tf_idf Analysis of New Hampshire Civil Cases
Daniel Lee
1/30/2019
Data
The analysis below is from data collected in the Belcknap County Superior Court and Concord Business and Commerce Dispute District Court during 2018 summer.
- 108 cases of scanned documents
- 409 court cases of meta data
Extract complaint pages
- We should complete entering the data for BCDD in the spreadsheet. Only 58 BCDD cases are entered into the spreadsheet while there are 74 scanned PDF documents.
- Can we simplify the nature of suit (CaseType)? There are some cases where Sam and Jeramiah left with more than one NOS.
- After leaving out unaccounted cases in the spreadsheet and ones without an uniquely identified NOS, there are only 62 cases used in the analysis.
Extracted complaint pages of first few cases
## [1] "Complaint to Partition Case 04/26/2016 Closed Status: Party information Attorneys Plaintiff Signorine, Anthony Martin, Stephen T., ESQ Retained 877-645-2909(W) Defendant Michaud, Stephanie Date Events & Orders of the Court Index 01/04/2016 Complaint to Partition Index #1 Filed by: Attorney Martin, Stephen T., ESQ 01/04/2016 Summons on Complaint Index #2 01/04/2016 Service Michaud, Stephanie served 03/07/2016 03/07/2016 Service A tty J. Kristen Gardiner accepted service o/b/o Stephanie Michaud 03/10/2016 Acceptance of Service Index #3 Filed by: Attorney Martin, Stephen T., ESQ 03/30/2016 Settlement Letter (Rule 39) Index #4 04/22/2016 Neither Party Docket Markings Index #5 Filed by: Attorney - OTHER Gardiner, J. Kristen, ESQ; Attorney Martin, Stephen T., ESQ \"No fees, no costs; judgment for neither party; no further action for the same cause.\" TARGF'I date Time standards PAGE 1 OF 1 Printed on 04/26/2016 at 9:51 AM THE STATE OF NEW HAMPSHIRE BELKNAP, SS SUPERIOR COURT Anthony Signorine, Plaintiff v. Stephanie Michaud, Defendant Docket No. 211-2016-CV-00001 DOCKET MARKING It is hereby stipulated' tKaTthe aBm^aptiSned^ctiOTnriay-heTnarked:-^^-— “No fees, no costs; judgment for neither party; no further action for the same cause.” Respectfully submitted, ANTHONY SIGNORINE By His Attor MAI Dated: T. Martin, Esq. (Bar No. 19567) 22f. Bridge Street, Suite 3 Concord NH 03301 (603) 856-0202 (Ext. 1) STEPHANIE MICHAUD By Her Attorneys, RICE LAW OFFICE, PLLC Dated: I (jp ¦, Esq. (Bar No. 16839) Jnion Avenue niaNH 03246 (603) 528-5299 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Belknap Superior Court Telephone: 1-855-212-1234 64 Court St. TTY/TDD Relay: (800) 735-2964 Laconia NH 03246 http://www.courts.state.nh.us RULE 39 NOTICE FILE COPY Case Name: Anthony Signorine vs. Stephanie Michaud Case Number: 211-2016-CV-00001 Please be advised that Attorney Stephen T. Martin has notified the court that this case has been settled and that an agreement will be filed with the court. If the agreement is not filed by April 29, 2016, the court shall take such action as justice may require. March 30, 2016 Abigail Albee Clerk of Court (477) C: Stephen T. Martin, ESQ; J. Kristen Gardiner, ESQ NHJB-2463-S (10/01/2013) 4. I J STATE OF NEW HAMPSHIRE JUDICIAL BRANCH BELKNAP SUPERIOR COURT Anthony Signorine, Plaintiff, v. Stephanie Michaud, Defendant. Docket No.: 211-2016-CV-00001 —- AGGEPTANGE-OF SERVICE —“ - I, Attorney J. Kristen Gardiner, Counsel for Defendant Stephanie Michaud, in the above- captioned matter, hereby accept service of the Summons in a Civil Action on behalf of the Defendant, and I hereby waive all formal service of process requirements. Laconia, NH 03246 (603) 528-5299 kgardiner@ricelaw-office.com CERTIFICATE OF SERVICE COMES NOW Attorney J. Kristen Gardiner, Counsel for the Defendant, and hereby certifies that I have caused a copy of the foregoing to be served upon Stephen T. Martin, Counsel for thcPlaintiffrat 22*Bridge Street,’Suite 3; Concord, NH 03301. — ---- - Dated: STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Telephone: 1-855-212-1234 TTY/TDD Relay: (800) 735-2964 http://www.courts.state.nh.us SUMMONS IN A CIVIL ACTION Case Name: Anthony Signorine vs. Stephanie Michaud Case Number: 211 -2016-CV-00001 Date Complaint Filed: January 04, 2016 A Complaint has been filed against Stephanie Michaud in this Court. A copy of the Complaint is attached. The Court ORDERS that ON OR BEFORE: February 18, 2016 Anthony Signorine shall have this Summons and the attached Complaint served upon Stephanie Michaud by in hand or by leaving a copy at his/her abode, or by such other service as is allowed by law. March 10, 2016 Anthony Signorine shall file the return(s) of service with this Court. Failure to do so may result in this action being dismissed without further notice. 30 days after Defendant Stephanie Michaud must file an Appearance and Answer or other is served responsive pleading form with this Court. A copy of the Appearance and Answer or other responsive pleading must be sent to the party listed below and any other party who has filed an Appearance in this matter. Notice to Stephanie Michaud: If you do not comply with these requirements you will be considered in default and the Court may issue orders that affect you without your input. Send copies to: Stephen T. Martin, ESQ Law Offices of Martin & Hippie PLLC 22 Bridge Street Suite 3 Concord NH 03301 BY ORDER OF THE COURT January 04, 2016 Abigail Albee Clerk of Court (477) NHJB-2678-S (10/23/2013) 1. STATE OF NEW HAMPSHIRE JUDICIAL BRANCH BELKNAP, SS SUPERIOR COURT Anthony Signorine, 59 Stark Street, Laconia, NH 03246 Plaintiff, v. Stephanie Michaud, 162 Farrarville Road, Belmont, NH 03220 Defendant. Docket No.:____________________ COMPLAINT TO PARTITION REAL ESTATE COMES NOW the Plaintiff, Anthony Signorine, by and through the undersigned Counsel, and for his Complaint to Partition Real Estate, states as follows: JURISDICTION. CAUSE OF ACTION. AND VENUE 1. Plaintiff (“Anthony”) invokes this Court’s jurisdiction pursuant to RSA § 498:1 and RSA § 547-C:2. 2. Anthony’s cause of action arises pursuant to RSA § 547-C and New Hampshire’s common law. 3. Venue in this Court is appropriate pursuant to RSA § 547-C:2 because the real estate at issue is located in Laconia, New Hampshire, a municipality within Belknap County. PARTIES AND REAL ESTATE AT ISSUE 4. Anthony is an individual who resides at 59 Stark Street, Laconia, New Hampshire. 5. Defendant Stephanie Michaud (“Michaud”) is an individual who resides at 162 Farrarville Road, Belmont, New Hampshire. 6. When referred to collectively, Anthony and Michaud will be referred to as the “Parties.” Page 1 of 4 7. The real estate that is the subject of this Complaint is the land and buildings thereon located at 59 Stark Street, Laconia, New Hampshire (the “Property”). SALIENT FACTS 8. On July 23,2013, the Parties purchased the Property as joint tenants with rights of survivorship. 9. On or about the same day, the Parties also co-signed a Promissory Note and a Mortgage which secures the Note. They gave the Property as collateral. 10. The monthly mortgage payment, in the amount of $1,354.05 consists of principal, interest, and taxes and insurance. The amounts assigned for taxes and insurance are placed in an escrow account that the mortgage company maintains, and the mortgage company pays the taxes and insurance from the escrow account when they become due. 11. Since July 23,2013, Anthony has paid the majority of mortgage payments, utility payments, and other expenses and obligations associated with the Property. Michaud contributed $600.00 per month. 12. On or around July 11,2015, Michaud voluntarily vacated the Property. She ceased making monthly payments at that time. Upon information and belief, Michaud wishes to be relieved of her obligations under the Note and Mortgage. However, Michaud refuses to release her interest in the Property. 13. Through December 2015, Anthony has paid a total of $38,224.58 in total mortgage payments. He has paid a total of $ 11,053.80 in utilities. 14. Michaud no longer resides at the Property, she no longer wishes to reside at the Property, she no longer wishes to have an ownership interest in the Property, she no longer Page 2 of 4 1 1 # contributes any money or other support to the Property, and she desires to be relieved from her obligations under the Mortgage and Note. 15. Anthony wishes to retain sole title to the Property. CAUSES OF ACTION Count I (Partition) 16. Anthony incorporates by reference, and re-alleges, all previous Paragraphs of this Complaint. 17. RSA § 547-C:l allows a person holding an interest in real estate to petition for a partition of said real estate. 18. Anthony and Michaud own the Property as joint tenants with rights of survivorship. Anthony wishes to partition the Property because Michaud no longer resides at the Property, and upon information and belief, she no longer wishes to reside at the Property. Furthermore, Michaud does not contribute any financial or other support to the maintenance of the Property, and she desires to be removed from her obligations under the Note and Mortgage. 19. Anthony wishes to retain sole title to the Property. 20. Therefore, this Court should equitably partition the Property. PRAYER FOR RELIEF WHEREFORE the Plaintiff respectfully requests that this Honorable Court grant the following relief: A. Partition the Property in an equitable manner allowing Anthony to retain sole ownership of the Property, compel Michaud to release her ownership interest in the Property; and B. Grant all further relief that this Honorable Court deems just and proper. Page 3 of 4 Vi Dated: December 31, 2015 =Stephen T. Martin, Esq. 22 Bridge Street; Suite 3 Concord, NH 03301 smartin@nhlegalservices.com 603-856-0202 (Ext. 1) NH Bar#: 19567 Page 4 of4 "
## [2] NA
## [3] "Complaint - Civil Index #1 Filed by: Attorney Roberge, Benjamin R., ESQ Petition for Execution ofLien for Condo. Assess. Under RSA 356-B:46 01/05/2016 Summons on Complaint Index #2 01/05/2016 Service Colwell, Jennifer unserved 03/02/2016 Return of Service Index #3 as to NH Secretary ofState 03/07/2016 Voluntary Non-suit Index #4 Filed by: Attorney Roberge, Benjamin R., ESQ Target Date Time Standards PAGE 1 OF 1 Printed on 03/08/2016 at 11:51 AM THE STATE OF NEW HAMPSHIRE BELKNAP, SS. SUPERIOR COURT Docket No. 211-2016-CV-00003 Paugus Bay Plaza Condominium Association v. Jennifer Colwell VOLUNTARY NONSUIT NOW COMES the Petitioner Paugus Bay Plaza Condominium Association, by and through counsel Donais Law Offices, PLLC, having successfully resolved this matter with the Respondent, and respectfully requests that the Clerk mark the docket accordingly noting: “The Petitioner hereby enters a voluntary nonsuit with prejudice.” Respectfully Submitted, Paugus Bay Plaza Condominium Association By its attorneys, March 3, 2016 Donais Law Offices, PLLC Benjamin R. Roberge (#17156) 444 Willow Street Manchester, NH 03103-6217 (603) 624-7100 ben.roberge@donaislaw.com CERTIFICATION OF SERVICE I hereby certify that a copy of the foregoing was sent this day via USPS first class mail, postage prepaid, to Jennifer Colwell, pro se. Benjamin R. Roberge s t i # THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Telephone: 1-855-212-1234 TTY/TDD Relay: (800) 735-2964 http://www.courts.state.nh.us SUMMONS IN A CIVIL ACTION Case Name: Paugus Bay Plaza Condo. Assoc, v Jennifer Colwell Case Number: 211-2016-CV-00003 Date Complaint Filed: January 05, 2016 A Complaint has been filed against Jennifer Colwell in this Court. A copy of the Complaint is attached. The Court ORDERS that ON OR BEFORE: February 19, 2016 Paugus Bay Plaza Condominium Association shall have this Summons and the attached Complaint served upon Jennifer Colwell by in hand or by leaving a copy at his/her abode, or by such other service as is allowed by law. ' March 11,2016 • Paugus Bay Plaza Condominium Association shall file the return(s) of service with this Court. Failure to do so may result in this action being dismissed without further notice. 30 days after Defendant Jennifer Colwell must file an Appearance and Answer or other responsive is served pleading form with this Court. A copy of the Appearance and Answer or other responsive pleading must be sent to the party listed below and any other party who has filed an Appearance in this matter. Notice to Jennifer Colwell: If you do not comply with these requirements you will be considered in default and the Court may issue orders that affect you without your input. Send copies to: Benjamin R. Roberge, ESQ Donais Law Offices PLLC 444 Willow Street Manchester NH 03103 BY ORDER OF THE COURT January 05, 2016 Abigail Albee Clerk of Court (477) NHJB-2678-S (10/23/2013) THE STATE OF NEW HAMPSHIRE BELKNAP, SS. SUPERIOR COURT Docket No. 211-2016-CV-___________ Paugus Bay Plaza Condominium Association v. Jennifer Colwell PETITION FOR EXECUTION OF LIEN FOR CONDOMINIUM ASSESSMENTS UNDER RSA 356-B-.46 Parties 1. Paugus Bay Plaza Condominium Association (the “Association”) is a New Hampshire Condominium Association located at 131 Lake Street, Gilford, New Hampshire. It has a principal mailing address of Paugus Bay Plaza Condominium Association, c/o Evergreen Management, Inc., 67 Water Street Suite 203, Laconia, NH 03246. 2. Jennifer Colwell is the owner of real property located at Unit 222, 131 Lake Street, Gilford, Belknap County, State of New Hampshire (the “Condominium Unit”). The Condominium Unit represents one (1) of sixty-three (63) resort units located within the Association. Ms. Colwell has a contact address of 1094 Trapelo Rd., Waltham, MA 02451. Jurisdiction and Venue 3. This Court has subject matter jurisdiction over this claim pursuant to the provisions of 4. This Court has personal jurisdiction over the Respondent because this matter involves unpaid regular and/or special assessments due to the Association for property owned by the Respondent located in Belknap County. 5. Venue is appropriate in Belknap County because the Association may be found there and because the Condominium Unit owned by the Respondent is located in Belknap County. Material Facts 6. The Paugus Bay Plaza Condominium was created on May 4, 1995 by recording its Declaration of Condominium (the “Declaration”) in the Belknap County Registry of Deeds at Book 1334, Page 459. 7. The Association’s Board of Directors has imposed regular and special assessments upon condominium unit owners to provide for maintenance, repair and improvement of the common areas, and the provision of utilities to the units, pursuant to the authority granted to the Board in the Association Declaration and Bylaws. 8. The Respondent acquired the Condominium Unit by virtue of a Warranty Deed recorded in the Belknap County Registry of Deeds at Book 2704, Page 0381 on April 29,2011. 9. The Respondent has failed to pay regular assessments, late fees and collections costs due to the Association. 10. The monthly assessment on the Condominium Unit continues to accrue without full payment by the Respondent from July 1, 2015 through the present, inclusive. The Respondent also owes additional assessments for months beyond this six- (6-) month period. 11. All of the assessments, fees and costs sought in this action fall within the six- (6-) year period prescribed by RSA 356-B:46, IV. -2 - 12. On December 22, 2015, the Association recorded a Memorandum of Lien against the Respondent’s Unit in the Belknap County Registry of Deeds at Book 3010, Page 212, pursuant to the provisions of RSA 356-B:46. Count I - Execution of Lien 13. All prior paragraphs are hereby included in this Count by reference. 14. RSA 356-B:46,1(a) provides, in pertinent part: “The unit owners' association shall have a lien on every condominium unit for unpaid assessments levied against that condominium unit in accordance with the provisions of this chapter and all lawful provisions of the condominium instruments, if perfected as hereinafter provided.” 15. The Respondent has failed to pay monthly assessments due to the Association. 16. The Association has perfected its lien against the Respondent’s Unit in accordance with the provisions of RSA 356-B. 17. The Association now seeks leave to execute that lien to recover the amount secured thereby, along with collections costs as provided under RSA 356-B:46, V. Count II - Past-Due Assessments and Fees 18. All prior paragraphs are hereby included in this Count by reference. 19. As of the date of this Petition, the Respondent owes unpaid assessments and other charges in the amount of $1,435.87. all properly assessed by the Association pursuant to its authority under the Declaration and Bylaws. 20. The Association now seeks damages in the full amount of the unpaid assessments, along with collections fees and costs as provided in RSA 356-B:15. -3- 4 * 21. The specific claim for attorney’s fees and costs, recording costs and other expenses associated with the Association’s collections efforts continue to accrue and will be finalized upon conclusion of this matter. WHEREFORE, the Petitioner Paugus Bay Plaza Condominium Association requests that this Honorable Court grant: A. A Writ of Execution authorizing the sheriff to take and sell the Condominium Unit to recover the amount secured by the Association’s perfected lien, plus collections costs associated therewith; B. Judgment in the amount of $1,435.87, plus collections costs and fees; and C. Such further relief as the Court finds just and fair. Respectfully Submitted, Paugus Bay Plaza Condominium Association By its attorneys, January 4,2016 Donais Law Offices, PLLC Benjamin R. Roberge NH Bar #17156 444 Willow Street Manchester, NH 03103-6217 (603) 624-7100 ben.roberge@donaislaw.com - 4 - JUDICIAL BRANCH SUPERIOR COURT Telephone: 1-855-212-1234 TTY/TDD Relay: (800) 735-2964 http://www.courts.state.nh.us SUMMONS IN A CIVIL ACTION Case Name: Paugus Bay Plaza Condo. Assoc, v Jennifer Colwell Case Number: 211-2016-CV-00003 Date Complaint Filed: January 05, 2016 A Complaint has been filed against Jennifer Colwell in this Court. A copy of the Complaint is attached. The Court ORDERS that ON OR BEFORE: February 19, 2016 Paugus Bay Plaza Condominium Association shall have this Summons and the attached Complaint served upon Jennifer Colwell by in hand or by leaving a copy at his/her abode, or by such other service as is allowed by law. March 11, 2016 Paugus Bay Plaza Condominium Association shall file the return(s) of service with this Court. Failure to do so may result in this action being dismissed without further notice. 