-; ,--'Iu,~;~:-T -.- 'H If" .\. ,.)~.r '\' -< ,',1: ,'. I;" ...1 ... -,\', TOTJ..L CtiARGrs 1.75 1.00 53.00 29.00 7.00 1.00 .061 2.00 .121 430.00 1.75 I. ~.OO 4.00~' 2.79 2.79 8.50. I 8.50 I I 17.00 : 17 .00 ' 17.00l 8.50 ' I 8.50.. 8.50~ 8.50 j 16 .50 32.25 ' 2.75 2.00 2.00 5.S0. 325 11_00 1.00 ].50 rSI UhEI-lAr;F fST C,Q';fRAGE FST COvE~AGF [5T CO.'ERAGE !!l': C') ~l() , ,'~<'", .-(, W);> !!6 co NO j INS CO ~JO" 1.75 I. 00 53.00 II 29.00 7.00 I I I ~JO. 00 I 1.75 i 4.00 i ~. 00 i 2.79 ! 2.79'; 8.50 i 8.50 I 17.00 I 17.00 i 17.00~ 8.50 i 8.50.., 8.50.., 8.50 · 16.50 ]2.25. 2.75 2,00 2.00 550 125 11.00 1.00 1.50 195320 l"AT'PlT AVOlif,T I .00 .06 2.00 .12 ,., t ,t. ,: ,~t';i. ;". '_I: ~;' ..r;.----.----T--,-----:-= I i l".._~_..______,_.._ _~__"..__"_" __,_.___ .J,.____ '", ;" ' , , -1 -- .... -- HOL V SPIRIT HOSPIT AL "--r--" L_ --.. _.,.,~. .. ',.\ I' .\", lH':J I-J E:ll;~~rif~i~:~'~-I- ~=~~-=l~=~'; 1~'~'~lj~ Lij_o_~a~~jh~~_~lul~Lr--- - - --- -_~~__u~J _ Hel . F 1 HAL; 02l-Hn~~--J --1Nf'. .J ~, j HOLY SPIRIT '~~~'~'I~~~""HH I." 1'1?'-11 ' '+' ',0,\ ~Wrntl21S1 SIRl[ J BIRTH-DATE FEI. 23-15120/.4"1" HILL, PENNSYLVANIA 1 lOll ;>288 03/30/43 NAM[ ARTHUR , BIllG8 222 EA8T "AIM STREET 8HIRE"ANSTO~N.PA 17011 'NO AODFUSS COB ,l' "',.,0.'1<.'1 F"I'!II',I,I;'.H1111 ,:._,',,11.",' f ( ~r!l';\rj' 'jllV( I 361 86 195320 AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I '~.:',U~~l,,';' I $ ~~f c,(ll,PI'ONS OF !;C''lJ'iTAI 'i[HVICfS S[lWIC[ CODE 01/29 ~UBE CONNCT 3/1011412786 01/29 IIABD/OBST SERIES013610196 01/29 TELEPHONES 018911100 01/29 ,SALES TAX TELE 018911~00 I 01129 iTELEVISION 0189\2200 01/29 !SALES TAX TV 018912500 01/29 ~OO" 626 019013318 01l30KCL INJ 20"EO 104~~00~4 01/30KCL INJ 20"EO 1044~00~~ 01/30 ~CL INJ 20"EO 1044400~4 01/30 KCL INJ 20"EQ 054~400~4~ 01/30 :05/0 9NS 100002161306\ 01/30 ~5/0.9N8 1000021613061 01/30 D5/0_9N8 1000021613061! 01l30D5/0.9N8 1000021613061 01/30 !D5/0.9N8 1000011613061 o 1130D5/0. 9NS 100002161306 I 01/30 :D5/0.9NS 10000116\3061 01/30 D5/0.9NS 1000011613061 01/30 DEXTROSE 51 1001161]1~1 01/30 .GRADUATES 018' 011411598 01/30 ELECTROLYTES 012520200 01/30 CBC U/3 PART D1012530120~ 01/30 SPEC COLLECT FE01251010]II 01/30 TELEPHONES 018"II00~ 01/30 SALES TAX TELE 018911~00~ 01/30 TELEVISION 018"2200~ 01/30 SALES TAX TV 01'912500~ 01/30 ROO" 626 01901331'~ 01/31 KCL INJ 20"EO 054~400~48 01/31 KCL INJ 20"EO 10~4~00~4. 01/31 KCL INJ 20"EO 10~4~004~1 01/31 KCL INJ 20"EO 0544400~~' 01/31 DS/0.9NS 100001161]0619 . I I .<" ,'I. ;, ~ 101101 CHAAGUi 1.50 158.00 i 1.00 i .06 I 2.00 I .12 ! 430.00 ! I 4.00 i 4.00 i 4.00~ 4.00 i 17.00 ! 17.00 i 17.00 ! 17.00'" 8.50 i 17.00, 8.50 i 8.50-4 7.25 I I. 00 53.00 ' 29.00 7.00 1.00 ' .06 2.00 .12 ~JO _ 00 . ~. 00 . ~.OO ~.OO.., ~.OO 8.50 fc,l (I~""f ~,\!", (",I (lIVlI-lAr;r r:~1 CO'JfR.MiE ',~;1 covEn.t.Of: .'.'; 'c 'ji')' ,~l~; ,'(1 tin.' :1j',; co NO 1 ;~~s CO "K)! PAI,fNl ,U,t()U',< I. SO I 158.00 ! i , 1 .00 .06 2.00 .12 430.00 I ~. 00 i 4.00 i 4.00-1 4.00 ! I 17.00 i 17.00 . 17.00 ! I 17.00"1 8.50 i 17.00J1 8.50 I.SOl 7.25 I 1.00 i 5].00 II 29.00 7.00 I 00 .06 2 00 Ie ~JO.OO . ~_OO ~.OO ~,OO.. 4 00 8.50 PAr,,-';! ',{."lt1t" r- i ... l)AH ;' ; I' lot '\ ".J ','~\ ('I: i '.\' 1 \I '! ii, i ,-~,-=--:::-~~~-~--- ..~~J=~~~._::,_~~~=-~~ --==-=r;--.---r----l- =- - --- '~ii','~.;f' '-, )n, ! \, . ,\ ,., -- I : " \ '!' HOLY SPIRIT HOSPITAL l,'____________.,.__L ,.. ,'.', , 'f',.',.,','^,.'O,', c,,:; ~':;'lq~,. '~1 .:~'rl~r? t ,~!., ".", j .\~ q' " i' ,.', [: '" -1 ~ , j HOLY 5P1AIT' ~~~~~~ ~t"""''' n ""'''' . -F~N~L j:oal t-3/HL:"-J ... , SIO, .II t~OR1H 21ST STRI:l.l Ell RTH-DATE __ FEI. 23-15121~ r L_ PI:NNSYlVANIA17011.22BB 031J0/~3 '~~G~~.E~IIi)t~-r--'-~-' '~~~'~~~~',11L~JQ~'L~~9jj"02;-;'ii9jl-~r- - =====-.... j o t=J COB OJ',, .11.....' I (" ~J.'P,\I., '.,\I.,lI .. II"" '" '.'1,\" POliCY 'IUI,llIt H _.~"_..._-,-,-------'-'- --- NAMf ARTHUR e 81"8 222 EAST HAIN STREET SHIRE"ANSTOUN,PA 17011 1 361 86 195320 GUARA,...'OIl AHO J ADORESS AZIZKHAN REZA HD PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~j.111 ,,,,OuNI 0'1 $ 'P*, PA'f'lfNT " DATf ;1[ ';,(H'PT.or.':; e'f srU\lcr l(HAl EST Cl'lV(HAt,[ rSi (Tvll1.!>.li[ PO~Trll 1,('le,I": At <;.[llV'l~r~ COO[- CtMRGF.:, ;to':,: en ~jO 1 t;'~ (n !K' ~ 1131 D5/0.9NS 1000021613061 17.00 17.00 1131 ID5/0.9NS 1000021613061 17.00 17.00 1/31 :D5/0.9NS 1000011613061 8.50 8.50 I 1131 IANlllOCATH 22 011412169 2.75 2.751 1131 'TRANS-DRESS IV 011412251 1.00 1.00 I 1/31 IENE"A ADULT SODOll~12S67 2.00 2.00 , 012520200 53.00 53.00 1/31 iELECTROL YTES 1131 :C8C 1113 PART DI012S301201 29.00 29.00 1/31 [SPEC COLLECT FE0125101031 7.00 7.00 1131 ,ABD/OBST SER I ESO I 36 10 \96 158.00 158.00 I 1131TELEPHONES 0189111 00 1.00 , , ! 1131 ,SALES TAX TELE 018911~00 .06 1 I 1/31 TELEVISION 018912200 2.00 , I 1131 SALES TAX TV 0\8912500 .12 I i 1/31 ROO" 626 019013318 ~30.00 ~30 . 00 \ 02/01 APAP 500"" TAB 04~~28002 ~. 00, ~.OO 02101 KCL INJ 20"EO 104~400~4 4.00 I 4.00 i 02/01 KCL INJ 20"EQ 10~4~00~~ 4.00, ~.OOJ 02/01 KCL INJ 20"1:0 1044400~4 4.001 4.00~ 02/01 KCL INJ 20"EO 054~400~~ 4.00 4.00 02101 KCL INJ 20"1:0 1044400~4 ~.OO~ ~.OO 02/01 KCL INJ 20"EQ 05~4~0044 ~. 00 i 4.00 , 02101 BISACODYL 10"~ 014~56010 1 .00 ' 1.00 i 100002161306 I , 17.00 i 02/01 D5/0.9NS 17.00 02101 DS/O.'NS 1000021613061 cJ 17.00 17.00 , 100002161306 " 17.00.., , 02/01 D5/0.9NIl 17.00-< 02101 D5/0.'NS 1000011613061 , 8.50 i 8.50 ' 02101 D5/0.9NS 1000021613061' 17.00... 17.00.., 02101 D5/09NS 1000011613061~ 8.50 8.50 02/01 ANESTHESIA SET 011613103. 16.50 16.50 02101 STATHASTER 011~12246~ 11.00 11 .00 ' 02/01 ELECTAOL YTES 012520200 53.00 53.00 02/01 C8C Y/3 PART DI01eSJ0120~ 29 00 29.00 . 02/01 SPEC COLLECT FEOl1510103t 7.00 700 ,';T covEPAGf EST C(J..H~AGf ~"1 ,I ';1 iN'> ,-:0 ~IO 1 INS CO NO" ,\"~(l\:rll I .00 .06 2.00 .12 , !', .~' I' ^ , -r.--_-=-=~.~,=.~r__=_~=-_~~'~~.=I=~, __~~:~t.~i~;lMRt~~--. ___ I ..... [1A' f :< .' o;~" i", '- )!:. j".~ ~ ~ .' , !; ; , ;,Ii't:....\l, c)lIt.':,l'f":' t1 '-;t\tt',Sr"\HH_' -",l; ltl ',' .! .' t '-\:-1 <t ".ll'';;. \H r.;' '.' HOL Y SPIRIT HOSPITAL L I. __ _______ _ ,I; ",I'P!H ,'~T C;~Ht.t T '."'. . ~ - l- .;' I,' l. .~, ~q, ~t . ,! " ',V'-t', I',', t'" -.'.' ''o.;''''' " "'.', '-,"'" ;\".q .j.:' .':, . 'I): [J 1~:':~~1 ['" . C--J ~ IlllLl'M 1[) I.UMIlLI1,'.llr.121,'7 , I " , HOLY SPIRIT HOSPITAL F.INAL :~a/I-3/9l1 _ 503 tlORTH 21ST SIRElT BIRTH-DATE f-.J FElt 23_1512't1{fHILLPENNSYLVANIA17011.2288 03/30/43 1:I~G~~~a.~~~~:;'" ~~==~--~r~;:;'~~'~~:~J1=~~~!~]~:1i~ii;~~F~iJ-- . - ---~ GUARA~IOR H.ul[ ARTHUR , BI"S 222 EAST "AIN STREET SHIRE"ANSTOWN.PA 17011 '"0 AOORESS COR ,",","',;"'f'11I POtIS- Nij"'"lH ~j"'U;t.tI(" (,(".ll''''" r~~,-~{ - -. ,-- 1 361 86 195320 AZIZ~HAN REZA "D PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ,,/j ~ I_I 'MOU" OF I $ ~ PA'f'MEtH , OAlf Pt1S1fO O[SCRIPTlm.s OF HOSPITA.l SERv'CES 5EJMcr CODE 02/0 I ;TELEPHONES 01891 I I 00 02101 !SALES TAX TELE 018911~00 02/01 ~ELEVISION 018912200 02101 :SALES TAX TV 018912500 02/01 ~OOH 626 019013318 02/02 ~EP 75"' INJ VIOI4~OeI20 02/02 ~PAP 500"' TAB 0~4428002 02/02 HYDROXY 25"'I"L01~~28068 02/02 KCL INJ 20"EO 10~4~004~ 02/02 ~CL INJ 20"EO 104~4004~ 02/02 KCL INJ 20"EO 05444004~ 02/02 KCL INJ 20"EO OS4~40044 02/0Z D5/0.9NS 1000021613061 02/02 D5/0.9NS 1000021613061 02/0Z D5/0.9N9 l000011613061~ 02/02 D5/0.9NS 1000011613061 02/0Z ELECTROLYTES 012520200 02/02 CBC WI] PART 010125301201 02/02 DIFFERENTIAL 012530180 02/02 SPEC COLLECT FE0125101031 02/02 TELEPHONES 01.911100 02/02 SALES TAX TELE 018911400; 02/0Z TELEVISION 018912200 02/02 SALES TAX TV 018912500, 02/02 ROO" 626 019013318~ 02/03 TRI"ETHOB 200"'Oe44560'8~ 02/03 ANESTHESIA SET 0116131039. OZI03 0510 45NS/20KI00216112169 02/03 D5/045N8/eO~10021613216~ 02/03 0510 45NS/20K10011613216~ 02/03 AN'IOCATH 22 0114121691 02/03 AN'IOCATH 18 011~12230] 02103 J-LOOP 0114122311 02/03 STAT"ASTER 0114122~6' IOIAl (,t-+ARGf.., 1.00 i .06 I 2.00 I .121 430.001 1.75, ~. 00 I 1.00 I 4.00 I ~.00-1 4.00 I 4.00., 17.00jl 17.00 I 8.50 . 8.50l 53.00 I 29.00 i 11.00 I' 7.00 1.00 ' .06 i 2.00 i .12 ' 430.00 , 5.58 : 16.50 2~.00 24.00 1200 2.75 2.50 3.2S 11.00 f,SI C(\Vn~Al;F [SI COIIU~Ar.r (Sf COv[RAGE eST cnvEnAGE 'Wi co MJ ~ I!~'; CO 1m ~ ~NS CO r:o J INS CO NO" PArlHoT "'!"'OUN1 430.00 1. 75 4.00 1. 00 ~.OO 4.00l 4.00 ~'001 17.00 17.00 8.50 8.50~ 53.00 I 29.00 ' 11.00 7.00 430.00 5.58 ' 16.S0 24.00 24.00 12.00 2.7S . 2.50 3.2S 11.00 I , I I r- ---- --------_! , f',.' t." 0'1' "'I~, !-. '" ',}\.'I ~! -' 1~. ..------- ..---------r.-- _. --" _.L______., I;! I=:.-=:=-T____---==-::J~-- : t 1\"1 'I t'H ,;" q~ '.' "I j HOl Y SPIRIT HOSPlT AL l~-;~-;-;: -:..~~l.----~. 11111 ~{.\:. r --- u"__'_ "',":".1 ,:c,"~ t_ I ' .JI t .... i".:' . ;';' , ,. , i r'"I)fIIH ., : ~_: Ht ~ I t ,\,"', c..,,\. , '," ! , .\\h 'i "1.", ~ 1!()!:Hi\ll!) ~j\JMIHH;o11"i17117 HOl Y SPIRIT HOSPITAL 503 NORTH 21ST STREll BIRTH-DATE FEI' 23_15129WHILL.PENNSYLVANIA17011.2288 03/30/43 I ":~~~_J~j~-l2~~r:~~~~/9'JF~~--~-=~=~- -:~l _He!. - [i~~.Lj~." , I" - ,--;; --I"-'\~I-~' . 10,; I n i I : :-c~~~~~-~':~~r::"[ I N."[ ARTHUR G BI'GS 222 EAST "AIN STREET SHIRE"ANSTOUN.PA 17011 .'0 ADORESS [;~'-~J [J COB 11;';IJI\A'l':~f (.',It.,II'MU tlA.lJ[ ',1",'-1' ',"'.'['1 <l f'Oll(~'" 111,1,11\( 11 1 361 86 I AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7iad ~ I .~~,~::!"rl' I $ , . S(li!Pflr)NS (1f t'\~:-;PI1Al <.,lAVICP; SERVICE CODE ()Al[ I PO'-;TlD I 02/03IiTRANS-DRESS IV 011~12251 ,02/03 ELECTROLYTES 012520200 02/03 iELECTROLYTES 012520200 .02/03 !ELECTROLYTES 012520200 02103 ;CBC U/3 PART 010125301201 02/03 ~CBC U/3 PART DIOl25301201 02103 'CBC U/3 PART 010125301201 02/03 DIFFERENTIAL 012530180 02/03 SPEC COLLECT FE0125101031 02/03 ABD/OBST SERIESOl3610196 02/03 TELEPHONES 018911100 02/03 SALES TAX TELE Ol8911~00 02/03 TELEVISION 018912200 02/03 SALES TAX TV 018912500 02/03 ROO" 626 019013318 02/0~ HEPARIN 10" UNIOI~420036 02/04 TRI"ETHOB 200"C03~456088 02/0~ TPN-PHARHACY Ol4~99999 02/0~ DEXTROSE lOX 1011613052 02/0~ NACL 0.9 250 011613066 02/0~ LIPIDS lOX 500011613082 02/04 ANESTHESIA SET 111613103 02/04 D5/0.45NS/20KI0011613216 02/04 D5/045NS/20KI0011611216~ 02/0~ AVI SET 230 01l613370~ 02/04 AVI SET 230 011613370~ 02/0~ STATHASTER 011~122~69 02/04 ADAPTOR PRN lL Oll~12331' 02/04 ENE"A 8ET SS 011~12569~ 02/04 ENE"A SET SS 0114125694 02/04 V-CATH PIC 0114128086 02/04 CHE"ISTRY PROFI0125201054 02/04 PHOSPHORUS, SER012520190' 02/04 ELECTROLYTES 0125202003 \'j . __~ I '" . ...'-.---- .-'--'--'--------".'--"-. --- ~'-"1' ~.~.;;~--T,'.------- ;j\,q<-,,},. )\'1',' \t.~~~-:+.~- ~ ',.,'Ii 1 , ';", ' .11 ..... .',;', : '<I , , ,.. ", , " T01Al l:IIAHtll'; 1.00 53.00 53.00 53.00 29 .00 29.00 29.00 11.00 7.00 I 158.00 I 1.00 I .06 i 2.00 ' .,21 430.00 2.02 I 8.371 375.00, 8.50 ! 7.25 i 57.75 i 181.50 i 12.00 I 12.00~ 26.00 : 26.00 . 11 .00 ' 2.50 475 4.75 168.75 6],00 27.00 53.00 1::';;1 COV[RAf",( f<;l LnvE~M;f. ~!.'"'; co NO I !r.~, (C! rID:: ($T COVERAGf :N'~ CO NO) f. S T COVERAGE IN'> CO 'l04 1.00 53.00 53.00 53.00 29.00 ~::::j 11.00 7.00 158.00 I ~30.00 2.02 8.37 375.00 8.50 7.25 57.75 181.50 I 12.00 ! 12.001 26,00 i 26.00 ' 11 .00 ! 2.50 i 4.75 4.75 ' 168.75 63.00 27.00 53.00 -:=~-~=:=_:_~-- ; 't t A 't, .:~! toil \ ;'.\'o t\~l r ~, '1,-. HOl Y SPIRIT HOSPITAL 195320 PAT/[tH AYOlJt~ T , ~ .,. ; " 1.*-.._-,.. '_-< ; ,; ~',' B< "'", ~l', !l! '" , ',I', 1.<,1 ~ 11. ',If It' .",-.!" "'.." ;,", t. I.. '-" GH.; .C,.I,.uL._______ u_. _. _._._____. __j ,'j .' ,.,' .; *,:,;1 , , "',,' t", -- FI NAl ;o.u-H,L9-L--- uJ I'-"" ';0,1 1"''''4 I ~'J HOl Y SPIRIT '~~~<~~+~tUMIJER 231~12~.\7 . '+' ~,03 NOf1hl21ST STREET 23-151211l'f HILL PENNSYLVANIA 17011.2286 B~~~~~~:~E t--~ --~----- ~~_,L_ !'A!iltn tMl.lt BIGGS .FRANCES I FEI . T--'-:~I-;;;-~~.;!I~T:. r.,;, 1,.,,-.-'~,.:::.-,-~~:~;:;-';-;-:~ ------r-- -- 35ruJ-::i[ft~-i:JiviiL.9ill2;i Q1~- -, (;UARAN10R "'AUE ARTHUR , BleGS 222 EAST "AIN STREET SHIRE"ANSTOUN.PA 17011 AND ADORESS CQ.B l;r,(.'ljAtlC(, CUMPAlj't NAME I;Hi ,,,1' ';l,"'!lt'~ POue-,- N\JMIIER 1 361 86 I 195320 ,. ','J AZIZKHAN REZA "D PLEASE RETURN THIS PORTION WITH YOUR PAYMENT '7~ ~ I A~~';,,".W 1$ L;: DATl POS1!:.O DE5CAIP110tJS OF HOSPITA.l SHI'J'CES srRVICE CODE 02l041"AGNESIU" 012520270 02/0~ ALT IS'PT) 012520~50 02/0~ ~RANSFERRIN 012520542 02/0~ ~8C U/3 PART DIOl25301201 02104 iSPEC COLLECT FE01251 01 031 , 02/04 'ABD/OBST SERIES013610196 02/0~ ~ELEPHONES 018911100 02/04 iSALES TAX TELE 0 18911 ~OO 02/0~ ~ELEVISION 018912200 02/0~ _ALES TAX TV 018912500 02/0~ ROO" 626 019013318 02/05 HYDROXY 2S"Il/"LO~4~28068 02/05 POVIDINE PR I .2014~8~091 02/05 TPN-PHAR"ACY Ol~499999 02/05 LIPIDS lOX 500011613082 02/05 AVI SET 230 011613370 02/05 TRANS-DRESS IV 011~lee51 02/05 GLUCOSE 012520109 02/05 ELECTROLYTES 012520200 02/05 SPEC COLLECT FEOl25101031 02/05 TELEPHONES 018911100 02/05 SALES TAX TELE 018911400 02/05 TELEVISION 018912200 02/05 SALES TAX TV 018912S00 02/05 ROO" 626 019013118~ 02/06 TPN-PHAR"ACY 01~~99999 02/06 LIPIDS lOX 500011613082 02/06 AVI SET 230 011613170~ 02/06 SKIN STAPLE RE"011~12227~ 02/06 GLUCOSE 012520109~ 02/06 ELECTROLYTES 012520200~ 02106 SPEC COLLECT FE0125101031! 02/06 A8D/08ST SERIESOl3610196~ 02/06 TELEPHONES 018911100' 'i " '" ~ ,,-t 0'; '\\ - , ~ ., ';' .; , TOIAL CHARQES 29.00 18.00 35.00 29.00 7.00 158.00 1.00 .06 2.00 .12 430.00 4.00 I 1.00 I 375.00 57.75 I 26.00 I 1. 00 20.00 53.00 7.00 1.00 .06 2.00 .12 430.00 375.00 57.75 26.00 ~.2S 20.00 53.00 7.00 158.00 l. 00 lST COyErIAGf, t';l C(lvf,HA,(.f: 1 ESI COVERAGE ESf COvERAGE iNS CO NO 1 ill'; CO NO 1. I~S CO NO.1 INS CO NO" PA.TlENT AMOUNf 29.00 18.00 35.00 29.00 7.00 158.00 1.00 .06 2.00 .12 ~30.00 4.00 1. 00 375.00 S7.T5 26.00 1. 00 20.00 53.00 7.00 1.00 .06 2.00 .12 ~30.00 375.00 57.75 26.00 ~.25 20.00 53.00 7.00 158.00 I .00 I ".'11(',,!:, '.,< 1, \ 1ft! '.,if:!.! ~r~:=_:._-:-:t::::=:=:=t~:-~.~. '</ A'::;t ",l,'~l) t','\"~,.tN~ r',l t',>' ~, ; '.. . ,,"'H~fj r ;'-'Ift ri :------::.-- ";'.! .' 'r:; 'II<. -. ',,'; .. I . ~ ;,; "..!O ~" " ,','I 7~ HOL Y SPIRIT HOSPITAL ;'(\,' ~'~\)FP!t ,'!lST S1f~EET , .. "..1I.i f).\' ,~, ',' 1"(: ^",'; ',;,\.. ,'! -,,;k'.(,.. ";_ ';' '!<' "'-"1', ,. "..,\;.: . , ;. , ' ..., ~" I ,','>'!"; .. .\\,1~' H,L ,".'\. 1 !", I L'rll~ '",,1 ".l,'l ~ o [H.CL 'T-- - -~-'---1 f [LJ[ nAI 1LJ tJUMH[H 2] 1~12~,17 . " , i; , i."" " ~ HOLY SPIRIT HOSPITAL j I 503 NORTH 21ST STREET -F IH~L -0<:/13/93 CAMP HILL PENNSYLVANIA 17011-2288 BIRTH-DATE -LNP__ FEI. 23-1512747 . 03130/~3 Fi'CQf~:~~:~~~'~'" ~-~--_.'~~;~~~:':;;-d~'~.~~Jff;~~~;;i~;~~tJ.-=-~---- ~ CU~AA"'TOR '4AlolE ARTHUR Q BI"S 222 EAST "AIN STREET SHIRE"ANSTO~N,PA 17011 ..0 ADDRESS COB Ilj<.H,'I1A1K~ rOI..'f'MIV NAI,.IE ""'~"".':""IU" Pl11 "--:-f tk,')UrH I 361 86 195320 AZlZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7ia'" ~ I '~,uM".'