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OHAHDIRSBURG ARIA LIrl SUPPORT
8IaVIOI,
plaintiff
V.
I IN THI OOURT or OOHMON PLIAS
I OUHBIRLAND OOUNTY, PIIflfBYLVANIA
I
I OIVIL AOTION - LAW
I
I
I NO.
I
rKAMOIS ROOIWILL and
STIWART aOOIWILL,
Defendant.
~ 0 M P L A I N T
~ND NOW comes Plaintiff by and through its attorney,
~~thur ~. Kusic, Esquire/ and respectfully represents the
following:
1. Plaintiff, CHAMBERSBURG AREA LIFE SUPPORT SERVICE,
is an ambulance service organized and existing under the laws of
the Commonwealth of pennsylvania with its facilities located at
P.O. Box 427, Chambe~sburg, Franklin county, Pennsylvania.
2. Defendants, FRANCES ROCKWELL and STEWART ROCKWELL are
adult married individuals residinq at 100 Baldwin Boulevard,
Shippensburg, Cumberland county, Pennsylvania.
3. on or about January 29, 1990 through March 30/ 1993/
Defendant, Frances Rockwell was given necessary emergency medical
treatment
and emergency ambulance transportation to the
Chambersburg Hospital.
Plaintiff in good faith provided the
necessary emergency medical services to the Oefendant, Frances
Rockwell and thereafter billed the Defendants for those services
and expenses incurred, which are its usual and customary charges
for these services.
4. Copies of the bi 11 ing for services rendered to
Defendant, Frances Rockwell by Plaintiff are attached hereto, made
a ~art hereof and marked Exhibit "A".
5. on or about Mar.ch 30, 1993, Defendant, stewart
Rookwell exeouted an Assignment of Benefits whereby he requested
payment of medical benefits bf' made to the Plaintiff. As evidence
whereof, a copy of the Assignment of Benefits is attached hereto,
made a part hereof and marked as Exhibit "8".
6. A1 though Defendant, stewart Rockwell was not
provided any medical services, he would be unjustly enriched as the
services provided were necessary medical services for his wife's
health and welfare.
7. Defendants are indebted to Plaintiff in the amount
of Eight Hundred and Thirty and 00/100 ($830.00) Dollars. ~s
evidence whereof, a copy of the Defendant, Frances Rockwell's
summary of Accounts is attached hereto, made a part hereof and
marked Exhibit "C".
8. Demand has been made upon Defendants for prompt
payment amount due, which demand has gone unheeded.
WHEREFORE, Plaintiff prays your Honorable Court to enter
Judgment in its favor and against Defendants in the amount of
$830.00, along with interest at the rate of 6% per annum and the
costs of this proceeding.
RESPEc'rFl.JLLY SUBM
/'
/ - ,43:
,.---
A thu'~./Kusic, u.tre
4201 Crums Mill Road
Post Office Box 11.585
Harrisburg, PA 171.08
(71.7) 540-5610
Supreme Court No. 07207
Attorney for the plaintiff
DATED:
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Chlmbtrllllll1l AIel
AdYIIICId UII luppon ltrvlce
P.O. Box 187
Chlmbtraburg, PA 17201
Phone: (71712804-5171
STATrMENT OATI
PATI-.N'; INM~~
loj-lIE
STATEMENT DATI
PIITIIN~'NUt.i~EII
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:,,1)'; '. ?AAD tE.DOWS
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'IQ"ll '1"11 101 ,'c ,..,
TO INSURE PROPIR CREDI T.
PLEAse RETURN THIS PORTION
OF THE STATEMENT WITH YOUR
PAYMENT
THANK YOU. CMLSS
RUN I/O,
DATI OF SERVICI CODE
DESCRIPTIOI/
CHAllal
BALAl/CE RUN NO.
CODE
CHARGE
3..
)It ~"11V
~ 111'),1')5.110,!15,1.5,1~~
110,;1/
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"00 Ca,dlla MQnilQrln'il
1100 Ollvaen Thefapv,,Alrwl., Malnt.nlnce
.,10 Patient AIIIIII'M'"
"18 InU'lvenoul TheraP'(/Blood Orawlng
.,20 Indotrac:hllllntublUoo
"25 DlflbnlllUoo
"30 MI.t TrouM' ~ppUCltlon
.,40 Medll;:lhon AdmlnlltraUon
"4& Monitoring or VItal Slllo'
"&0 MedlClI CQmmlnct Cl)mmuoleaUon.