30 days after Defendant Jennifer Colwell must file an Appearance and Answer or other responsive is served pleading form with this Court. A copy of the Appearance and Answer or other responsive pleading must be sent to the party listed below and any other party who has filed an Appearance in this matter. Notice to Jennifer Colwell: If you do not comply with these requirements you will be considered in default and the Court may issue orders that affect you without your input. Send copies to: Benjamin R. Roberge, ESQ Donais Law Offices PLLC 444 Willow Street Manchester NH 03103 BY ORDER OF THE COURT January 05, 2016 Abigail Albee Clerk of Court (477) NHJB-2678-S (10/23/2013) X V THE STATE OF NEW HAMPSHIRE BELKNAP, SS. SUPERIOR COURT Docket No. 211-2016-CV- Paugus Bay Plaza Condominium Association v. Jennifer Colwell PETITION FOR EXECUTION OF LIEN FOR CONDOMINIUM ASSESSMENTS UNDER RSA 356-B;46 Parties 1. Paugus Bay Plaza Condominium Association (the “Association”) is a New Hampshire Condominium Association located at 131 Lake Street, Gilford, New Hampshire. It has a principal mailing address of Paugus Bay Plaza Condominium Association, c/o Evergreen Management, Inc., 67 Water Street Suite 203, Laconia, NH 03246. 2. Jennifer Colwell is the owner of real property located at Unit 222, 131 Lake Street, Gilford, Belknap County, State of New Hampshire (the “Condominium Unit”). The Condominium Unit represents one (1) of sixty-three (63) resort units located within the Association. Ms. Colwell has a contact address of 1094 Trapelo Rd., Waltham, MA 02451. Jurisdiction and Venue 3. This Court has subject matter jurisdiction over this claim pursuant to the provisions of RSA 491:7. -1 - 4. This Court has personal jurisdiction over the Respondent because this matter involves unpaid regular and/or special assessments due to the Association for property owned by the Respondent located in Belknap County. 5. Venue is appropriate in Belknap County because the Association may be found there and because the Condominium Unit owned by the Respondent is located in Belknap County. Material Facts 6. The Paugus Bay Plaza Condominium was created on May 4, 1995 by recording its Declaration of Condominium (the “Declaration”) in the Belknap County Registry of Deeds at Book 1334, Page 459. 7. The Association’s Board of Directors has imposed regular and special assessments upon condominium unit owners to provide for maintenance, repair and improvement of the common areas, and the provision of utilities to the units, pursuant to the authority granted to the Board in the Association Declaration and Bylaws. 8. The Respondent acquired the Condominium Unit by virtue of a Warranty Deed recorded in the Belknap County Registry of Deeds at Book 2704, Page 0381 on April 29,2011. 9. The Respondent has failed to pay regular assessments, late fees and collections costs due to the Association. 10. The monthly assessment on the Condominium Unit continues to accrue without full payment by the Respondent from July 1, 2015 through the present, inclusive. The Respondent also owes additional assessments for months beyond this six- (6-) month period. 11. All of the assessments, fees and costs sought in this action fall within the six- (6-) year period prescribed by RSA 356-B:46, IV. - 2 - 12. On December 22, 2015, the Association recorded a Memorandum of Lien against the Respondent’s Unit in the Belknap County Registry of Deeds at Book 3010, Page 212, pursuant to the provisions of RSA 356-B:46. Count I - Execution of Lien 13. All prior paragraphs are hereby included in this Count by reference. 14. RSA 356-B:46,1(a) provides, in pertinent part: “The unit owners' association shall have a lien on every condominium unit for unpaid assessments levied against that condominium unit in accordance with the provisions of this chapter and all lawful provisions of the condominium instruments, if perfected as hereinafter provided.” 15. The Respondent has failed to pay monthly assessments due to the Association. 16. The Association has perfected its lien against the Respondent’s Unit in accordance with the provisions of RSA 356-B. 17. The Association now seeks leave to execute that lien to recover the amount secured thereby, along with collections costs as provided under RSA 356-B:46, V. Count II - Past-Due Assessments and Fees 18. All prior paragraphs are hereby included in this Count by reference. 19. As of the date of this Petition, the Respondent owes unpaid assessments and other charges in the amount of $1,435.87. all properly assessed by the Association pursuant to its authority under the Declaration and Bylaws. 20. The Association now seeks damages in the full amount of the unpaid assessments, along with collections fees and costs as provided in RSA 356-B: 15. - 3- 21. The specific claim for attorney’s fees and costs, recording costs and other expenses associated with the Association’s collections efforts continue to accrue and will be finalized upon conclusion of this matter. WHEREFORE, the Petitioner Paugus Bay Plaza Condominium Association requests that this Honorable Court grant: A. A Writ of Execution authorizing the sheriff to take and sell the Condominium Unit to recover the amount secured by the Association’s perfected lien, plus collections costs associated therewith; B. Judgment in the amount of $ 1,435.87, plus collections costs and fees; and C. Such further relief as the Court finds just and fair. Respectfully Submitted, Paugus Bay Plaza Condominium Association By its attorneys, January 4,2016 Donais Law Offices, PLLC tO/rfc Benjamin R. Roberge NH Bar #17156 444 Willow Street Manchester, NH 03103-6217 (603) 624-7100 ben.roberge@donaislaw. com - 4 - "
## [4] "Complaint - Civil Index #1 Filed by: Attorney Roberge, Benjamin R., ESQ Petition for Execution ofLien for Condo. Assess. Under RSA 356-B:46 01/05/2016 Summons on Complaint Index #2 01/05/2016 Service Rooney, Kevin D. unserved 03/11/2016 Motion to Extend Time for Service Index #3 Filed by: Attorney Roberge, Benjamin R., ESQ 03/11/2016 Granted (Judicial Officer: O'Neill, James D, III) 03/30/2016 Voluntary Non-suit Index #4 Filed by: Attorney Roberge, Benjamin R., ESQ \"Petitioner hereby enters a -voluntary nonsuit with prejudice.\" Tmicei Due Time Standards PAGE 1 OF 1 Printed on 03/30/2016 at 2:03 PM II 4 THE STATE OF NEW HAMPSHIRE BELKNAP, SS. SUPERIOR COURT Docket No. 211-2016-CV-00004 Paugus Bay Plaza Condominium Association v. Kevin Rooney VOLUNTARY NONSUIT. . . ~ NOW COMES the Petitioner Paugus Bay Plaza Condominium Association, by and through counsel Donais Law Offices, PLLC, and respectfully requests that the Clerk mark the docket: “Petitioner hereby enters a voluntary nonsuit with prejudice.” Respectfully Submitted, Paugus Bay Plaza Condominium Association By its attorneys, March 23,2016 Donais Law Offices, PLLC &nlt Benjamin R. Roberge NH Bar #17156 444 Willow Street ^ _ Manchester, NH 03103-6217 (603) 624-7100 ben.roberge@donaislaw. com CERTIFICATION OF SERVICE I hereby certify that a copy of the foregoing was sent this day via USPS first class mail, postage prepaid, to Kevin Rooney, pro se. £+/lfL_______ Benjamin R. Roberge -1 - 4- THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Belknap Superior Court Telephone: 1-855-212-1234 64 Court St. TTY/TDD Relay: (800) 735-2964 Laconia NH 03246 • http://www.courts.state.nh.us NOTICE OF DECISION FILE COPY Case Name: Paugus Bay Plaza Condo. Assoc, v Kevin D. Rooney Case Number: 211 -2016-CV-00004 Please be advised that on March 11,2016 Judge O'Neill, III made the following order relative to: Motion to Enlarge Time for Service Motion Granted March 11,2016 Abigail Albee Clerk of Court (477) C: Benjamin R. Roberge, ESQ NHJB-2501-S (07/01/2011) 3. THE STATE OF NEW HAMPSHIRE BELKNAP, SS. SUPERIOR COURT Docket No. 211-2016-CV-00004 Paugus Bay Plaza Condominium Association v. Kevin D. Rooney MOTION TO ENLARGE TIME FOR SERVICE 1. By Summons dated January 5, 2016, this Court ordered that service be completed by February 19, 2016 and that return of service be filed by March 11, 2016. 2. Because the Respondent is an out-of-state resident, the Petitioner, through counsel, had the Summons served upon the NH Secretary of State pursuant to the provisions of RSA 510:4. 3. The Petitioner then sent notice of that service, along with a copy of the Summons, to the Respondent via USPS Certified Mail (Item #7009 2820 0003 7030 7259). 4. The USPS attempted to deliver the same on February 12,2016, but was unsuccessful. 5. As of the date of this filing, that mailing has not been’picked up by the* Respondent, * despite the delivery of a notice of its availability to his residence. See attached USPS Tracking Page. 6. The Petitioner therefore requests an additional 45 days to complete the final step in the completing service under RSA 510:4. -1 - m WHEREFORE, the Petitioner Paugus Bay Plaza Condominium Association requests that this Honorable Court: A. Permit an additional 45 days to serve the Respondent; B. Issue a new Summons to reflect the updated dates; and C. Grant such further relief as the Court finds just and proper. Respectfully Submitted, Paugus Bay Plaza Condominium Association By its attorneys, March 9, 2016 Donais Law Offices, PLLC Benjamin R. Roberge NH Bar #17156 444 Willow Street Manchester, NH 03103-6217 (603) 624-7100 ben.roberge@donaislaw. com -2 - S v English Customer Service USPS Mobile Register/Sign In musps.com Customer Service > USPS Tracking® Have questions? We’re here to help. Get Easy Tracking Updates > Sign up for My USPS. Tracking Number 70092820000370307259 On Time Expected Delivery Day; Friday, February 12,2016 Product & Tracking information Available Actions Postal Product: Features: First-Class Mail® Certified Mail™ Return Receipt Text Update*, See tracking for related item: 9590940301685120431444 Email Updates DATE & TIME STATUS OF ITEM LOCATION February 12, 2016,10:27 Notice Left (No Authorized DORCHESTER am Recipient Available) CENTER, MA 02124 We attempted to deliver your item at 10:27 am on February 12,2016 In DORCHESTER CENTER, MA 02124 and a notice was left because an authorized recipient was not available. You may arrange redelivery by using the Schedule a Redelivery feature on this page or calling 800-ASK-USPS, or may pick up the item at the Post Office indicated on the notice. If this item is unclaimed by February 27, 2016 then it will be returned to sender. DORCHESTER February 12, 2016.8:24 am Arrived at Unit CENTER, MA 02124 February 11, 2016,10:42 Departed USPS Facility BOSTON, MA 02205 pm February 11, 2016,11:24 Arrived at USPS Destination BOSTON, MA 02205 am Facility February 11, 2016,5:31 am Departed USPS Facility MANCHESTER, NH 03103 February 10, 2016,11:11 Arrived at USPS Origin MANCHESTER, NH 03103 pm Facility February 10, 2016,5:25 pm Departed Post Office MANCHESTER, NH 03101 February 10, 2016,11:25 am Acceptance MANCHESTER. NH 03101 Track Another Package Manage Incoming Packages Tracking (or receipt) number Track all your packages from a dashboard. No tracking numbers necessary. Sign up for My USPS > HELPFUL LINKS ON ABOUT.USPS.COM OTHER USPS SITES LEGAL INFORMATION Contact Us About USPS Home Business Customer Gateway Privacy Poflcy Site Index Newsroom Postal Inspectors Terms of Use FAQs USPS Service Updates Inspector General FOIA Forms & Publications Postal Explorer No FEAR Act EEO Data Government Services National Postal Museum Careers Resources for Developers Copyright © 2016 USPS. AH Rights Reserved. Search or Enter a Tracking Number Q thEstate of new hamps^Ne JUDICIAL BRANCH SUPERIOR COURT Telephone: 1-855-212-1234 TTY/TDD Relay: (800) 735-2964 http://www.courts.state.nh.us SUMMONS IN A CIVIL ACTION Case Name: Paugus Bay Plaza Condo. Assoc, v Kevin D. Rooney Case Number: 211-2016-CV-00004 Date Complaint Filed: January 05, 2016 A Complaint has been filed against Kevin D. Rooney in this Court. A copy of the Complaint is attached. The Court ORDERS that ON OR BEFORE: February 19, 2016 Paugus Bay Plaza Condominium Association shall have this Summons and the attached Complaint served upon Kevin D. Rooney by in hand or by leaving a copy at his/her abode, or by such other service as is allowed by law. March 11,2016 Paugus Bay Plaza Condominium Association shall file the return(s) of service with this Court. Failure to do so may result in this action being dismissed without further notice. 30 days after Defendant Kevin D. Rooney must file an Appearance and Answer or other responsive is served pleading form with this Court. A copy of the Appearance and Answer or other responsive pleading must be sent to the party listed below and any other party who has filed an Appearance in this matter. Notice to Kevin D. Rooney: If you do not comply with these requirements you will be considered in default and the Court may issue orders that affect you without your input. Send copies to: Benjamin R. Roberge, ESQ Donais Law Offices PLLC 444 Willow Street Manchester NH 03103 BY ORDER OF THE COURT January 05, 2016 Abigail Albee Clerk of Court (477) NHJB-2678-S (10/23/2013) X. s. - h*. THE STATE OF NEW HAMPSHIRE BELKNAP, SS. SUPERIOR COURT Docket No. 211 -2016-CV-____________ Paugus Bay Plaza Condominium Association v. Kevin D. Rooney PETITION FOR EXECUTION OF LIEN FOR CONDOMINIUM ASSESSMENTS UNDER RSA 356-B:46 Parties 1. Paugus Bay Plaza Condominium Association (the “Association”) is a New Hampshire Condominium Association located at 131 Lake Street, Gilford, New Hampshire. It has a principal mailing address of Paugus Bay Plaza Condominium Association, c/o Evergreen Management, Inc., 67 Water Street Suite 203, Laconia, NH 03246. 2. Kevin D. Rooney is the owner of real property located at Unit 338, 131 Lake Street, Gilford, Belknap County, State of New Hampshire (the “Condominium Unit”). The Condominium Unit represents one (1) of sixty-three (63) resort units located within the Association. Mr. Rooney has a contact address of 221 Minot Street #4, Dorchester, MA 02124. Jurisdiction and Venue 3. This Court has subject matter jurisdiction over this claim pursuant to the provisions of RSA 491:7. -1 - L 4. This Court has personal jurisdiction over the Respondent because this matter involves unpaid regular and/or special assessments due to the Association for property owned by the Respondent located in Belknap County. 5. Venue is appropriate in Belknap County because the Association may be found there and because the Condominium Unit owned by the Respondent is located in Belknap County. Material Facts 6. The Paugus Bay Plaza Condominium was created on May 4, 1995 by recording its Declaration of Condominium (the “Declaration”) in the Belknap County Registry of Deeds at Book 1334, Page 459. 7. The Association’s Board of Directors has imposed regular and special assessments upon condominium unit owners to provide for maintenance, repair and improvement of the common areas, and the provision of utilities to the units, pursuant to the authority granted to the Board in the Association Declaration and Bylaws. 8. The Respondent acquired the Condominium Unit by virtue of a Warranty Deed recorded in the Belknap County Registry of Deeds at Book 2788, Page 986 on August 3, 2012. 9. The Respondent has failed to pay regular assessments, late fees and collections costs due to the Association. 10. The monthly assessment on the Condominium Unit continues to accrue without full payment by the Respondent from July 1, 2015 through the present, inclusive. The Respondent also owes additional assessments for months beyond this six- (6-) month period. 11. All of the assessments, fees and costs sought in this action fall within the six- (6-) year period prescribed by RSA 356-B:46, IV. - 2 - * ^ % 12. On December 22, 2015, the Association recorded a Memorandum of Lien against the Respondent’s Unit in the Belknap County Registry of Deeds at Book 3010, Page 215, pursuant to the provisions of RSA 356-B:46. Count I - Execution of Lien 13. All prior paragraphs are hereby included in this Count by reference. 14. RSA 356-B:46,1(a) provides, in pertinent part: “The unit owners' association shall have a lien on every condominium unit for unpaid assessments levied against that condominium unit in accordance with the provisions of this chapter and all lawful provisions of the condominium instruments, if perfected as hereinafter provided.” 15. The Respondent has failed to pay monthly assessments due to the Association. 16. The Association has perfected its lien against the Respondent’s Unit in accordance with the provisions of RSA 356-B. 17. The Association now seeks leave to execute that lien to recover the amount secured thereby, along with collections costs as provided under RSA 356-B:46, V. Count II - Past-Due Assessments and Fees 18. All prior paragraphs are hereby included in this Count by reference. 19. As of the date of this Petition, the Respondent owes unpaid assessments and other charges in the amount of $2,158.91. all properly assessed by the Association pursuant to its authority under the Declaration and Bylaws. 