..9' I $ OATE P05!fO DESCRIPTIONS OF ~r)SPlTAL S[Rl,'tCES 5E~\'ICf CODE 018911400 018912200 018912500 On01JJ18 01~488010 I 02/07 TPN-PHAR"ACY 01~499999 02/07 LIPIDS lOX 500011613082 02107 IAVI SET 230 011613370 02/07 ,TELEPHONES 018911100 02/07 SALES TAX TELE 018911400 02/07 TELEVISION 018912200 02/07 SALES TAX TV 018912500 02/07 ,ROO" 626 019013318 02/08 POVIDINE PR 1.2034~8~091 02/08 TPN-PHAR"ACY 01~499999 02/08 LIPIDS lOX 500011613082 02/08 AVI SET 230 011613370 02/08 TRANS-DRESS IV Oll~'2251 02/08 ~DAPTOR ~RN LL 011412331 02/08 CHE"ISTRY PROFI012SeOl0S 02/08 PHOSPHORUS, SER0125e0190 02/08 ELECTROLYTES 012520200 02/08 "~~NESIU" 012520270 02/08 ALT (S~PTI 012520450 02/08 TRANSFERRIN 012S205~2~ 02108 CBC U/3 PART DI012SJOl20li 02/08 SPEC COLLECT FEOl25101031~ 02/06 ABD/OBS7 SERIESOl36101962 02/08 TELEPHONES 018911100~ 02/08 SALES TAX TELE 018911~003 02/08 TELEVISION 018912200. 02/08 SALES TAX TV 01'912500' 02/08 ROO" 626 019013318~ 02/09 TPN-PHAR"ACY 01~4999993 ~. . _~...~I'"._''' ,., I .._, ,~~~^!,_.~,,,.,,~'.~f :~__., ';f~\I~,,~~.l,:,)l,l~.~TrON" 1(\ 'Hf-- "--"-1 -" > .' ..'':'''' "., I " -""','j"l ......--- - - - ~ PAll ;")! !!h!,~ I\'<'i~;(, i)'i ['14'! ',; ,i:, I' f TOTA.L CHARGES .06 2.00 .12 430.00 12.85 375.00 57.75 26.00 1.00 .06 2.00 .12 430.00 , .29 375.00 57.75 26.00 1.00 2.50 63.00 27.00 53.00 29.00 18.00 35,00 29.00 7.00 158.00 , 1.00 ' 06 2.00 .12 ' 430.00 125 00 j [SJ CO'.'EJIA,G[ ESI CCvEUA-Gt lSI r:-OV[R,,\,GE. EST COVERAGE Ir.s co NO' .~~~ CO "lO 2 INS CO NO:) INS CO NO 4 PArIE'U A.Malml .06 2.00 .12 ~JO. 00 12.85 375.00 57.75 26.00 1.00 .06 2.00 .12 430.00 1.29 375.00 57.75 26.00 1. 00 2.50 63.00 27.00 Ii 53.00 29.00 I 18.00 15.00 ! 29.00 I 7.00 ! 158.00 i 1.00 .06 2,00 .12 430.00 125.00 I -r--~ H~~~'~~~~I~'~~~~I~~L 1=--" ~,iY~ ~,.("n;H ,"'~J '~lP~-lr ~, '., ,',.' I' ... ',_, \'~ "\ I ,\,,1', \'4\"- Hi::, ~'.i t-;< ,....... , : b-HCLI,_- --- -'_.~--'--::l ' , ,i, 'i, ' ,~:, I,':' . \ , ; 1',1 I' 1,1,1, I',:; ~F INAl [~/13-/9;1-1 f-.-J ~ , ~ HOLY SPIRIT ;~~~'~\~ ~tUMBER 23';'2"47 . r;'--~'d ... 503 NORTH 21ST STREET BIRTH-DATE r""". '1 FEI. 23-1512'tW HILl. PENNSYLVANIA 17011.2288 03/30/~3 1'41iPd tlM,If, GUARANTOR NAME ARTHUR , BI"S 222 EAST "AIN STREET SHIRE"ANSTOWN.PA 17011 "0 ADDRESS COB itj",I:UMiCF C()"'I'M~Y NAV[ "'''''t>' t,I'Y!l[ll PDlICY t.u~.'nf-l~ 1 361 86 I 195320 AZIZ~HAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I '~~,~:rN~' 1$ OA.TE POST EO DESCRIPTIONS or HOSPITAL SERVICES SERVICE CODE LIPIDS lOX 500011613082 LIPIDS lOX 500011613082 TELEPHONES 018911100 02/09 SALES TAX TELE 018911~00 02/09 ~ELEVISION 018912200 02/09 ~ALES TAX TV 018912S00 02/09 IROO" 626 019013318 02/10 AVI SET 230 021613370 02/10 [IV FILTER 0.22"0216137~6 02/10 ~ElF 0100100701 , _. _ BUllL .- ('\40 r t ',': t liL 1;, 1', ~ I'., , 'if S fl1l\.il Otll ~TI(I'.' 'il ,.;;;,~, ';S Of. i:f "'l-,I "~Ii" 1,:,111\ ,'.,;( ,,'f Tor"'l CHARGES F.ST COVERAG[ p,T CO',I[I"lAf,[ ESI CO'.[RAQ[ EST COVERAGE INS CO NO ' l~jS (;0 tJO") INS fO NO J INS CO NO 4 PAI!(NT AMOL",r 57.75 57.75 I. 00 .06 2.00 .12 ~30.00 52.00 32.50 18.02 18.02 57.75 57.75 1.00 .06 2.00 .12 430.00 52.00 32.50 ffiS2 .-iTI, ".1.-:.-, r ___---.1= I LPAY ; \ t t\ ('f 'it t~l' I' ,,\' ~'i ~.;' '.) l--l~=- TH I S A"OUfltL 196 1 b . 1)1 HOl Y SPIRIT HOSPITAL -,1.\ "'~~,nlll ',,~1 l.,rr1!! ! \ i\\'1 " i ,\ ' FEI ~, i HOLY SPIRIT f~~~~\~~t".HJlf\ ?:1-,:,I2i,'7 . ... 503 NORIH 21ST STREI:1 BIRTH-DATE . 2'3-t 51 eCfW HILl. PENNSYLVANIA 17011.2288 0'3/'30/~3 I'A! ~n ''':'~f~ ~ ~~~~:~~~~;~~~\:~~~~~~-------~ t,,":l .~~~~ o COB Ilj~,I!IA~jC! r:~~~E "II(~:I' '".....Plll POliCY NU",M1Efl NA..E ARTHUR e 81"S 222 EAST MAIN STREET SHIRE"ANSTOUN.PA 11011 1 '361 86 195'320 ,"0 AZIZKHAN REZA "0 AODRESS PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~6U \ .~~,u,~~.~. \ $ DfSCRIPTIONS Of SERVIC( lOl,!.l EST COVEHAGE f "> r c\.~v(l').Anf. (51 COv[RAGE EST COVERAGE PAT'fNT HOsPlT AL SERVICES CODE CHARGES INS CO NO 1 it;'> cO NOZ :N~) co NO.1 INS co NO 4 .\MO,)tn SU"" RY OF PAY/ADJ 18.02 18.02 SUH" RY OF CHARllES R&C iE"1 PR 17DAYS, ~30.00 1310.00 7310.00 PHARMCY 250 2787.09 2787.09 f IV THERAPY 260 1 t'36.50 1136 .50 I MIS SUPPLies 270 9t O. SO 9t 0 . SO I I LABORATORY 300 2560.00 2560.00 OX X-RAY 320 126~.00 H!64.00 CT SCAN 350 685.00 685.00 OR SERVICES 360 1026.00 1026.00 ANESTHESIA 370 290.00 \ 290.00 I"AGING SERV ~02 36~.00 36~.00 RESPIRATORY SV ~10 171.00 \ 171.00 E"ERGENCY ROO" ~50 20~.00 20~.00 RECOVERY ROO" 710 251.00 251.00 E~G/ECG 130 46.00 \ ~6. 00 : TELEPHONE 993 18.02 \ 18.02 TELEVISION 99~ 36.04 \ 36.04 ANES SERVICES 96~ ...... \ 61 1 . 00 I I I SU8-~OTAL OF CHAttelS 19670.15 \19616.09 \ 5~.06 I ' , I i i i , l. ~'>t H,',\ \-T...---O.-.'Y-' L .-- :-.^'-".::'-";,~P ~ : ._nuu,. ..... ',t ',; '....; ..:... '., ,;': '~ . 1,""2.13 \,9616. "T--------'- ntFf~ "-U_ Q~JESr:!~"'<, 1,! "Hi f~U:~I~f~:; ~_1fFI;{ : " 'j,,\~" jfl HaL Y SPIRIT HOSPIT AL Pi..tA.St S[~-..jU PAyt,,\tN1 T(l ',0,,1. N(!HfH _'1';:'1:j-Tf1;f.l1 ..J'AYj.H 8 A"OUfnI96t9'09.-, ". ",', ','.\' :--;.1 -,j.~, ;, ,~',' , "l',' .."...,,;', 0<;'\ , I " ' , ' ',j ;; I"~. '\<1 '~~'t ., ; l' r ;: '\ ii' ~ ~~_A\H i"l~, ;'A !. ,. ".".. ... . , ..~ 1 -.-,.. 1'1' :i ! f I'j .. ," 'Ill .1" r^'~,' HII; 1'1 jl' ("\'l.I~~'1 I nMMl1flW,_A1 TH "1 1 un; I (IIJN1Y ii, 1111'I'Lh: ~.f1: " "'.n i l H li L Y ',' II, IT II', :_' f I 1 ^'. v' . Hll.;:' AhlHUh I I " 'il ". ,1. l' f: ~ ..I'-i' .- .... l Lei ., :; , .; wr;, r ;, :]':',' r) r oj 1 nq . [ d, l 1 ; '-' ~ : : L"'::" " l . h 1 .. h 1 , " 'I1;J;';; t: , 1 (1.:1 I w . .".. . I, " , " lll'. ,I ~ I . . "I; I ,.lit . '" .. l' . i" t,\"i;: ,. " W t,- j'.,I! t' ",f. :1' ", ""': ~ 1; ~ .l WI: - r:. H<: ;j"::'1'('1 ;Jr~ . 0;'. v:1 ;:~: t I '!"If A; In N Fi '!!Ht, ,j ,'. . ';. ..,;' ~; ~ i. . ; ,j f':'.' fI,I'-: H :' ",t., 1\ :1' : 'w' I...~' . ! ,II . II A LE n , f. , , ,:" ..' . . . f".;l .. I . , A'o r\ h ! 1 ! Ii' At,l , , ,! ! v...,\ :1 ;,._....;, r;. ; .. 1,' :' , .' ;1: /' ,./" " /' :~'t'~., _ /<_4~ l "".. " r ~ "', -1."! rr ,-, i\t! ,- ...- -; , .. a ,~j.: . IJ \. , /1 !'- 1.1'.l..L~ " ~ ,"'/1.4... (." /ll.;~~ . ~~. . ... . .. , ~HERIFF'S RETURN NCJT FOU~l~! CASE NO: 1995-04?04 r COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HOP SPIRIT HOSPUAJ,.____. V5. BIGGS ARTHUR G ET AL R. Thomas Kilne ;; her 1 f i, \Ii t"t i ' b f' 1 r: Cl rj u i)' 3 v 0 r n a C' cor d .1 n 9 tL) law, says, that hE' made a dlllr;l~r.t ;:;12~r':~', 3r:d lnqlJlr:,' for the '''It,hlfl named defendant. t (I "1 t. : _.~J .GG~_XBb'iS,~'2..._J__.n .--.--- .. bui:. was unable to locate __HE',L_ 1f: h~::f" !:J.l11'iJlc'-~:. i~~ ~her~t0r~ r~turrlS t r,,, COMPLAINT ----'~ .,"_._-,----,---,~_.,---,~-,-_.,...,--_._--'-~-'---_..._----- NOT__.EYUtil'__._ as to the Y~thln r13~eij d~fe~ja~~ -. __,_____'__._ . _-.._ ,_._ ,_,_..,.'_._~__ _ m'_.__.___.'.._ pj ~~~~~'__fJ~~ NC E2-J____.. ~EE:_~ti['~,N'L MOVED TO L;.EI!IGfLti!='-"P;__,-~-D_CRH-,->\.. __.,t:-; _ '.'__'__. _'~_ .~,_" _,.___ _.___~_____ m___ E ~~~\~J_ _~.r.;LF:..~j;?_li__.l!I~I.I_,., ~_ \(~j::._~f-: L~ . ?h"~'rlff's (c-.sts: ['Ock"t.lng 3ervlce A f f i ,i ~ \' 1 t '_~1,,; r: r. .'3l' ;,;';'" d n;:;)i.-:.f ;:::-;..- // ,,/ //" ....,.-<~ F::-'-;-:"_''':j :;~l:.f.~' :-rr .....,"- is. 0l~ . iZ~"l . ,,!,-,' ..,..".7 .~-ri~~r ",,"> . Ii.", :?, .tt~:'" l,PTH~'h V'l-'T ; 1..: .- ~'I' ,. '.; '::'-1 ;:; a.~;j ;;-'Jb:::.::'r::..v..::-,j +-': :,,:.~. >'. . t ~ 1 ;- 12 ~ j~v "1 (i,t.c:.~ l, \ , , ~... i. . \ (.. ,,>-.' ~ t-1t..- . l' 1 ,~~ ... r-t' HOLY SPIRIT HOSPITAl., IN THE COURT OF COMMON PLEAS CUMIlERI,AND COUNTY PENNSYLVANIA Pla1ntJtf V. ARTHUR G. BIGGS and FRANCES I. BIGGS, Defendant CIvIL ACTION - LAW NO. tWTlClA Le han demandado a usted en 1 a corte. S 1 usted QU i ere detenaerse de estas demandas expuestas en las paglnas slgulentes, usted tlene Vlente (20) dlas de p1azo a1 partlr presentar una aparrencla escrlta 0 en persona 0 por abogado y archlvar en la ~orte en forma escr1ta sus defensas 0 sus obJeclones alas demand as en contra de su persona. Sea aVlsado Que Sl usted no se defiende. 1a corte tomara medldas y puede entrar una orden contra usted Sln preV10 aV1SO 0 notlf1caclon Y por cua1au1er QueJa 0 a11vlo Que es pedld0 etl 1a pel1C1on de demanda. Usted puede perder d1nero 0 SUS proPledades 0 otros derechos lmportantes para usted. LLEVE ESTA DEMANDA A UN ABOGADO INMEDIATAMENTE. 51 NO TIEtjE ABOGADO 0 SI NO TIEtjE El DINERO SUFICIENTE DE PAGAR TAL SERvIClO, VAYA EN PERSONA 0 LlAME POR TELEFOl>;O A LA O'ICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SU PUEDE CONSEGUIR ASISTENCIA LEGAL: Resoectful Iv subm1~tej: LAWYER REFERRAl, Cumberland Co. Court Admin. Fourth Floor One Courthouse Square Carlisle, PA 17013-3387 (717) 240-6200 ('-~ ----, .- AR'HUR A. ~USI . ESQUIRE 4.01 (ru~s M.11 Road Po,;t ('ff,ce Bo' 67(l1~- I"ic:.t" 'stlurt? PA '71'.2 I'" i ~40-~6'0 S"~EMt: ._IXPT Nil. 07207 f.l'"PtJ". FOP PI,l>!',TIP [ ,'.,",11 , HOLY SPIRIT HOSPITAL, plaintiff . . IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA . . V. : CIVIL ACTION - LAW . . ARTHUR G. BIGGS and FRANCES I. BIGGS, Defendants 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, HOLY SPIRIT 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. Defendants, ARTHUR G. BIGGS and FRANCES I. BIGGS are adult married individuals residing at 222 East Main Street, Shiremanstown. Cumberland County, Pennsylvania 17011. 3. On or about January 24. 1993 through February 10, 1993. Plaintiff. at the request of the Defendants, did provide health care services to Defendant, Frances I. Biggs. 4. Plaintiff in good faith provided the necessary health care services to the Defendant, Frances 1. Biggs and thereafter billed Defendants its usual and customary charges for the services rendered. As evidence thereof, a copies of the billing for services rendered to Defendant, Frances I. Biggs are attached hereto, made a part hereof and marked Exhibit "A". " 5. Plaintiff did credit Defendants' account with all payments made on the account and there now remains a balance due and owing of $19,616.09. 6. The purpose of this communication is to collect a debt and any information obtained will be used for that purpose. COUNT I. (Plaintiff v. Frances I. Biggs) (Quantum meruit) 7. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 6. 8. Plaintiff did render health care services to Defendant with the reasonable expectation that payment for such services would be made by the party benefitted. 9. Should Defendant not be required to pay for the balance due for the services rendered. Defendant would be unjustly enriched at Plaintiff's expense. WHEREFORE, Plaintiff pray your Honorable Court to enter JUdgment in its favor and against Defendant Frances I. Biggs in the amount of $19,616.09, along with interest at the rate of 6\ per annum and the costs of this proceeding. .- COUNT I I . (Plaintiff v. Arthur G. Biggs) (Doctrine of necessaries) 10. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 9. 11. Plaintiff believes and therefore avers that the health care services rendered, upon request, to Defendant Frances I. Biggs. wife of the Defendant Arthur G. Biggs, were necessary for her benefit and welfare. 12. Plaintiff believes and therefore avers that pursuant to the "doctrine of necessaries", Defendant Arthur G. Biggs, as spouse of the recipient of health care services. is liable to Plaintiff for the balance due. 13. Should Defendant Arthur G. Biggs not be held liable to Plaintiff for payment of services rendered his wife, he would be unjustly enriched as the services were necessary to benefit the health and welfare of his spouse and their marital union. 14. Plaintiff has made demands for payment upon Defendant. which demands remain unheeded. WHEREFORE, Plaintiff prays your Honorable Court to enter Judgment in its favor and against Defendant Arthur G. Biggs in the amount of $19,616.09 along with interest at the rate of 6\ per annum and the costs of this proceeding. COUNT III. . (Plaintiff v. Arthur G. Biggs) (statute) 15. plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 14. 16. pursuant to 23 pa.C.S.A. 4321, married persons are liable for the support of each other. 17. pursuant to 23 pa.C.S.A. 4102. where debts are contracted for necessaries by either spouse, a creditor may institute suit against the husband and wife for the price of the necessaries. 18. plaintiff did render necessary health care services to Defendant Frances I. Biggs with the reasonable expectation that such services would be paid for by the persons benefitted, which in the instant case include said Defendant and her spouse, Defendant Arthur G. Biggs as partner in the marital union. 19. plaintiff has made demands for payment upon Defendant, which demands remain unheeded. WHEREFORE, plaintiff prays your Honorable Court to enter Judgment in its favor and against Defendant Arthur G. Biggs in the amount of $19,616.09 along with interest at the rate of 6\ per annum and the costs of this proceeding. COUNT IV. (Plaintiff v. Arthur G. Biggs & Frances I. Biggs) (Tota 1) 20. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 19. 21. Plaintiff has made demands for payment upon the Defendants for the balance due of $19,616.09, which demands remain unheeded. 22. 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 Defendants in the amount of $19.616.09 along with interest at the rate of 6\ per annum and the costs of this proceeding. 'E'0~. S . : :-' -0 . ______ Art ur A~USiC' Esquire----- 4201 Crums Mill Road Post Office Box 11585 Harrisburg. PA 17108 (717) 540-5610 supreme Court No. 07207 Attorney for the Plaintiff DATED: HOLY SPIRIT HOSPITAL, Plaintiff V. ARTHUR G. BIGGS and FRANCES I. BIGGS, Defendants . IN THE COURT OF COKMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. V E R I F I C A T ION I, MR. GEORGE BOWERS , the CREDIT OFFICE MANAGER of HOLY SPIRIT HOSPITAL verify that the statements made in the COMPLAINT are true and correct and that I am authorized to make this Verification on behalf of HOLY SPIRIT HOSPITAL. I understand that false statements herein are subject to the penalties of 18 Pa. C. S. section 4904. relating to unsworn falsification to authority. HOLY SPIRIT HOSPITAL ~c-~ By: TITLE: e~t" t7"r..~ ..,,,....,,... DATE: lJ/~~/f'.s- HxnllllT "^" ~ FlOE HAL 10 NUM8EH 23.)5127'" HOL V SPIRIT HOSPITAL '. 503 NORTH 21ST STREET BIRTH-DATE FEI. 23-IS12m' Hill. PENNSYLVANIA 17011.2288 03/30/43 --- ~'~~"---:_' - ~"I~j'7~~;~~G~~~;'~~~I'^i:1~~_~ -~. - ~ 101'11)/ 11'11 :l^" ,,' I'll!,' 11:11 "/,111,11"1\ -f-(~Ab --IL-_-5 B Ices.. "^IIU~' t4Ap.,!