I'I.IAII MAleI CHICXI PAY"ILI TOI CMl.11
,l ~Q "~I ,ILL ,~uA InDU"""~t run I"I~ ~t"VjLt
SHIO DAYS
I'I.IA8E PAV
AMOUI/T DUe
OVEII e&PMl9
AMOUI/TDUI
CURREI/T
31.e DAYS
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NAME
ADDRESS
CITY
INS. INfO
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CHAMe~RS8URG
ALS SERVIC E, INC.
ACCOUNTS: PAYABLE
"
pat ient . info
-
PLEASE MARK IN RED IF RUN WAS
A ~ VEH.'Icu: ACCIDENT OR
~ 11.1\ VEllla.E ElElA'I'ED
FIl\5T l.).ST
1 Q 12 S ~. '] I 1 I t' .. } n ~ ~\ '~ : ~ '. .: 1 :
~OC~WEll. FRiUCE5 F
q 1 ',:l Atill T nOTTP ~n STATE" _II
H:i'P,II::EIJ~". P.I !1257
C~.'~~/:r. 3,:"'( 117 532-S2\1f,
\., I t II
call info
L~1HoNJH,11 (it ~ 5lirr',~.j S~t.L'"
DATE OF SERVICE / / Ii "/ i U
,
~rocedure codes
j 100
'f~:
11/5
120
12/5
~130
140
14/5
1/50
APT
lOT
ZIP
8FNnl=7Vnll~
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RUN HUM'BER ~ '65"
Bru..m; GUIDE
$125.00 (ClASS 3)
CARDIAC MONITORING
OXYGEN THERAPY
PT ASSESS
I V THERAPY
E T TUBE
DUFIB
MAST
MEOS
VITALS
MED CMND
Monitor
Oxygen
Assessment
Vitals
(or any combo of these)
$200.00 (~ 2)
Monitor Med Ccmn.and
Oxyg~n ~~crostick
Assessment Dr3W Blood
tV
Meds (or any canbo of these)
Vitals
$250.00 (ClASS l1RAU1A OR CARDIAC)
Monitor J:II !I.ed CaImar1d
Oxygen Meds ard/or
Assessment Vitals ET 'I\lbe
Def.ib
Mast
charge info
..
CHARGE _ - 12~ ~ 250 circle
DATE BILLED /;/ 3rt:
BILLED BY } / L
Rf~I'u...Jd \I.s-<io/+dr
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SIRVICES CODES
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~.~i~2~!!~Y!=!!~-~~~~~~.~.~~.~...~~~~~~:......~~!~~!..:~~~.~..~~~..~!~~!!..
~ Ivai/Han. (B..e Rate)
prolonged oreater E/K
99499
99499-21
10223
Type W0017
Serv
91
210 .00
30.00
~
Rhythm Ecg (1-3 Lds "Onitor)9304~ Z0224~
Ecg 12 Ld. w/o report 93005 Z0224
60.00
cardioversion (electrical)
9296~~
90.00
Defibrillation ~ ______
Endotr.acheal Intubation
31500>
94656
75.00
Ventilation Assistance 6
mngmt. for assisted or con-
trolled breathing
Nonpressuri:ed inhalation 94640
for acute airway obstruction
, (MED NEB: Alupent)
~/' Venipuncture, IV Therapy, 36406
/erc
~ Venipuncture. collect 36415
Specimans
25.00
/
~ $35 =
.., _ (t--t.
,,::....""'l
No. IV's
Included in IV rate
Intraosseous
36680
90784
90798
90799
90782
50.00
IV Medication Admin.
Noo____ x $4.00 =
4.00
Theophyline IV Admin.
IT / 10 MED Admin.
SQ MED Admin.
1M MED Admin.
No.____ x 54.00 =
No.____ x $4.00 .