20. The Association now seeks damages in the full amount of the unpaid assessments, along with collections fees and costs as provided in RSA 356-B: 15. - 3 - % V K 21. The specific claim for attorney’s fees and costs, recording costs and other expenses associated with the Association’s collections efforts continue to accrue and will be finalized upon conclusion of this matter. WHEREFORE, the Petitioner Paugus Bay Plaza Condominium Association requests that this Honorable Court grant: A. A Writ of Execution authorizing the sheriff to take and sell the Condominium Unit to recover the amount secured by the Association’s perfected lien, plus collections costs associated therewith; B. Judgment in the amount of $2,158.91, plus collections costs and fees; and C. Such further relief as the Court finds just and fair. Respectfully Submitted, Paugus Bay Plaza Condominium Association By its attorneys, January 4,2016 Donais Law Offices, PLLC Benjamin R. Roberge NH Bar #17156 444 Willow Street Manchester, NH 03103-6217 (603) 624-7100 ben.roberge@donaislaw.com - 4 - "
## [5] "Complaint - Civil Index #1 01/07/2016 Summons on Complaint Index #2 01/07/2016 Service Foote, Deborah served 02/11/2016 02/11/2016 Service In hand 02/23/2016 Return of Service Index #3 Filed by: Attorney Parenteau, Jacques N. 03/15/2016 Appearance Index #4 Filed by: Defendant Foote, Deborah Pro Se Appearance 03/15/2016 Answer Index #5 Filed by: Defendant Foote, Deborah Pro Se Answer 04/20/2016 CANCELED Structuring Conference 04/20/2016 Assented to Motion to Continue Index #6 Filed by: Attorney Delaney O'Hara, Diana, ESQ Structuring Conference 04/20/2016 Granted (Judicial Officer: O'Neill, Janies D, III) 05/16/2016 Structuring Order - Stipulated Index #7 Filed by: Attorney Parenteau, Jacques N.; Defendant Foote, Deborah PAGE 1 OF 2 Printed on 05/17/2016 at 12:13 PM Belknap Superior Court Case Summary m Case No. 211-2016-CV-00005 PAGE 2 OF 2 Printed on 05/17/2016 at 12:13 PM THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Belknap Superior Court Telephone: 1-855-212-1234 64 Court St. TTY/TDD Relay: (800) 735-2964 Laconia NH 03246 http://www.courts.state.nh.us NOTICE OF DECISION FILE COPY Case Name: American Modern Home Insurance co. v Deborah Foote Case Number: 211-2016-CV-00005 Please be advised that on June 14, 2016 Judge O'Neill, III made the following order relative to: Stipulation of Dismissal Approved June 16, 2016 Abigail Albee Clerk of Court (480) C: Deborah Foote; Jacques N. Parenteau NHJB-2501-S (07/01/2011) STATE OF NEW HAMPSHIRE BELKNAP, ss SUPERIOR COURT Case No. 211-2016-CV-0005 AMERICAN MODERN HOME INSURANCE COMPANY a/s/o Sherry Sampas v. DEBORAH FOOTE STIPULATION OF DISMISSAL Now comes the parties, American Modern Home Insurance Company a/s/o Sherry Sampas, and Deborah Foote and respectfully request this Court dismiss this case with prejudice. Respectfully submitted, Respectfully Submitted, The Defendant, American Modern Home Insurance Co., By/^wws, d£ jJO£aa eborah Foote Jacques N. Parenteau New Hampshire Bar ID No. 18399 Jp@nesubro.com Diana D. O’Hara New Hampshire Bar ID No. 19057 do@nesubro.com •^> I*|Jwl» Parenteau & O’Hara, P.C. Of counsel Insurance Recovery Legal Associates 959 Concord Street, Suite 200 Io/\\ 4y/i* Framingham, MA 01701 (508)232-6267 Dated: 1 0 Zs3LZ. 1LO. iiiif V.tf i > V . • 5ft «'.H r.iD. .1 j v 3 tonm <J5 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Belknap Superior Court Telephone: 1-855-212-1234 64 Court St. TTY/TDD Relay: (800) 735-2964 Laconia NH 03246 http://www.courts.state.nh.us NOTICE OF DECISION FILE COPY __ Case Name: American Modern Home Insurance co. v Deborah Foote Case Number: 211-2016-CV-00005 Please be advised that on May 16, 2016 Judge O'Neill, III made the following order relative to: Structuring Conference Order ADR Order (copy attached) ^Scheduling notice attached** May 17, 2016 Abigail Albee Clerk of Court (480) C: Deborah Foote; Jacques N. Parenteau; Diana Delaney O'Hara, ESQ NHJB-2501-S (07/01/2011) 1 From:The UPS Store 603 755 3389 05/12/201 I 13:52 #226 P.002/003 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Belknap Superior Court Case Name: American Modern Home Insurance Co a/s/o Sampas v. Foote Case Number: 211 -2016-CV-00005 (if known) CASE STRUCTURING AND ADR ORDER* (See Superior Court Rule 5) 1. Plaintiffs Counsel: Trial Diana D. (THara___________ At conference Diana n. D'Wa™ 2. Defendant’s Counsel: Trial ProSe ________ At conference Pro Se_________ 3. Causes(s) Of action: Neplipenpft Counterclaims 4. Insurance carrier: _________ Disclosure of policy limits by: 5. CU The parties have agreed to file a motion with the Merrimack County Superior Court within 30 days requesting that this matter be placed on the Business and Commercial Dispute Docket. 6. If defendant claims that unnamed parties are at fault (see DeBenedetto v. CLD Consulting Engineers Inc., 153 N.H. 793 (2006)), defendant shall disclose the identity of every such party and the basis of the allegation of fault no later than_______ _________________________ Plaintiff shall then have 30 days from the date of disclosure to amend the initiating pleading. 7. Is there an agreement to waive statutory expert disclosure requirements under RSA 516:29-b? <U+25A1> Yes 0 No 8. 0 The parties have exchanged e-mail addresses and agree that the e-mail service of pleadings between the parties shall be considered in compliance with Superior Court Administrative Order 46. 9. Plaintiffs disclosure of experts and reports due: 09/01/2016__________ Defendant’s disclosure of experts and reports due: 10/01/2016_______ 10. The following deadlines apply: All interrogatories propounded by 07/01/2016__________ All depositions to be completed by 09/01/2016_________ All dispositive motions to be filed: no later than 120 days' prior to the’trial Completion of ail discovery: 09/01/2016_______________ Deadline for filing all other pre-trial motions: no later than 14 davs prior to trial Deadline for filing of witness and exhibit lists: no later than the trial management conference In actions to recover damages for personal injuries, independent medical examinations pursuant to Superior Court Civil Rule 28A must be conducted by the completion of discovery. 11. Jury trial requested? <U+25A1> Yes 0 No 12. If jury trial previously demanded, is it now being waived? 0 Yes <U+25A1> No 13. Requested trial date: lt/jQ8/20I6__________ Estimated trial length: 1 dav________________________ 14. Jury trial assignment: Trial Mgt Conf.: ..... ^ $$ry Selection:__________________ 15. Bench trial assignment: Trial Mgt Conf: li/nMi\" Week of:__________ __ 16. Trial counsel and self-represented parties shall agdear,^^&fe||l||jianagement conference and be prepared to address settlement potential. by counsel shall be available for contact by telephone during the trial management conference. All pending pretrial motions shall be heard at the trial management conference, or as scheduled by the court. Failure to appear at the trial management conference or trial may result in dismissal, default or other sanctions. *1 F rom:The UPS Store 603 755 3389 05/12/2016 13:52 #226 P.003/003 Case Name: American Modern Home Insurance Co a/s/o Sampas v. Foote__________________________ Case Number: 211-2016-CV-00005___________________ ________________________________________ CASE STRUCTURING AND ADR ORDER* 17. ADR (Alternative Dispute Resolution) Orders 0 The parties stipulate and agree as follows: OR 0 The parties do not agree and request that the Court complete this section A. Type of ADR 0 Mediation 0 Neutral Case Evaluation 0 Binding Arbitration Name of person chosen to do ADR: __________________ 0 Paid 0 Volunteer Names of alternates: 1._________________ _ 2._________ _________________ B. Scheduling your ADR Session: Date ADR shall be completed bv / ^ j i Iks You and the other side must contact the person selected to schedule the ADR session. c- ADR Reporting: The Plaintiff shall file a copy of the ADR report with the court within 30 days of the ADR session. If the ADR report is not timely filed, the court may schedule a show-cause hearing to determine the status of the ADR process and to impose sanctions appropriate to the circumstances, if necessary. 18. 0 The parties are exempt from Rule 32 ADR. 19. Other orders: Attorney for Plaintiff Date Attorney for Defendant Date Attorney for Plaintiff Date Attorney for Defendant Presiding Justice !SSP m IP b (Sr ftl 4\" T> # 91 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Belknap Superior Court Telephone: 1-855-212-1234 64 Court St. TTY/TDD Relay: (800) 735-2964 Laconia NH 03246 http://www.courts.state.nh.us NOTICE OF DECISION FILE COPY Case Name: American Modern Home Insurance co. v Deborah Foote Case Number: 211-2016-CV-00005 Please be advised that on April 20, 2016 Judge O'Neill, III made the following order relative to: Assented - Motion to Continue Structuring Conference Granted **Revised scheduling notice attached** April 20, 2016 Abigail Albee Clerk of Court (480) C: Deborah Foote; Jacques N. Parenteau; Diana Delaney O'Hara, ESQ NHJB-2501-S (07/01/2011) In STATE OF NEW HAMPSHIRE BELKNAP, ss SUPERIOR COURT Case No. 211-2016-CV-0005 AMERICAN MODERN HOME INSURANCE COMPANY a/s/o Sherry Sampas v. /VU..CJ) DEBORAH FOOTE TRICIAA. COOK AND JAMES COOK PLAINTIFF’S MOTION TO CONTINUE CASE STRUCTURING CONFERENCE (ASSENTED-TO) Now comes the plaintiff, American Modem Home Insurance Company a/s/o Sherry Sampas, and respectfully requests this Court continue the Case Structuring Conference, currently scheduled for April 20,2016, to May 18,2016. As grounds therefore, the plaintiff states that the defendant notified counsel today that her husband has been hospitalized. A Case Structuring Order form has been completed, but the defendant has not signed and returned the form to counsel’s office due to her husband’s hospitalization. The defendants assent to this motion. Respectfully submitted, Respectfully Submitted, The Defendant, American Modem Home Insurance Co., Jacques I'O’arenteau New Hampshire Bar ID No. 18399 Jp@nesubro.com Diana D. O’Hara New Hampshire Bar ID No. 19057 do@nesubro.com Parenteau & O’Hara, P.C. 959 Concord Street, Suite 200 Framingham, MA 01701 (508)232-6267 i. THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: PylKnaf) .^Lpprinv Couv-h __________________ Case Name: AlWlfnn Morifl .m \\(\\°){\\YnnC£, C<\\ \\ICS ..PlPhw'nfoptik*. Case Number: o?l i 'olC>llJ)\" CXl\" CCf^OfP (if known) ANSWER Requested: <U+25A1> Jury Trial (as allowed by law) Bench Trial 1. Name of person answering: Qp.lor)k7xjo -F/Yrkf^ (Relationship to case):_______________________________ 2. Attorney Name_____________________________________ Bar ID# 3. I am answering the Complaint filed by Amo_n ran PAnH0 Yn 4Wy)P I fYM Jkfi f\\P Aa . Answer each paragraph in the Complaint in corresponding numbered paragraphs: 1. Paragraph 1 Answer: 2. Paragraph 2 Answer: &ta....3fcCfKbihdaf, Cnr. A 3. Paragraph 3 Answer: ggre.Q Continue on using separately numbered paragraphs (attach additional sheets if necessary) asyec lr>'Qyfes II.This ums an orridfnt-.i uw noh-fmi,™ -to.hfc COAflles&nr rvojirynt,.X did hm/f. nimirmfanlr^.s nPrnhii I. J------------ , ----- .... ¦ - - ¦ , i. ^ Til I \\ t-UI I W —^ Utxtt nnrl.in ft .bit of a humy 4hrvf rtaij. Thp.nuwr rrP I certify that on this date I provided a copy of this document to the parties who have filed an appearance for this case by: <U+25A1> Hand-delivery OR J3 US Mail OR <U+25A1> Email (only when there is prior agreement of the parties to use this method of service). JV- fi|- JlP----------------- vQiJbmdJo-fe^IZ) ________ _ Date Signature (In presence of Notary/Justice of the Peace) State of ji H County of. This instrument was acknowledged before me on iy Debotah iO-ft Cd&re- H)jS> My Commission Expires Wj3j ' ' Affix Seal, if any Signature of f>k5tar)al Officer / Title JANE SEAL, Justice of the Peace My Commission Expires April 3,2018 NHJB-2689-S (10/01/2013) «r ***** ft • -tice^.wJrucle. uns.rYk pmsent nrrL-ftni '/.=> n jHl) X left Cl pos)Ct.o(\\.hiy..\\Jth\\c\\p..nppnlnq'ipinq - rr v 3 iui-th mumme^nrci y phcbne.,nixmhtir. ... . ................... .. lai. homages.ytfy e. mmisfnmtr aP..aPPua... scratches -to -toe: paiiQh, Ciacardtog -/n palirs rerrsrd -Pi leri -fhntonla^ Lac6rtiCL...p6lir.e...AnnP) nc> pictures ix^hen ak -top, scene,* ............ to f\\r\\ arnrbn-h} T ^r^mirhpri tor painf^+h/s is ¦nhyH le-Pt a. nnrlr loi-trh mij namp, nnrl phnnp.nhmlm vs. <@jnst leaving as people uxtocL <do. THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Sx \\Knft p 5upfnor Cr.ur h Case Name: tenoin ^ndQjrn-HorviQ Instway^ce Co. V3 Apmmh^Af^. Case Number: d?l<-c30lLP-rv-CCoO5 (if known) APPEARANCE/WITHDRAWAL APPEARANCE Type of appearance (Select One) (^1 Appearance <U+25A1> Limited Appearance (Civil cases only) If limited appearance, scope of representation: Select One: <U+25A1> As Counsel for: (Name) (Address) (Telephone Number) (Name) (Address) (Telephone Number) (Name) (Address) (Telephone Number) Cpd will represent myself (self-represented) WITHDRAWAL As Counsel for Type of Representation: (Select one) <U+25A1> Appearance: <U+25A1> Notice of withdrawal was sent to my client(s) on:______________ at the following address: <U+25A1> A motion to withdraw is being filed. <U+25A1> Limited Appearance: (Select one) <U+25A1> I am withdrawing my limited appearance as I have completed the terms of the limited representation. <U+25A1> The terms of limited representation have not been completed. A motion to withdraw is beina filed. y I certify that on this date I provided a copy of this document to the parties who have filed an appearance for this case by: <U+25A1> Hand-delivery OR ® US Mail OR <U+25A1> Email (only when there is prior agreement of the parties to use this method of service). Date Signature Dtoohlondfr C.nr. Rrl Deborah -forae Mailing Address J Printed Name Motl+Mk CSFCPl de.brmhfr/)be ©QmcuL mrvi Email Address - asufe_________ Telephone NH Bar ID # if attorney NHJB-2318-S (03/24/2014) U * Ht ATE OF NEW HAMP wiis * t i-i -4. £3? JUDICIAL BRANCH %'' '/,- *• S' \\%% SUPERIOR COURT %' Belkr^p’Superior Gdur& Telephone: 1-855-212-1234 ^ S4:,Court St; '' r ** TTY/TDD Relay: (800) 735-2964 // iTaconia NH ’03^46^, http://www.courts.state.nh.us v ^ V/' SUMMONS IN A CIVIL ACTION Case Name: American Modern Home Insurance co. v Deborah Foote Case Number: 211-2016-CV-00005 Date Complaint Filed: January 07,2016 -¦*. - A Complaint has been filed against Deborah Foote in this Court. A copy of the Complaint is attached. The Court ORDERS that ON OR BEFORE: February 21, 2016 American Modern Home Insurance co. shall have this Summons and the attached Complaint served upon Deborah Foote by in hand or by leaving a copy at his/her abode, or by such other service as is allowed by law. March 13, 2016 American Modern Home Insurance co. shall file the return(s) of service with this Court. Failure to do so may result in this action being dismissed without further notice. 30 days after Defendant Deborah Foote must file an Appearance and Answer or other responsive is served pleading form with this Court. A copy of the Appearance and Answer or other responsive pleading must be sent to the party listed below and any other party who has filed an Appearance in this matter. Notice to Deborah Foote: If you do not comply with these requirements you will be considered in default and the Court may issue orders that affect you without your input. Send copies to: Jacques N. Parenteau Parenteau & OHara 959 Concord Street Suite 200 Framingham MA 01701 Diana Delaney O'Hara, ESQ Parenteau & OHara PC 959 Concord Street Suite 200 Framingham MA 01701 BY ORDER OF THE COURT January 07, 2016 Abigail Albee Clerk of Court (480) NHJB-2678-S (10/23/2013) </ - f V STATE OF NEW HAMPSHIRE BELKNAP, ss SUPERIOR COURT Case No._____________________ AMERICAN MODERN HOME INSURANCE COMPANY a/s/o Sherry Sampas v. \" ~ -» . DEBORAH FOOTE * - • . - - COMPLAINT The Parties 1. The plaintiff, American Modern Home Insurance Company (hereinafter \"American Modern\"), is a duly organized corporation authorized to do business in the State of New Hampshire and has a principal place of business located at 7000 Midland Boulevard, Amelia, OH, 45102. 2. The defendant, Deborah Foote (hereinafter “Foote”), is a resident of the State of -__ New Hampshire and resides, at 842 Stockbridge Drive, Alton, MH, 0380^ 3. The subrogor, Sherry Sampas (hereinafter “Sampas”), is a resident of the State of New Hampshire and resides at 9 Kingsley Avenue, Laconia, NH, 03246. Facts Common to All Counts 4. At all relevant times, American Modern insured Sampas’ vehicle. 