( GUARANTOJl ,."ut. ARTHUR II BllOllS 222 EAST "AIN STREET SHIRE"ANSTOUN.PA 17011 AND ADDRESS con " ,'" II ~ .H I' I ' , '1,'1' .\11 ~ ~ II. ~J1 - '- -- --~- . '" ~,. " ',''''', I 361 86 AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I A~.:';~i'N';' Is 8Alf POS!tt) DESCRIPTIONS OF HOSP,' Al SERVICES SERVlC[ COOE DETAIL OF CURRENT CHARIOES. PA 1/23 'LUCOSE 1/23 RENAL PROFILE 1/23 A"YLASE. BLOOD 012S203~0 1/23 CBC U/3 PART DI012S301201 1/23 SPEC COLLECT FE012SI01031 1/231sTAT HANDLINIO F012S10J68 1/23 iSTAT HANDLIN' F012SI0371 1/23 iSTAT HANDLIN' FOl2510373 1/23 ~TAT HANDLIN' F012SI0374 1/23IABD/OBST SERIESOI3610\96 1/23 iGALLBLADDER US 0136"..06 1/24 ~EP 75"1l INJ VI01..~02120 1/2~ ~EP 75HG INJ VI01..~02120 , 1/24 ~S 10HIO VIAL Ol..~0212SI 1/24CFX IGH IVP8 FR02"~080~S 1/24 'CFX 2'" IVPB 014~080~6 1/2~ ~ENTYL 10"' A"P02"~12033 1/2~ ~YDROXY SO"'I"LOI44280691 1/2~ HYDROXY 50"e/HL01..4280691 1/2~ iTORADOL 30"'I"L034~28089 1/24 ANES CHARGE 03..499990 1/24 ~ACL 0.9 1000 011613063 1/24 LRS 1000 011613068 1/2~ ,ANESTHESIA SET 011613103 1/2~ 0510 45NS/IOK100l161331~ 1/24 05/0~5NS/IOKI001161331~ 1/24 0510 45NS/IOKI00116133t..~ 1/2~ ~5/0 ~SNS/10~100216133t~~ 1/24 'DS/0.~5NS/IOK100116IJJI"~ 1/24 D5/0~5NS/IOKIOOll61331~~ 1/24 SECONDARY SET 1011613316~ 1/24 ~ASK OXYllEN ADUOII~10621~ 1/24 lXERCISER VOLU"011~1078S. I":' .j',' '., ,'" 1 TOtAL CHARGl~ HENTS AN 20.00 62.00 53.00 29.00 7.00 10.00 i 10.00 II 10.00 10.00 I 158.00 i 364 . 00 I 1.75 I .75 2.00 64.50 214.1~ 81.34 I 1.00 1.00 7S.00 18.75 8.50 9.50 16.50 12.00 12.00 I 12.00 2~.OO 12.00 12.00"'; 7.25 2.50 17 75 151 COVEIlMiE f'<;T covrrIAC,! [SI (OVIRAGr (<;1 CC1'lfRA(jE INS CO NO 1 I~;', fa t.o, illS en NO 1 ;~j" (,0 NQ <1 NTS ADJUSTH 20.00 62.00 53.00 29.00 7.00 10.00 10.00 10.00 10.00 158.00 36".00 1.75 1.75 2.00 64.50 21~.1~ 81.34 1.00 1.00 7S.00 18.75 8.50 9.50 16.50 12.00 12.00 12.00 2~.00 12.00 , 12.00-- 7.25 . 2.50 17_75 o 1"0';1' "0 I I'llIICYPl!iIJIlPI --,._----- 195320 r>ATI[t..T AVOUNI I -" 1''''''-- -- u --.- - 11 H~~ ~.'~;I~{;; '~~~~l; ~L l.._u __ ~~~~~_--E- ',':"."j ',I' "", -- T~~~--~=-~:]::'-:-_:~_ Ht fll; All ()vt <.:,!l1lt,j. II "t1 t'l1 I'," ~I ~,.; ! If I' I ;~~;~-;~"I ~-T -. .... ,.1'! I', I ! t ~1l H i ( I'; Ill'.:, . ; ["\!! \'1 '11;,I( I ',', ',d," 'tl 'i' ; ~1( .1 i , ! l' . f; t I ! ", : ,A,",_\ >1 1,\ HeI . ''''I ('I I hll ~, J HOLY SPIRIT F~~E~~~~~tJMBER 2.1:~,127017 ... 503 NORTH 21ST STREET BIRTH-DATE FEI. 23-15121W Hill. PENNSYLVANIA 17011.2288 03/30/~3 f_ "" -' ""~'~~'~I-[~~;-I~;'~ ~~~~~0~J'~'~~~~;:~;".~r~;r-~~u .. - L__ _.L____ _Ei~.u_ OJl~{,.i3]~LLO_.'1 L.L______ n LJ CJ -1 , ['All 1'1 11111 (Mil nr PHI V !lILt F-I~Alo _-8-_ S l'AIIININA"l: BII:I:S .FRANCES I GUARA....fOR t.lAMr ARTHUR CO Blcoc;S 222 EAST "AIN STREET SHIREI1ANSTOUN.PA 17011 '-0 AOORfS~ COB , ',' ,...1\, , I': .,t ~'. ','!.! I, f',','ifl^~j(", ""I',H" ';,\0," I' t 186 195320 361 i __I AZIZKHAN REZA 110 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ,*eut I ':'~,;.;;'.;)' IS '! 'I' ',.~, '\ ~~' ~.,' . , _~---~~-----_..._-:..-r.=~=__-.L::= _ .L .. -__. l"'l'f."~'''.'" 1'IlllHAII I),'t""l'.." '..I I' lA", ".!'Ii. :,"'It' 1 -'__ ,-._, '-' 1III',i';:t..",,, ii' ,') . " ..' '.,', .. HOLY SPIRIT HOSPIT Al .- .... Ii ",!!' IIi i. i ",' '~,j" ',,1. t,ll)ill H 11,:1 t I ....' I .j ,f' I ' .....~,H ,; , I ilAlF l'nSlf,' Of SCHIPIIO,",S or tlOSPITAt SHI,:tCES SER\'ICf COOE 1/24 ANI:IOCATH 20 1/2~ AN;IOCATH 20 011412168 1/2~ TOOTHETTES DENT011~12233 1/2~ STATI1ASTER 011412246 1/2~ TRANS-DRESS IV 011~12251 1/24 AD"ISSION ~IT 011412605 1/24 IRRIGATION SET 011412676 1/24 GASTRO;RAPHIN 013620896 1/2~ CONT OPTIRAY 10013622332 1/2~ CONT OPTIRAY 50013622333 1/24 CHEMISTRY PROFI012520105 I/~~ ELECTROLYTES 012520200 1/24 AI1YLASE, BLOOD 0125203~0 1/24 lIPASE 012520350 1/24 ,UR IN, (NO I1ICROO 1252211 0 1/24URIN, (NO I11CROOl2522110 1/2~ il1ICROSCOPIC, UROl2522190 1/24 'MICROSCOPIC, UROl2522190 1/24 ,CBC U/3 PART DI0125JOl201 1/24 :CBC U/3 PART DI0125J01201 I /2~ 'DIFFERENTlAL 012530180 1/24APTT 012510310 I /24PROTHR0I18IN TlM012530J20 , 1/24 URINE CULTURE 0125~02108 , 1/24 URINE CULTURE Ol2S~02108 1/24 TYPE/SCREEN 012580107~ 1/24 CELL PANEL 012S801~0~ 1/24 ANTII:EN SCREEN 0225801~5? 1/24 CROSSHATCH, BL0022S80200q 1/24 SPEC COLLECT FEOI2SIOI01\: 1/24 SPEC COLLECT FE012S10103( 1/24 STAT HANDllNll F012510J68~ 1/2~ STAT HANDLIN; F012510J71~ 1/2~STAT HANDLIN; FOle510173d TOTAL OIARGES 2.50 2.50 3.00 I 1.00 1.00 6.00 3.50 28.75 153.25 77.00 63.00 53.00 53.00 53.00 11.00 1 1.00 I 1.00 11.00 29.00 29.00 I 1.00 31.00 I 20.00 26.00 26.00 5~. 00 . 7~.00 52,00 : 106.00 . 700 700 10.00 10.00 10.00 . -l EST C:O\'[HM.! FSI COvfHAGr f';; li;.!I..~I,1 f';1 (O,..E~l.\(,{ INS CO t~(} l 11;<:' CO UI)? It,', r' ',1' , .r.', co "-.jO I P,'! t'.' "'t,""',: 2.50 2.50 3.00 11.00 1.00 6.00 3.50 28.75 153.25 77.00 63.00 53.00 53.00 53.00 I 11.00 I 1.00 I 11.00 i 11.00 I 29.00 I 29.00 I 1.00 I 31.00 . 20.00 i 26.00 I 26.00 i 54.00 ! 74.00 ' 52.00 i 106.00 . 1.00 7.00 10.00 10.00 1000 ! iT t- L. -IfCLL.-----.--r - r'll'l I I "iI!! ,,1 "L ' .:.11 ,lIlt, 11"1. lI,j, I n u F I HAL~-.t+3 .lNf'_.J . - ~ FEDERAL I D NUMBER 23.1,512747 HOLY SPIRIT HOSPITAL 503 NORTH 21ST STREET BIRTH-DATE FEI. 23-1 51 2'f1M1' HILL. PENNSYLVANIA 17011.2288 03/30/4J o l"OSp,,,,,I .:lli~SS.F-R~~~~'~'~~IL~=3= ~~~~~'~;~a]~J~T~L~~:;~;J~ii~;~'3 ~'j:-[___~~~-----~ l,"AIIA""f"1 ""\ll ARTHUR' BI'IlS 222 EAST "AIN STREET SHIRE"ANSTOUN,PA 17011 ,"0 AOOAtSS COR .....1;1..".'1 <,{'J"M,.';"'" .1' '. ','" " POt ICV t~lJMllrH J61 86 AZIZI<HAH REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~tUt I '~;):~iT,S' L$ :,1,1( "l'~TI :1 DfSCHIPTlONS OF HOSPITAl sER....lcrs S[RvICE COO[ t/24 STAT HANDLIN' F012510J74 1/2~ ABD/OBST SERIES013610196 1/24 CT ABD ~ CONTRA013613602 t/2~ CRNA BASE UNIT 084910301 t/2~ CRNA TIKE UNITS05~9103021 1/24 GNl UI INTUBAT 01~911100 t/2~ INCENTIVE SPIROOl5010020 1/2~ BRE-EXERC/RETRA015010024 1/24 OXYGEN HALF HOUOl5010501 1/2" EO VISIT LEVEL 011710401 1/24 RR-BASE RATE 01/210300 1/24 RR-BASE RATE 1/021210301 t/24 EI<Il 012711100 t/2~ TELEPHONES 018911100 t/24 ISALES TAX TELE Ol8911~00 t/24 TELEVISION 018912200 1/24 SALES TAX TV 018912500 1/2" ~OO" 626 019013318 I t/25 ~FX 1'" IVPB FR024~08045 1/25 iTORADOL 30"e/"lOI4~28089 1/25 ~ORADOL 30"'I"L03~428089 1/25 iCHLORASEPTlC SPO 1448~086 1/25 ~RS 1000 011613068 1/25 ID5/0."5NS/I01<100216IJJ1~~ 1/25 ~5/0.~5NS/I0~1002161131~~ 1/25 :05/0 ~5NS/I 01<1 00216\331 ~~ 1/25 .D5/045NS/I0~1001161331~~ 1/25 IXPLORATORY LAP0110030138 1/25 POP, COUNT 011020~2~~ 1/25 SPON'E COUNT 100110204253 1/25 PENCILET "K IIR01102~283a 1/25 STPLS SKIN 35U 0110244069 1/25 TUBE sueT CV REOII02~4~6S 1/2STIPOLISHER "ED 0110502656 .1 ,\... !', " -~,--,-_...- -_..,~,... ..._--, --'-' .. ~ . ",;~;;;-;,;;,~- . i .-,...-.-.--------_----.&.._. _.. - ..t i I I~ "" _jut',' '\ ,.~ ' "'I " ",,~~t' . II I I , '", ,..i .... :," .!'.,qiil'\l',~'~~~, ~ 'I i' i I I (, ~' i TOTAl C.HAIlGf S I 10.00 'I 158.00 685.00 ! I 296.00 I 315.00 I 290.00 ~8. 00 19.00 9.00 204.00 2St.00 ~6.00 1.00 . .06 ' 2.00 ! .12 i 430.00 ' 6~ .50 i 25.00 I 75.00 13.00 9.50 2~.00 2~.00 24.00- 1200 114 00 550 2 25 7.50 20.15 2 75 I 50 1,__~_~__~L. .. 1--=--~ !- ---------.- " ',!" " ',' " "I ~.l I ~,." ''''1', I' f<:,T cnVf'lAf,f f!'>T (lIVlIIAf,l I lST U)\lFRAG[ F~Jl f'.()';fflAGF j/jS en r.lO \ I~~') rl. tl'l 'l ' iW, C(l NO '\ .f~r> (,( 1 ~jO' 10.00 158.00 685.00 296.00 i , 315.00 I 290.00 ~8.00 19.00 9.00 I 20~ . 00 I 25 l. 00 I I i ~6. 00 1 I I ! HO.OO i 64.50 I 25.00 75.00 i 13.00 9.50 2~.00 2~.00 2~.00-i 12,00 II ~ 00 550 2.25 750 20 75 2 15 I 50 --~ i, I;' ; ',I r.! ' I ,~, ',H '.! ! HOl Y SPIRIT HOSPITAL '"I; '",1;111 '\,Il! " ,,' "" 195320 PATlErt! AMOUN f 1.00 .06 2.00 .12 _He! . '.".d"'( 1"\ FINAl.- ._Hie ~ FEDERAL I D NUMBER 23.1512747 , HOLY SPIRIT HOSPITAL '. 503 NORTH 21ST STREET BIRTH-DATE FEI. 23-1512CfW Hill. PENNSYLVANIA 17011.2288 03/J0/~3 tJ o (1;.111,.1 Hilt !d,q '" I ," I . I~' I I B_ _ __L___r>^'IINT '~A'-'I ,JlliiCS . FRANC "~~"";'~~'~Jj ~(;j-ri'iV;~i':11-~"~~'~-I- ::J:~-. ..J (iUAnANTOA N.....f ARTHUR G BI"S 222 EAST "AIN STREET SHIRE"ANSTOUN.PA 17011 '.0 AOORESS COB ...'. JI.AI~(f II 1'.'1' A', 'f' tlM..'1 ...' ","'HlI1 NlllC't/lJt.1IHH 1 361 J.._ I 195320 AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I '~;;-;;t',,7r I $ <JAIL .nSIlO DESCRIPllONS Of HOSPlT At SERVICE S SERViCE CODE 1/25 eROUND PAD ADULOll~1031~ 1/25 SPONGE LAP 17X30ll~107031 1/25 SPONGE lAP 17X2021~1070~ 1/25 GRADUATES DISP 011411598 1/25 TED THleH LGE-Ol1412162 1/25 PAD CO"P 8X7 011~I2302 1/25 SPONGE OVER ~X4011~12303 1/25 ADAPT DRESS 3X8011412~5~ 1/25 CATH-SET FOL 16011~12S36 1/25 TAPE DER"CEL I.Ol1~I2766 1/25 ELECTROLYTES 012520200 1/25 CBC U/3 PART DI0125301201 1/25 ROUT SENS ("ICI012540110 1/25 ROUTINE 10 0125~0112 1/25 SPEC COllECT FE0125101031 1/25 OR-LEVEL II 011010300 1/25 OR-LVL II ADD1/031010301 1/25 BRE-EXERC/RETRAOI501002~ 1/25 BRE-EXERC/RETRAOI5010024 1/25 BRE-EXERC/RETRAOI5010024 1/25 BRE-EXERC/RETRA01S01002~ 1/25 TELEPHONES 018911100 1/25 SALES TAX TELE 018911~00 1/251TElEVISION 018912200 1/25 SALES TAX TV 018912500 1/25 ROO" 626 019013318 1/261CFX 110" VIAL 024~080~71 1/26 ITE"AZEPA" 30"' 01~~14041~ 1/26 ~ISACODYL 10"G 014~S6010~ 1/26 ~5/0.~5NS/I0~1001161331~ 1/26105/0.45NS/IOKIOOl1613314 1/26 iSPECI PAN 01 1~12226\ 1/26 ~ALE" SU"P 16FR011~12ee8~ 1/26 !CATH RUBBER 15FOlI4125J~1lI __--L- 11,'11,,\, ,'."-1 'il' ,'1,.,'.',,'4 r-AfIf.N''''l,..,.t\tH j- ~HlHA.l.'OU(':ill(l"l",I""lt _,' ____, _~,_____ flLJ';!~t ~S ()ff In " '- ~b; ~'1 '\8 -------,_..'...,' "'-~"---'- -. A 1t h t 1111! H I '\1:, ll~~(; ,,. 1.\11 ,'oj .1 H',:: I TOTAL CHARGE S 8.25 7.25 18.50 l. 00 23.75 2.50 1.00 5.00 31 .25 I. 75 53.00 29.00 25.00 19.00 7.00 38~.00 6~2.00 19.00 19 .00 19.00 19.00 1.00 .06 2.00 .12 ' 430.00 I 50.50 1.00 1 1,00 ' 12.00 i 12.00 i 2.00 S.50 7,50 EST COVERAGE Pi! COvERAGf ES1 (tl'.[RAGf EST CO'lERAGE INS CO NO I I~<; 1":0 NO 2 !t.~i (J) Wl I IN" CO NO 4 PAIIP.T "'MQUt,r 8.25 7.25 18.50 l. 00 23.75 2.50 1.00 5.00 31.25 l. 75 53.00 29.00 25.00 19.00 7.00 38~.00 6~2.00 19.00 19 .00 19.00 19.00 i 430. 00 i 50.50 i 1.00 i 1.00 ' 12.00 : 12.00 ' 2.00 ' 5.S0' 7. SO: -r---n-t==r--- PltA~l Sit,mPA\~1tl'il II,) 'I HOl Y SPIRIT HOSPITAL L . i,p~ NOJ~III ."'-;1 ~lHll 1 ( ,V.'I'I(II \ 1',\ '11 '."'", [~ ;0'....\. ,.."....'lil..! ".',,\;. ','I'. L_ -----, ','--1" ',' , '" , FINAl. INP ,JI. _ ~__S -Bl CUARANTOR AODRUS DAll >>OSllD 1/26 1/26 1/26 1/26 1/26 1/26 1/26 1/26 1/26 1/26 1/26 1/26 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/27 1/28 ~,~ HOl V SPIRIT r~~"~~~+~~UMBER 231..512747 I;-";~;;~ It' 503 NORTH 21ST STREET BIRTH-DATE r'DC,p.IIol FEI. 23-1512'tW HILL. PENNSYLVANIA 17011.2288 03/30/"3 1.1"\(1I I'll :1""(1' "\!II/II'l1 iJ,.ll"'ltlll "AllfNT r4Al,l1 ~.~I~~'~I~~.lI~~JIE'~~~-f~~~b~-'-.-_._------~ IoiAM[ ARTHUR , BI"S 222 EAST "AIN STREET SHIRE"ANSTOUN.PA 17011 AND COB HI',IIIlMjU ((~I.II'^,j' 'jAMI I,"'~ ,.' ",,1,,11'1 " "OII:;V NUJ,lIl[ll 1 361 86 195320 AZIZ~HAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~tue I A~~~~",'II~' I $ O[SCRIPTlONS Of HOSPITAL SERVICES S[RVIC[ COO[ AOHISSION ~IT 011~12605 IRRIGATION SET 011412676 TUBE CONNCT J/IOII~I2786 ELECTROLYTES 012520200 CBC U/3 PART 010125301201 SPEC COLLECT FE0125101031 BRE-EXERC/RETRAOI501002~ TELEPHONES 018911100 SALES TAX TELE 018911~00 TELEVISION 018912200 SALES TAX TV 018912500 ROO" 626 0190133181 TE"AZEPA" 30"1l 01~4140~1 HYDROXY 25"'I"LO~4~28068 HYDROXY 25"'I"L04~428068 ANESTHESIA SET 011613103 05/0.~5NS/IOKIOOll613314 D5/0.~5NS/l0KI001161331~ D5/0.~5NS/l0~10011613314 ANGIOCATH 20 011~121'8 J-LOOP 0114122311 STAT"ASTER 011~12246 TRANS-DRESS IV 011~12e51~ ELECTROLYTES Ol2520200~ ~RIN, (NO "ICROOI2522110~ ~ICROSCOPIC. UR012S22190~ !CBC un PART 010125301201, ISPEC COLLECT FE0125101031; ~ELEPHONE8 018911100' SALES TAX TELE 0189114003 ~ELEVISION 018912200~ ~SALES TAX TV 018912500~ 00" 626 0190131182 EP 75"G INJ V1024~02120e I I __1-.__ fl.""" 'I'; '., ".'.. TQrAt CHAHl.F S 6.00 3.50 1. 50 53.00 29.00 7.00 19.00 1.00 .06 2.00 .12 430.00 1. 00 4.00 I ".00 i 16.50 I 12.00 I 12.00 I 12.00-; 2.50 I 3.25 11.00 1.00 53.00 11.00 11.00 29.00 7.00 ' 1.00 06 2.00 12 ~30,OO 3.50 f.S! C:l)VEIl"'G~ fSl cnVfHA(.[ I~;r COV(R....GF [Sf COvUIAGE INS co NO 1 INS cn NO'} I'.'> CO NO:l INS CO NO" PA11E.NT A~nUNT 6.00 3.50 1.50 53.00 29.00 7.00 19.00 ~30.00 I. 00 4.00 ~.OO 16.50 12.00 12.00 12.00 2.50 1.25 11.00 1.00 53.00 11.00 I 1.00 29.00 7.00 ~30.00 350 f',\lIENl NlIt"f~f~ Hil f H AI i Ol't <,t" '1,1" i<l 1,,1~1 '.', I .11 "': ",1 II.. .-l~=: __-~T=-~__~J . ',,1 , , I :", '~t ~,it t .(1 I 'A ~ t.ll r J' \() "",.\, ",-,"", 1',;"j.,,,",,,,..tlf'lt'l .".,! . ';',' . ,'", t " I" I ,\",", ',,',Iln ,'.:. ""I. ..I """1" ',," ;" ." '. ,.. , " , .-_. 'ATl.j~, t ITHt H l'l)',li~'H, H~ [1.,\ II (\I ",I In, 1\ f HOl V SPIRIT HOSPITAL ',(), t~tilnH 1':1 ',tHl! ! ,\"~' till j 1',\' , , .' 'hi' tJ HcLI1-'----------j" . ~ f'lOERAL I 0 NUMBER 23.1~12747 '''1 ,,! . ":.111',1 ",,"".." ""."" HOLY SPIRIT HOSPITAL . t F INAL ~21'+3 503 NORTH 21ST STREET BIRTH-DATE '''''... "" _INP_ J - FEI. 23-15129W Hill. PENNSYLVANIA 17011.2288 03/30/43 .:lG~SSi~~i - ----t~'~'j~~~~~~Jr~'~-[~~./~~/;'31~~;I~;.;~~r~\r-- -" -~- __~-_-_:u J liUAnAN'on tjAMf ARTHUR I; BI"S 222 EAST "AIN STREET SHIRE"ANSTOUN.PA 17011 'NO AOORUS COB ','.' I,:,',' ""I..lI':.....- 'j,\','1 ." .' "~'. ~~~:C:~':~J 361 186 t , I i I _H_ j "0 _ __L__. _________u PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~(Ut I ';~:~;~'.;,' I s : All -''>11,) l)fSClII"Tlor~:j Of ti(1SI'IIAl ~HWIC[ " S[HVICE COO( 1/28 "EP 75"' INJ VI01~~02120 1/28 TE"AZEPA" 30"1; 01~~14041 1/28 ELECTROLYTES 012520200 1/28 CBC U/3 PART DI012S301201 1/28 SPEC COLLECT FEOl25101031 1/28 TELEPHONES 018911100 1/28 SALES TAX TELE 018911400 1/28 TELEVISION 018912200 1/28 ,SALES TAX TV 018912500 1/28 'ROO" 626 019013318 1/291"EP 75"G INJ VI01~~02120 1/29 KCL INJ 20"EO 05~~~00~~ , 1/29 iKCL INJ 20"EO 1 04~400~4 1/29 ITRI"ETHOB 200"GOI~~56088 1/29 ITRI"ETHOB 200"'014~56088 1/29!D5/0.9NS 1000011613061 1/29 i05/0.9NS 1000011613061 1/29 D5/0.9HS 1000021613061 1/29 05/0.9N5 1000021613061 1/29 D5/0.9H6 1000021613061 1/29 D5/0.9NS 1000011613061 1/291D5/0.9HS 1000011613061 1/29 105/0. 9N5 100001161 3061 1/2911D5/0.9NS 1000011613061' 1129 ,ANESTHESIA SET 0116131 03~ 1/29 Il:ASTRIC SUCTlOHOII~I2002 1/29AN'IOCATH 22 011~I2169 1/29 ADAPTOR PRN Oll412171~ 1/29 'SPEC I PAN 0114122261 1/29 SALE" SU"P 16FROII~1222n 1/29 J-LOOP 011~12231~ 1/29 iSTAT"ASTER 01l412246~ 1/29 iTRAHS-ORESS IV 011~12251~ 1/29 IIRRI'ATlON SET 0114126761 i __.L If .'1 h", .,,,.... '" . 11' t !-u t l.1 All l)la ~,llt i~r) !', 'HI f-'\".!~t ','.'