No.____ x $4.00 ·
Temp. Transcutaneous
Pacing
Cricothyrotomy
92953
~lJ
JG
100.00
100.00
31605
Chest Decompression
HAST
Included in baae rate
CPR
92950
Included in base rate
10/9'
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SHERIFF'S DEPARTMENT
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157 LINCOLN WAY EAST, CHAMBERSBURG, PENNSYLVANIA 17201 (717) 261.3877
---._~~~..~S R!C:r:T~~~~S:~,*1~~I~-~F'~~~URN . ~~U~~~~i::I~~~~;'Pf~m ~'~;'~~;;-lHlnl
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eIa-'uD!ure. J4f.!!..JJRl9r..~_.~!I'!!~~-'nn_._... ''''_n_.._ ."", u,,_J~~lZ6a_,_.
3, DEFENDANT ISI 4 fYI'E Of Willi on COMPLAINT
rr....... . IC...rc Iol\lkvall_______.._..____________._ ~J..Ii~._,
{ & I/AME r;~:~::UA~ ;:::~O~:.=~~~:...~J..:':VICl_~:'~l HC:::~_.)I'II11I'~1I1 :~~E.l::I:~~r IA:E:~~~,_
1\, AODRESSISlr.el or RFD, Aporl",o"t No,. Clly, !lnll', fWII, 51010 ""'I liP Cooo'
AT ___l!Hl. IlAldvin lou1-r.LJMtPt!lill.Jll'&,.I~,_ln' 1....__,_._.. _.___. .____,____
7,INDlCATE UNUSUAL SERVIr.E 0 COMMON OF 1'.\ () DEPUTllE n OTIIEII
Now, 10_, I, SHERIFF OF FRANKLIN COUNTY. P^'~do horoby"J.,p;Jii1.o-lhoSti;;;iij'of---'
_Counly 10 olloculo Ihls Wrll ond mako ,olurn IhAreol or.cordlnu
10 lew, Thl. depllloUon being made Bllhe reQuesl and 'Isk 01 Iho plolnlilf, __.._______ .,
. - - .-.JIIJtJlM.LJ.l.l1~/...I.--.-__
.. 1IfIEcw.lHlIlftUC11ONS OR OTHER INFORMATION THAT WILL ASSIST IN UPEDlnl/O IlERYlCEI
SERVE
.
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NOn! ONlY AI'I"UC"A1 ~ ON WRIT OF EXECUTION: N,B, WAIVER OF WATCHMAN-Any d.puly "horill 10vYlng upon or ollnchlng ony proporly undor
wUhln writ m.v teave IBme without n watchmon. III CU610tly of wlmllU!vt!l I~ 'ound III pOlU'UJIISlofl, oller nolllYIIlU purao/1 01 levy or /Jllochmunl, without
Ilablllly on IMoor. 01 such deI).J'V or the eltlA!J.lllo (J!.!Lmmmill.l!~.!t!.~!..!!!!J'..!..f)~Ii:.l- n Ion or rumo~11 or AflY slJch to orl bo'oru ~hu'i11'6 6111e Iheteo'
t. S1aNATUIIE 0/ ATlOIlHEY 0' olhor ORIOII/ATOR 10 fELEPHONE NUMBEA 11 DATE
.u:cbllr A.. lute . ,
12. SEND HOncE OF IlERVlCE COPY TO I/AME AND ADDRESS BELOW: IThio .,.. mu.t be completod II "Ollc.,. to bo moilod)
4201 C"'- 11.111 .... Bard.bllrl, ..} 17106-701L-
&Me! BELOW FOR USE OF SHERIFF ONLY - DO NOT WRITE BELOW THIS UNE
13, I acknowledge 'ocelpt 01 Ihe W'i1} S10I/ATURE 01 Aulholl"" FCSD D',puly or Clork ond Till. 14 Dole Aocel..d 16, E'PlrBliOnIHeoll"!l dale
Of compl.lnt..lndlcaled above, 1-10-96 3-1-96
16.1 hereby CERTlFY and RETURN thai I 0 hO\'l! pat5onolly sllrvcd, 0 hllYtJ IOQliiUVidOilCo 01 6urvtcu 05 shown in "Romnrks", 0 havu okQculed OIS shown
In "Remllkl",lhe wrll Of complaint descnbed on the Hldlvidunl company, corporoUo/l, Qlc., ollhe uddro!!1I shown abovo or onlhu IndivIdual, company,
cOfporlllon. ate,. lllhe .dd,e..ln.orled below by hOl1dllng" TRUE ""d .lTTESTED COPY Iho,eol
-, -
.!L_O I hereby cerllfy and return B NOT FOUND because t nll1l~~htl! to lo(;o!u the IndiVIdual, company, corporollon, etc, nomed above, (See remarks belo!J
18, NBfTMt and lit.., of Individual served III nol 6hown f1bovel 10 ApOllO" OllUllpbJcr ag'/lnlfdl.cf.hon l/wn
, .- '--11 f b tb 'nldltll,l HI lhe del.n.llmll 1111.I81 pIKe of
fUC.. ....e... - Of 0 .bod< U
20" Addrel. of where served (complele only II dlflerenllhan shown ubo\lol 15lroet or AFD~ Aparlmenl No., 2"' 01110 of 5efVk:O 22 TIme
City. Bolo. TWp, SIlt. and Zip Code I M::
le~T
Milft
24
30, REMARKS:
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FEB"'61996
19
6th
96
so ANSwER.