5. On or about November 5, 2014, Sampas’ vehicle was legally parked and unoccupied in a parking lot at the rear of 426 Union Avenue, Laconia, NH. At the same time and place, Foote negligently operated her vehicle while backing into the parking space next to Sampas’ vehicle and collided with the driver’s side rear panel of Sampas’ vehicle. As a result and in accordance with the terms and conditions of Sampas’ insurance policy, claims were made against American Modern for property damage. American Modem paid the sum of $4,928.29 in satisfaction of its obligation to and/or on behalf of its insured. Pursuant to tEe terms and conditions of the insurance.policy.and-applicable New~„ Hampshire law, American Modern now stands subrogated to the rights and causes of actions of Sampas, the subrogor, to the extent of payments made to and/or on behalf of Sampas and asserts its subrogation rights through this Complaint. Count One - Negligence against Deborah Foote American Modern hereby re-alleges each and every allegation contained within paragraphs 1 through 9 as it specifically sets forth herein. On or about November 5, 2014, Foote negligently and carelessly operated her motor vehicle. Due to the defendant’s negligence, she stmck Sampas’ legally parked and unoccupied vehicle located at 426 Union Avenue, Laconia, NH, causing property damage. Consequently, the defendant’s negligence caused the plaintiff to suffer damages. American Modern states the property damage was caused by the negligence and carelessness of the defendant, Foote. WHEREFORE, the plaintiff seeks judgment against the defendant in the amount of $4,928.29 and such other and further relief that this Honorable Court deems fair and just. REQUEST FOR JURY TRIAL The plaintiff, American Modern, respectfully requests a jury trial on all issues pleaded or to be pleaded. Respectfully Submitted, American Modern Home Insurance Co., -By ifk attorney? Jacques N. Par New Hampshire Sar ID No. 18399 Jp@nesubro.com Diana D. O’Hara New Hampshire Bar ID No. 19057 do@nesubro.com Parenteau & O’Hara, P.C. 959 Concord Street, Suite 200 Framingham, MA 01701 (508) 232-6267 Dated: BELKNAP COUNTY SgERIE'E'S DEPARTMENT rAA of service'4 BELKNAP, SS • 02/11/2016 I have this day served the within named DEBORAH FOOTE a copy of a Summons and Complaint by delivering to her in the following manner: IN HAND, at 842 STOCKBRIDGE CORNER RD, ALTON, NH, at 07:00pm. Deputy /Sheriff Scott G Corbett Deputy Sheriff Belknap County Sheriff's Department Service 25.00 Post & Hand 1.00 Travel 22.40 Prepayment 37.20 Total’ ™ 4 8.40 to J-«4» m tu N> CO CD M © • • THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Belknap Superior Court Telephone: 1-855-212-1234 64 Court St. TTY/TDD Relay: (800) 735-2964 Laconia NH 03246 http://www.courts.state.nh.us January 07, 2016 FILE COPY Case Name: American Modern Home Insurance co. v Deborah Foote Case Number: 211 -2016-CV-00005 Enclosed summons to be served on defendant(s) in a manner allowed by law. Abigail Albee Clerk of Court (480) C: Jacques N. Parenteau NHJB-2012-DFPS (07/01/2011) . THE STATE OF NEW HAMPS JUDICIAL BRANCH SUPERIOR COURT Telephone: 1-855-212-1234 TTY/TDD Relay: (800) 735-2964 http://www.courts.state.nh.us SUMMONS IN A CIVIL ACTION Case Name: American Modern Home Insurance co. v Deborah Foote Case Number: 211-2016-CV-00005 Date Complaint Filed: January 07, 2016 A Complaint has been filed against Deborah Foote in this Court. A copy of the Complaint is attached. The Court ORDERS that ON OR BEFORE: February 21, 2016 American Modern Home Insurance co. shall have this Summons and the attached Complaint served upon Deborah Foote by in hand or by leaving a copy at his/her abode, or by such other service as is allowed by law. March 13, 2016 American Modern Home Insurance co. shall file the return(s) of service with this Court. Failure to do so may result in this action being dismissed without further notice. 30 days after Defendant Deborah Foote must file an Appearance and Answer or other responsive is served pleading form with this Court. A copy of the Appearance and Answer or other responsive pleading must be sent to the party listed below and any other party who has filed an Appearance in this matter. Notice to Deborah Foote: If you do not comply with these requirements you will be considered in default and the Court may issue orders that affect you without your input. Send copies to: Jacques N. Parenteau Parenteau & OHara 959 Concord Street Suite 200 Framingham MA 01701 Diana Delaney O'Hara, ESQ Parenteau & OHara PC 959 Concord Street Suite 200 Framingham MA 01701 BY ORDER OF THE COURT January 07, 2016 Abigail Albee Clerk of Court (480) NHJB-2678-S (10/23/2013) STATE OF NEW HAMPSHIRE BELKNAP, ss SUPERIOR COURT Case No. AMERICAN MODERN HOME INSURANCE COMPANY a/s/o Sherry Sampas v. DEBORAH FOOTE COMPLAINT The Parties 1. The plaintiff, American Modem Home Insurance Company (hereinafter \"American Modern\"), is a duly organized corporation authorized to do business in the State of New Hampshire and has a principal place of business located at 7000 Midland Boulevard, Amelia, OH, 45102. 2. The defendant, Deborah Foote (hereinafter “Foote”), is a resident of the State of New Hampshire and resides at 842 Stockbridge Drive, Alton, MH, 03809. 3. The subrogor, Sherry Sampas (hereinafter “Sampas”), is a resident of the State of New Hampshire and resides at 9 Kingsley Avenue, Laconia, NH, 03246. Facts Common to All Counts 4. At all relevant times, American Modern insured Sampas’ vehicle. 5. On or about November 5, 2014, Sampas’ vehicle was legally parked and unoccupied in a parking lot at the rear of 426 Union Avenue, Laconia, NH. At the same time and place, Foote negligently operated her vehicle while backing into the parking space next to Sampas’ vehicle and collided with the driver’s side rear panel of Sampas’ vehicle. As a result and in accordance with the terms and conditions of Sampas’ insurance policy, claims were made against American Modern for property damage. American Modem paid the sum of $4,928.29 in satisfaction of its obligation to and/or on behalf of its insured. Pursuant to the term's and conditions of the insurance policy and applicable New Hampshire law, American Modern now stands subrogated to the rights and causes of actions of Sampas, the subrogor, to the extent of payments made to and/or on behalf of Sampas and asserts its subrogation rights through this Complaint. Count One - Negligence against Deborah Foote American Modem hereby re-alleges each and every allegation contained within paragraphs 1 through 9 as it specifically sets forth herein. On or about November 5, 2014, Foote negligently and carelessly operated her motor vehicle. \"Due tothe defendant’s negligence, she stmck Sampas’ legally parked and unoccupied vehicle located at 426 Union Avenue, Laconia, NH, causing property damage. Consequently, the defendant’s negligence caused the plaintiff to suffer damages. American Modem states the property damage was caused by the negligence and carelessness of the defendant, Foote. WHEREFORE, the plaintiff seeks judgment against the defendant in the amount of $4,928.29 and such other and further relief that this Honorable Court deems fair and just. REQUEST FOR JURY TRIAL The plaintiff, American Modern, respectfully requests a jury trial on all issues pleaded or to be pleaded. Respectfully Submitted, American Modem Home Insurance Co., By ifh attorneys Jacques N. PareMeau New Hampshire Bar ID No. 18399 Jp@nesubro.com Diana D. O’Hara New Hampshire Bar ID No. 19057 do@nesubro.com Parenteau & O’Hara, P.C. 959 Concord Street, Suite 200 Framingham, MA 01701 (508) 232-6267 Dated: "
## [6] "Complaint - Civil Index #1 01/11/2016 Motion to Attach with Notice Index #2 Filed by: Attorney Fontaine, Michael J., ESQ 02/19/2016 Granted - No Objection (Judicial Officer: O'Neill, James D, III) 01/11/2016 Summons on Complaint Index #3 01/25/2016 Service Coyman, Terrence J served 01/18/2016 01/18/2016 Service In hand at 23 Drouin Dr., Belmont 01/25/2016 Appearance Index #4 Filed by: Defendant Coyman, Terrence J Pro se defendant 01/25/2016 Answer Index #5 Filed by: Defendant Coyman, Terrence J 01/28/2016 Return of Service Index #6 Filed by: Attorney Fontaine, Michael J., ESQ 03/21/2016 CANCELED Structuring Conference 03/21/2016 Writ of Attachment Index #7 (returns ofservice) 03/24/2016 Appearance Index #8 Filed by: Attorney Sullivan, Shawn Joseph, ESQ Atty Shawn Sullivan /defendant PAGE 1 OF 2 Printed on 03/29/2016 at 9:44 AM Belknap Superior Court Case Summary Case No. 211-2016-CV-00006 03/28/2016 Structuring Order - Stipulated Index #9 Filed by: Attorney Fontaine, Michael J., ESQ 03/28/2016 ADR Ordered 03/30/2016 CANCELED Structuring Conference 04/19/2016 Affidavit of Military Service Index #10 Filed by: Attorney Fontaine, Michael J., ESQ 04/19/2016 Affidavit of Damages Index #11 Filed by: Attorney Fontaine, Michael J., ESQ 04/19/2016 Motion for Attorney Fees Index #12 Filed by: Attorney Fontaine, Michael J., ESQ GRANTED - see c.o, #14 04/19/2016 Motion for Summary Judgment Index #13 Filed by: Attorney Fontaine, Michael J., ESQ GRANTED - see c.o. #14 05/24/2016 Court Order (Judicial Officer: O'Neill, James D, III) Index #14 re: Motion for Summary Judgment and Motion for Attorney Fees - (both GRANTED) 09/29/2016 CANCELED Status Conference ADR Status 10/12/2016 CANCELED Final Management Conference 10/26/2016 CANCELED Bench Trial °/&l 10 Jb ocker M Ada n ^ /a pp/?d vv A. #7 Target Date Time Standards * PAGE 2 OF 2 Printed on 05/24/2016 at 10:11 AM THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Belknap Superior Court Telephone: 1-855-212-1234 64 Court St. TTY/TDD Relay: (800) 735-2964 Laconia NH 03246 http://www.courts.state.nh.us NOTICE OF DECISION File Copy Case Name: Concord Hospital v Terrence J Coyman Case Number: 211-2016-CV-00006 Enclosed please find a copy of the court’s order of June 14, 2016 relative to: Re: Docket Markings June 16, 2016 Abigail Albee Clerk of Court (480) C: Terrence J Coyman; Michael J. Fontaine, ESQ; Shawn Joseph Sullivan, ESQ NHJB-2503-S (07/01/2011) \\(d TH^TATE OF NEW HAMPSlfttE SUPERIOR COURT BELKNAP, SS DOCKETNO. 211-2016-CV-006 Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman DOCKET MARKINGS The parties have agreed that the docket may be marked as follows: \"Judgment for the Plaintiff in the amount of $85,139.63 plus attorney's fees of $1,702.50, costs of $368.20 and statutory interest. Defendant has agreed to pay, and Plaintiff has agreed to accept the reduced sum of $50,000.00 in full settlement of this matter provided the funds are received by Plaintiffs counsel in the following manner: Defendant agrees to pay $5,000.00 on or before June 8,2016 and then beginning July 8, 2016, Defendant agrees to pay $400.00 per month continuing on the eighth (8th) day of each month thereafter until $50,000.00 has been paid in full. TIME BEING OF THE ESSENCE. If any payment is more than ten (10) days late, the entire Judgment balance, along with attorney's fees, statutory interest and costs, minus any payments made, will be due immediately. Defendant assents to the granting of a new attachment prior to the expiration of said attachment if the total due to Plaintiff as set forth herein has not been paid in full by the date the attachment lien is to expire.\" The Parties agree that the reduced sum of fifty thousand dollars ($50,000.00) may be paid in advance of the payment schedule set forth herein without penalty. The Parties agree that any funds held in escrow per any attachment will be applied to the reduced settlement amount if the Defendant’s periodic payments have been timely and in accordance with this agreement. Dated: Michael J. Fontaine, Esquire Attorney for Plaintiff, NHBN: 832 Welts, White & Fontaine, P.C. 29 Factory Street, P.O. Box 507 Nashua, NH 03061-0507 (603) 883-0797 U\\ Dated: ^ ^ , Defendant sullivan, Esquire Attorney for Defendant, NHBN: 6904 Law Offices of Shawn J. Sullivan, PLLC 10 Ferry Street, Suite 317 Concord, NH 03301 (603) 225-3362 m 1)1;} . j v' !i: i-ft r. ' Vi uiib.l THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Belknap Superior Court Telephone: 1-855-212-1234 64 Court St. TTY/TDD Relay: (800) 735-2964 Laconia NH 03246 http://www.courts.state.nh.us NOTICE OF DECISION File Copy Case Name: Concord Hospital v Terrence J Coyman Case Number: 211-2016-CV-00006 Enclosed please find a copy of the court’s order of May 24, 2016 relative to: Re: Motion for Summary Judgment and Motion for Attorney's Fees May 24, 2016 Abigail Albee Clerk of Court (480) C: Michael J. Fontaine, ESQ; Shawn Joseph Sullivan, ESQ NHJB-2503-S (07/01/2011) STATE OF NEW HAMPSHIRE BELKNAP COUNTY SUPERIOR COURT CONCORD HOSPITAL, INC. d/b/a CONCORD HOSPITAL v TERRENCE COYMAN Docket No.: 16-CV-06 ORDER Order in reference to pending Motions submitted by the Plaintiff. Subsequent to review, the Court renders the following determination(s). In reference to the Plaintiffs Motion for Summary Judgment (filed 4-19-16), the Court finds after review of the pending pleading(s) and the applicable New Hampshire law, that summary judgment is appropriate. The Court would further note that the Defendant has failed to file an Objection to this Motion. Accordingly, the Motion for Summary Judgment is GRANTED. In reference to the Plaintiff’s Motion for Attorney’s Fees (filed 4-19-16), after review of the said pleading as well as the applicable New Hampshire law, and again noting that the Defendant has not filed an Objection to same, the Court finds that the Plaintiff has provided sufficient basis to grant the relief requested. Accordingly, the Plaintiffs Motion for Attorney’s Fees is also GRANTED. SO ORDERED. Presiding Justice THE STATE OF NEW HAMPSHIRE SUPERIOR COURT BELKNAP, SS DOCKET NO. 211-2016-CV-006 Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman MOTION FOR SUMMARY JUDGMENT NOW COMES Plaintiff, Concord Hospital, Inc. d/b/a Concord Hospital, by and through its attorneys, Welts, White & Fontaine, P.C., in the above-entitled matter and moves for summary judgment and states in support thereof as follows: 1. That the Plaintiff provided medical and health care services and/or supplies to the Defendant, Terrence J. Coyman, per Plaintiffs statement of account attached hereto. 2. That Plaintiff is owed for said medical and health care services and/or supplies in the sum of $85,139.63 plus actual attorney’s fees pursuant to the Treatment Authorization And Administrative Acknowledgment signed by Defendant. 3. That demand has been made on Defendant by Plaintiff, yet Defendant has failed to pay said sum. 4. Plaintiff has attempted to resolve this matter with Defendant on numerous occasions by way of forwarding itemized billing statements and mailing written correspondence requesting payment and/or financial information and offering the opportunity to apply for financial aid, all without success. 5. That there are no genuine issues to any material fact and the Plaintiff is entitled to judgment as a matter of law. 6. That the Defendant has appeared. 7. That attached hereto is an affidavit based upon personal knowledge of admissible j which it appears affirmatively that the affiant will be competent to testify. WHEREFORE, Plaintiff respectfully requests that this Honorable Court: A. Grant the Motion herein and enter a summary judgment against the Defendant, Terrence J. Coyman; B. Alternatively schedule a hearing on the matter; and C. Grant such other and further relief as the Court may deem just and equitable. NOTICE TO DEFENDANT/OR PLAINTIFF THIS MOTION FOR SUMMARY JUDGMENT IS FILED IN ACCORDANCE WITH RSA 502- a:27c AND RSA 491:8-a. IF YOU OBJECT TO THE FACTS SET FORTH IN THIS MOTION, YOU MUST FILE YOUR WRITTEN OBJECTION WITHIN 30 DAYS. YOUR OBJECTION MUST BE ACCOMPANIED BY AN AFFIDAVIT SETTING FORTH SPECIFIC FACTS SHOWING THAT THERE IS A GENUINE ISSUE FOR TRIAL. IF YOU FAIL TO FILE AN OBJECTION AND AN ACCOMPANYING AFFIDAVIT WITHIN 30 DAYS, THIS MOTION MAY BE ACTED UPON WITHOUT A HEARING OR TRIAL AND JUDGMENT ENTERED IN FAVOR OF THE PARTY WHO FILED THIS MOTION. CERTIFICATION OF SERVICE AND COMPLIANCE PURSUANT TO SUPERIOR COURT RULE 42 I hereby certify that a copy of the above Motion was this day mailed, postage prepaid, to Shawn J. Sullivan, Esquire, The Concord Center, 10 Ferry Street, - Box 12, Suite 309, Concord, NH 03301 and that the Affidavit of Damages has been filed with this Court in accordance with Superior Court Rule 42 whereby a final judgment or decree is sought. Copies of all pleadings have been mailed to the Defendant. A hearing as to final judgment or decree may be requested by any party. Respectfully submitted, Concord Hospital, Inc. d/b/a Concord Hospital by its attorneys, Welts, White & Fontaine, P.C. Michael J. Fontaine, Esquire NH Bar #: 832 29 Factory Street, P.O. Box 507 Nashua, NH 03061-0507 (603) 883-0797 THE STATE OF NEW HAMPSHIRE SUPERIOR COURT BELKNAP, SS DOCKET NO. 211-2016-CV-006 Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman PLAINTIFF’S MOTION FOR ATTORNEYS’ FEES NOW COMES the Plaintiff, Concord Hospital, Inc. d/b/a Concord Hospital, by and through its attorneys, Welts, White & Fontaine, P.C., and respectfully requests that this Court award Plaintiff its reasonable attorneys’ fees and states as follows: 1. That the Treatment Authorization And Administrative Acknowledgment (copy attached) executed by the Defendant upon which this claim is based contains the following provision under the section entitled ASSIGNMENT OF BENEFITS AND PAYMENT TERMS: “In the event that the bill is not paid pursuant to these terms and the account is placed with an attorney or agency for collection, I agree to pay actual attorney’s fees and cost of collection.” 2. In addition to the time spent on this matter to date, Plaintiffs attorneys anticipate the expenditure of additional time to collect this judgment in view of the fact that Defendant has made no payments on the account since the involvement of Plaintiff s attorneys. 3. As the account was placed on a contingency fee basis, Plaintiff s attorneys did not keep a contemporaneous record of the time spent, but have reconstructed from the file a schedule of time spent to date on this case pursuant to the attached bill. WHEREFORE, Plaintiff respectfully requests that this Court: A. Award Plaintiff its attorneys’ fees in the amount of $1,702.50: and B. Grant such other and further relief as may be just and prc CERTIFICATION I certify that a copy of the within Motion was mailed, this date, postage prepaid, to Shawn J. Sullivan, Esquire, The Concord Center, 10 Ferry St, - Box 12, Ste 309, Concord, NH 03301 Respectfully Submitted, Concord Hospital, Inc. d/b/a Concord Hospital by its attorneys, Welts, White & Fontaine, P.C. Dated: NH Bar #: 832 29 Factory Street, P.O. Box 507 Nashua, NH 03061-0507 (603) 883-0797 S:\\My Documents\\PLEADINGS\\CONCORD\\Coyman Final MAF.docipp THE STATE OF NEW HAMPSHIRE SUPERIOR COURT BELKNAP, SS. DOCKET NO. Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman AFFIDAVIT AS TO TERRENCE J. COYMAN -The undersigned, being first duly sworn, states that; L 1 am the i(\\ l) Wn\\1 l N ^ Sbu^KNU^CxA of the Plaintiff. 2. I am familiar with the books and records of the Plaintiff and I have personal knowledge of the matters stated herein and am authorized to make this Affidavit on behalf of Plaintiff. 3. Defendant, Terrence J. Coyman, received medical and health care services and/or supplies from Plaintiff on or about the dates specified in Plaintiffs Complaint. 4. The charges reflected on the bill are the standard charges of the hospital for the services and supplies provided and the charges of $85,139.63 are reasonable. 