~ t I( I ., " "" I. ' \'-1. f'-"ltNT NtNtt" Ek r- -'--------~,.,. .----- - --- 'An jl, !1!Ht H i't~'-,ll~~;, 'l~ (ifdl (11 ' lli,lt ! -, ----,--- . -----~_.. AZIZKHAN REZA TOTAl CHAIlGE~, t-f,J COV[UAr.r ,';1 C()'Jf'IlAf.(; ':;T (()Vff.l~rlf f',j C()VERAGE IN':; co ~IO I ~; ~ ;" 0 roO? Ilj~, r.n t.if)! I f;<; CO NO : ~',l.I,p,T ~I,"): t,l 1.75 1.00 53.00 29.00 7.00 1.00 .06 2.00 .12 430.00 1.15 ~.OO ~.OO 2.79 2.19 8.50 8.50 17.00 17.00 17.00 8.50 8.50 8.50 8.50 16.50 32.25 2.75 2.00 2.00 5.50 325 11,00 1.00 t 3.50 , 1.75 I. 00 53.00 29.00 7.00 ~30 . 00 I 1.751 ~. 00 I ".00 2.79 J 2.79 I 8.50 I 8.50 i 17.00 I 17.00 i 17.001 8.50 i 8.50~ 8.50- 8.50 ' \6 .50 : 32.25 ' 2.7S' 2,00 1 2.00 . S. SO ! 3 25 11,00 1.00 3.50 ~,\)l ~H~Hl.f "~ 1 PI t 1 I ,00 .06 2.00 .12 -----r-.-------- r--1---, --1 -1-_____ .. ___ l'I~A~1 ',I r~l\ I:,doli ~;' ':) HOl Y SPIRIT HOSPITAL ._ , 'j., .'.l,"', E---- ----- t, '.";'."'J.'l't.;! 1 ..1, I,',.", . I '."1 '.' " ,',.l,. ." I-~..; .\1".". ,,\ "I. ..,,'j i .\~~I' i, , I' ,--,', ' '~I h ~ FEDERAL I D. NUMBER 23.1512747 HOLY SPIRIT HOSPITAL 503 NORTH 21ST STREET BIRTH-DATE FEI. 23-15129W HILL. PENNSYLVANIA 17011.2288 03/30/43 LJ 1~"'1 :.l! "l I",' "^ll (,I 1101\,' "11 ':,If ,.ll\lli FINAL~2 _.JJIL-J __B, _ 5 ___ "A' t(PH PlAMI ..JU"S . FRANCES I --- --~~~~~' ""~I"~3~^'~_''''~~>0T''~':\I'''' "~'~I~~i1.-.~.-= --~---]- :uL.B~ 11-HLHL'-_____~______ (.UAIlA'jl(1R Idl"l( ARTHUR , BIGGS 222 EAST "AIN STREET SHIRE"ANSTOUN,PA 17011 ..0 A(l(lf'l(SS COB ,.,. ",I' " 'Y"!" ~")l", y '.' 11,11'1 I' !1.',!iIlM,1 I ""i"/I'.\I.' ~.^Ml 361 86 195320 AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I A~.:'yU~il,,~' I S I i , i'" I ;::::.:: ::t:,,:..~... ~~;~~I~;a~~I~~:~ J:'~ . . , "; '....~, I'"",';",' I':. ",,', .....A' "' '-I' I ,\.. ;,;l~ tJPnltt ,'1ST '~Inll ' ,:,",1 '.' \"."j ,',"", '.,- 11',: ," , " .""., "";'1" ,.." I ^~ I ~ ~,\l[ I-'OSTU' DESCRIPTIONS OF 11QSPlTAl SERI.'ICr'i S[lWln (oor 1/29 TUBE CONNCT 3/1011~12786 1/29 ABD/OBST SERIES013610196 1/29 TELEPHONES 018911100 1/29 SALES TAX TELE 018911400 1/29 TELEVISION 018912200 1/29 SALES TAX TV 018912500 1/29 ROOH 626 019013318 1/30 KCL INJ 20"EQ 10~~400~4 1/30 KCL INJ ~O"EQ 10~4400~~ 1/30 KCL INJ 20"EQ 10~~400~4 1/30 KCL INJ 20"EQ 05~4~00~~ 1/30 D5/0.9NS 1000021613061 1/30 D5/0.9NS 1000021613061 1130 iD5/O.'1NS 1000021613061:.1 1130 jD5/0.9NS 1000021613061~ 1/30 iD5/0.9NS 1000011613061~ 1130 jD5/0.9NS 10000216110619, 1130 jD5/0.9NS 1000011613061j 1/30 D5/0.9NS 1000011613061 1/30 iDEXTROSE 5X 1001161J1~1 1/30 IGRADUATES DlSP 011411598 1130 ;ELECTROLYTES 012520200 1130 iCBC U/3 PART 01012530120 I' 1/30 'SPEC COLLECT FE01251010311 1/30 jTELEPHONES 0189111009 1130 SALES TAX TELE 0189114003 1130 ,TELEVISION 018912200Ei 1/30 SALES TAX TV 0189125009 1/30 ~OO" 626 0190133182 1/31 ~CL INJ 20"EQ 0544~00~4~ 1/31 MCL INJ 20"EQ 10~4~004~8 1/31 MCL INJ 20"EQ 104~400448 1/31 ~CL INJ 20"EO 054~~00~~8 1131 'D5/0.'NS 100001\6130619 II'I"AI _n_ r I ..., :t-~l! '."..ft~1 ~ .--~ - - ._-~----,~,.._=.~~ -.. 'A 11 I', t 11 tit" 1'( )', l!r~ll -,I; i All (11 ',Ill'. I\.. t TOTAl CHARr.['. 1.50 158.00 1.00 .06 2.00 .12 I ~30. 00 I ~. 00 i ".00 I ~.OOJ ~. 00 i 17.00 I' 17.00 17.00 I 17.001 8.50 i 17.00.., 8.50 i , 8.50-, 7.25 I 1.00 I 53.00 29.00 7.00 : 1.00 i .06 i 2.00 .12 ~30.00 ~OO ~.OO 4.00-: 4.00 8.50 \ ','\','1 Hil feST ;:OVERAGr f51 CovEfl/l(,r lSI COVERAGE EST COV[I1AGE It.'; CO NO' IWi co t.n.! INS CO NO J INS CO NO ~ f'A 1'1 " ~ '''''In')',l I. 50 158.00 I ,00 .06 2.00 .12 430.00 ~.OO 4.00 ~.OO 4.00 17.00 17.00 17.00 17.00 8.50 17.00 8.50 8.50 7.25 I. 00 53.00 29.00 7.00 .00 .06 2 00 12 ~30.00 ~,OO ~. 00 i ~.OO-i ~.OO 8.50 i i '.1 ",'" 'h',i' ~~,l'-~l----------\ r J,'" '" ~ FEDERAL I D NUMBER 23.1512147 , , "," ,., "" ,,,,. "'" HOLY SPIRIT HOSPITAL I F IHAL 1 "e-1+31'-9-3 .- 503 NORTH 21ST STREET BIRTH-DATE 1",..1'."" -lNP__1 FEI' 23-15129W HILL. PENNSYLVANIA 17011.22BB 03130/~3 .. ~",~:~;'~i;:"'---. T",,'I::d:Tt I~;;;~~Ei~~i;~il:J . . -=--] GI).IIAN10" ARTHUR G BIGGS 222 EAST "AIN STREET SHIRE"ANSTOUN,PA 17011 'IAur ..0 .ODRESS tJ CO" 't~<;lIIlA"CI (!II,"'Mj'i '1.\1,'1 ." 1"<,'),1111 I'.'I'/'!, t.'IlII' 361 86 195320 _" ____._.__'.'.___ _...-n_ __' -.'--- AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I '~'~';::.t'"7' 1$ DAH DESCRIPTIONS or I SrRlilcr TOTAL EST CCW[flAlif 1,51 COVLflA(.f, f Sf COytllAGE EST COvERAGt FAlIE'jl .>OSl(l) HOSPIlAL SE.RvtClS COOL ('.I1AIlG[S INS CO NO \ IN<; CO NO;> It."> en ~ln] INS CO NQ ~ .\I.ln\ltll 1131 D5/0.9N8 1000021613061' 17 .00 17.00 1131 D5/0.9NS lOOO021613061! 17.00 17.00- 1/31 05/0.9NS 100001161306n 8.50 8.50 1131 ANlllOCATH 22 0Il~12169. 2.75 2.75 1/31 TRANS-DRESS IV 011~12251! 1.00 1.00 1131 ENE"A ADULT SODOII~125671 2.00 2.00 1/31 ELECTROLYTES 012520200; 53.00 53.00 1/31 CBC U/3 PART 010125301201 29.00 29.00 1131 SPEC COLLECT FE0125101031 7.00 7.00 I 1131 ABD/OB8T 9ERIES01J610196~ 158.00 158.00 1/31 TELEPHONES 018911100c 1.00 I I .00 1/31 SALES TAX TELE 018911~00' .06 .06 1/31 TELEVISION 0189122001 2.00 2.00 1131 SALES TAX TV 018912500 .12 .12 1/31 IROO" 626 019013318l 430.00 ~30.00 2/01 APAP 500"' TAB 0~~~28002l ~.OO 4.00 2/01 KCL INJ 20HEO 1 0~4~00~~1 4.00 ~.OO 2/01 KCL INJ 20"EO I O~~~OO~~l 4.00 ~.OO 2/01 KCL INJ 20"EO I 04~400~~1 ~ .00- ~. 00- 2/01 KCL INJ 20"EO 054~~00~~1 ~.OO ~.OO 2/01 KCL INJ 20"EO 10~~400~41 ~. 00- ~.OO 2/01 KCL INJ 20HEO 05~~~00~~1 4.00 ~.OO 2/01 BISACOOYL 10"; 01~~56010C I . CO ' 1.00 I 2/01 05/0.9N9 lOOO021613061~ , I 17.00 i 17.00 I I 000021613061 ~ , I 2/01 05/0.9NS 17.00 l 17 . 00 ~ 2/01 D5/0.9M9 1000021613061 C t7.00-4 17.00 I ! 2/01 D5/0.9NS 10000\1 61 3061 ~ 8.50 i 8.50 . i 2/01 2/01 2/01 2/01 2/01 2/01 2/01 D5/0.9NS 1000021613061~ D5/0.9NS 1000011613061~ ANESTHESIA SET 0116131039 I ' \STAT"ASTER 0114122~6~ ELECTROLYTES 012520200~ ICBC un PART DI012S10120ti ISPEC COLLECT FEOl25tOl031 litH HAl 'lll~.l '~'.l ,'I"",', \1.00"1 8.50 ' 16. SO ' 11.00 53.00 e9 00 . 7.00 , 17.00-4 8.50 i 16.50 I 11 .00 \ , 53 00 i 29.00 ! 7,00 I -==::r~=--l- RHlR AH UVlS1l0t~'; 1l\ fl11 t1US1~ESS nt' Kl ,>! '\ ~t13 ~'l'lt4 t'UA",l ~~lNn PA'JMtNI Tn , i[_ I I ~ ',A: I'A: I ~.;' I:H I "U, I;.IA" HI' 1\;1 "f"':,lV- I" H &,", ,..,I. ,i '., T' ~ t ~' ,.".t'.' ":.., .\ ' ' , ,f ;' "",, '. I ',. h....' :'''\;,11- _,_,.,,_...J...._ I,'AnFNT NlJl,t~lR .-- 'An l~ tlTHI:.H rOSllNCi II; i'.ill nt qlWICl HOl Y SPIRIT HOSPITAL ',(}:I NIlI11H .""1 SlHU T I':;', ,\'.' .',>, ". ,',', ".-",. I .:',' :'At~1 Hill f'.\ "{ill .':l-'M , , , Hel.,. n - -, . 1 ,- -1 ~ HOLY SPIRIT'.HEDOLSJ1p^LITI AD LNUMUEIl 23. 1.!.121.1 I I ' ", , : ,,', 'I '1"11 ; '~II' " , ",1' I '''I. Pil , , F'INALj:-42,/-\~,l.9-lL . 503 NORTH 21ST STREET BIRTH-DATE "CO'," "" .IN!'.u FEI. e3_ISI2'tWHILL.PENNSYLVANIA17011.2288 03/30/43 .:l"S.~'F~~~~~~~;l-uJ-~:"-';';~~'~'; I.JJ_~~- E;~';;~~~';'JG~~;;;i~'~I~;J" _-~_~:-=_"I l~ COB ....' "A'i' I ' , ','I ,\rl' '~A"'I ." ". '.'I'l" I'11IH,tt!II,'Ilfll '.\IAII"~T(lR 'jA"" ARTHUR II BI,eS 222 EAST "AIN STREET SHIRE"ANSTOUN,PA 17011 I 361 86 1 \95320 L______ .110 "'OORfS~ AZIZKHAN REZA HD PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~<Ue I AMOliNIOf 1$ PAV!.l[W .lA'! !l! ,>OIIPI,OP.<; Of <;'IH"'IO /(11101 1510)"UIM,1 f',! rnVIIlAr",[ f')1 COvfHAG[ [;.! ,(lVfl,A.(,r PAllfljf p, ,~; 11 :) t~( ";I'IT Al SI 11I"rr', COOl 11,,,1;(-,1" I""; ('(I r~() 1 1'4", ('llll).' It.'; tll '101 ".', (() r41).t A"'O'I'<I 2/01 ,TELEPHONES 018911100 1.00 1.00 2/01 is ALES TAX TELE 018911~00 .06 .06 2/01 TELEVISION 018912200 2.00 2.00 2/01 SALES TAX TV 018912500 .121 .12 2/01 ROO" 626 019013318 ~30.00 HO.OO 2/02 i"EP 75"' INJ VIOI"~02120 1 . 75 I I. 75 2/02IAPAP 500"' TA8 0~~~28002 ~. 00 ' 4.00 2/02 HYDROXY 25"'I"L01"~28068 1 00' 1 . 00 2/02 lKCL INJ 20"EO 10~4~004" - I ~.OO ~. 00 i 2/02 iKCL INJ 20"EO 10~~~00~4 ~ OOJ ~.OO . , 2/02 iKCL INJ 20"EO 05~4400~" ~.OO~ 4.00 2/02 iKCL INJ 20"EO 05~4400~4 4.00 4.00 2/02 105/0. 9NS 1000021613061 17.00 17.00 , 2/02 DS/0.9NS 1000021613061 17.001 17.00 2/02 jDS/O. 9NS 1000011613061 8.50 8.50 2/02 DS/0.9NS 1000011613061 8.50 8.50 2/02 ELECTROLYTES 012520200 53.00 53.00 2/02CBC IUJ PART 010125301201 29.00 29.00 2/02 ~IFFERENTIAL 012530180 11.00 11.00 2/02 ~PEC COLLECT FE0125101031 7.00 7.00 2/02 TELEPHONES 018911100 1.00 I . O~ 2/02 SALES TAX TELE 0189110400 .06 i .06 2/02 ,TELEVISION 018912200~ 2.00 i 2.00 2/02 ISALES TAX TV 018912500 I .12 : .12 I 2/02 :ROOI1 626 0\9013318~ ~30. 00 I 0430.00 2/03TRII1ETHOB 200"G0204"56088 5 .58 : 5.58 2/03 'ANESTHESIA SET 011613103, 16 SO ! 16.50 2/03 IDS/04SNS/20KI00216\J216~ 24.00 2~.00 2/03 OS/0~SNS/eOKI00216IJ216' 24.00 24.00 2/03 '0510. 04SNS/20KI 001 16132169 12.00 12.00 2/03 ~N'IOCATH e2 011~12169~ 275 2.75 ' 2/0] ANGIOCATH 18 011 ~12230l 2.50 ' 2.50 I 2/03 J-LOOP o I 141 223 II 325 3,25 I 2/0]STATI1ASTER 011"'22~6' II _ 00 11.00 ."" ---- --'-;:-;~~-<-~1 ,.----101. ".H ,"Ill 'J\'{ ',I -,-, - - , ~1".'\II',', i'lI I .,' ';'.' 'I," - . ..... .\ 1 Ii' ~ ! I' I ! l I, ;', ' i' -;' 'i, (l.'l, l! ,... .! I ~ , ' '....': . -'------ '"t -----1-------- ._,.,..~,- PU A~f ~;f t~ll ,'A""'! '.' ~() HOL Y SPIRIT HOSPITAL ;)(n NnnlH ,'1<...;1 '. H~ll ! (.~'~~f't~ll! 1'.'\"" "'~'r\ \ . , I' -",-, . >1, I '; \ ll'll ''''f, ".... III ~lf', ~ .'\1., .1' '" ' , ., Will ~ "', ~'" l ,,' '. ..,,,'. o\l,lo'fli-, ".,) IA -- . ,1.',1 "". '''I; '., ,0,' , ",~ , ...'. _,"1' f',l',' _HCLJlJ-_- --- I,ll" '~'^!I'II ~ HO[H^lIDNlJMBU~:':ll')177'" ,1' "I 11'.1 " , '''' '" I HOL V SPIRIT HOSPITAL FINAL -o~-3-M3' 503 N?RTH 2151 SIRELT BIRTH-DATE INL_ FEI. 23_15129~PHILL.IENNSYLV^NI^17011'2288 03/30/43 I_~l~~~~~;~-_ -_~_ J~.~_'~"~.'::'~';IJl_;~ 1~;'/2~/~'3Io2;;'~L~~1~;_L_=~ - - . --j LJ r~I:':"" I con " ,(.(,'j.I' ''','I'hlp'IA'A' .'" . '. ~.tll" !'Oll! . 'juI)lIllj ',UAU"P\ll{J1l ''''MI ARTHUR , 81GlOS 222 EAST "AIN STREET SHIRE"ANSTOUN.PA 17011 I 361 86 195320 ,"0 AOORESS - AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~(Ut I ":;~~I.;il,:l' I $ llAl( DESCRIPTIONS Of s[nVICr IDIAI f-'il UWIllAr,f ",' (,("V['....".r f'll rn,pIA"'-,r f',f COvERAGf PATI[~. r P()<:.1!P HOSPITAl SlRVIC[~ COOl ('I1A1.'..' II~'; en t;O' ";. (.(l 'l'):> "4", (n NO I ".,> co r./O.. ..""nUl; I 12/03 TRANS-DRESS IV Oll~12251 I .00 1.00 12/03 ELECTROLYTES 012520200 53.00 53.00 12/03 ELECTROLYTES 012520200 53.00 53.00 12/03 ELECTROLYTES 012520200 53.00-t 53.00 12/03 CBe 11/3 PART 010125301201 29.00 I .. 00 j 12/03 CBC U/3 PART 010125301201 29.00l 29.00 12/03 CBC U/3 PART 010125301201 29.00 29.00 )2/03 DIFFERENTIAL 012530180 11.00 11.00 12/03ISPEC COLLECT FE0125101031 7.00 ! 7.00 I )2/03 'ABD/OBST SERIESOl3610196 158.00 i 158.00 12/03 TELEPHONES 018911100 I .00 I t .01 )2/03 SALES TAX TELE 018911~00 .06 .01 12/03 TELEVISION 018912200 200 2.01 12/03 SALES TAX TV 01891 2500 .12 ." 12/03 ROO" 626 019013318 430.00 I 430.00 I<UO~ HEPAR IN 10" UNIOI~~20036 2.02 2.02 )2/04 TRI"ETHOB 200"1003~~56088 8.37 ; 8.37 I 12/04 ITPN-PHAR"^CY 014~99999 375.001 375.00 12/0~ 10EXTROSE lOX 1011613052 8.50 I 8.50 )2/04 ,NACL 0.9 250 011613066 7.25 I 7.25 )2/0~ iUPIDS lOX 500011613082 57.75 57.75 )2/0~ IANESTHESIA SET 111613103 181.50 : 18\. 50 )2/0~ 105/0. ~5NS/201(1 0011613216~ 12.00 . 12.00 i )2/ O~ 105/0. ~5NS/20K 100 II 613216~ 12.00"" 12.00-1 12/0~ !AVI SET 230 011613370 26.00 ' 26.00 ! 12/0~ !AVI SET 230 01l613370~ 26_00 26.00 I 12/0~ ISTATHASTER 01l~122~69 11.00 11.00 )2/0~ ~DAPTOR PRN LL 011~12331~ 2.50 2.50 )2/04 ~NE"A SET SS 0114125694 4,75 ~,75 )2/0~ ~NE"A SET 55 01l~12S69~ ~.75 ~ 7S )2/0~ ~-CATH PIC 011~12808' 168.75 168.75 )210~ iCHE"ISTRY PROFI012S201054 63.00 61.00 )2/0~ ~HOSPHORUS, SER012520190~ 27,00 27.00 )2/04 ~LECTROlYTES 0125202003 53.00 53.00 Ill",l;;..1 ','1',1 .<lI.."j''''.'" I'AIII....' N.'~t4(.. l..';UPl All Out s! !Ol\,l' RIJ';!l\It Ss f II J!( t "'It'ti}:'1"{joO .1~,-- --.Ho~"~~tl~(j~.~f~~I~~-L -ri-~---T-- E_- '-,\' ! '. 1"\ ('''Iii "';"', HI ~d ",,' ,A,,' ,,,,.; r,t 'H!.I ",?'~ 1 Ii! I ! .....1'. <,,'-," ,'.' "" -.. :'.\!! I',! 11 H~ Ii 1'\ )t~ 11".,", I IH 1'.\'! ''II H"i\ i , \ '.. ~ t' ~ ~ '~' I' , , ' >, ;..;, ',.) . '. ,.. . [.H.~hJr-~-,-:-'" '""" ~ rEDERAL ID NUMOER23.151U47 ,,' I . ,,,,, '" , HOLY SPIRIT HOSPITAL . FINALl-oc/-l~ 503 NORrH 21ST STREU BIRTH-DATE ,,,,.... "" -IHU FEI' 23-1512m' HILl. PENNSYLVANIA 17011.2288 03130/~3 l~i"iS~..:i~~~'- .----...-~-r_-'C'-~'~'i],J.._~.~ ..1..~.;'~.,;~' !,~"... -;;.2;'~~~.~J:";~f--......" .-~..._-" \'~" 'i,l I r 1.".n..lOn I NAMl I .." I AoonfSS con '!<"'II..uiC! (;l','IM,-. ~.M..ll ;... '-'.,,'.'Itl" ~ .~. I'. It to, '. . j, J I. ~ lIP. _ _u..__.___.._____~.__ ARTHUR G BIGGS 222 EAST "AIN STREET SHIREHANSTOUN.PA 17011 361 86 195320 AZIZKHAN REZA MD PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I '~~~~;r,sr Ls OAT{ [11 S(llll'll(1tlS Of srmn(1 101M 1<;1 COVIll,r.r,[ lSI COV[HA(.f. I.:' I covf RA(.[ f ,:" t COvE HAm PATlnn Pll~; If n ,,, '~:J'ITI.\ Sl!WICES Cn(l( (~lAIl(-.r s 'lj~, (n t~() , IN'; (;0 N07 'W.(11 tjn,} 'rj~ CO 'K)t AWJUt~t I2IO~ ItAGNESIUIt 012520270 29.00 I 29.00 I2IO~ ALT ( SGPTl 012520~50 18.00 I 18.00 I2IO~ TRANSFERRIN 0125205~2 35.00 35.00 12/04 CBC U/3 PART 010125301201 29.00 29.00 12/0~ SPEC COLLECT FE012510103~ 7.00 7.00 12/0~ ABD/OBST SERIES013610196 158.00 158.00 I2IO~ TELEPHONES 0189111009 1.00 12/04 SALES TAX TELE 018911~00~ .06 I2IO~ TELEVISION 018912200 2.00 12104 SALES TAX TV 018912500, .12 12/04 ROO" 626 019013318 ~30.00 430,00 12/05 HYDROXY 25Mll/ltLO~~428068 4.00 4.00 12/05 rOVIDINE PR 1.2014~8~091 1.00 1.00 12/05 TPN-PHARltACY 01~~99999 375.00 375.00 12/05 ~IPIDS lOX 500011613082 . 57.75 57.75 12/05 ~VJ SET 230 011 61 3370"- 26.00 26.00 12105 ITRANS-DRESS IV 011~12251 1.00 1. 00 12105 ~LUCOSE 012520109 20.00 20.00 121 05 LECTROL ytES 012520200 53.00 53.00 12/05 ~PEC COLLECT FEOl25101031 7.00 7.00 12/05 ~ELEPHONES 018911100 1 .00 I .O( 12105 iSALES TAX TELE Ol8911~00, .06 .O( 12/05 ~ELEVISION 018912200~ 2.00 e.O( 12/05 IALES TAX TV 018912500i .12 .1, 12105 !ROO" 626 0\9013318' 430.00 ~30.00 12/06 ~PN-PHARMACY 01~499999 375 . 00 I 375.00 12/0& LIPIDS lOX 500011613082 57.75 i 57.75 12/06 ~VI SET 230 01161J370~ 26.00 ' 26.00 12/0& ~KJN STAPLE RElt011412227~ ~.25 4.25 12106 iGLUCOSE 012520109~ 20.00 20 00 i 12/0& ELECTROLYTES 01252020031 53.00 53.00 12/06 ,SPEC COLLECT FEOl251 01 031; 7.00 7.00 12/06 ABD/OBST SERIESOl3610196e 158.00 158.00 12/06 lELEPHONES 018911100'; 1.00 1 .O( ~-- -~~~ -'-'.::- ..-:.:------ --r- - -- - ---r--------- .-- -1------I,--1 =t . --;:;;-,.-:.;M""'l--- ;::,':~,;:,;.~'.,:~':~';'''''' ., :", --:~~~~~I~l;~~~~~I~~L - L.~__----~--- ...... '" ".:,', 1;\1'1',' t;", "..\ ...;;" 1'1 .;t, I' .u" , ,,:,-, I! !,!I~'ltHl'll~"I!~;', ;,niNonlH.ll~l Sr.Ufl "\"'1 r,:' f': 'I .',1'1'. . h. \;'1' ;,.\" <', ',1 Ii',:"! \ ,\'}1" Hil, 1'1\ 1 'I \ :.'H~i ; \ ." ~"', t ,..." I.'