3 t, AfFIRMED _ oubocrlbed 10 beloro m. IhlO
34, dIIV 0/
37,
r.bnaary
.11 S'U,'ulur. 01
Dep 5h"'11I Robert C. Ku~
JII BIllnlllUlllol6hllllll
........WII~W'''*''.'~ ""biOi
SHERIFF OF FRANKUN Cool/TY
~ro."
1-6-96
:It! Oa..
Mr. ~IPT OF THE SHERIFF'S Fl!'fO
OF AUTHORllED ISSUING AUTHOAITY AND TITLE,
REI
,
Jt) DI\I.tlllclIl'IGll
'CSD'lIl0i3
4. SHERIFF'S DEPARTMENT
In .TnfJ CQurt cT C.::mmon Ple::s or C:.Jt'.;:":~It'I=nd C,:,u:-;':y, P5nn=syl'le:nla
Chambersburg Area Life 6upport Service
'IS,
Frances Rockwell
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Afiidavit or Semc:.l3
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Arthur A. Kusio, Esquire
supreme Court NOI 07207
4201 Crums Mill Road
Harrisburg, PA 17112
(717) 540-5610
ClIAMBERSBURG AREA LIl'E SUPPol\'r
SERVICE,
Attorney for plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIl. AC'l'ION - LAW
NO. 95-7262 Civil Term
Plaintiff
v.
FRANCES ROCKWELl, "nd
STEWAR'r ROCKWELL,
Defendant
lMfQBIhNT NOTICE
TO: Stew" rt RockWl> II
DATE OF NO'1'ICE: April 1, 1996
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED 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 ~ HEARING AND
YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD
TAKE THIS NOTICE '1'0 A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER'
OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO
FIND OUT WHERE YOU CAN GET LEGAL HBLP:
LAWYER RE~'ERRAL
Cumberland County Court AdmJ.n.
Fourth Floor
One Courthouse Square
Carlisle, PA 17013-3387
RESPECTFULLY SUBMITTED:
(717)240-6200
ART~
THE PURPOSE OF THIS COMMUNICATION IS TO COLLECT A DEBT AND ANY
INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
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CHAMBeRs BURG AReA LIFe sUPPORT
seRVICE,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY PENNSYLVANIA
PlLl1ntjff
V.
CIVIL ACTION - LAW
FRANCES ROCKWELL and
STEWART ROCKWELL,
Defendants
NO. 95-7262 Civil Term
P RAE C I P F.
TO THE PROTHONOTARY:
Pursuant to Rule 237.1 of the Pennsylvania Rules of Civil
Procedure. Notlce of Praecipe for Entry 6f Default Judgment has
been given to the Defendants: a copy of said noticEl i!l attached
hereto.
Please enter Judgment in favor of the Plaint"f and
against Defendants ln the amount of
$830.00
along with
interest at the rate of
6%
from January 26, 1996 __,' and the
costs of this proceeding for fai lure to enter' a defonse or
otherwise fi Ie a responS1ve pleading in the above captioned matter,
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RESPECTFULLY SUBMITTED:
DATE:.
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<<df~~_,._.
ARTHUR A. KUSIC, ESQUIRE
4201 Crums Mill Rood
P.O. Box 67015
Harrisburg I PA 17106
(717) 540-5610
ATTORNEY FOR PLAINTIFF
SUPREME COURT NO. 07207
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