5. The charges reflected on the attached statement were entered in such books in the regular course of business of Plaintiff at about the time of the transactions out of which they arose. 6. Defendant has made $.00 payments to the Plaintiff for these services and supplies. 7. Defendant is now indebted to the Plaintiff for a total amount due of $85,139.63 plus actual attorney’s fees. 8. That Plaintiff has also incurred costs and statutory interest in an amount as set forth on the attached Taxation of Costs. ’ ' 9. The indebtedness is due and unpaid, and all just and lawful offsets, payments and credits have been allowed as indicated on the attached statement of account. There are no valid setoffs or counterclaims against this claim and, in my opinion, there is no valid defense to this action. Plaintiffs signature STATE OF NEW HAMPSHIRE MERRIMACK, SS. Subscribed and sworn to before me this 20j‘5 My Commission Expires: Robert B. Welts, Jack S. White Of Counsel Michael J. Fontaine George H. Thompson, Jr. Thomas J. Leonard Collection Dept: 603-546-1650 DaviM. Peters Fax: 603-883-8925 John S. Polgrean WELTS, WHITE & FONTAINE, P.C. OFFICE@LAWYERSNH.COM Courtney Curran Vore Attorneys At Law Daniel P. Hakansson Israel F.Piedra Concord Hospital, Inc. d/b/a Concord Hospital 250 Pleasant Street Concord, NH 03301 For Legal Services rendered from 02/11/15 thru 03/25/16 RE: Terrence J. Coyman Receipt and review of claim; review background documents; open file; draft demand letter to Defendant; acknowledgement letter sent to client; draft second demand letter to Defendant; letter to Defendant requesting accident and insurance info; Financial Information Form letter sent to Defendant; draft third demand letter to Defendant; Financial Information Form letter re-sent to Defendant; e-mail Ms. Willard re asset check; telephone conference with insurance company re case; letter to Defendant re conversation with insurance company; mail copy of bills to Defendant; on-line research re property ownership; telephone conference with Defendant re case; review e-mail received from client authorizing suit and info on spouse; review documents received from client; on-line research re property ownership; prepare Complaint and Motion to Attach With Notice; prepare Affidavit of Damages and Military Affidavit; letter to client re executing documents; letter to Court re filing Complaint and Motion to Attach With Notice; letter to sheriff re service of Summons and Motion to Attach With Notice; review returns of service from sheriff re Summons and Motion to Attach With Notice; letter to Court re filing served Summons and Motion to Attach With Notice; review copy of Appearance and Answer filed by Defendant; telephone conference with Defendant re case; prepare Interrogatories; letter to Defendant re Interrogatories; letter to Defendant with discovery; follow-up letter sent to Defendant; review letter received from Attorney Shawn Sullivan enclosing signed Proposed Case Structuring; telephone conference with Defendant’s attorney re case; review Notice received from Court granting attachment; letter to Court requesting attested copies of granted Motion to Attach With Notice; letter to Defendant’s attorney re overdue Interrogatories; prepare Writ of Attachment; letter to sheriff re real estate attachment; prepare Motion For Conditional Default; review returns on real estate attachment; letter to Court re filing served Motion to Attach With Notice and Writ of Attachment; review file; telephone conference with Court re hearing; review e-mail received from Court with revised notice of hearing; telephone conference with Defendant’s attorney re new hearing date; telephone conference with Defendant’s attorney re case; office conference with Attorney Peters re status of case; left telephone message for Defendant s attorney re Case Structuring Conference and overdue Interrogatories; review e-mail received from Defendant’s attorney re discovery; telephone conference with Court requesting if Appearance filed by Defendant’s attorney; review copy of Appearance filed by Defendant’s attorney; e-mail Defendant’s attorney re hearing; review e-mail received from Defendant’s attorney re hearing date and Interrogatories; e-mail Defendant’s attorney re case and attached Judgment Docket Marking Agreement for review; telephone conference with Court re hearing off, review Notice received from Court re new hearing date; review Notice received from Court granting Case Structuring Conference Order; review e-mail received from Defendant’s attorney re Interrogatory answers and requesting if a Motion For Conditional Default was pending; e-mail Defendant’s attorney re no Motion For Conditional Default, requesting answers to Interrogatories and requesting if Defendant completed the Financial Information Form and was willing to sign Docket Marking Agreement; review e-mail received from Defendant’s attorney with answers to Interrogatories attached; e-mail Defendant’s attorney’s office re case; review Interrogatory answers received from Defendant’s attorney; prepare Motion For Summary Judgment; prepare Motion For Attorney’s Fees; prepare Statement of Attorney’s Fees; prepare Taxation of Costs; letter to Court re filing same. Michael J. Fontaine, Esquire = 1.8 hours x $290.00/hour = $ 522.00 Paralegals = 8.7 hours x $115.00/hour = $1,000.50 Administrative Assistants -- 2.4 hours x$ 75.00/hour = $ 180.00 TOTAL DUE: = $1,702.50 J . CONCORD TREATMENT AUTHORIZATION HOSPITAL , AN© AOIVIONISTRATIVE 31-57-34 1427200149 09/29/14 Pleasant Street, Concord, NH 03301 . ACKNOWLEDGMENT COYMAN,TERRENCE J J22S-2711 www.concordhosphal.org 03/21/57 M SP BURNS,SEAN AUTHORIZATION FOR TREATMENT: I authorize my providers) or his/her designee(s) or consultant(s), in charge of my care at Concord Hospital, to administer any treatment deemed necessary or advisable in the diagnosis and treatment of my condition. I certify lhat no guarantee has been made as to the results that may be obtained. I further authorize my provider(s) and their designee(s) to administer such anesthetics and perform such operation and procedures, as they deem necessary. I recognize that the need for prompt medical attention precludes authorization of a more detailed or specific nature before proceeding, Any tissues or parts surgically removed may be disposed of by Concord Hospital in accordance with the customary practice. I agree that Concord Hospital may request and use my prescription medication history from other healthcare providers or third-party pharmacy benefit payors for treatment purposes, I recognize that I may withdraw this request for treatment, or any part of it, before a procedure, test, or medication is administered. ELECTRONIC MEDICAL RECORD ACKNOWLEDGMENT: Concord Hospital primarily uses electronic medical record systems to capture medical information in both the inpatient and outpatient settings. These systems allow my information to be available to my healthcare providers and the staff at Concord Hospital, Concord Hospital Medical Group practices, and other providers who are Involved in my care, which would include my primary care provider, specialty care providers, consulting providers, on-call providers, emergency/urgent care providers, hospitalists and other hospital-based providers. Concord Hospital is committed to protecting my privacy in accordance with applicable state and federal laws, A complete description of how my health information may be used and disclosed is contained in the Concord Hospital Notice of Privacy Practices, available to me upon request, • HEALTH CARE EDUCATION: I acknowledge that Concord Hospital Is a teaching institution, and health care workers in training are important members of my health care team. I understand that trainees, under appropriate supervision, may perform or observe some of the health care services that I receive. Additionally, I understand that students may perform certain services under appropriate supervision. PERSONAL VALUABLES: I understand that Concord Hospital is not responsible for my personal possessions. If I choose to keep personal belongings during my hospital stay, I may request that these items be stored in the hospital safe. RECEIPT OF PATIENT INFORMATION: I acknowledge that! have been offered and/or provided a copy of the Patients' Bill of Rights. ASSIGNMENT OF BENEFITS AND PAYMENT TERMS: I agree to assign to Concord Hospital, all insurance benefits otherwise payable to or on behalf of the undersigned for the services rendered. I agree that I am responsible to pay the balance owed if the insurance or personal Information I have given is not true. I understand that 1 remain liable for all charges not covered by insurance or other benefits, I agree to pay Concord Hospital in accordance with Its regular rates arid terms for ail services rendered. All amounts are due immediately, upon receipt of the bill for said services, In the event that the bill is not paid pursuant to these terms and the account is placed with an attorney or agency for collection, I agree to pay actual attorney's fees and cost of collection. I understand that if I am presenting .with a work-related injury, it is my responsibility to provide Concord Hospital with accurate information regarding my employer and my workers' compensation insurance. I further understand that i remain liable for all charges not covered by workers’ compensation, health insurance, or other benefits. Priniary Tnaurance: UNINSURED SELT PAY Insurance: NONE Saccmdary Insurant I understand and acknowledge that many of the providers on the Concord Hospital medical staff are not employees or agents of Concord Hospital, but rather are Independent contractors/treating providers who have been granted the privilege of using the Concord Hospital facilities for care and treatment of their patients, I understand and acknowledge that Concord Hospital cannot be held legally responsible or liable for the conduct of these providers. I further understand that I will be billed separately for the services provided by these providers. I agree to assign to my treating providers all insurance benefits otherwise payable for the services rendered and agree that I will be responsible for any amount not covered. I grant permission to my treating providers to release my medical records for the purpose of claims adjudication. halndSl s/rkrtnwlortnp that I nndarsf and and anree to the terms set forth above. Print name and relationship to patient Patient la unable to personally authorize because: * A D N * Form «: C70060; Adoplod: 9/00: Revised: 2/20/14 F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ’ATIENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1427200149 09/29/14 10/02/14 l DOCTOR SEAN BURNS ^1 INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY 23 DROUIN DR GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 0 2/27/15 \\ INSURANCE COMPANY 1-------1 GROUP NO. POLICY NO. BILLING DATE 1 DATE DESCRIPTION OF SERVICE AMOUNT CODE DESCRIPTION QTY ***120 SEMI-PRIVATE ROOM 09/29 003000 ROOM 6016 P 1 1,715 .00 09/30 003000 ROOM 6016 P 1 1,715 . 00 10/01 005501 ROOM 5018 S 1 1, 800 . 00 AREA TOTAL *** 5,230 .00 ***250 PHARMACY/ADMIN-OP INJECTED 09/29 001513 DAKINS 2.5G/1000ML 1 5 .84 09/29 001887 LIDOCAINE HCL 2% 1 24 .74 09/29 001945 PROPOFOL INJ 200MG/20ML AMP 1 30 .16 09/29 002019 CLINDAMYCIN 600MG IN D5W 50ML 1 138 .99 09/29 002070 CLINDAMYCIN 900MG IN 50ML D5W 1 150 .52 09/30 002019 CLINDAMYCIN 600MG IN D5W 50ML 1 138 .99 09/30 002019 CLINDAMYCIN 600MG IN D5W 50ML 1 138 .99 09/30 002019 CLINDAMYCIN 600MG IN D5W 50ML 1 138 .99 10/01 001887 LIDOCAINE HCL 2% 1 25 . 98 10/01 001945 PROPOFOL INJ 200MG/20ML AMP 1 31 .67 10/01 002019 CLINDAMYCIN 600MG IN D5W 50ML 1 138 .99 10/01 002019 CLINDAMYCIN 600MG IN D5W 50ML 1 145 .96 10/01 002019 CLINDAMYCIN 600MG IN D5W 50ML 1 145 .96 10/01 002019 CLINDAMYCIN 600MG IN D5W 50ML 1 145 .96 10/01 002166 BUPIVACAINE-EPI .25%-.0005% VL 1 32 .44 10/01 002328 ROCURONIUM BR INJ 50MG/5ML SDV 1 34 .23 10/02 002019 CLINDAMYCIN 600MG IN D5W 50ML 1 145 .96 10/02 002019 CLINDAMYCIN 600MG IN D5W 50ML 1 145 .96 AREA TOTAL *** 1, 760 .33 ***259 DRUGS/OTHER OP NOT INJECTED 09/29 000023 ACETAMINOPHEN 325MG 2 1 .44 09/29 002347 GABAPENTIN CAP 100MG 1 0 .72 09/29 002384 OXYCODONE HCL TAB 5MG 3 2 .52 09/29 002384 OXYCODONE HCL TAB 5MG 3 2 .52 09/29 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/29 000321 DIAZEPAM 5 MG 1 0 .72 TOTAL CHARGES Continued I.D. NO. 22-2594672 RECEIVED MAR o 3 2015 ESTIMATED INSURANCE CONCORD HOSPITAL 5032 (REV. 9/10) PLEASE PAY THIS AMOUNT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 •ATIENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1427200149 . 09/29/14 10/02/14 2 DOCTOR SEAN BURNS INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY GROUP NO. POLICY NO. BILLING DATE 23 DROUIN DR BELMONT NH 03220 Ob/27/15 INSURANCE COMPANY *-------1 GROUP NO. POUCY NO. BILUNG DATE DATE DESCRIPTION OF SERVICE AMOUNT CODE DESCRIPTION QTY 09/29 000383 MILK OF MAGNES 30ML 1 1 .26 09/29 000508 DOCUSATE SOD.100MG 1 0 .72 09/29 000557 FERROUS SULF TAB 325MG 1 0 .72 09/30 001164 SENNA 187 MG 2 1 .44 09/30 002347 GABAPENTIN CAP 100MG 1 0 .72 09/30 002347 GABAPENTIN CAP 100MG 1 0 .72 09/30 002384 OXYCODONE HCL TAB 5MG 2 1 .68 09/30 002384 OXYCODONE HCL TAB 5MG 2 1 .68 09/30 002384 OXYCODONE HCL TAB 5MG 2 1 .68 09/30 002384 OXYCODONE HCL TAB 5MG 3 2 .52 09/30 002384 OXYCODONE HCL TAB 5MG 3 2 .52 09/30 002384 OXYCODONE HCL TAB 5MG 3 2 .52 09/30 002384 OXYCODONE HCL TAB 5MG 3 2 .52 09/30 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/30 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/30 000321 DIAZEPAM 5 MG 1 0 .72 09/30 000508 DOCUSATE SOD.100MG 1 0 .72 09/30 000508 DOCUSATE SOD.100MG 1 0 .72 09/30 000557 FERROUS SULF TAB 325MG 1 0 .72 09/30 000557 FERROUS SULF TAB 325MG 1 0 .72 09/30 000058 ASCORBIC ACID 500MG 1 0 .72 10/01 002347 GABAPENTIN CAP 100MG 1 0 .72 10/01 002384 OXYCODONE HCL TAB 5MG 3 2 .52 10/01 002384 OXYCODONE HCL TAB 5MG 2 1 .68 10/01 002384 OXYCODONE HCL TAB 5MG 3 2 .52 10/01 002384 OXYCODONE HCL TAB 5MG 3 2 .67 10/01 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 10/01 002485 OXYCODONE HCL TAB CR 10MG 3 18 .72 10/01 000321 DIAZEPAM 5 MG 1 0 . 72 10/01 000321 DIAZEPAM 5 MG 1 0 .72 10/01 000508 DOCUSATE SOD.100MG 1 0 .72 10/01 000557 FERROUS SULF TAB 325MG 1 0 .72 10/02 001164 SENNA 187 MG 2 1 .44 10/02 002347 GABAPENTIN CAP 100MG 1 0 . 72 TOTAL CHARGES <U+25BA> Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL 5032 (REV. 9/10) PLEASE PAY THIS AMOUNT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ATIENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1427200149 09/29/14 10/02/14 3 DOCTOR SEAN BURNS INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY 23 DROUIN DR LJ GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 012/27/15 INSURANCE COMPANY GROUP NO. POLICY NO. BILLING DATE I DATE DESCRIPTION OF SERVICE AMOUNT ! CODE DESCRIPTION QTY 10/02 002384 OXYCODONE HCL TAB 5MG 3 2.67 10/02 002384 OXYCODONE HCL TAB 5MG 3 2.67 10/02 002384 OXYCODONE HCL TAB 5MG 3 2.67 10/02 002384 OXYCODONE HCL TAB 5MG 3 2.67 10/02 002485 OXYCODONE HCL TAB CR 10MG 3 18.72 10/02 000321 DIAZEPAM 5 MG 1 0.72 10/02 000508 DOCUSATE SOD.100MG 1 0.72 10/02 000557 FERROUS SULF TAB 325MG 1 0.72 10/02 000058 ASCORBIC ACID 500MG 1 0.72 AREA TOTAL *** 170.25 ***302 LAB-IMMUNOLOGY 10/02 001345 CRP 1 66.00 AREA TOTAL *** 66.00 ***305 HEMATOLOGY LAB 09/30 005140 CBC WITH AUTO DIFF1 (BILLING COMPONEN 1 129.00 10/02 005140 CBC WITH AUTO DIFF1 (BILLING COMPONEN 1 135.00 10/02 005152 SED RATE(AUTOMATED) 1 54.00 AREA TOTAL *** 318.00 ***310 PATHOLOGY LAB 09/29 002305 LEVEL 4 SURG PATH 1 208.00 09/29 002311 DECALCIFICATION 1 48.00 10/01 002305 LEVEL 4 SURG PATH 1 218.00 10/01 002311 DECALCIFICATION 1 50.00 AREA TOTAL *** 524.00 ***360 OR SERVICE 09/29 009802 OR-2 PER (PANEL) 49 8,739.00 10/01 009802 OR-2 PER (PANEL) 73 11,257.00 AREA TOTAL *** 19,996.00 ***370 ANESTHESIA Continued TOTAL CHARGES I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL <U+25BA> 5032 (REV. 9/10) PLEASE PAY THIS AMOUNT F/C:OH P/T:i/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 •ATIENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1427200149 09/29/14 10/02/14 4 DOCTOR SEAN BURNS INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY GROUP NO. POLICY NO. BILLING DATE 23 DROUIN DR BELMONT NH 03220 OB/27/15 INSURANCE COMPANY 1------- 1 GROUP NO. POLICY NO. BILLING DATE DATE DESCRIPTION OF SERVICE AMOUNT CODE DESCRIPTION QTY 09/29 001272 ANESTHESIA, GENERAL ASA 2 PER/MIN 100 2, 116 .00 10/01 001272 ANESTHESIA, GENERAL ASA 2 PER/MIN 109 2, 391 .00 AREA TOTAL *** 4, 507 .00 ***636 DRUGS-SPECIFICALLY IDENTIFIED 09/29 001879 MORPHINE SULFATE SYR 2MG/1ML 1 21 .12 09/29 000224 FENTANYL CIT INJ 250MCG/5ML 3 24 .11 09/29 002269 ONDANSETRON HCL 4MG/2ML VIAL 4 20 .87 09/29 000244 MEPERIDINE HCL 25MG/ML TUBEX 1 48 .39 09/29 002864 FENTANYL CIT INJ 100MCG/2ML 1 21 .45 09/29 003154 HYDROMORPHONE HCL 2MG/ML SYR 1 32 .37 09/29 003154 HYDROMORPHONE HCL 2MG/ML SYR 1 32 .37 09/29 003154 HYDROMORPHONE HCL 2MG/ML SYR 1 32 .37 09/29 000533 DEXAMETHASONE 1ML 8 41 .74 09/29 000076 LACTATED RINGERS 1000ML 2 173 .80 09/29 000076 LACTATED RINGERS 1000ML 1 86 .90 09/30 001879 MORPHINE SULFATE SYR 2MG/1ML 1 21 .12 09/30 001879 MORPHINE SULFATE SYR 2MG/1ML 2 42 .24 09/30 001879 MORPHINE SULFATE SYR 2MG/1ML 1 21 .12 09/30 001879 MORPHINE SULFATE SYR 2MG/1ML 1 21 .12 10/01 001409 SUCCINYLCHOLINE 0.2G 10 91 .42 10/01 001879 MORPHINE SULFATE SYR 2MG/1ML 2 42 .24 10/01 001879 MORPHINE SULFATE SYR 2MG/1ML 2 42 .24 10/01 001879 MORPHINE SULFATE SYR 2MG/1ML 1 22 .18 10/01 001879 MORPHINE SULFATE SYR 2MG/1ML 1 22 .18 10/01 002269 ONDANSETRON HCL 4MG/2ML VIAL 4 20 .87 10/01 002864 FENTANYL CIT INJ 100MCG/2ML 1 22 .52 10/01 002864 FENTANYL CIT INJ 100MCG/2ML 1 22 .52 10/01 002864 FENTANYL CIT INJ 100MCG/2ML 1 22 . 52 10/01 004739 MIDAZOLAM 2MG/2ML INJECTION 8 152 .96 10/01 000533 DEXAMETHASONE 1ML 8 41 .74 10/01 000076 LACTATED RINGERS 1000ML 1 86 . 