.. . !-Hsr~r" n" ,;':~.',,::, ~ HOLY SPIRIT'~~~'~'I~~~IJMBEnnl',';'''' l_~ i i , FI~ALI~er-t CAMP ~~L3L~~:~~;;/L"v'A~::~~~'12288 BIRTH-DATE I""~"_'J ~N FEI. 23-1512747 03/30/43 i~s ~ :FR';~~'~i~ 1 =~~----L"_~~',Jj~~_ t:;~:/'9'3 j 02;~;'_~;~~ L'^;~_~-~- ~~: I GUAJ1,1Nl0n N"M( ARTHUR ~ BI~IlS 222 EAST HAIN STREET SHIREHANSTOUN,PA 17011 "'" "'OURESS COB ,'.'. ,p,HI" "''''I',V" 1;1\"1 1"lll,.,,';'.'IIIIl 86" .'..'1 195320 361 I 1- ,_,"_ AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~<Ut I '~~:';.;:',;;' I $ [lAll I'l''';![P [Jf,scnIPTIONS (If ..OSPI T At SUlVlC[ S Sff-lVl(l coor 2/06 SALES TAX TELE Ol8911~00 2/06 TELEVISION 018912200 2/06 SALES TAX TV 018912500 2/06 ROO" 626 019013318 2/07,VIT-K INJ 10H' 01~48S010 2/07 ITPN-PHAR"ACY 014~99999 2/071LIPIDS lOX 500011613082 2/07 IAV 1 SET 230 011613370" 2/07 ,TELEPHONES 0189111009 2107 iSALES TAX TELE 018911400~ 2/07 iTELEVI SION 018912200 2I07ISALES TAX TV 018912500, 2/07 IROOH 626 0190133181 2I08POVIDINE PR 1 .203~~84091 2/08 'TPN-PHARHACY 0 I ~499999 2/08 ~lPIDS lOX 500011613082 ~/OB AVl SET 230 0116133701 2108 TRANS-DRESS IV 011~12251 2/08 !ADAPTOR PRN LL 01 I~I2J31 2108 iCHE"ISTRY PROFI012520105 2/08 ~HOSPHORUS, SER012S20190~ 2/08 ~LECTROLYTES 012520200~ 2108HACNES lUH 0125202706 2/08 ALT (S~PT) 012520~50~ , 2/08 !TRANSFERR IN 0 125205~29 2/0B :CBC U/3 PART DI012530120l' 2108 :SPEC COLLECT FE0125101031' 2108ABD/OBST SERIESOl36101962 2/08 TELEPHONES 0189111009 2/0B SALES TAX TELE 018911~003 2/08 TELEVISION 0189122006 2/0B ,SALES TAX TV 0189125009 2/08 ~OO" 626 019013318e 2/09 'TPN-PHAR"ACY 0 I ~~999993 __ ~ _'J__.',____~~~2_',.,_~_._:.__..:..._ "::I_N:..N"~"~_r - ::;.I,I,.~; :' ',~:-,':.,' ", " '", '.., ---,--- ---,- " ., '- --- .- MlI I', I j1HIIlI'tl'.'I~J\, tit {IA11 . ,I '_lll'.1( I H~:~~-~~~I'~~I~~I~~L-=rc~~~-1 [__~~~ . . .\. I .... I '.' I j ~ ".", ... "', tll . ; I ' I < ", ", f ,I ", '.il,IJ\lH1H ,,'! -.'1'1 t ~ .H_ I " + 'I' '",,,", ""- ll:ll :.~ 1'''1 .u', """,lli- ',' h", ;' . , 'II l " ",of III '"t;AIl(i1', .06 2.00 .12 I ~30.00 i 12.85 ! 375 00 I 57.75. 26.00 ' 1.00 .06 2.00 .12 430.001 1.29 : 375 . 00 57.75 26.00 I .00 ! 2.50 i 63.00 I 27.00 : , 53 _ 00 ! 29.00 1800 35.00 29.00 7 00 158 00 I .00 06 2 00 12 "30 00 125 00 I :,f COV!:JIAC,F f ',I L(h'fll"'t.! 1')1 ([llifRMif 1,1 ("o..IIIMif ,~.~ co NCl' ,~.', C(I t,ll;' .rj'; r I) Nn I ",', ('1 t." 4 f>^ I IHlT 4MlJlifP -''t _L ~30.00 12.85 375.00 57.75 26.00 ~30.00 1.29 375.00 57.75 26.00 1.00 2.50 63.00 27.00 53.00 29.00 i 18.00 35.00 29 00 7.00 ' 158.00 ~30.00 125.00 , /,','1 'lq if,', ," ;,'; I.~'~~j-:------:--: ,,'" " I " .,,'1' I"., i,'I.'I'I. I FI~ALr~UH,t.-9 . . l_IH ~ FEDERAL I D NUMBEfl23.151U47 HOLY SPIRIT HOSPITAL 503 NORTH 21ST STREET BIRTH-DATE i!3-15129W HILL. PENNSYLVANIA 17011-2288 03110/~3 LJ "1)';1' fj{J l S_ _5_ f':,~.II::.1 :;.\1,11 ____... LJlL"S _ "ERANCES I FEI . _I~:' :'''-~''~~~~ ~ I~__l~';S~~~;~j ~~~ ~'~~~i~jf. '~l-- - ----- - - -- ---I r ! , (,u"Jl...~1t'n COB 1!I'-)llllAWf I./JMI'Ar~, 'Jill," ',I" ~'" '.1 '''''11 'l POt IC" t~';"'IH'1l "'I."', ARTHUR , BleoeoS i!i!2 EAST "AIN STREET SHIRE"ANSTOUN,PA 17011 I 361 86 I 953i!0 "0 AOOA(SS AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~<J41 '~~'';,,'','N~' 1$ [lA'! OESClllPllONS OF SERVICt IOTAl EST COV[UAC,( fST COV[flAGF ESl CO\oERAGE [S' COVERAGE PAllIN' ."l'-.'!O HOSPll Al Sf RVICE S COOl (""mi[e; INS CO NO' 1Wi CO pm2 INS (0 NO;I INS CO NO , AMOUNT .2/09 LIPIDS 10Y. 500011613082 57.75 57.75 'U09 LI P I OS lOX 500011613082 57.75 57.75 'U09 TELEPHONES 01891 I 100 I. 00 I .OC 'U09 SALES TAX TELE 018911~00 .06 .Of '2/09 iTELEV I S I ON 018912200 2.00 2.0C 12/09 ISALES TAX TV 018912500 .12 .1< '2/09 ROO" 626 019013318 "30.00 "30.00 '2/10 AVI SET 230 021613370 52.00 52.00 '2/10 ilv FILTER 0.22"0216137"6 32.50 32.50 'UIO ISElF 0100100701 18.02 18.0c 't.I'.... 'I',' '.' I I I i 1\9652 . Ti1i96.1 6 :ott---- ..~ ~ - 'H! I'LtA.',l SfM'PA)MtNI TO HOl V SPIRIT HOSPITAL PAY THIS A"OUNT 19616.0Q 1,0'1 NCHllH /1'-1l Sn-~l t 1 .,,,,.,/'\,'~'t"',~:II~~l::t~t:,,t'l ;:i '\".\"'''' ,d'" t ,u.,jf,; (.\MI'Hilt .^ 1"llll.':)~K ..,." ',' ,,' '," -L--'I_LAt:] ------ IA1'II,l "t.llJI'lll HI III... t'll Ull! ',Ii' IN' - -."' ~,",It~t ,', I 'II f 3546116_ ' . " " '" ...... ~ ' . ' : . of ,.- "I 1', ! I'., , ..' " t I' ~,~,l,.~._.____ ... :,,\1! Illfll,,1 t'll I - . F I HAL c/-HI JNL_ ~ II, T' "I 1'111,1''11 ~ FEDERAL I D NUMBER 23.1512747 HOLY SPIRIT HOSPITAL . . . 503 NORTH 21ST STREET FEI. 23-15129~'f HILL. PENNSYLVANIA 17011.2288 B~~~~~~:~E LJ . ' ttfl~.P tl<J B __S_.___I~~~t~~~~._. _-B~ ,FRANCI':S I .-- "'-""'-'~'~I"i:n-~'~J~'i';~~'~~I~:~i;~;~jtIJu_------_. J COB ,1.'.l)IlM~(f (!l~P.uH' "AMI "..' ",,".""" Pf)ltC~ 'i:j..IHlf' GlJAA,uHon NAIl', ARTHUR G BIGGS 222 EAST MAIN STREET SHrRE"ANSTOUN.PA 17011 1 361 86 195320 '"0 "OVRlSS AzrZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I AMOllfH or I S PAVVUtf " DAlf DESCRIPTIONS Of I SERVIC[ TOTAL EST covFnAGE [ST CQVEnA[,E r S, COvE "AGE [S1 COVERAGE P"TfENT pnsltu HOSPI' Al ~[R\.'ICl S CODE CHARGl S INS CO NO 1 INS CO NO? IN~) CO NO J INS CO NO" ,\,MOUNf SU""I RY OF PAY/AOJ 18.0e. 18.02 SU""I RY OF CHAR'ES R&C ! E"l PR 170AYSD 430.00 7310.00 7310.00 PHAR"ACY 250 2787.09 2187.09 rv THERAPY 260 1136.50 1136.50 "IS SUPPLIES 270 9\ 0.50 910.50 LABORATORY 300 2560.00 2560.00 OX X-RAY 320 126~.00 le6~.00 CT SCAN 350 685.00 685.00 OR SERVICES 360 1026.00 1026.00 ANESTHESIA 370 290.00 290.00 IMAllIN' SERV 402 364.00 36~.00 RESPIRATORY SV ~IO 171. 00 171.00 EMERllENCY ROOM ~SO 20~.00 20~.00 RECOVERY ROO" 710 251.00 251.00 I EKll/EC' 730 ~6.00 46.00 TELEPHONE 993 18.02 18.02 TELEV IS J ON 99~ 36.0~ 36.0~ ANES SERVICES 964 611.00 611 .00 I : , SUB-' OTAL OF CHARGES 19670. IS 119616.09 S~. 06 I i ! I I I I I I , i I I , , , I I i I I "AHENT NUU8l'H HI tl;~ All \Jut SIION'. '" '.1' ,,! ;' ~11'.(1 >.;-. , ,~ I (i"' t , ?h \ ;'1111 _ 3S~6 I 1.'-. ..... ,\H I', f l1H~ n 1'1 i-,"'j(, '11(\.\'[ (11 -,Ill,,"l Pll ASl SEND PA.)MtNf Tn HOL Y SPIRIT HOSPITAL 1)0.1 NORTH :ll'-;t STRfLl (A\H' HIll ~'A 1 ,()11 ;'?8A PAY THIS A"OUNT 1961"6.09_ .... :',I:{'~....l 1.\ 1 'I ~.I U!l1. "n ......v BE ,..1 (t ~.-,Anv '"I' ^'. .....H' ,! '. ~ i', I',,! t ... Ht t..j 111~" 11'( I .\... -,. 1'1'1' '" I ." . . . '_ ; I. _'. t 4 "~' 1 ','. :~, '.< I j.., "" . ,. f ,.. . "j .. ~,' ' _ ":, . , . ; ..., ~, I ",' ,\ ' I . , 1"41 .. HOLY SPIRIT HOSPITAL, Plaintiff IN THE COURT OF COKMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA . . . . . . v. CIVIL ACTION - LAW . . . . ARTHUR G. BIGGS and FRANCES I. BIGGS, Defendants . . 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, HOLY SPIRIT 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. Defendants, ARTHUR G. BIGGS and FRANCES I. BIGGS are adult married individuals residing at 222 East Main Street. Shiremanstown. Cumberland County, Pennsylvania 17011. 3. On or about January 24, 1993 through February 10. 1993. Plaintiff, at the request of the Defendants. did provide health care services to Defendant. Frances I. Biggs. 4. Plaintiff in good faith provided the necessary health care services to the Defendant, Frances I. Biggs and thereafter billed Defendants its usual and customary charges for the services rendered. As evidence thereof, a copies of the billing for services rendered to Defendant, Frances I. Biggs are attached hereto, made a part hereof and marked Exhibit "A". 5. Plaintiff did credit Defendants' account with all payments made on the account and there now remains a balance due and owing of $19,616.09. 6. The purpose of this communication is to collect a debt and any information obtained will be used for that purpose. COUNT I. (Plaintiff v. Frances I. Biggs) (Quantum meruit) 7. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 6. 8. Plaintiff did render health care services to Defendant with the reasonable expectation that payment for such services would be made by the party benefitted. 9. Should Defendant not be required to pay for the balance due for the services rendered, Defendant would be unjustly enriched at Plaintiff's expense. WHEREFORE. Plaintiff pray your Honorable Court to enter Judgment in its favor and against Defendant Frances I. Biggs in the amount of $19.616.09, along with interest at the rate of 6% per annum and the costs of this proceeding. .. COUNT II. (Plaintiff v. Arthur G. Biggs) (Doctrine of necessaries) 10. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 9. 11. Plaintiff believes and therefore avers that the health care services rendered, upon request, to Defendant Frances I. Biggs, wife of the Defendant Arthur G. Biggs, were necessary for her benefit and welfare. 12. Plaintiff believes and therefore avers that pursuant to the "doctrine of necessaries", Defendant Arthur G. Biggs. as spouse of the recipient of health care services, is liable to Plaintiff for the balance due. 13. Should Defendant Arthur G. Biggs not be held liable to Plaintiff for payment of services rendered his wife. he would be unjustly enriched as the services were necessary to benefit the health and welfare of his spouse and their marital union. 14. Plaintiff has made demands for payment upon Defendant, which demands remain unheeded. WHEREFORE, Plaintiff prays your Honorable Court to enter Judgment in its favor and against Defendant Arthur G. Biggs in the amount of $19,616.09 along with interest at the rate of 6% per annum and the costs of this proceeding. c::OUNT_~U_! (Plaintiff v. Arthur G. Biggs) (statute) 15. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 14. 16. Pursuant to 23 Pa.C.S.A. 4321. married persons are liable for the support of each other. 17. Pursuant to 23 Pa.C.S.A. 4102. where debts are contracted for necessaries by either spouse, a creditor may institute suit against the husband and wife for the price of the necessaries. 18. Plaintiff did render necessary health care services to Defendant Frances I. Biggs with the reasonable expectation that such services would be paid for by the persons benefitted, which in the instant case include said Defendant and her spouse. Defendant Arthur G. Biggs as partner in the marital union. 19. Plaintiff has made demands for payment upon Defendant. which demands remain unheeded. WHEREFORE, Plaintiff prays your Honorable Court to enter JUdgment in its favor and ,lgainst Defendant Arthur G. Biggs in the amount of $19,616.09 along with interest at the rate of 6\ per annum and the costs of this procppdinq. COUNT IV. (Plaintiff v. Arthur G. Biggs & Frances I. Biggs) (Total) 20. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 19. 21. plaintiff has made demands for payment upon the Defendants for the balance due of $19,616.09, which demands remain unheeded. 22. 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 Defendants in the amount of $19.616.09 along with interest at the rate of 6% per annum and the costs of this proceeding. -_0'. Art ur A. Kusic, Esquire 4201 Crums Mill Road Post Office Box 11585 Harrisburg, PA 17108 (717) 540-5610 Supreme Court No. 07207 Attorney for the Plaintiff DATED: I{XIl) IlI'l' "^ n ~'~~'l" """""'" I"'!, , FUMl --1HE-. !JAIIIl' 1'111 V 11111 ~ FEDEllAL I D NUMBER 23.'~'2747 HOLY SPIRIT HOSPITAL . 503 NORTH 21ST STREET BIRTH-DATE FEI. 23-1512W'f HILL. PENNSYLVANIA 17011.2288 03/30/43 o t'{\<;l'rjl) _B _ _____ __ S_ _ _ __1~~~f_;l rlAJ.l'_____ ____ ~_ _ _'~~~'I. NT NU~~ I~_ :~ __ A~~l._ -B~S__.EBAHt.ES I - -_.~ AI ",11' ," 1(1 ~ J tl A 11 I'll ',I ,Ii ^ '4' ,I II ^ , I , ) ^ 'y " . 1-'--9 9 I coo IrJ<"lI1lAr.(! Ull.ll'M"'IAl/' ',1/-,,",1 '.''''IUll ,",llttC.' tlllMIII,I1 GtJAIIANTfln ~A"[ ARTHUR II 811OIOS 222 EAST "AIN STREET SHIRE"ANSTOUN,PA 17011 I 361 86 195320 '"0 AnDRESS AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT '7~ ~ I '~~;~ir,,~' 1$ J :JAIL P[SCIlIPtlONS Of I SHIVICL TOlAl rST COVfflAC,l r 5' COVE HAG[ l";! COvfRAGl [ST COVERAGE PAT!HH PtY,Hll Il()$PI' Al Sf nVICE S COOl CHARGlS INS CO t.O , lt~., CO NO '2 Itj<; C(l NOl IN"; CO NO 4 A'-'OUNT DETAI L OF CURRENT CHARllES. PA' "ENTS AN[ ADJUST"E NTS 1/23 'LUCOSE Ol2520109E 20.00 20.00 1/23 RENAL PROFILE 012520155< 62.00 62.00 1/23 A"YLASE, BLOOD 012520340" 53.00 53.00 1/23 CBC ~/3 PART 010125301201 29.00 29.00 1/23 SPEC COLLECT FE0125101031 7.00 7.00 1/23 ISTAT HANDLINll FOl25103681 10.00 10.00 1/231STAT HANDUN' F012510371~ 10.00 10.00 1/23 STAT HANDLINll FOl25103731 10.00 10.00 1/23 iSTAT HANDUNG FOl2510374E 10.00 10.00 1/23 IABD/OBST SERIESO I 3610196. 158.00 158.00 1/23 IGALLBLADDER US 01 3611406~ 364.00 364.00 1/2~ "EP 75"10 INJ VIOl4~02120. 1.75 1.75 1/24 "EP 75"G INJ VIOI4~02120. 1.75 1.75 1/24 "S 10"10 VIAL 01~~021251 2.00 2.00 1/24 ICFX IG" IVPB FR0244080~55 64.50 64.50 1/2~ iCFX 2G" IVPB 014408046: 21~.1~ 21~. I~ 1/24 ~ENTYL 10"' AHP024412033! 81. J4 81.34 1/24 HYDROXY 50HIO/"LOl4~280691 1.00 1.00 1/2~ ~YDROXY 50"G/"LOI4~280691 1.00 l. 00 1/~~ TORADOL 30"'I"L03~428089! 75.00 75.00 1/24 ANES CHARIOE 03~4999901 18.75 18.75 1/24,NACL 0.9 1000011613063! 8.50 8.50 1/24 'LRS 1000 011613068' 9.50 9.50 1/24 ~NESTHESIA SET 011613103' 16.50 16.50 1/24 105/0. 45NS/l OKl 001161 3314~ 12.00 12.00 I 1/24 ~5/0.~5NS/IOKI001161331~ 12.00 12.00 1/24 '0510. ~5NS/I OKI 001 \613J14~ 12.00 12.00 i I 1/2~ ~5/0.45NS/IOKI002161331~ 2~.00 24.00 I , i 12.00 i 12 OO-! 7.25 2.50 17.75 12.001 12.00 7.25 2.S0 17.75 1/24 P5/0.~5NS/l0KI00lI613314~ 1/24 P5/0.~5NS/IOKI001161331~ 1/24 I.SECONDARY SET 101161]316~ 1/24 "ASK OXYllEN ADUOII~10621 1/24 EXERClSER VOLU"011410785 " I" : 't ~;' .; I'Al:tt.1NlI'-UlIII HI.IHAII \}ill',lidN'; In'Hf ----- th)L,tl~1 ',~; ~ III '", t ',' '''I,''It< fll! Aq St NO f'AYMlNl Tn HOLY SPIRIT HOSPITAL ',In NOR1H 21ST STAH.1 (. AMP Hill PA 1 ml1 ~);)HH -. '.,It !',! IIH! H h)~"l'~'j il P^!! (\1 ',I H\IC! \:'IIII"''''''II'AI'I,'''''''I\''''',''''''' 1,'1 '111:''1'-;,1,;,.1,\1; "1:.1-il.l,-tl' II'l\','I', ,'",1', "" l":l ,',-" Il.I' ,. I ','",1."", I ',Ahl_ll, '.. f'A ;. "I '. "I' ~".f. ' ..,...... . . ','I " ~ ".' ,\ , "'.\.1 _HCl_e____ Id-',I-r flATI 111 F~~AL I :~'''''- _"~~H'" _'NP ~ ~ FEDEI1AL LD NUMBER 23.\512747 HOLY SPIRIT HOSPITAL '. 503 NORTH 21ST STREET 81 RTH-IlATE FEI. 23-1 512'tW HILL. PENNSYLVANIA 17011.2288 03130/43 r;~~':~ In1',I',t,ll BICCS-~f'JiAttCES I -:~-- _"".":.~:~""", . l::':'''''~;~i~~~f'~it-----=-----~ 32 _ .1 _ -- . -~--~_~ I".! II 1,1 'jAI,I, PAl' "-I' l~lIVIIIII '.1 r _lL___._S_ ________________ ______ ____ . __________ coo Itj".!jIlAtlC! (O"WM" rlA!.'1 ,Il ",I' t, ;'.'1\1 " 1'111" ~ ,~, ~ I,~ III I' GU"R"~'OA .......[ ARTHUR (; 8lelOS 222 EAST "AIN STREET SHIRE"ANSTOUN.PA 17011 361 86 195320 "0 AOORES5 AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I "~;;<;'::",,';r I $ DAll C'lsn~If'TIONS or 1 :.