90 10/01 000076 LACTATED RINGERS 1000ML 1 86 .90 10/02 001879 MORPHINE SULFATE SYR 2MG/1ML 1 22 . 18 TOTAL CHARGES <U+25BA> Continued l.u. NU. ^-2by4b/2 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL <U+25BA> n i r- a r'w— nA\\/ ti im ah a i i h it 5032 (REV. 9/10) OS Z J F/C:OH ’ATIENT NAME P/T:I/P CONCORD HOSPITAL ACCOUNT NO. c A 250 Pleasant Street, Concord, NH 03301 GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1427200149 09/29/14 10/02/14 5 DOCTOR SEAN BORNS INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY 23 DROUIN DR GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 2/27/15 INSURANCE COMPANY 1------ 1 GROUP NO. POLICY NO. BILLING DATE DATE DESCRIPTION OF SERVICE AMOUNT CODE DESCRIPTION QTY 10/02 001879 MORPHINE SULFATE SYR 2MG/1ML 1 22 .18 10/02 001879 MORPHINE SULFATE SYR 2MG/1ML 1 22 .18 10/02 001879 MORPHINE SULFATE SYR 2MG/1ML 2 44 .36 10/02 000076 LACTATED RINGERS 1000ML 1 86 .90 AREA TOTAL *** 1,516 .08 ***710 RECOVERY ROOM 09/29 001000 RECOVERY ROOM PATIENT 1 0 .00 09/29 008000 AMU PATIENT 1 0 .00 09/29 009900 RECOVERY - PER MINUTE 135 1,620 .00 10/01 001000 RECOVERY ROOM PATIENT 1 0 .00 10/01 008000 AMU PATIENT 1 0 .00 10/01 009900 RECOVERY - PER MINUTE 75 975 .00 AREA TOTAL *** 2,595 .00 TOTAL CHARGES 36,682.66 10/21 A8005 253 UNINSURED SELF PAY DISCNT 099 14,673.06CR TOTAL PAYMENTS/ADJUSTMENTS 14,673.06CR THANK Y|<PU FOR USING CONCORD HOSPITAL'S SERVICES. CONCORD HOSPITAL IS DEDICA'. D te: TO PROVIDING THE HIGHEST QUALITY HEALTHCARE AT THE MOST REASONfAB LE COST. **** BENEFITS ASSIGNED TO CONCORD HOSPITAL**** TOTAL CHARGES 22,009.60 I.D. NO. 22-2594672 0.00 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL 22,009.60 5032 (REV. 9/10) PLEASE PAY THIS AMOUNT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ATI ENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 l DOCTOR PETER WILSON c^l INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY 23 DROUIN DR GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 INSURANCE COMPANY 1------- 1 GROUP NO. POLICY NO. BILLING DATE I DATE DESCRIPTION OF SERVICE AMOUNT CODE DESCRIPTION QTY ***120 SEMI-PRIVATE ROOM 09/07 002005 ROOM 6156 S 1 1,715 .00 09/08 002005 ROOM 6156 S 1 1,715 .00 09/09 002005 ROOM 6156 S 1 1,715 .00 09/10 002005 ROOM 6156 S 1 1,715 .00 09/11 002005 ROOM 6156 S 1 1, 715 .00 09/12 002005 ROOM 6156 S 1 1,715 .00 09/13 002005 ROOM 6156 S 1 1,715 .00 09/14 002005 ROOM 6156 S 1 1,715 .00 09/15 002005 ROOM 6156 S 1 1, 715 .00 09/16 002005 ROOM 6156 S 1 1,715 .00 09/17 002005 ROOM 6156 S 1 1,715 .00 AREA TOTAL *** 18,865 .00 ***250 PHARMACY/ADMIN-OP INJECTED 09/07 001887 LIDOCAINE HCL 2% 1 24 .74 09/07 001921 D5/NACL 0.45%+KCL 20 1000ML BAG 1 97 .29 09/07 001945 PROPOFOL INJ 200MG/20ML AMP 1 30 .16 09/07 001945 PROPOFOL INJ 200MG/20ML AMP 1 30 .16 09/07 002328 ROCURONIUM BR INJ 50MG/5ML SDV 1 30 .67 09/07 000698 KETAMINE 50MG/ML 10M 1 7 .52 09/08 001831 ESMOLOL INJ 10MG/ML 1 34 .18 09/08 001831 ESMOLOL INJ 10MG/ML 1 34 .18 09/08 002037 FAMOTIDINE INJ 20MG/2ML 1 20 .87 09/08 002328 ROCURONIUM BR INJ 50MG/5ML SDV 1 30 .67 09/08 002328 ROCURONIUM BR INJ 50MG/5ML SDV 1 30 .67 09/08 000617 GLYCOPYRROLATE 0.2MG 3 236 .34 09/08 000698 KETAMINE 50MG/ML 10M 1 7 .52 AREA TOTAL *** 614 . 97 ***255 DRUGS/INCIDENT RAD 09/07 008323 CT-OPTIRAY-320,PER ML 100 200 . 00 AREA TOTAL *** 200 .00 TOTAL CHARGES <U+25BA> Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL RECEIVED FEB 0 3 2015 snap /rfv Qhn\\ PI FA.QF PAY THI.Q AMOI IMT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ATI ENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 2 DOCTOR PETER WILSON c'T INSURANCE COMPANY TERRENCE J COYMAN 1099085 UNINSURED SELF PAY 1 GROUP NO. 23 DROUIN DR POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 ^ INSURANCE COMPANY 3 GROUP NO. POLICY NO. BILLING DATE DESCRIPTION OF SERVICE CODE DESCRIPTION QTY ***258 IV SOLUTIONS 09/07 003135 N-K IRRIGATION SOL 500ML BTL 2 39.32 09/08 001555 NACL 0.9% 100ML 1 86.90 09/08 001555 NACL 0.9% 100ML 1 86.90 09/08 001555 NACL 0.9% 100ML 1 86.90 09/08 001555 NACL 0.9% 100ML 1 86.90 09/08 000093 NACL 50 ML 1 86.90 09/08 000097 D5W 100 ML IV BAG 1 86.90 09/08 000097 D5W 100 ML IV BAG 1 86.90 09/08 000097 D5W 100 ML IV BAG 1 86.90 09/09 001555 NACL 0.9% 100ML 1 86.90 09/09 001555 NACL 0.9% 100ML 1 86.90 09/09 001555 NACL 0.9% 100ML 1 86.90 09/09 000093 NACL 50 ML 1 86.90 09/09 000097 D5W 100 ML IV BAG 1 86.90 09/09 000097 D5W 100 ML IV BAG 1 86.90 09/09 000097 D5W 100 ML IV BAG 1 86.90 09/10 000093 NACL 50 ML 1 86.90 AREA TOTAL *** 1,429.72 ***259 DRUGS/OTHER OP NOT INJECTED 09/08 001853 DOCUSATE NA/SENNA 1 0.72 09/08 001853 DOCUSATE NA/SENNA 1 0.72 09/08 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/08 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/08 002384 OXYCODONE HCL TAB 5MG 2 1.76 09/08 002384 OXYCODONE HCL TAB 5MG 1 0.88 09/08 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/08 002384 OXYCODONE HCL TAB 5MG 1 0.88 09/08 000567 FOLIC ACID IMG 1 0.72 09/08 000608 VITAMIN MULTI W/MIN 1 0.72 09/09 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/09 001853 DOCUSATE NA/SENNA 1 0.72 09/09 001853 DOCUSATE NA/SENNA 1 0.72 TOTAL CHARGES <U+25BA> Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL 5032 (REV. 9/10) PLEASE PAY THIS AMOUNT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ’ATIENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 3 DOCTOR PETER WILSON INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY 23 DROUIN DR GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 \\ INSURANCE COMPANY 1-------1 GROUP NO. POLICY NO. BILLING DATE DATE DESCRIPTION OF SERVICE AMOUNT CODE DESCRIPTION QTY 09/09 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/09 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/09 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/09 002347 GABAPENTIN CAP 100MG 1 0 .72 09/09 002347 GABAPENTIN CAP 100MG 1 0 .72 09/09 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/09 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/09 002384 OXYCODONE HCL TAB 5MG 2 1 .76 09/09 002384 OXYCODONE HCL TAB 5MG 2 1 .76 09/09 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/09 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/09 003041 ACETAMINOPHEN 500MG TABLET 2 1 .44 09/09 000328 MAALOX PLUS 30ML UD 1 1 .68 09/09 000328 MAALOX PLUS 30ML UD 1 1 .68 09/09 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1 .37 09/09 000567 FOLIC ACID IMG 1 0 .72 09/09 000608 VITAMIN MULTI W/MIN 1 0 .72 09/10 000152 CYCLOBENZAPRINE 10MG 1 0 .72 09/10 001853 DOCUSATE NA/SENNA 1 0 .72 09/10 001853 DOCUSATE NA/SENNA 1 0 .72 09/10 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/10 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/10 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/10 002347 GABAPENTIN CAP 100MG 1 0 .72 09/10 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/10 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/10 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/10 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/10 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/10 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/10 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/10 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/10 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1 .37 09/10 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1 .37 TOTAL CHARGES <U+25BA> Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL <U+25BA> 5032 (REV. 9/101 PI FASF PAY THIS AMDI IMT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ATI ENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 4 DOCTOR PETER WILSON cA INSURANCE COMPANY TERRENCE J COYMAN |099085 UNINSURED SELF PAY 1 GROUP NO. 23 DROUIN DR POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 ^ INSURANCE COMPANY 2 GROUP NO. POLICY NO. BILLING DATE j DATE DESCRIPTION OF SERVICE AMOUNT 1 CODE DESCRIPTION QTY 09/10 000567 FOLIC ACID IMG 1 0.72 09/10 000608 VITAMIN MULTI W/MIN 1 0.72 09/11 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/11 001583 THIAMINE HCL 100MG 1 0.72 09/11 001853 DOCUSATE NA/SENNA 1 0.72 09/11 001853 DOCUSATE NA/SENNA 1 0.72 09/11 002154 IRON COMPLEX CAP 150MG 1 0.72 09/11 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/11 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/11 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/11 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/11 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/11 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/11 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/11 002384 OXYCODONE HCL TAB 5MG 2 1.76 09/11 002485 OXYCODONE HCL TAB CR 10MG 3 17.79 09/11 002485 OXYCODONE HCL TAB CR 10MG 3 17.79 09/11 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1.37 09/11 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1.37 09/11 000567 FOLIC ACID IMG 1 0.72 09/11 000608 VITAMIN MULTI W/MIN 1 0.72 09/12 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/12 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/12 001583 THIAMINE HCL 100MG 1 0.72 09/12 001853 DOCUSATE NA/SENNA 1 0.72 09/12 001853 DOCUSATE NA/SENNA 1 0.72 09/12 002154 IRON COMPLEX CAP 150MG 1 0.72 09/12 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/12 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/12 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/12 002347 GABAPENTIN CAP 100MG 1 0.72 09/12 002347 GABAPENTIN CAP 100MG 1 0.72 09/12 002347 GABAPENTIN CAP 100MG 1 0.72 09/12 002384 OXYCODONE HCL TAB 5MG 2 1.76 TOTAL CHARGES Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL 5032 (REV. 9/101 PI FASF PAY THIS AMOI IMT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 •ATIENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 5 DOCTOR PETER WILSON INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY 23 DROUIN DR GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 INSURANCE COMPANY 1-------1 GROUP NO. POLICY NO. BILLING DATE j DATE DESCRIPTION OF SERVICE AMOUNT CODE DESCRIPTION QTY 09/12 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/12 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/12 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/12 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/12 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/12 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/12 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1 .37 09/12 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1 .37 09/12 000567 FOLIC ACID IMG 1 0 .72 09/12 000608 VITAMIN MULTI W/MIN 1 0 .72 09/13 000152 CYCLOBENZAPRINE 10MG 1 0 .72 09/13 000152 CYCLOBENZAPRINE 10MG 1 0 .72 09/13 001583 THIAMINE HCL 100MG 1 0 .72 09/13 001853 DOCUSATE NA/SENNA 1 0 .72 09/13 001853 DOCUSATE NA/SENNA 1 0 .72 09/13 002154 IRON COMPLEX CAP 150MG 1 0 .72 09/13 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/13 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/13 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/13 002347 GABAPENTIN CAP 100MG 1 0 .72 09/13 002347 GABAPENTIN CAP 100MG 1 0 .72 09/13 002347 GABAPENTIN CAP 100MG 1 0 .72 09/13 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/13 002384 OXYCODONE HCL TAB 5MG 2 1 .76 09/13 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/13 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/13 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/13 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/13 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/13 003041 ACETAMINOPHEN 500MG TABLET 2 1 .44 09/13 003041 ACETAMINOPHEN 500MG TABLET 2 1 .44 09/13 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1 .37 09/13 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1 .37 09/13 000567 FOLIC ACID IMG 1 0 .72 Continued TOTAL CHARGES <U+25BA> I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL <U+25BA> 5032 (REV. 9/10) PI FASF PAY THIS AMOI IMT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ATI ENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 6 DOCTOR PETER WILSON INSURANCE COMPANY TERRENCE J COYMAN 1099085 UNINSURED SELF PAY 23 DROUIN DR 1 GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 ^ INSURANCE COMPANY 3 GROUP NO. POLICY NO. BILLING DATE DATE DESCRIPTION OF SERVICE CODE DESCRIPTION QTY 09/13 000608 VITAMIN MULTI W/MIN 1 0.72 09/14 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/14 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/14 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/14 001583 THIAMINE HCL 100MG 1 0.72 09/14 001853 DOCUSATE NA/SENNA 1 0.72 09/14 001853 DOCUSATE NA/SENNA 1 0.72 09/14 002154 IRON COMPLEX CAP 150MG 1 0.72 09/14 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/14 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/14 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/14 002347 GABAPENTIN CAP 100MG 1 0.72 09/14 002347 GABAPENTIN CAP 100MG 1 0.72 09/14 002347 GABAPENTIN CAP 100MG 1 0, 72 09/14 002384 OXYCODONE HCL TAB 5MG 3 2, 64 09/14 002384 OXYCODONE HCL TAB 5MG 3 2, 64 09/14 002384 OXYCODONE HCL TAB 5MG 3 2, 64 09/14 002384 OXYCODONE HCL TAB 5MG 3 2 64 . 09/14 002384 OXYCODONE HCL TAB 5MG 3 2, 64 09/14 002384 OXYCODONE HCL TAB 5MG 3 2. 64 09/14 002485 OXYCODONE HCL TAB CR 10MG 3 17.79 09/14 002485 OXYCODONE HCL TAB CR 10MG 3 17.79 09/14 003041 ACETAMINOPHEN 500MG TABLET 2 1.44 09/14 003041 ACETAMINOPHEN 500MG TABLET 2 1.44 09/14 003041 ACETAMINOPHEN 500MG TABLET 2 1.44 09/14 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1.37 09/14 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1.37 09/14 000567 FOLIC ACID IMG 1 0.72 09/14 000608 VITAMIN MULTI W/MIN 1 0.72 09/15 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/15 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/15 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/15 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/15 001583 THIAMINE HCL 100MG 1 0.72 TOTAL CHARGES Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL <U+25BA> 5032 (REV. 9/10) PI FASF PAY THIS AMOI IMT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ATI ENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN, TERRENCE J 1425000260 09/07/14 09/18/14 7 DOCTOR PETER WILSON INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY 23 DROUIN DR GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 INSURANCE COMPANY 1------- 1 GROUP NO. POLICY NO. BILLING DATE date DESCRIPTION OF SERVICE AMOUNT 1 CODE DESCRIPTION QTY 09/15 001853 DOCUSATE NA/SENNA 1 0 .72 09/15 001853 DOCUSATE NA/SENNA 1 0 .72 09/15 002154 IRON COMPLEX CAP 150MG 1 0 .72 09/15 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/15 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/15 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/15 002347 GABAPENTIN CAP 100MG 1 0 .72 09/15 002347 GABAPENTIN CAP 100MG 1 0 .72 09/15 002347 GABAPENTIN CAP 100MG 1 0 .72 09/15 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/15 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/15 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/15 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/15 002384 OXYCODONE HCL TAB 5MG 3 2 .64 09/15 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/15 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/15 003041 ACETAMINOPHEN 500MG TABLET 2 1 .44 09/15 003041 ACETAMINOPHEN 500MG TABLET 2 1 .44 09/15 003041 ACETAMINOPHEN 500MG TABLET 2 1 .44 09/15 003041 ACETAMINOPHEN 500MG TABLET 2 1 .44 09/15 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1 .37 09/15 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1 .37 09/15 000567 FOLIC ACID IMG 1 0 .72 09/15 000608 VITAMIN MULTI W/MIN 1 0 .72 09/16 000152 CYCLOBENZAPRINE 10MG 1 0 . 72 09/16 000152 CYCLOBENZAPRINE 10MG 1 0 .72 09/16 000152 CYCLOBENZAPRINE 10MG 1 0 .72 09/16 001583 THIAMINE HCL 100MG 1 0 .72 09/16 001853 DOCUSATE NA/SENNA 1 0 .72 09/16 001853 DOCUSATE NA/SENNA 1 0 . 72 09/16 002154 IRON COMPLEX CAP 150MG 1 0 .72 09/16 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/16 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/16 002175 MAGNESIUM OXIDE TAB 400MG 1 0 . 72 TOTAL CHARGES <U+25BA> Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL <U+25BA> 5032 (REV. 9/10) PI FASF PAY THIS AMOI IMT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ATI ENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 8 DOCTOR PETER WILSON INSURANCE COMPANY TERRENCE J COYMAN 1099085 UNINSURED SELF PAY 23 DROUIN DR 1 GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 ^ INSURANCE COMPANY 2 GROUP NO. POLICY NO. BILLING DATE DATE DESCRIPTION OF SERVICE AMOUNT CODE DESCRIPTION QTY 09/16 002347 GABAPENTIN CAP 100MG 1 0.72 09/16 002347 GABAPENTIN CAP 100MG 1 0.72 09/16 002347 GABAPENTIN CAP 100MG 1 0.72 09/16 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/16 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/16 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/16 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/16 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/16 002485 OXYCODONE HCL TAB CR 10MG 3 17.79 09/16 002485 OXYCODONE HCL TAB CR 10MG 3 17.79 09/16 003041 ACETAMINOPHEN 500MG TABLET 2 1.44 09/16 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1.37 09/16 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1.37 09/16 000567 FOLIC ACID IMG 1 0.72 09/16 000608 VITAMIN MULTI W/MIN 1 0.72 09/17 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/17 000152 CYCLOBENZAPRINE 10MG 1 0.72 09/17 001583 THIAMINE HCL 100MG 1 0.72 09/17 001853 DOCUSATE NA/SENNA 1 0.72 09/17 001853 DOCUSATE NA/SENNA 1 0.72 09/17 002154 IRON COMPLEX CAP 150MG 1 0.72 09/17 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/17 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/17 002175 MAGNESIUM OXIDE TAB 400MG 1 0.72 09/17 002347 GABAPENTIN CAP 100MG 1 0.72 09/17 002347 GABAPENTIN CAP 100MG 1 0.72 09/17 002347 GABAPENTIN CAP 100MG 1 0.72 09/17 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/17 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/17 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/17 002384 OXYCODONE HCL TAB 5MG 3 2.64 09/17 002384 OXYCODONE HCL TAB 5MG 3 2.52 09/17 002485 OXYCODONE HCL TAB CR 10MG 3 17.79 09/17 002485 OXYCODONE HCL TAB CR 10MG 3 17.79 TOTAL CHARGES Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL <U+25BA> 5032 (REV. 9/10} PI FASF PAY THIS AMOI IMT F/C:OH P/T:I/P ci CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 'ATIENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 9 DOCTOR PETER WILSON INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY GROUP NO. POLICY NO. BILLING DATE 23 DROUIN DR BELMONT NH 03220 0 1/30/15 INSURANCE COMPANY 1-------1 GROUP NO. POLICY NO. BILLING DATE DATE DESCRIPTION OF SERVICE AMOUNT CODE DESCRIPTION QTY 09/17 003041 ACETAMINOPHEN 500MG TABLET 2 1 .44 09/17 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1 .37 09/17 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1 .37 09/17 000567 FOLIC ACID IMG 1 0 .72 09/17 000608 VITAMIN MULTI W/MIN 1 0 .72 09/18 000152 CYCLOBENZAPRINE 10MG 1 0 .72 09/18 000152 CYCLOBENZAPRINE 10MG 1 0 .72 09/18 001583 THIAMINE HCL 100MG 1 0 .72 09/18 001853 DOCUSATE NA/SENNA 1 0 .72 09/18 002154 IRON COMPLEX CAP 150MG 1 0 .72 09/18 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/18 002175 MAGNESIUM OXIDE TAB 400MG 1 0 .72 09/18 002347 GABAPENTIN CAP 100MG 1 0 .72 09/18 002347 GABAPENTIN CAP 100MG 1 0 .72 09/18 002384 OXYCODONE HCL TAB 5MG 3 2 .52 09/18 002384 OXYCODONE HCL TAB 5MG 3 2 .52 09/18 002384 OXYCODONE HCL TAB 5MG 3 2 .52 09/18 002384 OXYCODONE HCL TAB 5MG 3 2 .52 09/18 002485 OXYCODONE HCL TAB CR 10MG 3 17 .79 09/18 003041 ACETAMINOPHEN 500MG TABLET 2 1 .44 09/18 003041 ACETAMINOPHEN 500MG TABLET 2 1 .44 09/18 004919 POTASSIUM PHOSPHATE 250MG TAB 1 1 .37 09/18 000567 FOLIC ACID IMG 1 0 .72 09/18 000608 VITAMIN MULTI W/MIN 1 0 .72 AREA TOTAL *** 615 .83 ***260 IV THERAPY 09/07 004102 IV INFUS/THERAPY/PROPHYLAXIS INIT 1 335 .00 09/07 004107 IV PUSH-NEW/ADDITIONAL 2 536 .00 09/07 000776 TX/PRO/DX INJ SAME DRUG ADON 3 603 .00 AREA TOTAL *** 1,474 .00 ***278 SUPPLY IMPLANTS 09/07 001600 SMITH AND NEPHEW TRIGEN LOW PROFILE 4 3,536 .00 TOTAL CHARGES <U+25BA> Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL 5032 (REV. 9/1 (N PI FASF PAY THIS AMOI IMT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 'ATIENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 10 DOCTOR PETER WILSON INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY POLICY NO. BILUNG DATE 23 DROUIN DR GROUP NO. BELMONT NH 03220 0 1/30/15 N INSURANCE COMPANY 1------- 1 GROUP NO. POLICY NO. BILLING DATE DATE DESCRIPTION OF SERVICE CODE DESCRIPTION QTY 09/07 001609 SMITH AND NEPHEW TRIGEN META NAIL, R 1 4,915.00 AREA TOTAL *** 8,451.00 ***300 LABORATORY 09/07 008413 CREATININE,WHOLE BLOOD 1 58.00 AREA TOTAL *** 58.00 ***301 LAB-CHEMISTRY 09/07 007283 POTASSIUM 1 73.00 09/07 007283 SODIUM 1 30.00 09/07 007283 CHLORIDE 1 73.00 09/07 007284 CALCIUM,IONIZED 1 12.00 09/07 007284 GLUCOSE 1 73.00 09/07 007418 COMPREHENSIVE METABOLIC PANEL 1 87.00 09/07 008310 ETHANOL,SERUM 1 95.00 09/07 008604 MEDICAL URINE TOXICOLOGY SCREEN 1 360.00 09/07 009804 VITAMIN D,25-OH TOTAL 1 189.00 09/08 007120 MAGNESIUM 1 87.00 09/08 007276 ABG W/COOX 1 330.00 09/08 007279 CALCIUM,IONIZED 1 194.00 09/08 007280 CHLORIDE 1 17.00 09/08 007281 SODIUM 1 17.00 09/08 007282 POTASSIUM 1 17.00 09/08 007418 COMPREHENSIVE METABOLIC PANEL 1 87.00 09/08 008626 GLUCOSE 1 57.00 09/09 007120 MAGNESIUM 1 87.00 09/09 007279 CALCIUM,IONIZED 1 53.00 09/09 007330 PHOSPHORUS 1 73.00 09/09 007417 BASIC METABOLIC PANEL 1 73.00 09/10 007120 MAGNESIUM 1 87.00 09/10 007330 PHOSPHORUS 1 73.00 09/10 007417 BASIC METABOLIC PANEL 1 73.00 AREA TOTAL *** 2,317.00 TOTAL CHARGES Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL <U+25BA> snap fRFV 0/1 m PI FA.QF PAY THIS AMHI IMT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ATI ENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 li DOCTOR PETER WILSON e'T INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY 23 DROUIN DR GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 o 1/30/15 INSURANCE COMPANY GROUP NO. POLICY NO. BILLING DATE j DATE DESCRIPTION OF SERVICE AMOUNT 1 CODE DESCRIPTION QTY ***302 LAB-IMMUNOLOGY 09/07 003010 ANTIBODY SCREEN 1 85.00 09/07 003070 RH TYPING 1 55.00 09/07 003800 ABO GROUP 1 90.00 AREA TOTAL *** 230.00 ***305 HEMATOLOGY LAB 09/07 005140 CBC WITH AUTO DIFF (BILLING COMPONEN 1 129.00 09/07 005155 PTT 1 80.00 09/07 005159 PT/INR 1 53.00 09/08 005140 CBC WITH AUTO DIFF (BILLING COMPONEN 1 129.00 09/09 005140 CBC WITH AUTO DIFF (BILLING COMPONEN 1 129.00 09/09 005153 HCT 2 118.00 09/09 005154 HGB 2 118.00 09/10 005140 CBC WITH AUTO DIFF (BILLING COMPONEN 1 129.00 09/10 005153 HCT 1 59.00 09/10 005154 HGB 1 59.00 09/11 005153 HCT 1 59.00 09/11 005154 HGB 1 59.00 09/13 005153 HCT 1 59.00 09/13 005154 HGB 1 59.00 09/14 005153 HCT 1 59.00 09/14 005154 HGB 1 59.00 09/15 005153 HCT 1 59.00 09/15 005154 HGB 1 59.00 09/16 005153 HCT 1 59.00 09/16 005154 HGB 1 59.00 09/17 005153 HCT 1 59.00 09/17 005154 HGB 1 59.00 AREA TOTAL *** 1,711.00 ***307 UROLOGY 09/07 006016 URINE MACROSCOPIC 1 38.00 09/10 006001 URINALYSIS, REFLEX 1 106.00 TOTAL CHARGES <U+25BA> Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL 5032 (REV. 9/10) PLFASF PAY THIS AMOIINT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ATI ENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 12 DOCTOR PETER WILSON c/T INSURANCE COMPANY TERRENCE J COYMAN |099085 UNINSURED SELF PAY 23 DROUIN DR 1 GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 ^ INSURANCE COMPANY 3 GROUP NO. POLICY NO. BILLING DATE DATE DESCRIPTION OF SERVICE CODE DESCRIPTION QTY AREA TOTAL <U+2605><U+2605><U+2605> 144.00 ***320 DX X-RAY 09/07 001575 ER-FEMUR-1-VIEW 1 405.00 09/07 001779 ER-FOREARM-LEFT-2-VIEWS 1 370.00 09/07 001798 ER-PELVIS-l-TO-2-VIEWS 1 471.00 09/07 001817 ER-ANKLE-1-VIEW-LEFT 1 333.00 09/07 001901 ER-HAND-2-VIEWS-LEFT 1 279.00 09/07 002067 ER-FOOT-1-VIEW-LEFT 1 333.00 09/07 002067 ER-FOOT-1-VIEW-LEFT 1 333.00 09/08 002063 FOOT-LEFT-2-VIEWS 1 333.00 09/08 002303 FEMUR-LEFT-2-VIEWS 1 405.00 09/08 003186 C-ARM-W/IMAGE->1HR 1 1,074.00 09/08 003408 C-ARM-OR-FLUORO->1HOUR 1 1,074.00 AREA TOTAL *<U+2605>* 5,410.00 ***324 CHEST X-RAY 09/07 001601 ER-CHEST-1VIEW(AP/PA) 1 304.00 AREA TOTAL <U+2605><U+2605>k 304.00 ***351 CT SCAN/HEAD 09/07 008003 CT-BRAIN-W/O-CONTRAST 1 2,081.00 AREA TOTAL kk<U+2605> 2,081.00 ***352 CT SCAN/BODY 09/07 008043 CT-CHEST-WITH-CONTRAST 1 3,094.00 09/07 008081 CT-C-SPINE-W/O-CONTRAST 1 2,648.00 09/07 008157 CT-ABD/PEL-WITH-CONTRAST 1 5,794.00 AREA TOTAL 11,536.00 ***360 OR SERVICE 09/07 009803 OR-3 PER (PANEL) 219 29,722.00 AREA TOTAL k ic k 29,722.00 Continued TOTAL CHARGES I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL <U+25BA> 5032 (REV. 9/10) PI FASF PAY THIS AMOIIMT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ATIENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 13 DOCTOR PETER WILSON c^r INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY 23 DROUIN DR GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 INSURANCE COMPANY GROUP NO. POLICY NO. BILLING DATE DATE DESCRIPTION OF SERVICE AMOUNT CODE DESCRIPTION QTY ***370 ANESTHESIA 09/07 001280 ANESTHESIA, EMERGENCY 284 5 ,970.00 AREA TOTAL * * * 5 ,970.00 ***420 PHYSICAL THERAPY 09/08 007303 IP(PT)-GAIT TRAINING/STAIRS 1 137.00 09/10 007311 IP(PT)-THERAPEUTIC ACTIVITIES 1 137.00 09/11 007303 IP(PT)-GAIT TRAINING/STAIRS 2 274.00 09/11 007621 IP(PT)-SELF CARE/SAFETY INSTR 1 137.00 09/12 007311 IP(PT)-THERAPEUTIC ACTIVITIES 2 274.00 09/13 007303 IP(PT)-GAIT TRAINING/STAIRS 1 137.00 09/14 007311 IP(PT)-THERAPEUTIC ACTIVITIES 2 274.00 09/15 007303 IP(PT)-GAIT TRAINING/STAIRS 1 137.00 09/15 007311 IP(PT)-THERAPEUTIC ACTIVITIES 1 137.00 09/16 007300 IP(PT)-THERAPEUTIC EXERCISE 1 137.00 09/17 007621 IP(PT)-SELF CARE/SAFETY INSTR 1 137.00 AREA TOTAL * * * 1 ,918.00 ***424 PHYSICAL THERAPY EVALUATION 09/08 007000 IP(PT)-EVALUATION 2 334.00 AREA TOTAL * * * 334.00 ***430 OCCUPATIONAL THERAPY 09/10 008312 IP(OT)-SELF CARE/ADL 1 141.00 09/11 008312 IP(OT)-SELF CARE/ADL 2 282.00 09/17 008312 IP(OT)-SELF CARE/ADL 2 282.00 AREA TOTAL * * * 705.00 ***434 OCCUP. THERAPY EVALUATION 09/08 008000 IP(OT)-EVALUATION 2 356.00 AREA TOTAL * * * 356.00 ***450 EMERGENCY ROOM 09/07 007008 INSERT TEMP INDWELLING SIMPLE 1 208.00 Continued TOTAL CHARGES <U+25BA> I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL <U+25BA> CfVJO /DCU I PI PAQF PAV TNIQ AMO! IMT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 'ATIENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 14 DOCTOR PETER WILSON t^T INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY 23 DROUIN DR GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 INSURANCE COMPANY 1------- 1 GROUP NO. POLICY NO. BILLING DATE | DATE DESCRIPTION OF SERVICE AMOUNT 1 CODE DESCRIPTION QTY 09/07 007419 FX CL METATARSAL W/MANIP 28475 1 831 .00 09/07 007448 CRITICAL CARE ADD'L UNT 1 606 .00 09/07 007654 CRITICAL CARE 99291 1 3,219 .00 AREA TOTAL *** 4,864 .00 ***636 DRUGS-SPECIFICALLY IDENTIFIED 09/07 001879 MORPHINE SULFATE SYR 2MG/1ML 1 29 .52 09/07 002269 ONDANSETRON HCL 4MG/2ML VIAL 4 20 .87 09/07 002269 ONDANSETRON HCL 4MG/2ML VIAL 4 20 .87 09/07 000230 MORPHINE SULF PCA 30MG/30ML 3 134 .11 09/07 000230 MORPHINE SULF PCA 30MG/30ML 3 134 .11 09/07 002864 FENTANYL CIT INJ 100MCG/2ML 1 21 .45 09/07 002864 FENTANYL CIT INJ 100MCG/2ML 1 21 .45 09/07 002864 FENTANYL CIT INJ 100MCG/2ML 1 21 .45 09/07 005378 DIPHTHERIA-PERTUSSIS-TETANUS INJ 1 67 .55 09/07 000076 LACTATED RINGERS 1000ML 2 173 .80 09/07 000854 PHENYLEPHRINE 1% 1ML 1 53 .55 09/08 001652 GENTAMICIN 40MG/ML 1 45 .36 09/08 001652 GENTAMICIN 40MG/ML 1 45 .36 09/08 001652 GENTAMICIN 40MG/ML 1 45 .36 09/08 001660 CEFAZOLIN 4 45 .88 09/08 001660 CEFAZOLIN 4 45 .88 09/08 001660 CEFAZOLIN 4 45 .88 09/08 001879 MORPHINE SULFATE SYR 2MG/1ML 1 29 .52 09/08 001879 MORPHINE SULFATE SYR 2MG/1ML 1 29 .52 09/08 001879 MORPHINE SULFATE SYR 2MG/1ML 1 29 .52 09/08 001879 MORPHINE SULFATE SYR 2MG/1ML 1 29 .52 09/08 001879 MORPHINE SULFATE SYR 2MG/1ML 1 29 .52 09/08 002269 ONDANSETRON HCL 4MG/2ML VIAL 4 20 .87 09/08 000230 MORPHINE SULF PCA 30MG/30ML 3 134 .11 09/08 000230 MORPHINE SULF PCA 30MG/30ML 3 134 .11 09/08 002587 ENOXAPARIN INJ 40MG/0.4ML SYR 4 56 .34 09/08 002864 FENTANYL CIT INJ 100MCG/2ML 1 21 .45 09/08 002911 THIAMINE 100MG/ML 2ML VIAL 1 81 .98 TOTAL CHARGES <U+25BA> Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL 5032 (REV. 9/10) PI FASF PAY THIS AMOI IMT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 'ATIENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 15 DOCTOR PETER WILSON e'l INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY 23 DROUIN DR GROUP NO. POLICY NO. BILUNG DATE BELMONT NH 03220 0 L/30/15 INSURANCE COMPANY 1-------1 GROUP NO. POLICY NO. BILLING DATE DATE DESCRIPTION OF SERVICE AMOUNT CODE DESCRIPTION QTY 09/08 000455 CALCIUM GLUCONATE 2 76 .63 09/08 004733 HYDROMORPHONE HCL IMG/ML INJ 1 31 .27 09/08 000533 DEXAMETHASONE 1ML 4 20 .87 09/08 000842 NEOSTIGMINE IMG 1ML 1 1 .30 09/09 001652 GENTAMICIN 40MG/ML 1 45 .36 09/09 001652 GENTAMICIN 40MG/ML 1 45 .36 09/09 001652 GENTAMICIN 40MG/ML 1 45 .36 09/09 001660 CEFAZOLIN 4 45 .88 09/09 001660 CEFAZOLIN 4 45 .88 09/09 001660 CEFAZOLIN 4 45 .88 09/09 001879 MORPHINE SULFATE SYR 2MG/1ML 1 29 .52 09/09 001879 MORPHINE SULFATE SYR 2MG/1ML 1 29 .52 09/09 001879 MORPHINE SULFATE SYR 2MG/1ML 1 29 .52 09/09 002911 THIAMINE 100MG/ML 2ML VIAL 1 81 . 98 09/09 000528 DIAZEPAM 5MG/ML 2ML 2 93 .80 09/09 005424 MAGNESIUM SULF 2G/50ML INJ 4 138 .92 09/10 001879 MORPHINE SULFATE SYR 2MG/1ML 1 29 .52 09/10 002911 THIAMINE 100MG/ML 2ML VIAL 1 81 .98 09/13 002587 ENOXAPARIN INJ 40MG/0.4ML SYR 4 56 .34 09/14 002587 ENOXAPARIN INJ 40MG/0.4ML SYR 4 56 .34 09/15 001879 MORPHINE SULFATE SYR 2MG/1ML 1 29 .52 09/15 001879 MORPHINE SULFATE SYR 2MG/1ML 1 29 .52 09/15 002587 ENOXAPARIN INJ 40MG/0.4ML SYR 4 56 .34 09/16 002587 ENOXAPARIN INJ 40MG/0.4ML SYR 4 56 .34 09/17 002587 ENOXAPARIN INJ 40MG/0.4ML SYR 4 56 .34 AREA TOTAL *** 2,828 .20 ***710 RECOVERY ROOM 09/08 001000 RECOVERY ROOM PATIENT 1 0 .00 09/08 009900 RECOVERY - PER MINUTE 84 1,008 .00 AREA TOTAL *** 1, 008 .00 ***730 EKG-ECG 09/07 000700 EKG-ER 1 290 .00 TOTAL CHARGES <U+25BA> Continued I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL cnoo /on/ m*. PI PAQP PAV TWIQ AMO! IMT F/C:OH P/T:I/P CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 ATI ENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 16 DOCTOR PETER WILSON df]' INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY 23 DROUIN DR GROUP NO. POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 INSURANCE COMPANY GROUP NO. POLICY NO. BILLING DATE DESCRIPTION OF SERVICE CODE DESCRIPTION QTY AREA TOTAL <U+2605> * * 290.00 ***77]_ PREVENTIVE CARE SERV VACCINE 09/07 007659 IMMUNIZATION ADMINISTRATION 90471 1 22.00 AREA TOTAL * * * 22.00 ***981 PROFESSIONAL FEES 09/07 009045 *CRIT EKG INTERPRETATION....93010 1 49.00 09/07 009718 *CRITICAL CARE 99291 1 776.00 09/07 009719 *CRITICAL CARE ADD'L UNIT...99292 1 390.00 AREA TOTAL * * * 1,215.00 ***937 PRO FEE HOS VIS 09/08 009222 INIT HOSP-DAY E&M MOD SEVER 50MIN 1 361.00 09/09 009232 SUBSQT HOSP-DAY E&M MNR CMPL25MIN 1 182.00 AREA TOTAL * * * 543.00 ***999 NON COVERED SERVICES 09/07 005496 MEDICATION REC-ADMISSION NOTE 1 0.00 09/08 005496 MEDICATION REC-ADMISSION NOTE 1 0.00 09/08 005496 MEDICATION REC-ADMISSION NOTE 1 0.00 AREA TOTAL *** 0.00 TOTAL CHARGES 105,216.72 09/24 A8005 224 UNINSURED SELF PAY DISCNT 099 38,940.69CR 09/25 A8005 321 UNINSURED SELF PAY DISCNT 099 42,086.69CR 09/25 A8005 321 UNINSURED SELF PAY DISCNT 099 39,426.69 09/25 A8005 321 UNINSURED SELF PAY DISCNT 099 39,426.69CR 09/25 A8005 321 UNINSURED SELF PAY DISCNT 099 38,940.69 Continued TOTAL CHARGES <U+25BA> I.D. NO. 22-2594672 ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL <U+25BA> 5032 (REV. 9/10) PLEASF PAY THIS AMOl INT f/c:oh p/T:i/p CONCORD HOSPITAL 250 Pleasant Street, Concord, NH 03301 (603) 228-7145 (IN CALLING AREA), (800) 562-1542 (OUT OF AREA), (603) 230-7455 OTP) ATI ENT NAME ACCOUNT NO. GUARANTOR NO. ADMIT DATE DISCH. DATE PAGE COYMAN,TERRENCE J 1425000260 09/07/14 09/18/14 17 DOCTOR PETER WILSON c/1 INSURANCE COMPANY TERRENCE J COYMAN 099085 UNINSURED SELF PAY U GROUP NO. 23 DROUIN DR POLICY NO. BILLING DATE BELMONT NH 03220 0 1/30/15 (j^ INSURANCE COMPANY 1-------1 GROUP NO. POLICY NO. BILLING DATE DESCRIPTION OF SERVICE CODE DESCRIPTION QTY TOTAL PAYMENTS/ADJUSTMENTS 42,086.69CR THANK Y|iOU FOR USING CONCORD HOSPITAL'S SERVICES. CONCORD HOSPITAL IS DEDICA'.TED TO PROVIDING THE HIGHEST QUALITY HEALTHCARE AT THE MOST REASON LE COST. **** BENEFITS ASSIGNED TO CONCORD HOSPITAL**** [ab: 63,130.03 TOTAL CHARGES I.D. NO. 22-2594672 07W ESTIMATED INSURANCE <U+25BA> CONCORD HOSPITAL FT7T3TTTTJT <U+25BA> RH39 mru q/1 n\\ PI FA.QP PAY TWIQ AIWIOI IMT THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: BELKNAP COUNTY SUPERIOR COURT Case Name: Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman Case Number: 211-2016-CV-006 TAXATION OF COSTS Principal and Interest $85,139.63 Attorney’s Fees $ 1,702.50 Total Judgment $86,842.13 Entry Fee $ 260.00 Sheriff’s Service $ 87.20 Weekly Payment Motion $ Writ ofExecution $ Certificate ofJudgment (Exemplified) $ Attested Copies $ 21.00 Statutory Interest From 01/09/16 to 05/20/16 $ 651.49 From $ NH Secretary ofState / TJCC Filing $ Cert. Mail/Rest. Del./Return Receipt Requested $ Orders ofNotice $ Motion For Contempt $ Subpoena Duces Tecum $ Federal Express $ Real Estate Attachment Fee $ Out ofState Sheriff $ Payments $ TOTAL DUE: $87,861.82 APPROVED Date Clerk of Court THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: BELKNAP COUNTY SUPERIOR COURT Case Name: Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman Case Number: (if known) AFFIDAVIT AS TO MILITARY SERVICE I (WE) Concord Hospital, Inc. d/b/a Concord Hospital [enter names of petitioner] of Concord, NH [enteraddress]’ \" ’ ^ ” -- —— —- ----- - state the following facts showing that, to the best of my (our) knowledge and belief: 1) The respondent(s)/defendant(s) Terrence J. Coyman is (are) not in the military or other service of the United States included in the provisions of the Servicemembers Civil Relief Act (SCRA) and has (have) not been called by the governor to active duty for a period of 30 days or more as a member of the state guard or national guard or as a member of the militia within the meaning of RSA 110-C:2. (Please state supporting facts, i.e., where respondent(s)/defendant(s) is (are) living, employed, or approximate age sufficient to show not in military service). Example: Defendants are living at 23 Drouin Drive, Belmont, New Hampshire 03220 2) The respondent(s)/defendant(s)______________________________________ is (are) in the military or other service of the United States included in the provisions of the Servicemembers Civil Relief Act (SCRA) or has (have) been called by the governor to active duty for a period of 30 days or more as a member of the state guard or national guard or as a member of the militia within the meaning of RSA 110-C:2. (Please state the name of the branch service and the respondent/defendant’s address).__________________________________________________________ Date Vn pd6— iqnature of Petitioner/Plaintffr Signature State of New Hampshire / County of Merrimack This instrument was acknowledged before me on iMDate Wc6 Name of Petitioner\"/ COMMISSION \\ 5 My Commission Expires. Affix Seal, if any °'lif/;% \\j 5 EXPIRES : -.