(RVICr I TOlAl [SI ('O~'IIlA(,r E.ST cOVr'~AG[ 1ST CO,llIAl.F ,';1 COVlJ:lA,,1 rA TIEr~T POS1[O tiOSP:1 Al slRVICl~ (('l[lL niAJl(1[S INS co NO ' I"''' co tm2 IN~; en ti(ll It,s CO NO I "1.!Ot'tl! 1/24 ANIOIOCATH 20 011~12168~ 2.50 2.50 1/2~ ANlllOCATH 20 011412168~ 2.50 2.50 1/2~ TOOTHETTES DENTOII~12233~ 3.00 3.00 1/2~ STAT"ASTER Oll~I22~69 11.00 I 1.00 1/2~ TRANS-DRESS IV 011~12251~ 1.00 1.00 1/24 ADI'IISSION ~IT 011~I2605~ 6.00 6.00 1/24 IRRIGATION SET 011~12676~ 3.50 3.50 I 1/24 llASTROCRAPHIN 013620896 28.75 28.75 1/2~ CONT OPTIRAY 10013622332 153.25 153.25 1/2~ CONT OPTIRAY 50013622333~ 77.00 77.00 1/2~ CHEI'IISTRY PROF1012520105~ 63.00 63.00 1/2~ ELECTROLYTES 012520200~ 53.00 53.00 1/2~ A"YLASE. 8LOOD 0125203~0~ 53.00 53.00 1/24 LIPASE 012520350~ 53.00 53.00 1/2~ IURIN, (NO "ICROOI2522110~ I 1.00 11.00 1/2~ URIN, (NO "ICROOI2522110~ 11.00 11.00 1/2~ .,e.oscoPle. ..01.5.."'j 11.00 11.00 1/2~ I'IICROSCOPIC, UROl2522190 11.00 I 1.00 1/24 CBC U/3 PART DIOl25301201 29.00 29.00 1/24 CBC U/3 PART DI0125301201 29.00 29.00 1/2~ DIFFERENTIAL 012530180 11.00 11.00 1/24 APTT 012530310ll 31.00 31.00 1/24 IPROTHRO"BIN TlHOl2530J201 20.00 20.00 1/24 IURINE CULTURE 0125~0210~ 26.00 26.00 1/24 ~RINE CULTURE 0125~02108 26.00 26.00 I /2~ ITYPE/SCREEN 0125801071 5~.00 5~.00 1/2~CELL PANEL 01e5801~Oa 74.00 7~.00 1/24 !ANTI'EN SCREEN 0225801 ~57 52.00 52.00 I i 1/2~CROSSHATCH. BL002e580eOO~ 106.00 106.00 i i 1/2~ 'SPEC COLLECT FEOl2S1 01 031i 7.00 7.00 I i I I 1/24 SPEC COLLECT FE0125101031 7.00 7.00 I I ! 1/24 STAT HANDLINIO FOl25103680 10.00 i 10.00 I I I ! I 1/24 STAT HANDLIN!: F01251037104 10.00 i 10.00 I I 1/24 STAT HANDUNll FOl2SI01730 10.00 i 10.00 i i , 1 'u.1....,_ '! ,\,t.. 'i'" ..., ~-~~:t_~'~.~".'."!\t ,~-r .. __J .... .\ l! If! 11" " I '( l'~!;' g 1 '.': ,.1 I;;',!!l Ill' f ~ All (Jut,:>: Ill';', ' I . HI 11\:',I'\it", \II'{I ,,', "d," \1-< Pl[AS~, StND l'A,M(t~l 10 HOL Y SPIRIT HOSPITAL ',OJ Nom" ,'IS! SlF1HT l~A"'H' Hill ,",\ 1 t(11 1 ,1:)RA ,,_;,,0,\11..0\1 A!f~.l f!ll'....t.U'!1f Nt,CfC,',"'l> ",.;;.:':'~ ,,;OIl,,!',' : ~"",II,' "'-'~I,'" 1",'~ "'(1 .\A", 1-1'11':,0,. ,., ,", ",',,1 """,I", ';,1 ,.,:" "'". ,.\;, .., III,' ",H' 'I.,', " \"' I .' ',1,\'\ '" , ~'iS:~:~lii~~" I ----I=-~'~"""~'"~'~"-:".. ".1 ^lIl-,ll\';lIltlllAII IW""IIAlll,f I)~" o f""'''l ',.,;'; ---=-=~~~ jiC~--c-------r I <11111"11 1l^1t II. I': 1__ ,,'" 'I' I, H _~~'~~'2~ F I NALl-4c+-1-l _lNr-.-J ~ FEDERAL 10. NUMBER 23.1,512747 HOLY SPIRIT HOSPITAL . 503 NORTH 21ST STREET BIRTH-dATE FEI. 23-15Ie'tW Hill. PENN~YlVANIA 1701'.2288 03/30/43 con "j~.tJlIAPJrf cr,'."JAI.~ ~.,..I.lf ."",,"I.,JVHlII rf)lIC~ t/ljl,'mn ,jl:^Il"..HJH ',Aloll ARTHUR e; BI'IlS 222 EAST "AIN STREET SHIREI1ANSTOUN,PA 17011 I 361 86 195320 "toO AOORESS AZIZKHAN REZA 110 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I '~.i','(,",T,,~' I $ )Al( n[~cnIPT1Of.S OF I srllvlrt TOUl fST CQv[flA(,l Est COV(RAGl fSI CO\l[RAG[ EST COVERAGE PATt[rn O~H!l t1(J~PI' Al SERVICES COOl: CHARGES INS co r~ ' INS CO N02 "4'; CO fiO 1 INS CO NO.1 A\IO:JffI 1/24 STAT HANDLIN' F01251037~E 10.00 10.00 1/2~ ABO/OBST SERIES013610196~ 158.00 158.00 112~ CT ABO U CONTRA0136136021 685.00 685.00 1/2~ CRNA BASE UNIT 084910301, 296.00 296.00 112~ CRNA TII1E UNITS05~9103021 315.00 315.00 1/2~ 'NL UI INTUBAT 01~911100E 290.00 290.00 1/24 INCENTIVE SPIROOl501 0020~ 48.00 ~8.00 1/2~ BRE-EXERC/RETRAOI501002~' 19 .00 19.00 1/24 OXYllEN HALF HOUOl50l05014 9.00 9.00 1/24 ED VISIT LEVEL 011710~01~ 20~.00 20~.00 1/24 RR-BASE RATE Oll210300E 251.00 251.00 1/2~ IRR-BASE RATE 1/02121030IE 1124 EKe; 012711100~ 46.00 ~6.00 1/2~ ITELEPHONES 0189111 OO~ 1.00 I .00 1/24 ISALES TAX TELE 01891 1400: .06 I .06 1/24 !TELEVISION 0189122001 2.00 2.00 1/24 SALES TAX TV 0 I 8912500' .12 .12 1/24 ,ROO/1 626 01901J318l ~30.00 ~30.00 1/25CFX lG/1 IVPB FR02"~080~5! 6~.50 64.50 1/25 !TORAOOL 30"'I"LO 14~280891 2S.00 25.00 1/25 :TORAOOL 3011'I"L03~428089! 7S.00 75.00 1/25 ~HLORASEPTIC SP014~840861 IJ.OO 13.00 1/25 'LRS 1000 0" 61 30684 9.50 9.50 1/25 iOS/0.~SNS/IOKI0021613314E 2~.00 2~.00 1/2505/0.~5NS/IOKI0021613JI~~ 2~.00 24.00 1/25 OS/04SNS/IOKI002161331~~ 2~.001 24. 00- 1/25 n5/0_~SNS/IOKtOOI1613JI~= 12.00 ; 12.00 I 1/25 €XPLORATORY LAP011003013 114 00 I 114 . 00 1/25 1/25 1/25 1/25 1/25 1/25 POP & COUNT 011020~2~~! .SPONGE COUNT 10011020~2S PENCILET "K IIR01102~283 STPLS SKIN 35Y 011024406 TUBE SUCT CV REOII02~~46~ TIPOLISHER "EO 011050265~ 5. SO I 2.25 I I 7.50 i 20.75 ! 2.75 I ISO : I s. SO I 2.25 I 7.50 i 20.75 I 2.7S! I 1.50 i I I I j E'~ H '.' j -, """. :',",:", ," , _ -1------1-- l=-==-~ HI , I II Al \ IJIII ',T I( I".;' ~,' ! HI ' . I\I"-;'..!'.',I,II' f PttASl qNP!'A'd..'l'>Jlltl ",,,,,,. HOl Y SPIRIT HOSPITAL . '1\)1 ~JOH1H .'1~,1 slnt 11 , .\",H' HII l I',", ! '111 t .'.'hh '~.A., 1"'" , ...' II ': ! ,.~. '.' ,\ , .,\1, ,! '~,'l I. ,',q ,'",",' " Ii,),'" f "hill' -';;-';~""";;;;-T- ...... .',11 '~1I1 I ~ ,''. I~, 111\;, , :.:.,)', ,; '11\',111 "-' ",' ..,,',.... "t,JI r,III;11 IM!lOI 1'111 V 11'11 ~ FEDERAL 10. NUMBER 23.1,512747 , HOLY SPIRIT HOSPITAL '. 503 NORTH 21ST STf,EET BIRTH-DATE FEI. 23-1512'tW HILL. PENNSYLVANIA 17011.2288 03/30/43 r~I~;l _H td'! ,'I " , FINAL- .-lli lill'''', ~ j(} ", --^-"'_ _',,,~,:::;'n""^" ~;;;""iijB--___u_----~ l'AIIINI NM/I I'AI'I ',1 ~4\Jl.4mll COB t,,".IIIlANn ((JMI'A'/YNAI,II '.11, ,I """'11111 P0IIC'f fjl)',lhlll (iUAIIAN'OR .."ME ARTHUR , 8IG;S 222 EAST "AIN STREET SHIRE"ANSTOYN,PA 17011 361 86 195320 "0 ADDRESS - AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I '~.:','i..",',,~f 1$ :IATl [)[SC:RIPTlONS Of I SCRVlC( TOTAL EST COVEnAGr rSf COVERAGE f S, r (VIl- 'IAGE ESl COVERAGE PAllUlI "L~S If:.> tiOSPrTAl S[RvlCrS CODE CHARGES INS CO NO t r~S CO NOl INS 1,0 NO] iNS CO N04 A'-'OlJNT 1/25 GROUND PAD AOUL011 ~1 031..' 8.25 8.25 1/25 SPON;E LAP 17XJOI I~1070JI 7.25 7.25 1/25 SPONGE LAP 17X2021 ~1 0704' 18.50 18.50 1/25 ;RADUATES DISP 011"11598' 1.00 1.00 1/25 TEO THIGH LGE-Oll ~12162l 23.75 23.75 1/25 PAD CO"P 8X7 011~I2J02C 2.50 2.50 1/25 SPON;E OVER ~X~011"12303E 1.00 1.00 1/251ADAPT DRESS 3X8011~1245~ 5.00 5.00 1/25,CATH-SET FOL 16011~12536' JI.25 31.25 1/25 ;TAPE DERHCEL 1'011~I2766 1.75 1. 75 1/251ELECTROLYTES 012520200 53.00 53.00 1/25 CBC ~/J PART 010l25JOl201 29.00 29.00 1/251ROUT SENS ("ICI0125~01\0 25.00 25.00 1/25 ROUTINE 10 0125..01121 19.00 19.00 1/25 iSPEC COLLECT FEO 125101031 7.00 7.00 1/25 OR-LEVEL II 0110103001 38~.00 J8~.00 1/25 iOR-LVL II ADD1/031010301l 6"2.00 6"2.00 1/25 'BRE-EXERC/RETRAO I 5010024' 19.00 19.00 1/25 !BRE-EXERC/RETRAOt501002~' 19.00 19.00 1/25 !BRE-EXERC/RETRAOISOI002~' 19.00 19.00 1/25 iBRE-EXERC/RETRA01S0l 002~' 19.00 19 .00 1/25 iTELEPHONES 018911100. I. 00 1.00 1/25 ,SALES TAX TELE 01891\400~ .06 .06 1/25 ~ELEVISION 018912200 2.00 2.00 1/25 ~ALES TAX TV Ot8912500 .12 ! .12 1/25 'ROO" 626 0\90IJJI8~ ~JO. 00 I 430.00 1/26 :CFX 110" VIAL 02~~0804711 50.50 50.50 1/26 TEHAZEPA" 30"10 O,....,~O..I~ 1.00 i 1.00 I I 1/26 BISACODYL 10"10 01....5601001 1.00 1.00 I , I , 1/26 ~5/0.~5NS/I0~100lI6IJ31~~ 12.00 i 12.00 I I 1/26 D5/0...5NS/l0KI001161331.. 12.00 12.00 i 1/26 SPECI PAN 011~Ie2e6~ 2.00 . 2.00 I I 1/26 SALE" SU"P 16FROll~lee28 5.50 ' 5.50 l , 1/26 CATH RUBBER 15FOII~12SJ"8 7.50 7.50 i i 'lI'IF'OIl ,'11.,;1 l\j,' ,'1'-",",1 , ., I ,'l;f,;l ~..IMt'fn HHtR All ()ut "'11()",j~\ 10\ 'HI tHJSr"il SS l)f f let '\'! ....\."'iA PlEASE SEND P.'MENTIO HOl Y SPIRIT HOSPITAL ',0. NORTH ;>'SI SIRE[] ( A"~f' Hfll P.A 1",11, ~'('tlt~ ..::':~;i'~.A flA!-f..,ll:HI'NC,VA, tH ~jt !".Mi.;, ~', ",~H; ,I ".1' ",",ILI .....1 r. '",.., t"" ',:" boO r ,j .1' I ,', I,"'~;, I ' A'OIq fl', " ~.i t I;, "";, " I',' '.' ,.....,., ',i" t '"'' jl,', ' -. :,' I :', I II, Ij H f'{ I'.! r~J{. . :,'! "I ',I 11'.,'1. t LlATl OE5C-RIPTtONS or I s[nVICE TOtAL ~ST COVERAGE ESt COVERAGE Pit CC1vfRAGE [Sf COVERAGE PAllEN! "(l<;T(O HOSPITAl SERVICES COOl CHARG[S INS CO NO , IN~ CO NO 2 INS CO NO 3 INS CO N04 AI.'OlJ~JT 1/26 ADI'IISSION KIT 011~I2605l 6.00 6.00 1/26 IRRIGATION SET 011~12676. 3.50 3.50 1/26 TUBE CONNCT J/IOI1412786' I. 50 1.50 1/26 ELECTROLYTES 012S20200: 53.00 53.00 1/26 CBC U/3 PART DI012SJOl201 29.00 29.00 1/26 SPEC COLLECT FE0125101031 7.00 7.00 1/26 BRE-EXERC/RETRAOI50l002~' 19.00 19.00 1/26 TELEPHONES 018911100~ 1.00 1.00 1/26 ISALES TAX TELE Ol8911~00~ .06 .06 1/26 TELEVISION 018912200E 2.00 2.00 1/261SAlES TAX TV 018912500~ .12 .12 II.' ROO' ,., 01'OI""~ 430.00 ~30.00 1/27 ITEI'IAZEPAI'I 301'1' Ol~~I40~1 I. 00 1.00 1/27 ~YDROXY 25"'/I'tLO~~428068 ~.OO 4.00 1/27 ,HYDROXY 251'111/I'tL04~~28068 4.00 ~.OO 1/27 ~NESTHESIA SET 011613103~ 16.50 16.50 1/27 iD5/0.~5NS/10~IOOI 161331410 12.00 12.00 I 1/27 iD5/0.~5NS/l0KI00116IJ314e 12.00 12.00 1/27 105/0 45N8/ 1 O~ 100 I 16133 1 ~l: 12.00- 12.00. 1/27 ,ANGIOCATH 20 011412168S 2.50 2.50 1/27 :J-lOOP 0114122311 J.2S J.25 1/27 iSTATI1ASTER 01l~122~6' 11. 00 II. 00 1/27 iTRANS-DRESS IV 011~I2a51' 1.00 1. 00 1/27 ELECTROLYTES 012520200, 53.00 53.00 1/27 'URIN, (NO I'tlCROOl2S221101 11.00 I 1.00 1/27 ~ICROSCOPIC, UR012522190' 11.00 I 1.00 1/27 ~BC U/J PART DIOl25301201 29.00 29.00 1/27 ~PEC COLLECT FE0125101031 7.00 7.00 i 1/27 :TElEPHONES 018911100 1.00 I I .00 , .06 1/27 SALES TAX TELE 018911~00 I i _06 -jf~--~-- ,II ',' ",II r! 1'1. I' ~ I il^"I11 1'111 V IIllt ~ FEDERAL 1,0, NUMBER 23.1~t2747 HOLY SPIRIT HOSPITAL . . 503 NORTH 21ST STREET BIRTH-I1ATE FEI. 23- I 5 I 21W Hill. PENNSYLVANIA 17011.2288 03/30/~3 i F I HAL ~a/-H ---I-HE-~J . -~"Z~~'~'~~T----4-"'"'"~'~J:I~'; 1 tl~~ __^'~'''';:;''''IIl^~' ~::~.~,.'_I'~ p.hS COB 1"';lmAW,1 C()MI'Atp '.IIMI 1,IU"II.tilJllrn POlICy,.uMIlLJI C,UAIII'NTon NAt,l( ARTHUR , BI'IlS 222 EAST "AIN STREET SHIREI'tANSTOUN,PA 17011 195320 361 86 "0 ADORf.SS AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I ^~.:',t'f,,9f 1$ 1/27 1/27 1/27 1/28 TELEVISION SALES TAX TV :ROOI1 626 I1EP 75"' INJ 018912200~~ 018912500 0190 I 3118 V I 024~02120 . i -I 2.00 I .12 I ~30. 00 ! ] .50 ., ,I H.\, '1'1 "': '0' , ',-, I I ~30 . 00 Ii 3.50 _=t- -t--- =t= E-- - - H~~~~S;'~~~'~~~~'~~L I · ...: flO~ NORTH ~ll~T STRII.' ".,.\.; ,',A. 1~'I~"',~i1ii:~:.':,~.:A:..ll,~ ;~I ',.." ':,' . ',', f .."',1' ....'-" ,.,. (AMP Hill P~'\ 1'01', ,'l-\}\ ,Il ,., ", . -'~~:;;:'-;:-""""J- ...... .\q'.I', tllIlIHI':Y.IlMi H ;1.'\! I i a ',11<\11 I I~ftf I~ All Ut" ~,lhl"'\; I{ \ 'lit ~USI'..' ','-, (ll' ':,' ,"'1,'1,1."1/1 I~:~'" ""J o 2,00 , 12 1~ PI (")1 lilt :,',I\,'f l':ll lJATrm I'm.. 1111.l ~ FEDERAL I D. NUMBER 23.1.512747 HOLY SPIRIT HOSPITAL 503 NORTH 21ST STREET BIRTH-DATE FEI. 23-15129W HILL. PENNSYLVANIA 17011.2288 03/30/43 \~^,'f"~ '1""';. Noi -F-J~"\'; 2-M s__ I'Alll,NT NAME -__~_~~'~;~'~';t_:" -.':~J~ii"~~-"'~f- -::'~'~~j~E----------~ COB -----,--------.- - - --'--'-'-- ir;~,IJ"A'j(' C:rlJ.4PMj, ~1"',1I ',11("'" t.'IVtllll POIl(;~ fm'.lUf:1l I~A"E ARTHUR (; 81GGS 222 EAST "AIN STREET SHIREI1ANSTOUN,PA 17011 I 361 86 I 195320 (.UAnANTOR AND ADDRESS AZIZKHAN REZA 110 :'A'~ O[SCf"lIPTlQNS OF I SERVICE 10T"'l [~T COVE AAc,r l:ST COvERAGE "iT r,m'EAAGE EST COvE~AG[ PATi[NI .'(lS1FD H')SPtl Al SEFWfC[S CODE CHARGES INS en NO 1 IflS CO NQ"l IN"> CO NO) INS CO NO.s AMOUNr 1/28 I1EP 75"' INJ VI01~~02120~ 1.75 1.75 1/28 TEHAZEPA" 30l1G Ol~4140~U I. 00 1.00 1/28 ELECTROLYTES 012520200" 53.00 53.00 1/28 CBC U/3 PART 010125301201 29.00 29.00 1/28 SPEC COLLECT FEOl25101031 7.00 7.00 1/28 TELEPHONES 018911100 1.00 I .00 1/28 SALES TAX TELE 018911400 .06 .06 1/28 TELEVISION 018912200 2.00 2.00 1/28 SALES TAX TV 018912500~ .12 .12 1/281R00l1 626 019013318~ 430.00 ~30.00 1/29 HEP 7511G INJ VI01~~021201 1.75 1.75 1/29 IKCL INJ 20"EQ 05~~~00~4t ~.OO 4.00 1/29KCL INJ 20"EQ 104~400~~ 4.00 ~.OO 1/29 TRll1ETHOB 200HGOI~456088E 2.79 2.79 1/29 TRIHETHOB 200"'01~~56088E 2.79- 2.79- 1/29 105/0. 9NS 1000011613061' 8.50 8.50 1/29 \05/0. 9NS 1000011613061 8.50 8.50 1/29 D5/0.9NS 1000021613061 17.00 11.00 1/29 05/0.9NS 1000021613061~ 17.00 17.00 1/29 105/0. 9NS 1000021613061 17.00 17.00- 1/29!05/0.9NS 1000011613061' 8.50 8.50 1/29\D5/0.9NS 10000\1613061' 8.50- 8.50 1/29 0510, 9NS 1 000011613061 ~ 8.50- 8.50 1/29\D5/0.9NS lOOOOll61306H 8.50 8.50 ! 1/29 ANESTHESIA SET 011613103~ 16.50 16.50 1/29 ~ASTRIC SUCTIONOII~12002~ 32.25 32.25 1/29 ANGIOCATH 22 011~12169 2.75 2.75 ! , PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ,*<Ut I ^~r,t:.\'''N~' 1$ 1/29 ,ADAPTOR PRN 01 I~12171~ 1/29 ISPECI PAN 01HI22261 1/29 'SALEH SU"P 16FROll~12228~ 1/29 :J-LOOP Oll~122Jl~1 1/29 iSTAT"ASTER O\l~12246 1/29 iTRANS-DRESS IV 011 ~12251 1/29 'IRRIGATION SET 01 I~I26161 2.00 2.00 5.50 3.25 11.00 , 1.00 I 3.50 2.00 \ 2.00 5. SO I 3,25 i 11.00 1 1.00 ; 3. SO! .t:'I;,A, ",,,."" ["----=r --L -~ HHfR AU outql()t-.,!S HI IHi I' 'ASl "[ NI' I'A""'" Nl 1() fl\lSIN~'~')f)ftln II . ,1,., ' Me ,",'0'.". HOLY SPIRIT HOSPITAL ~I03 NOnlH '1ST stlHt 1 ., (:M.H' H!ll ~',,\ ':il~' ,'.\~t\ "'''~,A, .'ALf~.~ 11-\; -,;I. ',':" ,:1,";,1' "1\ I}';"', ,....'I', , '. , ' ',';. I '\' . ~ -! " ,",' .'. ..' :.'. ' I t_-- ~,! ';1' 1 ' ',...,. j I', H" ._"",.'''~~I~_j -. .>\:! . i 1'1'[ Ii I'lbllNti ;i ,.\'1 "f ,\ H\,.'IC( ,-, I"', tJ U I:s-:~~~~~"'I----:-nlm'~~ll'j~~'~~~a:l~~I~:F~'~"" -::'~ ;.~'~~~st--_. -~ ..~: -= _~ j ~ FEDERAL I D NUMBER 23.1512747 HOL Y SPIRIT HOSPITAL 503 NORTH 21ST STREET BIRTH-DATE FEI. 23_15129WHILL.PENNSYLVANIA17011.2288 03/30/43 .:.IF II "I; llAlllll HH''w' !l'L. FINAL~-3 ..mf-J ,UAllA~fOR ,..Ml ARTHUR II BU:GS 222 EAST "AIN STREET SHIRE"ANSTOUN,PA 17011 ..0 AOORESS COB r,w,'I'......',,, .")["Y'",',".III IN~,1II1M.{ f CiJ""',,~;. ~.^'JI I 361 86 195320 AZIZ~HAN REZ" "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~(Ut I .~~~u~t',sr I $ ";'If r ',";11 D Df!-.(HIPTIONS OF 11\lSPtlAL ~lnv'C[S S[RVlCf COOl 1/29 TUBE CONNCT 3/1011412786 1/29 ABD/OBST SERIES013610196 t/29 TELEPHONES 018911100 1/29 SALES TAX TELE 018911~00 1/29 TELEVISION 018912200 1/29 SALES TAX TV 018912500 1/29 ROO" 626 019013318 1/30lKCL INJ 20"EO 104~400~~ 1/30 KCL INJ 20"EO 10~~4004~ 1/30 KCL INJ 20"EO 104~~00~4 1/30 KCL INJ 20KEO 05444004~ 1/30 D5/0.9NS 1000021613061i 1/30 D5/0.9NS 1000021613061 1/30 D5/0.9NS 1000021613061 1/30 D5/0.9NS 1000021613061 1/30 D5/0.9NS 1000011613061~ 1130 D5/0.9NS 10000216130611' 1/30 DS/0.9NS 1000011613061 1/30 DS/0.9NS 1000011613061 1/30 DEXTROSE 5X 10011613141 1/30 GRADUATES DISP 011411598 1/30 ELECTROLYTES 012520200~ 1/30 ICBC lJl3 PART D1012530120!1 1130 ,SPEC COLLECT FE01251010311 1/3 0 iTELEPHONES 0189 111009 1130 ;SALES TAX TELE 018911~00~ t/30 TELEVISION 018912200~ 1/30 SALES TAX TV 018912500~ 1/30 ~OOK 626 019013318~ 1/31 ~CL INJ 20MEO 05~4400~~ 1/3t ~CL INJ 20"EO 1044~004~ 1/3t *CL INJ 20"EO 1044400~4 1/31 ~CL INJ 20"EO OS~4~004~~ 1/31 :DS/0.9NS 10000116110619, il,:'ll'''', ','II,i I, ..,h,.pl' ---, "'-'~'~I"~I~'_:~r .- ".\11 I',! 111<1 H P(l',TI~(i >Ill':" i !, H ',I H\ II l H( ft!~ Ali <JutSTI(.N~ 'I' 'H! \lltStN! ~:'; 4. If f I:,'t , . ~ ..; "+, ~ .' I I~ 10TAl Ct~"JIGfS l. 50 158.00 l. 00 .06 2.00 .12 430.00 4.00 ~.OO 4.00 ~.OO 17.00 17.00 17.00 17.00 8.50 i 17.00 8.50 8.50 7.25 1.00 53.00 i 29.00 I 7.00 , 1.00 I .06 I 2.00 i .12 ~30.00 I ~. 00 ; ~.OO ~.OO..., ~.OO 8.50 rSI COVE_RAGt EST COV[RAGf [ST 'OH,PMif E5T CO....EHAfif It~:, CI) t~() litIS CO NO 2 INS CO ~jO J 'N'i CO NO J l'AI'rooT "'.''''1',1 1.50 158.00 1.00 .06 2.00 .12 430.00 4.00 ~.OO ~.OO 4.00 17 .00 17.00 17.00 17.00 8.50 17.00 8.50 8.50 7.25 \. 00 53.00 29.00 7.00 00 ,06 200 12 ~30. 00 I I ~. 00 I ~. 00 I ~.OO~ I ~. 00 i 8.50 i i i t-- t=~=--=-j--- -----r-- H~~ ~S~~ll~I;;'~~~~I~ ~L L '10; tJonTH :'1S1 sou f I ,:..',;'~," 1''\'1''':' ----l--=- J "I '.! j ','.",' .....t.. CA~:!' HI[ i PA "[" 1,'.'1'11' i.,.'", _HC;l_:-lI} ------- 1"1' ":.Ii I It'll "nAif or ,,: 1 ' , 1'111 V HIli .---,--,---"-. FIN"L e-M' . _--1-H ~ FEDERAL I D NUMBER 23.1512747 HOLY SPIRIT HOSPITAL . 503 NORTH 21ST STREET b FEI. 23-1512r:l'f HILL, PENNSYLVANIA 17011.2288 B~~~~~/:jE I~'~:~J '0 11..____8 __.~~~~tlI NAP.U ~GS_~FRANr.F!: I "A',IN! PlUl,li1\l II ~. _ "il--_ ~~.~'."'" n~:_ ~p'" ":"''''-j~~i''~~'t-u. """.""" --- - ---J _AL ~ LtG ------___ COB INC:;U'IAt~, r ( (1M""'" ~l^','f ',11. ,(". I" v,., j, p, 'II" ~ to .".~n' II r,UAnANtOR I N.ur ARTHUR G Blcoc;S 222 EAST HAIN STREET SHIRE"ANSTOUN,PA 17011 1 361 86 195320 'NO AOORns AZIZKHAN REZA HD PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~o.et I '~f,'::.i'S 1$ l 2AI! , Dl$CRIPTIONS Of I srHVlcr TOTAL f Sf covrnAG[ [51 COvERAGl f'iT COVERAGI: L<;! Cmr"Ar,f I" " T IE ~ ; T .'("in,) l~nSPITAl SE.RVICES COOt CtiARGI, S IriS C:O NO 1 IW', CO '~(l'} 1'.5 CI') NOJ ,NS C:O t;{\: ,~t.lnl t,: 1/31 D5/0.9NS 1000021613061 ' 17.00 17.00 1131 D5/0.9NS 1000021613061' 17.00- 17.00 1/31 D5/0.9NS 1000011613061' 8.50 8.50 1/31 ANlllOCATH 22 01 I~12169, 2.75 2.75 1/31 TRANS-DRESS IV 011~12251 1.00 1.00 1/31 ENEMA ADULT SODOll~12567l 2.00 2.00 I 1/31 ELECTROLYTES 012520200: 53.00 53.00 , 1/'31 CBC U/3 PART DI0125301201 29.00 29.00 I 1/31 SPEC COLLECT FE0125101031 7.00 7.00 1131 ABD/OBST SERIES0136101961 158.00 158.00 11'31 TELEPHONES 01891 I 1 00' 1.00 1 .00 11'31 SALES TAX TELE Ol8911~00. .06 I .06 1/31 TELEVISION 0189122001 2.00 I 2.00 1/31 SALES TAX TV 018912500' .12 .12 1/31 'ROO" 626 0190133181 430.00 ~30.00 I 2/01 IAPAP 500H' TAB 0~~4280021 ~.OO ~.OO 2/01 ,KCL INJ 20HEO I 044~00~~1 4.00 I ~.OO 2/01 IKCL I NJ 20HEO I 0~4~ OO~~t '''1 ~.oo I 2/01 IKCL INJ 20"EO I 0~4400~41 4.00 ~.OO- 2/01 KCL INJ 20"EO 0544400~4l 4.00 ~.OO 2/01 KCL INJ 20"EO 1 04~400~41 4.00 ~. 00- 2/01 KCL INJ 20"EQ OS4~~00~~1 ~.OO 4.00 2/01 IBISACODYL 10"' 01~4560101 1.00 : 1.00 , 1000021613061' 2/01 ID5/0.9NS 17.00 I 17.00 1000021613061 ' , 2/01 ID5/0.9NS 17 . 004 17.00 2/01 ID5/0.9NS 1000021613061~ 17.00 17.00- 2/01 D5/0.9NS 10000116\306H 8.50 I 8.50 2/01 :D5/0.9NS 1000021613061' 17.00'" 17.00- I I 2/01 iD5/0.9NS 1000011613061~ 8.50 i 8.50 I 2/01 'ANESTHESIA SET 011613103 \6 .50 I 16.50 I , i 2/01 'STATHASTER 011~122~6~ 11.00 , 11.00 I I 2/01 IELECTROL YTES 012520200 53.00 I 53.00 i I 2/01 iC8C un PART DI012S101201. 29 00 ' 29.00 I I 101 :SPEC COLLECT FEO 12S 10 I OJ Ii 7.00 : 700 I i I i i , 2 j ~ I 'I ~.'! "4\ I..-II( 1-\ HI HH AH QUESl!nN<" 1{1 !HI HlISI~f ~:. ()frIO '\ r\ '~);'1 1fl I H~~~~~~;;;~~~~,~~:=1-=~j srn NORTH }1Sl '~trH 11 ",,,' .I':"'".l~ t.... , " '0' [--- ;,...,.......\.t !\if' I :,"1',' 1;,1 \ :' .. q,'I"""l q't';1 '.0;1 -,,1".',"" .... " l. 1111! Ii PI 'S 1.r~i. ,-, '[ t '. ',I H,I\ t l'A".H' Hll t 1'.\ ! 'i'" ','~l' ..'.' HOl Y SPIRIT f~~~~~~ ~tMUUl 23.\512141 [~;",; ,.~~~ ~ 503 NORTH 21ST STREET BIRTH-DATE .F;:] FEI. 23-ISI2m' HILL. PENNSYLVANIA 17011.2288 03/30/43 ~ - --- ---:[ 1"":'~~~'~'i_J~l~~~l~~;:.~~l ~'~fiizll~----==---- --l ,HCL 1'1-- - ''-- I '''I' '.11 11"11 i F.~ ~~L 1-4U-U~~ Uti [1.11(11 1'111',111\1 l B. _S lI'l"':'.~~~_u_ I_B1Ji~_.fJ{AliCES I ~ C.UAIl.'llQA Nu,n ARTHUR II BI"S 222 EAST "AIN STREET SHIRE"ANSTOUN,PA 17011 AND AOUAfSS con 'Pl',IIIlMlt I r,'tllJ:l'M;. tjAl.,I1 -,--..---.-..--,.,. -._- ,.,.,,,,'....,.,,, I'(lll(, ';11',111111 1 361 86 195320 -----,~----_.-_. ----,- ------,--,.,--,- AZIZKHAN REZA "D PLEASE RETURN THIS PORTION WITH YOUR PAYMENT "'J/ _ _L "~An I ....Ou,.IOf I $ IIf4IIIIe 'f""""'" "AYM[t~1 JAI' 1','!';II1J Of SCI~IP' IONS OF HO;,PIlAl S[lWICES SCUVlCE CODe 2/01 TELEPHONES 018911100 2/01 SALES TAX TELE 018911~00 2/01 TELEVISION 018912200 2/01 SALES TAX TV 018912500 2/01 ROOH 626 019013318 2/02 "EP 75"' INJ VI01~~02120 2/02 APAP SOOH' TAB 044~28002 2/02 HYDROXY 2S"G/"L01~428068 2/02 KCL INJ 20"EO 10~~4004~ 2/02 KCL INJ 20"EO 104~40044 2/02 KCL INJ 20"EO OS~~~004~i 2/02 KCL INJ 20"EO OS4~400~~ 2/021DS/0.9N5 1000021613061 2/02D5/0.9NS 1000021613061]. 2/02 D5/0.9N9 10000l1613061~ 2/02 D5/0.9NS 1000011613061~ 2/02 ELECTROLYTES 0125202003 2/02 CBC U/3 PART D1012S30120~ 2/02 DIFFERENTIAL 012530180 '2/02 !SPEC COLLECT FE0125101031 ,2/02 TELEPHONES 018911100i 2/02 ~ALES TAX TELE 018911400 2/02 ~ELEVI510N 018912200 2/02 IS ALES TAX TV 018912500;.1 2/02 ~OO" 626 019013318~ 2/03 :TRI..ETHOB 200"G02~456088~ 2/03 ~NESTHESIA SET 011613103 2/03 ~5/0.45NS/20KI0021613216] 2/03 ~5/0.~5NS/20KI0021613216~ U03 !D5/0,~5NS/20lCI00116\3216"1 2/03 ~N;IOCATH 22 011~12169~ 2/03 ~NGIOCATH 18 011412230~ 2/03 IJ-LOOP 011..,22311! 2/03 ~TAT"ASTER 0114122~6~ iI : 'I ,",, ,vl~.' '" \ . , ' ,,:,1 tiT !j,,'.ltlfn HI I I ~ A.ll I)t I. S' ii. )I\I~ 1 (\ I HI 1.1I~,1 ~~t ',', \ If , I~ 'I ',', -,-\.',\1'1 .... /I ! f t', I t 1. \1 i i 1'( )-; ! I~~( . \11 1\'\ 11 ! 11 ., H\h"! TOTAL CHARGES 1.00 .06 2.00 .12 430.00 1.75 ~.OO 1.00 ~.OO 4.00 4.00 4.00 17.00 17.00 8.50 8.50 53.00 29.00 11.00 7.00 1.00 .06 2.00 .12 00.00 5.581 16.50 24 00 I 24.00 I 12.00 2.75 ! 2.50 i J.25 i \I .00 l EST COv[HM.r fST COVERAGE rSI (Jl\l[ll.\(.t f ':01 ((lI.F.IlAfi! INS co NO' INS 1.0 tlO 2 INS ( P 'j(l1 "j'. r l1 '+/,'-l PATIf-'-jT '''10'.'',1 1.00 .06 2.00 .Ie ~JO.OO I. 75 4.00 1.00 ~.OO 4.00 ~.OO ~.OO 17.00 17.00 8.50 8.50 53.00 29.00 11.00 7.00 I .O( .06 2.0G .1 e ~30.00 5.58 16.S0 2~. 00 i 2~. 00 I 12.00 ! 2.75 i 2.50 I 3,25 I 11.00 I -t----:=:f== --r------r- ---- - E' - PllA..... SfMlIA"Ml'i' t{) ~ HOl Y SPIRIT HOSPITAL L --- --- ---- -- -- - . '",: I'.' "., ',I I ," 1){H NnnH~ :"'--1 ciTHt t 1 rJ\~~1 HlIl 1',\ 1 "":'Hr ~ , j HOLY SPIAIT I~~;;~ ~~"."" """'" \.Ce,','J ... 5 cAMP ~~CL~~:~~S~~:A~i:~~~"'2288 BIRTH-ElATE t""'~"\ FEl' 23-1 12141 03/30/43 .," ,~'~~~'; t "t~lr~~~;~i~f ~'~;'~'~ ;~'3h+----- .:-~~~---\ PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I '~;,;(,rN(lr \ $ \_H , '(\,\il! (1,',1\ ',I li'l! -- ."-'-- i FINAl; {JAIl 01 I'm\' I\\ll : .-B____--5~._~~111 tH ftAMF t RICr.~ ,ERANCI'~ I I GUARANTOR I I NAME ARTHUR G BIGGS 222 EAST "AIN STREET SHIREHANSTOUN,PA 17011 ANO .OORESS DAlE >>051[0 DESCRIPTIONS OF HQSPllAl SE~"ICl5 SERVICE CODE 12/03 TRANS-DRESS IV 011~12251 12/03 ELECTROLYTES 012520eoo 12/03 ELECTROLYTES 012520200 12/03 ELECTROLYTES 012520200 )2/03 CBC U/3 PART 010125301201 12/03 CBC U/3 PART DI0125301201 12/03 CBC U/3 PART 010125301201 12/03 DIFFERENTIAL 012530180 )2/03 SPEC COLLECT FE0125101031 )2/03 ABD/OBST SERIES013610196 )2/03 TELEPHONES 018911100 12/03 SALES TAX TELE 018911~00 )2/03 TELEVISION 018912200 )2/03 SALES TAX TV 018912500 )2/03 ROO" 626 019013318 12/0~ HEPARIN 10" UNIOI~~20036 12/04 TRIHETHOB 200"G03~456088 )2/04 TPN-PHARHACY 01~~99999 )2/0~ DEXTROSE lOX 1011613052 )2/0~ NACL 0.9 250 011613066 )2/0~ LIPIDS 10X 500011613082 )2/04 ANESTHESIA SET 111613103 l2/0~ D5/0.45NS/20~10011613216 )210~ i.D5/0.45NS/20~10011613216} )210~ ,AVI SET e30 011613310 12/041AVI SET 230 011613370 )210~ \STATHASTER 011~122~6 12/04 'I~DAPTOR PRN LL 011412331i~ )2/0~ ENE"A SET SS 011~12569 12/04 ~NEHA SET SS 011~12569 12/04 ~-CATH PIC 011~12808 12/04 ,CHE"ISTRY PROF I 0 12520 I 05~' 12/0~ \PHOSPHORUS, SER012520190 l2/0~ ELECTROLYTES 012520200 , ~__"L___ 't ,.tl;~1 '[11 N! NI,l .,' ~'\.' ,'~ -- I'Allil'>o1 N.iMt\11l J:jEHH AU, QUlS\10NS 1,) TIll BUSINi: s~ f)1 f In ,'1"l Jfn;'n~ ---.,-,,--"-- -,-,.,-,------"---- - ,.:,'! l~, (t1Htn r-nSlING 'I, !,,\:\. ill ~a,w'Lt lOTAl CHAPGE~ 1.00 53.00 53.00 S3.00 29.00 29.00 29.00 11.00 7.00 158.00 1.00 .06 2.00 .12 430.00 2.02 8.311 375.00 8.50 7.25 57.15 181 .50~ 12.00 12.00 26.00 ! 26.001 \ 11.00 2.50 4,75 ~.75 . 168.75 63.00 27.00 i 53.00 ' COB __.~~~~:...!j,:IJ-I-,-,--'~~ 1'0111""-'; "!'lll I 361 86 I 195320 ---' -,--'..'- AZIZKHAN REZA 1'10 ES1 (.ovEHAC,fc fST CovEf~AG[ [5t co.~tnM.l t ST CQ'JEHAG[ INS CO NO' l~~<; co t~O '2 ItlS co NO :\ :t15 CO t.O 4 r .\. lit ~. ' ..."K\t,'.l 1.00 53.00 53.00 53.00 29.00 29.00 29.00 11.00 7.00 158.00 1.01 .01 2.01 ", ~30.00 2.02 8.37 375.00 8.50 7.25 57.75 181.50 12.00 \ 12.001 26.00 \. 26.00 II .00 2,50 i ~. 75 : ~. 75 ' 168.75 ' 61.00 , 27.00 \ 53.00 : \ \ 1 I I H~~ ~'~;,;:,;~~';~I~';.L ~~ 503 NOIllH ."S! STl1111 ~-- ~=~- "'-',',.1, f'4"I...I'il;.;'....,\,,\;f I;t" " " . ,\." '." I I .,,',1', ll, 0, j " ,;.' r CMJI' till l 1'.\ 1 'i'l ";'H!{ ,', " r.-~U~--- I B S I'Alr!tjl '-jAI.lf j - -- --~-----._._~-,._------ L-Bl-"S . FRANCES I [~~"~'~;j~'~'~'i - ~'~ -'~IJ~~~]~~~F~~1~";;~J.:"~:L~~:_ ['^'~-;;1j -\'''''''1 --1 ------,-- j ----- l~CJ: '" ',I " , -.{,II ,I II'll ." -- .., ,-- --'- FINAL 2-14 -lH (1^1I (If I'HI v Itlll ~ FEDERAL I D NlJMBEI12J.1512747 HOL Y SPIRIT HOSPITAL 503 NORTH 21ST STREET BIRTH-DATE FEI. 23_15129WHILL.PENNSYLVANIAI7011.2288 03/30/..3 1,.",",,10. ! t-,uu I ,"0 Aoonus COR '1",IIlMKf ("","Atj~ t~^VI '" ".'.'''''' ..'- ,~--,~.. -,--- P(lIIl:..-tHlMllIl. ARTHUR , BIGGS 222 EAST "AIN STREET SHIRE"ANSTOUN,PA 17011 I 361 86 195320 I__m AZIZKHAN REZA "D PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I '~.f;:;f"";' L$ r~A tt O[SCUIPlIQN5 OF SERVICE TOUl EST COVf RAGE f S T COVE '~A(jf. I'iT COVHI,V,1 1,-,' '('l\l[flACil I'ATIHH "JSTflJ HOSPItAl 5EHVICE'l CODE CHAnGES INS CO NO I INS CO N02 INS CO NO_I .t;', CO NO 4 A',10ur/1 12I0~ "AfONESIU" 012520270 29.00 29.00 12/0.. ALT CSC:PT> 012520..50 18.00 18.00 12I0~ TRANSFERRIN 0125205~2 35.00 35.00 12/0.. CBC un PART 010125301201 29.00 29.00 12/0~ SPEC COLLECT FE0125101031 7.00 7.00 12/0~ ABD/OBST SERIES013610196 158.00 158.00 12/04 TELEPHONES 018911100 1.00 1 .O( 12/0~ SALES TAX TELE 018911..00 .06 .Ol 12/04 TELEVISION 018912200 2.00 2.0( 12/04 SALES TAX TV 018912500 .12 .1, 12/04 ROO" 626 019013318 UO.OO ~30.00 12/05 HYDROXY 25"C:/HLO~~"2806e ".00 ~.OO 12/05 POVIDINE PR I .201"~8~091 1.00 1.00 12/0S TPN-PHAR"ACY 01~~99999 375.00 375. 00 12/05 LIPIDS lOX 500011613082 57.75 57.75 I 12/05 AVI SET 230 011611370 26.00 26.00 '2/05 TRANS-DRESS IV 011~12251 1.00 1. 00 '2'05 rUCOJE 012520109 20.00 20.00 12/05 LECTROLYTES 012520200 53.00 53.00 12/05 SPEC COLLECT FEOl2510l031 7.00 7.00 12/05 TELEPHONES 018911100 1.00 I I.O( 12/05 SALES TAX TELE 018911~00~ .06 .O( 12/05 ~ELEVISION 018912200 2.00 1 2,O( 1 12/05 frALES TAX TV 018912500~ .12 . 1, 1 12/05 00" 626 019013318e "30.00 "30.00 12/06 TPN-PHARHACY 01~~99999~ 375.00 375 _ 00 12/06 LIPIDS lOX 500011613082S 57.75 \ 57.75 12/06 ~VI SET 230 011613370~ 26.00 26,00 12/06 ~KIN STAPLE RE"011~12227~ 4.25 ~.25 '2/06 \GLUCOSE 012520109(0 20.00 20.00 12/06 ~LECTROLYTES 012520200~ 5300 53,00 12/06 iSPEC COLLECT FEOl251 01 031\ 7.00 7.00 . 1 12/06 A8D/08ST SERIES013610196~ 158.00 158.00 '2/06 TELEPHONES 018911100. 1.00 I .O( I' ., I;", ~ " 1',' ',,' 1,' t ,~:..,...t"I~r- ... , .. 'I ! t i' I ,t I ~ I 't ~': 1 I' ~ ( i . ".\'j r'l '.f H,I( I ---1 fH' t I~ At t 4.)U[ Sli\)t~'. ~l '11l tlll"I"lt ....... l I' ~ l~'f ., 'l 'h ~ .. 1 U'\ __:=1----.- -- --r-- -]f- ------1- 'F- ---- _.1.___________ -- I'll A:-.l. .;t r-~[; I .\'~..l..;' 1(. , HOLY SPIRIT HOSPITAL .. __________ .L ',,, ':"'", . '0", I l_IOJ ~onlH .".....1 ';!I'if t ! C Af.~. Hll ( ;... ", h.' ,--H I !'ff,1 I ""I , ;',.11 11'11 'PAI! OF l'IIIV 11111 : F IHAL- FEI . ~ FEDERAL 10. NUMBER 23.1512747 HOLY SPIRIT HOSPITAL 503 NORTH 21ST STREET CAMP HILL. PENNSYLVANIA 17011.2288 BIRTH-DATE 23-1512747 03/io/~3 u . r~~:'-~'-)l ,--:~~t~ ~R~~~~~~'~~I-L-__---I~~~'~-f':'~';ll~;~J~~~~~rl_. -"~,,,,~I~B- - ---~---. ---~ 1 GllARANTOA ',.t,lt ARTHUR Q 8lQQS 2ee EAST "AIN STREET SHIRE"ANSTOWN,PA 17011 "0 ADURESS COB IIi',.JllANc:f r.OI,lPA'~Y NAM' .,"'~'. '.' \'''111 POlICY tll;','I'I Ij - -- 361 86 195320 AZIZKHAN REZA "0 PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I A~.:';:\l'N7r I $ ,1Al[ .~~<...' ~ II DESCRIPTIONS Of HOSPITAl SERVICES SfRVlCf COO{ 2/06 SALES TAX TELE 018911~00 2/06 TELEVISION 018912200 2/06 SALES TAX TV 018912500 2/06 ROO" 626 019013318 2/07 VIT-K INJ 10"' Ol~~880l0 2/07 TPN-PHAR"ACY 014~99999 2/07 LIPIDS lOX 500011613082 2/07 AVI SET 230 011613370 2/07 TELEPHONES 018911100 2107 ISALES TAX TELE 0 I 891 I ~OO 2/071TELEVISION 0 I 8912200 2/07 SALES TAX TV 018912500 2/07 IROO" 626 019013318 2/0B POVIDINE PR I .203~~8~091 2/0B ~PN-PHAR"ACY Ol~~99999 2/08 illPIDS 10X 500011613082 2/0B ~VI SET 230 011613370 210B ITRANS-DRESS IV 011~12e51 2/0B ADAPTOR PRN LL 011412331 2/0B ICHE"ISTRY PROFI01252010S 2/0B IPHOSPHORUS, SEROl2520190 2/0B ELECTROLYTES 012520200 2/0B ~AGNESIU" 012520270 2/0B ~LT (SQPT) Ol2S20~50 2/0B ~RANSFERRIN 012S205~2 2/08 ~BC U/J PART 010125301201 2/08 ISPEC COLLECT FE01251 01 031 2/08 ~BD/OBST SERIESOIJ610196 2/08 'TELEPHONES 018911100 2/0B SALES TAX TELE 018911~00 2/08 TELEVISION 018912200 2/08 SALES TAX TV 018912500 2/08 ~OO" 626 019013318~ 2/09 TPN-PHAR"ACY Ol~~99999~ , 11;'1 !,AI .[,' till ~' .'ll',''''~' I .':1 to.! , NllUlltH An['~ AU OUlSllONS I(~ 1t1l fit/SINf ~S ()f J lei 1,'l'l '6J ,?I]H - __' '_.__'n .- ',\1f' iltll H 1'()STlMi .; L .\ I, ,if q 11', let TOTAL EST COV[RAI1E EST COVERAGE ESI COVEnAGE. [51 COVEnAGE PAllEN I CuARGES It'S CO NO 1 !N~ CO P-K)2 IUS (0 NOJ I~.<; CO NO" AM(1UNf .06 .06 e.oo 2.00 .12 .12 430.00 ~30.00 12.85 12.85 375.00 375.00 57.75 57.75 26.00 26.00 l. 00 I.OC .06 .06 2.00 2.00 .12 .12 ~30.00 ~30.00 1.29 1.29 375.00 375.00 57.75 57.75 26.00 26.00 1.00 1.00 2.50 2.50 63.00 63.00 27.00 27.00 53.00 51.00 29.00 29.00 18.00 18.00 35.00 35.00 29.00 29.00 7.00 7.00 158.00 I 158.00 I .00 I 1 .00 06 .06 e.oo i 2 00 II! I ~30. 00 I 12 ~30 00 i 125.00 : 125.00 , I , , i I Pt [ASf SU'-Hl PA.'YMl Nl 10 HOL Y SPIRIT HOSPITAL SOJN0f1111.'lSI SH1[[T CA~4p HH t 1'.\ 1. II 1 :.'Htt 1d'l (ll 1I'lt 1,,\11 IIII'll 'PAil nl 1'1I1~' ILl I ~ FEDERAL I 0 NUMBER 23.1512747 HOLY SPIRIT HOSPITAL 503 NORTH 21ST STREET BIRTH-DAfE FE I' 23-151 C!~W HILL. PENNSYLVANIA 17011-2288 03130/~3 IH)';l'lItl f'.v,l'l'l - F-l-NAL -=________ I. --=] l~~is-:-FRr:I~~;~"~l ~--~~=F"~I;;;:',;~T1~~ ..1' M.I COB ---'..- -.-. -- ----,-_.-_' ------,.-- Ilj',illlAtlll (n".I'AtI' ttl\.Mf "..",.,'''',H'' I'Ollr:V rlllMlIl1l hAlo.t ARTHUR G BIGGS 222 EAST "AIN STREET SHIREI1ANSTOUN,PA 17011 I 361 \86 -----~------ 195320 I,U"RAN10R --'--- ..0 AZIZKHAN REZA 110 AOOR[SS PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ \ '::12;:;;'.:;'\ $ (lAn O[SCR1PTIONS Of SERVICE. 10TAl EST COVERAGf .<;1 COVfHAGf "SI Uh(llAr,f t <;1 Co.'[nAC",f PAllFNI l':,y;Illl HOSPITAL SERVICES COOE CHARC,f,S INS CO NO I INS (,0 un 2 iNS en N(ll IN<; co !lOt AMouNT 12/09 LIPIDS lOX 500011613082 57.75 57.75 .2/09 LIP IDS lOX 500011613082 57.75 57.75 12/09 TELEPHONES 018911100 1. 00 1 .O( 12/09 SALES TAX TELE 018911~00 .06 .Ol 1C!/09 TELEVISION 018912200 2.00 C!.O( 12/09 SALES TAX TV 018912500 .12 . 1, 12/09 ROOI1 626 019013318 ~30.00 ~30.00 12/10 Alii SET 230 02161]370 52.00 52.00 12/10 IV FILTER 0.2211021613746 32.50 32.50 IC!/IO SELF 0100100701 18.02 18.0c I I I I I .___--1_ \ \ i \ .... :,AH I~, t 11Ht It PUSlINCi .11-; i1Al\ I)' q n\il(t , ill ",...., "".....' ,"" , ' ~. ;' : -- 119'52.13 1'9,i-,. 09J--::-=-~:~=r---\--_.._~- .. ~~,~;\~~~~.'.~Y~c,!!I(1t"; '" "H Pl.tASl SlND PA'.MlNl ... I ',., ,....". HOLY SPIRIT HOSPITAL luy THIS A"O\mT 19616.09 , . f '. I. :'i, ...;, ill ~il I .",. j , ,,, "' ~,n:~NonIH21S1s11~t~1 ,{"j', \'" "I""'" I'M.H) H1\ l I'A ,/-\\\' " 'Hi-< R g RrCCg ,FRANr.I;g r I'AIII.NT NAMI ~~-';';'"'''''''''' ,-'- -----_._-".,~-- '>1)( A(,I A (ll,ll', ~~IC Jr; 1M Il --~ H CLJI.. l'A\il till 111'l !'j ll!ll --' -T-;;/1l1 (11 1,/,11111,\1 1'111\1'11111 ~ FEDERAL 1.0. NUMBER 23.1512747 HOLY SPIRIT HOSPITAL 503 NORTH 21 ST STREET FEI' 23_15129WHILL.PENNSYLVANIA17011-2288 B~~~~~~:~E r"':;I"'l . - FINAL cf-H CQ.B tNSUflANQ CllMPM,/Y NAI.'I l,>I"'J"IllJI,I11III POliCY r.\JMUER GUARANtOR NAME ARTHUR G BI"S 222 EAST MAIN STREET SHIRE"ANSTOUN,PA 17011 1 361 86 195320 AND ADDRESS AZIZKHAN REZA MD PLEASE RETURN THIS PORTION WITH YOUR PAYMENT 7~ ~ I 4.MOUNT or I $ PAYMlNT " our OESCRIPT IONS Of I SERVIC[ TOTAL ESt COV[RAG[ EST COVERAG[ f5T COVERAGE EST COvERAGE PATIENT POSTED HOSPIT Al 5[RvtCES COO[ CHARGES INS CO NO 1 INS CO NO 2 INS CO NO 1 INS CO NQ4 AMOUNT SUM"' RY OF PAY/ADJ 18.02. 18.02 SUM'., RY OF CHARllES R&C! E"I PR 17DAYS, ~30.00 7310.00 7310.00 PHARMACY 250 2787.09 2787.09 IV THERAPY 260 1 136 .50 1136.50 MIS SUPPLIES 270 91 O. SO 9\ 0 . 50 LABORATORY 300 2560.00 2560.00 OX X-RAY 320 1264.00 126~.00 CT SCAN 350 685.00 685.00 OR SERVICES 360 1026.00 1026.00 ANESTHESIA 370 290.00 290.00 IKAQIN' SERV ~02 364.00 36~.00 RESPIRATORY SV 410 171.00 171.00 EKERQENCY ROO" ~50 20~.00 20~.00 RECOVERY ROOK 710 251.00 251.00 EK'/ECQ 730 46.00 ~6.00 TELEPHONE 993 18.02 18.02 TELEVISION 99~ 36.0~ 36.0~ ANES SERVICES 96~ 611 .00 611 .00 SUB-1 OTAl OF CHAR'ES 19670. 15 19616.09 5~.06 I ! ! I I I I I , I i I i I H,llfHAI lotNl ~ ]11",.'14' I TnTAI J It t'l iUl:.U.,09I I PAY THIS AMOUNT - - PAHVU NUMBEI1 REfER AU OUESTK11\1S TO THf PlEASE SEND PA>M[NT TO 'C.lU. \ I , BUSINESS OffiCE 196f6.09_ ~'1rl 163,21:\8 HOl Y SPIRIT HOSPITAL -. 14.11 I':; t 11wn l'USlING 'olll)AI( l H ',;1 PVICt 503 NOflTtI :'lST STmU CAMP HILI PA 1 :(111 .):l~h "H ',.'1, 1''''';1 "'111'1\'";(', ~A'I' 6t, 'II I ",',AIi'l' I..',~l ,H,. ."'..i . ..,"11, ,\>'!', 1..'....1;': .',A' "';ll.. \ '. l ','. I ,:-Ilkl" " ."'P' .. :.'. ',"j,' '.. >- ~ "" ~2 (fQ ~~ c:~~! .- C\I lr> N :c '"- ~ 5-.: '-....:t c~:': ~ "'" ::".:':: C) , Co. U' ci If') ;:>, ,::::- . -' ..- .,1 !I ~j :: - . ::> c..; ll. V ( \0 + HOLY SPIRIT HOSPITAL, Plaintiff : IN THE COURT OP COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : : CIVIL ACTION - LAW : NO. 95-4904 Civil Tera v. : ARTHUR G. BIGGS and PRAHCES I. BIGGS, Defendants . . . . . . P RAE C I P E TO THE PROTHONOTARY: Please reinstate the Civil Action Complaint heretofore filed September 14, 1995 regarding the above captioned matter. RESPECTFULLY SUBMITTED: ~ , ~i r-~--- _. ARTHUR A. USIC, ESQUIRE 4201 Crums Mill Road Harrisburg, PA 17112 (717) 540-5610 SUPREME COURT NO. 07207 ATTORNEY FOR PLAINTIFF ,- Dated: , \~ >. ~ c~ ,- i.: UJ~ C"') --;..---: Q( 8::; -. -- ."2 O~ ;J ( Ci :'"1 l U~~ I B:! c -. , - .j t._ '" '- (- -. .' -.' . HOLY SPIRIT HOSPITAL, plaintiff I IH THI COURT OF CONHOH PLBAS I CUJUlBRLAHD COmITY, PIDlHSYLVUIA I I CIVIL ACTIOH - LAW I I HO. 95-4904 civil Tara I I v. ARTHUR G. BIGGS and FRANCIS I. 8IGGS, Defendants P R A I C I P B TO THE PROTHONOTARY: with regard to the above captioned matter, please enter of record the Return of Service attached hereto. RESPECTFULLY SUBMITTED: ESQUIRE Road 17112 ARTHUR A. KUSI 4201 Crums Mill Harrisburg, PA (717) 540-5610 Supreme Court No. 07207 Attorney for plaintiff -, \1-,'/ ; lYVII\ ~. . , , V >.; t. "'" '11)1 (Hili I);. : Y (I :1)( , .\ '\, ;V .1 (I " I)', , A '/ 1,(, A 1, A " A : ~1 I , 11\; .'11'\ , \ , ,)1 :\ i'^~.. '01 i , \.. " :'1 l\ I: II : I i (J!,. I{ J t )!\ ( AI I", ^ '\y ^, III lid ^ -<d:. l ( I'. ,'II: I, Il JV~, 'V. i ) ^II: '. ," II, ". \\ , I ;. ,V, " A\ <:;1'1 (11) l,'f Ll^ . , ",V.....ll'. ,lV' 1\ 'I II}', (:\1)\ ('.,! i\ l^ i ,1 ~ .:" n, I~ I ; (I (1 '101' I : /" I ' , , I:, ' . {( 1 ( :',', ~ , (I '. . ;~~'::VI(., : ;{}~ :~)iV;:l:.i~_', 1,(,', '01 /~ ( 1\ ,< 'v l' .\1 ; ~ (1 '.,. ( I !(J( A\' ^ \:' l^ \ ^,\ '.AV' W: ''';'' jt(, ,',) ^ 'II'. '. " , :v: ," ^" I . " I" ^ \j '~~ ~ I ,;1 j '\ I, ' ,i ; ( ! (:VV' '\ ,\ !,'" VllV 1 i fl.'. V ',:: 1 i :,\&1.\ ; 1 \1 ,,\\'(,' \ v/\ " ,^ ,\ ., , .AV. ,>/\ Y '" A': (I" ",~,<I ,l;;{ (. ^ 1)1'.' "-:'1 ^ ~ II'H, ^ ( ill,j lr\ 1~)I' ;;,::yjflltl!: ~~ "0,' ... ':.',1 A ,f~CJ /Iv y . (l~: : ,)A ~' '01' \ 1111" '01, \ "A" 1 : '11\ , " ~ J ,fI, {\l \; '^:':< '01: :\ ;-:.', I ^ Ii,'. '01' 1A ^" Ill; \I :'1 , ( ~ III . ,:) (II\; :Y V, I. : V I '11 '01, " '''^'' I 1 'iI' ),:\ I.^ 1:';1 " ," 1 II 'Y I) A " " ^ ^ "I, ., ' I. ':\ . 'I :y :y ^V :\1, A :\J ., ..~ 'II ., Y v" " , (I Oll;;" II ) \( , ^ i!)V ^i;" :) < ,\ , 11 '01 , . ,( I ~~ .. : I." :\ Il .\ .1 i\ (lW " '\ll\N'\ \ (],,\ ;l ,\ '. \\ " ",' , '\1; i \, ", ,yy " , . I t \ .. -) s4a1P ~N'!" ,/d "\ .' ,( ('IVV!).,; \ "', ii' " " ( (I., " V 11 t,. I, , ^!.\,: ^. Ji , I )~. :'-' l/\.\ \ 1 .' , , I " , , l"\' , , ^, I ^ , ^ ^ ;<; /, ,'ll " V: V ^ 1 : ., " '. \ vv; 'J { '.1,\ '", ;...., V!\ , , , " V I ")( , , ^,~ ~ :'J~:'\ V :', 'I , I I , " '^ II \ ~ ,.:;i... . " ~ " w I '_ I, f ::'. )/\ y 11 'vtli!tlt , " r.'i "J , " " .?S-~ /I, c:;;.--,,~,-- W 'j Y'"u," . \ ' , ., W '. '.V , , , ''(' ,\ " '/J -', -' ^". I, 'V V .. , \ ,^ \ W \ ., , ^ , , " I " ,oJ " V .. t, "- /\':\ " '.' 'V '\: t, . , , , \I , I '.IV '. \. ',~.." '. 11\ . " >Ji " ',./',\, " ; ,,\ :\ '"", , .' t " 'IJ IN ;,'" I.' Vi '!'.' \J.", Yo' v ....-' \ .. .<'#.' " /.,/ ,~ .;>CR("'f:I/ ~~?I".K ] fi'" . " v It, , :'r' . STATE OF FLORIDA COUNTY OF LEE }ss. I CHARLIE GREEIl ______________ __ ~k of the ~i1 CO\1Irt for said County. the same being a Court of Record DO HEREBY CERTIFY, that__ti~_g(, _~'//F,(' ~____ whose name Is subscribed to the deposition or certiricate of the proof or acknowledgment of the annexed In- strument and thereon written was at the time of taking such dlsposilion or proof or acknowledgment a Notary Public in and for such county. duly commissioned and sworn, and authorized by Ihe laws of this state to take deposilions and to admlnlsler oaths to be used In any court and for general purposes; and also to take acknowl- edgments and proofs of deeds of conveyances for land, lenements or heredilatments In said State of Florida. And furlher thol I am well acquainted wilh Ihe handwriling of such Notary Public and verily believe that the signature to said deposilion or certificate of proof or acknowlcdgmcnt is genuine; Ihat the impression of H____ ____ official seal is not required by law to be filed in this office. IN WITNESS WHEREOF. 1 have hereunto set my hand a~atrlXed Ihe seal of said Court. Ihis the ------________i. 9f n _________ day of _/l;J1il0 _. _. ___________. A.D. 19 910 , CHARLIE GREEIl Ci,'rk of CirclliI Court "'orlll 20 I 1502 by: J2. //:. ~~~4.1 D.c. bffice of the Sheriff Jolin.J. McDo\l9a!( StaU of FCorida. Coun~ of Lee . A F F I D A V I T STATE OF FLORIDA COUNTY OP LEE BEFORE ME, THE UN~IGNED AUTHORITY J-J' AND POR SAID COUNTY AND STATE, THIS :;--. _ ~?F "//k/ld. 1. 'lib FERSONALLY APPEARED ~.?'t'~/trO , THE UNDERSIGNED DEPUTY SHERIFP OF THE COUNTY OF LEE, STATE OP FLORIDA, WHO BEING BY ME FIRST DULY SWO)Ul_~ING TO LAW, HAKES OATH THAT HE HAS THIS DAY OP ~/~ /Y'f-C-. _ , lr//h DELIVERED A COPY OP THE A~~CHED SUMMONS TO (I) tiw \ 2!. 613ff- IN d 1/ h L t \ u). , . LEE ~OUNTY, F'LOIJiDA, SUMMONn ISSUED FROKO' . , .' . ~ , ('()t(.\ 101 [/i)nIJlCn I 'LrM , . [J I a ~TH SHERIFF'S R.ETURH THEREON. SERVED BY ~~4P' ~<) DEPUTY SifiRIFF, LEE COUNTY STATE OF FLORIDA COUNTY OF LEE was acknowledged before me (date) by take an oath. Public /ti7':~ 11M D....... ", ;.\ MY lUoUSSKJj I ~ EXPIAES ',,)'-. - i"Y SoolonW 18. I. '. ..jr:, :,." IQIGO "'" TD"..........__ OESCRIPl'ION ~~&f~~. W1!lIGB'l' ' OTHER ARK!D FORCES~ ~ 'f'''' ":. :i ;; "'--, .'.. ~.~ .".'.' . ........~. 1.&7~O Si\ \Iilf C'prf'>-' P3rkwa' 01 F')r1 \hm. Flurida 33qIZ.....I~ . 19.&II.H!.34~tl . STATE OF FLORIDA COUNTY OF LEE }ss. ~RlIJ__~~~~~________m____. .I ~-or till' ~ir" I'COU~ said County,lhe same being a Court 01 Record DO HEREBY CERTIFY, that _ kJ -<4'f(- < a~E:J':?J:~__ whose name is subscribed to Ihe deposition or certilicate 01 the proo or acknowledgrnent 01 Ihe annexed in- strumenl and Ihereon wrilten was at the time 01 laking such disposilion or prool or acknowledgment a Nolary Public in and lor such county, duly commissioned allll sworn, and authorized by the laws 01 this state to lake depositions and 10 adminisler oaths 10 be used in any court allll lor geneml purposes; and also 10 lake acknowl- edgments and prools 01 deeds 01 conveyallces lor land, lellements or Ill'reditallllents in said Stale 01 t'loridn. And lurlher that I am well acquainled wilh Ihe handwriting 01 such Notary Public and verily believe lhat the signature to said deposilion or certilicale 01 proof or acknowledgmellt is gl'nuiue; thaI the impression 01 official seal is not required by law to Ill' filed in this office. IN WITNESS Wllt:llt:Ot', I have hereunto Sl't my hallllaud affixl'd till' seal 01 said Court. a'/J ' lhislhe __._________ __/1 _ dayol/lltlle/; _ _ _,A.D. i9 1-& CHARLIE GREEN Cll'rk or Circllit ('ourt hy:t?..dL ~.. D.C. t'urlll 281 1502 : 6jfice of the Sheriff J onn. J. McDoU9aCC State of rCorUfa. , Coun~ of Lee' A F F I D A V I T STATE OF FLORIDA COUNTY OF LEE . BEFORE HE, THE UJf~IGNED AUTH~~TY Z AND ~OR SAID COUNTY AND STATE, THIS fi':-~ DAJ..fF --::17l/{C ....., 19 7(0 PERSONALLY APPEARED ~d4 t:L'ct1~~. -.::J , THE UNDERSIGNED DEPUTY / SHERIFF OF THE COUNTY OF LEE, STATE OF FLORIDA, WHO BEING BY ME FIRST DULY SWOlur ACCOijDING TO LAW, HAKES OATH THAT HE HAS THIS DAY 6k. OF ' ;c.;" - , 1 iG. DELIVERED A COpy OF THE \1,;'),,' I:)(-,-:J IN (. - "'~ LEE .COUNTY, FLOI)fDA, 7UHHONS ]SSUED FROM /2 til}{iJ~.U (L;I, L; iI/Ill r- /'6 L'I17l1l1tJn /1.t tL.:J- , ,j( 1'117~ SHERIFF'S RETURH THEREON. SERVED BY ~.P a,-#t'<J tiEPUTY SiJfiUFF, LEE COUHTY me STATE OF FLORIDA COUNTY OF LEE ~nstrumenc was acknowledged before 9 /C;9t (date) by . co me and did not take an oath. '.4'~~ Notary Public DESCRIPTION SEX ~ .l.GE 5'~ HAIR72M-NlP ~'K. WEIGB'l' . OTHER ARMED FORCES At" ~ ~~..-- --: -~'::. '. u '1'" .. ':,,1,'1.. .,'.1 ~~.~.~ ......- . . 1..l7~O Sit "lilt ('prn., P~rkwa' . Fort ""tn. Florida 33"1~.~'1O · 1"~11 ~!~.;~"n HOLY SPIRIT HOSPITAL, Plaintiff' IN THE CaURI VI COMMON PLEAS . CUMBERLAND COUNTY. PENNSYLVANIA CI VlL ACTION - LAW NO. 95-4904 Civil Term v. . . . . . . . . . . . ARniUR G. BlOOS and FRANCES I. BlOOS, Defendant CERTIFICATE OF SERVICE 1. Arthur A. "USIC. ESQUIre. do hereby certIfy that on thIs 11th dav of April . 1996. I placed In the UnIted States Ma 7 I true and correct cop 7eE of Ten Day Important Notice. addressed to following: Arthur G. Biggs Frances I. Biggs 2211 Croton court Lehigh Acres, FL 33936 S . ESQUIRE Crums M7 II oad P.O. Box 11585 Harr7sburg. PA 17112 (7171 540-5610 Attorne,Y for the Plaintiff Supreme Court 1.0. 07207 ,.,' . ' ,,' , . HOLY SPIRIT HOSPITAL, Plaintiff IN THE COURT OF COMMON PLEAS :~ COUNTY PENNSYLVANIA V. ARmUR G. BIOOS and FRANCES I. BIOOS, Defendants CIVIL ACTION - LAW NO. 95-4904 Civil Term TO: ARmUR G. BIOOS AND FRANCES I. BIOOS: Defendants You are hereby not if i ed that on . 7Jll~"i_dL -t!i-f( (; the follow1ng Judgment has been entered against y~ in the above- captioned case. Date: Amount: In the anount of $19,616.09 alonq with interest at the rate of 6% per annum fran September 14, 1995 .... the coots of thi. "'7'. ' j" ('f~ . .' t#.. .k] I "'." ,",W, th.:'oth not , ~ ~:d'." O/th. ",oP.' to receive this Notice under pa.~CiV.P. section 236 is: person(sl Arthur G. Biggs FranCeS I. Biggs 2211 croton Court Lehigh AcreS, FL 33936 Defendants Arthur A. Kusic, Esquire Supreme Court No: 01201 4201 Crums Mill Road Harrisburg, PA 17112 (717) 540-5610 Attorney for Plaintiff v. IN TilE COURT OF COMMON PLEAS CUMB~ COUNTY, PENNSYLVANIA CIVIL ACTION - LAW "- NO. 95-4904 Civil Tern1 HOLY SPIRIT HSOPITAL, Plaintiff ARTHUR G. BIa:iS and FRANCES I. BIGGS, Defendant ';'1 IMPORTANT NOTICE TO: ARTHUR G. BIGGS and FRANCES 1. BIGGS DATE OF NOTICE: APRIL 11, 1996 YOU ARE IN DEFAULT BECAUSE YOU HAVE FA] LED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY 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 A1 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 CUmberland County Court Administrator 4th Floor I Courthouse Square Carlisle, PA 17013 RE~;PI':CTFllJ.J.Y SllBMITTED: (717) 240-6200 .: ,..:::,...... 'j;' " , # ,/.' , . . .- - .' .--, ,. ~ y 1..__1J.,:-/. _._ AHTIIl1i< 1\. Kr~~rc. ESQUIRE THE PURPOSE OF THI S COMMUN 1 CAT I ON ]~; TU l.'OLJ.!:CT ^ DU\'! ANLJ ANY INFORMATION OBTAINEIl WI),\. III-' l!~;U) ',)1< TItAI l'UI<"ll~;L. 1I0LY SPIRIT 1I0SI'I'I'AI., l'la"'tlll / N 1/11 (',1/1111 1'1 Ctlt-fMtlN 1'/ f ,,:' C1JMBERIJINU ...'/lNlt. l'I-NNSn VAN/II CIVil IIU/UN '-IIW NO. 95-4'104 Ci vi! Tem v. ARTIlUR G. BlaiS and FRANCES I. BIGGS, Defendant CEIHII-ICATE Of SIRVICI. I. Arthur A. I\USIC. ESQuIre. an IJe't'tJ\ -ert'h th,H."J thIs 11th aav of April I q 96. 1 i' la_ ell '" 1/:e (1/1 J teJ States t-fa II true ana correcr ,:Q/l1e, of '!'en Day ImfXJrtant Notice. addressed to fo 11 ow, 119: Arthur G. Biggs Frances 1. Biggs 2211 Croton Court Lehigh Acres, fl, 33936 -~ ESQUIRE R<'ad '-1.lr'" l.,~t'u"}, P.~ . ~ 1 1 1 , '. ( 71 7f .I'Jl - "'~ t( 4ttll"1t-l'f .,H tne ri~l!nt 1ft SilPremtl ,',ll1ft'I.ll. O'2l),' ..---/