-g, SFPTFMRER18, Uj': Signature of Notary or Justice of the F-fgaceA 2018 = =. $ *s 4 m THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Belknap Superior Court Telephone: 1-855-212-1234 64 Court St. TTY/TDD Relay: (800) 735-2964 Laconia NH 03246 http://www.courts.state.nh.us NOTICE OF DECISION FILE COPY Case Name: Concord Hospital v Terrence J Coyman Case Number: 211-2016-CV-00006 Please be advised that on March 29, 2016 Judge O'Neill, III made the following order relative to: Structuring Conference Order ADR Order (copy attached) **Scheduling notice attached** March 29, 2016 Abigail Albee Clerk of Court (480) C: Michael J. Fontaine, ESQ; Shawn Joseph Sullivan, ESQ NHJB-2501-S (07/01/2011) JUDICIAL BRANCH http://www.cdurts.state.nh.us Court Name: Belknap County Superior Court________ Case Name: Concord Hospital v. Terrence J. Coyman Case Number: 211-2016-CV-006 CASE STRUCTURING AND ADR ORDER* (See Superior Court Rule 5) 1. Plaintiffs Counsel: Trial - Michael J. Fontaine At conference - Michael J. Fontaine 2. Defendant's Counsel: Trial - Shawn J. Sullivan At conference - Shawn J. Sullivan 3. Causes(s) of action: Payment for Medical Services Counterclaims: 4. Insurance carrier: N/A_______________________ Disclosure of policy limits by: N/A 5. DThe parties have agreed to file a motion with the Merrimack County Superior Court within 30 days requesting that this matter be placed on Jhe Business ajid Commercial Dispute Docket. 6. If defendant claims that unnamed parties are at fault (see DeBenedetto v. CLD Consulting Engineers Inc., 153 N.H. 793 (2006)), defendant shall disclose the identity of every such party and the basis of the allegation of fault no later than N/A Plaintiff shall then have 30 days from the date of disclosure to amend the initiating pleading. 7. Is there an agreement to waive statutory expert disclosure requirements under RSA 516:29-b? ISI Yes <U+25A1> No 8. <U+25A1> The parties have exchanged e-mail addresses and agree that the e-mail service of pleadings between the parties shall be considered in compliance with Superior Court Administrative Order 46. 9. Plaintiffs disclosure of experts and reports due: 90 days from the date of this Order Defendant’s disclosure of experts and reports due: 60 days from the date of this Order 10. The following deadlines apply: All interrogatories propounded by: Thirty (301 days from the date of this Order All depositions to be completed by: Close of Discovery All dispositive motions to be filed No later than 120 days prior to the trial Completion of all discovery: Sixty (60) days before trial Deadline for filing all other pre-trial motions: No later than 14 days prior to trial Deadline for filing of witness and exhibit lists: No later than the trial management conference 11. Jury trial requested*?* DYes M No 12. If jury trial previously demanded, is it now being waived? DYes DNo 13. Requested trial date: October 2016 Estimated trial length: One Half Day 14. Jury trial assignment: Jury selection:___________________ Trial MgtConf.__________________ <U+25A1> AM DPM 15. Bench trial assignment: Week of: ___________________ 16. Trial counsel and self-represented parties shall appear at the trial management conference and be prepared to address settlement potential. Parties represented by counsel shall be available for contact by telephone during the trial management conference. All pending pretrial motions shall be heard at the trial management conference, or as scheduled by the court. Failure to appear at the trial management conference or trial may result in dismissal, default or other sanctions. a Case Name: Concord Hospital v. Terrence^ C Covrrtan Case Nymber: 211-2016-CV-006 CASE STRUCTURING ANDADRORDE # 17. ADR (Alternative Dispute Resolution) Orders KThe parties stipulate and agree as follows: OR <U+25A1> The parties do not agree and request that the court complete this section. A. Type of ADR ta Mediation <U+25A1> Neutral Case Evaluation <U+25A1> Binding Arbitration Name of person chosen to do ADR: Philip B, Brouillard DPaid IXI Volunteer Names of alternates: 1. Gary M. Burt 2. James A. Shuchman B. Scheduling vour ADR Session: Date ADR shall be completed by 30 days before Trial. You and the other side must contact the person selected to schedule the ADR session. C. ADR Reporting: The Plaintiff shall file a copy of the ADR report with the court within 30 days of the ADR session. If the ADR report is not timely filed,Jhe.court may schedule a show-cause hearing to determine the status of the ADR process and to jmpose sanctions appropriate to the circumstan&es --'ifnggesgiry. ' 18. <U+25A1> The parties are exempt from Rule 32 ADR. 19. Other orders: 7sllW6 Date Attorney for Defendant Date Attorney for ^Attorney for Plaintiff Plaintiff Date Attorney for Defendant SO ORDERED: ^residing. Date NHJB-2700-S (10/01/2013) Page 2 of 2 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Belknap Superior Court Case Name: Concord Hospital v. Terrence J. Coyman, et al Case Number: 211-2016-CV-006 (if known) APPEARANCE/WITHDRAWAL APPEARANCE Type of appearance (Select One) 0 Appearance <U+25A1> Limited Appearance (Civil cases only) If limited appearance, scope of representation: - - « - * ¦* Select One: 0 As Counsel for: Terrence J. Covman 23 Drouin Drive. Belmont. NH 03220 (603) 396-3269 (Name) (Address) (Telephone Number) (Name) (Address) (Telephone Number) (Name) (Address) (Telephone Number) <U+25A1> I will represent myself (self-represented) WITHDRAWAL As Counsel for_______________________ __________________________ _______________________ Type of Representation: (Select one) <U+25A1> Appearance: <U+25A1> Notice of withdrawal was sent to my client(s) on:_______________ at the following address: <U+25A1> A motion to withdraw is being filed. <U+25A1> Limited Appearance: (Select one) <U+25A1> I am withdrawing my limited \"appearance as I have completed the terms ofthe limited” representation. <U+25A1> The terms of limited representation have not been completed. A motion to withdraw is being filed. I certify that on this date I provided a copy of this document to the parties who have filed an appearance for this case by: <U+25A1> Hand-delivery OR 0 US^aMp^Jv^ Email (only when there is prior agreement of the parties to use this method of service). 03/22/2016_____________________ Date Signatu ——- 10 Ferry St Suite 317_____________________ Shawn J. Sullivan. Esa.________________________ Mailing Address Printed Name Concord. NH 03301 sj s@sj sulllvanlaw.com________________________ Email Address (603) 225-3362 6904_________________________________________ Telephone NH Bar ID # if attorney NHJB-2318-S (03/24/2014) RETURNS OF SERVICE Real Estate Attachment ?lQs !s~n(\\jp Countv Date hj frlZOlb_____ I attached all the lands and tenements in the County of Belknap of the named Defendant/Respondent, Terrence J. Coyman___________ , to the extent ordered on page one (1) of this writ, by leaving at the Office of the Registry of Deeds of that County, a true copy of this writ, and of this return endorsed at Q G)~~] Fees: Register $ iM.°Q Service $ IPS 00 Deputy Sheriff or person making attachment Copy $ W Dep Scott Corbett Travel $ Total $ ,^..60 Trustee Attachment j County Date I attached the money, goods, chattels, rights and credits of the named Defendant/Respondent _____________________ , that were in the hands and possession of____________________ to the extent ordered on page one (1) of this writ, and summoned the trustee to appear as commanded by <U+25A1> giving in hand OR <U+25A1> leaving at the abode of _____________________ an attested copy of this writ. Service was made at________a.m./p.m. at the following address: Fees: Register $ Service $ Deputy Sheriff or person making attachment Copy $ Travel $ Total $ Completion of Service _____________________ County Date I notified the named Defendant/Respondent______________________ of the above attachments by <U+25A1> giving in hand OR <U+25A1> leaving at the abode of_________________________ an attested copy of the writ together with the endorsed return. Service was made at________a.m./p.m. at the following address: Fees: Register $___________ Service $___________ Deputy Sheriff or person making attachment Copy $___________ ____ Travel $ -> Total $___________ NHJB-2307-DFPS (02/14/2013) Page 2 of 2 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Belknap Superior Court Telephone: 1-855-212-1234 64 Court Street TTY/TDD Relay: (800) 735-2964 Laconia, NH 03246 http://www.courts.state.nh.us WRIT OF ATTACHMENT and TRUSTEE PROCESS Case Name: Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman Case Number: 211-2016-CV-00006 To the Sheriff or Deputy Sheriff of any county, the Plaintiff/Petitioner, his or her Attorney, or any other person: WE COMMAND YOU to attach the goods or the estate of Terrence J. Coyman________________ to the value of $114,000.00---------------------------------- dollars.: all real estate. WE ALSO COMMAND YOU to attach the money, goods, chattels, rights, and credits of the Defendant/Respondent in the hands of____________________________________ located at __________________________________________ ________ to the value of $________________ and summon the Defendant/Respondent or Trustee___________________________________ if found in your precinct, to appear at court, within thirty (30) days after service and show cause, if any, why the attachment should not be granted for the judgment which may be recovered by Plaintiff/Petitioner against the principal Defendant/Respondent. You shall also return this writ to the court indicating your actions on page two (2). This attachment is to secure any judgment or decree the plaintiff/petitioner may obtain in this action. Important Notice to Trustee: The named Trustee(s) shall complete and file the enclosed disclosure of trustee form with the court, the plaintiff/petitioner and the defendant/respondent within thirty (30) days of receipt or suffer the risk of default. Witness Tina L. Nadeau, Chief Justice, N ew>tdmpshjfej$ u plejlojLQojjrt 03/04/16 Date Michael J. Fontaine, Esquire (NHB #832) rv 15-185 WELTS, WHITE & FONTAINE, P.C. NHJB-2307-DFPS (02/14/2013) Page 1 of?9 Factory St., P.0. Box 507, Nashua, NH 03061 Case Name: Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman Case Number: MOTION TO ATTACH WITH NOTICE NOTICE TO THE DEFENDANT THE PLAINTIFF INTENDS TO ATTACH YOUR PROPERTY, AS SET FORTH IN THE ABOVE MOTION FOR PERMISSION TO DO SO, TO SECURE ANY JUDGMENT OR DECREE THE PLAINTIFF MAY OBTAIN IN THIS ACTION. YOU HAVE THE RIGHT TO OBJECT TO THE ATTACHMENT, AND TO HAVE A HEARING AS TO WHETHER if\" SHOULD BE MADE. IF YOU DO WISH TO OBJECT AND HAVE A HEARING, YOU SHOULD FILE A WRITTEN OBJECTION DETAILING THE REASONS THEREFOR, TOGETHER WITH A REQUEST FOR A HEARING, WITH THE CLERK OF COURT NOT LATER THAN 30 DAYS AFTER YOU HAVE BEEN SERVED WITH THE MOTION TO ATTACH. IF YOU FAIL TO OBJECT BY THAT DATE, YOU WILL BE DEEMED TO HAVE WAIVED ANY OBJECTION. IF YOU TRANSFER ANY PROPERTY AFTER RECEIVING THIS NOTICE, AND BEFORE THE ATTACHMENT, IF ALLOWED, IS MADE, YOU WILL BE SUBJECT TO THE PROVISIONS OF RSA 511-A:6. EVEN IF YOU DO NOT OBJECT TO THE ATTACHMENT, YOU SHOULD FILE AN APPEARANCE AND ANSWER WITH THE CLERK OF COURT BY 30 DAYS AFTER YOU HAVE BEEN SERVED UNLESS YOU ARE WILLING THAT THE PLAINTIFF HAVE JUDGMENT BY DEFAULT. Plaintiff or Plaintiffs Lawyer ORDER TVu.i\\>n-) f. (stju+u-*1 )>V*v*^; 1 I The motion to attach is denied. The Plaintiff is granted permission to make the above attachment(s) within ____________days. Date__2/lH/lb I V'*' File: 15-185 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH httD:/Avww.courts.state.nh.us Court Name: BELKNAP COUNTY SUPERIOR COURT Case Name: Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman Case Number: (if known) MOTION TO ATTACH WITH NOTICE The Plaintiff requests permission to make the following attachments in the above- referenced civil action. Category of Property to be attached Name of Defendant Real Estate Other Description Amount of Attachment Terrence J. Coyman XX All real estate $114,000.00 In support of this Motion, the Plaintiff certifies that: The plaintiff believes there is reasonable likelihood that the Plaintiff will recover judgment, including interest and costs, in the amount of $114,000.00. To be Signed by the PlaintifTfor Affiant) (in case of a corporation or partnership, a duly authorized officer or partner shall sign.) State of New Hampshire, County of Merrimack This instrument was acknowledged before me on \\l|&)|/5 byD'QRi V()CQtf(AV) My Commission Expires Q H Affix Seal, if any ' n . +4 > : •* • '41 THE STATE OF NEW HAMPSfflIRE JUDICIAL BRANCH SUPERIOR COURT Telephone: 1-855-212-1234 64 CourtY Jtf. TTY/TDD Relay: (800) 735-2964 ;^,^iconia:'NH :63246 £ http://www.courts.state.nh.us VA 'A- SUMMONS IN A CIVIL ACTION ’Mi Pi*** J> ’*- *i ***<r 1 , f, Case Name: Concord Hospital v Terrence J Coyman Case Number: 211-2016-CV-00006 Date Complaint-Filed: January 11,2016 . s , - A Complaint has been filed against Terrence J Coyman in this Court. A copy of the Complaint is attached. The Court ORDERS that ON OR BEFORE: February 25, 2016 Concord Hospital shall have this Summons and the attached Complaint served upon Terrence J Coyman by in hand or by leaving a copy at his/her abode, or by such other service as is allowed by law. March 17, 2016 Concord Hospital shall file the return(s) of service with this Court. Failure to do so may result in this action being dismissed without further notice. 30 days after Defendant Terrence J Coyman must file an Appearance and Answer or other is served responsive pleading form with this Court. A copy of the Appearance and Answer or other responsive pleading must be sent to the party listed below and any other party who has filed an Appearance in this matter. Notice to Terrence J Coyman: If you do not comply with these requirements you will be considered in default and the Court may issue orders that affect you without your input. Send copies to: Michael J. Fontaine, ESQ Welts White & Fontaine PC 29 Factory Street PO Box 507 Nashua NH 03061-0507 BY ORDER OF THE COURT January 11,2016 Abigail Albee Clerk of Court (296) NHJB-2678-S (10/23/2013) THE STATE OF NEW HAMPSHIRE SUPERIOR COURT BELKNAP, SS DOCKET NO. Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman COMPLAINT NATURE OF THE ACTION 1. This is a breach of contract and/or unjust enrichment action for failure to pay for professional healthcare services and/or supplies. JURISDICTION 2. This Court has jurisdiction over this matter as the Plaintiffs principal place of business is located within this County and/or the Defendant resides within this County. PARTIES 3. The Plaintiff, Concord Hospital, Inc. d/b/a Concord Hospital, is a New Hampshire.corporation with a principal place ofbusiness at 250 Pleasant Street, Concord, NH 03301. 4. The Defendant, Terrence J. Coyman, is an individual with a last known address of 23 Drouin Drive, Belmont, New Hampshire, 03220. COUNT I IN A PLEA OF ASSUMPSIT AGAINST TERRANCE J. COYMAN 'i : % 5. Plaintiff incorporates herein by reference the allegations set forth in paragraphs 1- 4 above. 6. Plaintiff provided professional healthcare services and/or supplies to Defendant on or about September 7, 2014 through October 2,2014, account numbers 1425000260 and 1427200149, incurring a bill totaling $141,899.38 and any payments, adjustments and/or credits applied to the same have reduced the balance to $85,139.63. 7. Defendant received these professional healthcare services and/or supplies and promised or is obligated to pay. 8. Defendant signed a Treatment Authorization and Administrative Acknowledgement, agreeing to pay for services rendered by Plaintiff. 9. Plaintiff sent several itemized bills and numerous letters, offered to consider payment plans and advised Defendant of charitable care options. 10. Plaintiff has made proper demand for payment on Defendant, but payment has not been provided. 11. Upon information and belief, Defendant is also presently pursuing a personal injury action and Plaintiff has offered to refrain from collecting this bill until Defendant resolves his/her personal injury case provided Defendant agrees to pay the bill from the personal injury action but Defendant refused. 12. Defendant is currently indebted to Plaintiff in the amount of $85,139.63 for said professional healthcare services and/or supplies, plus actual attorney’s fees pursuant to the Treatment Authorization and Administrative Acknowledgement signed by the Defendant. COUNT II 13. Plaintiff incorporates herein by reference the allegations set forth in 2 paragraphs 1-11 above. 14. Plaintiff provided professional healthcare services and/or supplies to Defendant onorabout September 7, 2014 through October 2, 2014, account numbers 1425000260 and 1427200149, including a bill totaling $141,899.38 and any payments, adjustments, and/or credits applied to the same have reduced the balance to $85,139.63. 15. Defendant received the benefit of these services, promised or is obligated to pay therefore, and/or has been unjustly enriched thereby. WHEREFORE, Plaintiff respectfully requests that this Honorable Court issue Judgment against the Defendant in the sum of $85,139.63, plus actual attorney’s fees pursuant to the Treatment Authorization and Administrative Acknowledgment signed by the Defendant, and provide such other and further relief as this Court deems just and equitable. Dated: Respectfully submitted, Concord Hospital, Inc. d/b/a Concord Hospital By and through its attorneys Welts, White & Fontaine, P.C W42 3 % File: 15-185 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: BELKNAP COUNTY SUPERIOR COURT Case Name: Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman Case Number: (if known) MOTION TO ATTACH WITH NOTICE The Plaintiff requests permission to make the following attachments in the above- referenced civil action. Category o'f Property to be attached\" Name of Defendant Real Estate Other Description Amount of Attachment Terrence J. Coyman XX All real estate $114,000.00 In support of this Motion, the Plaintiff certifies that: The plaintiff believes there is reasonable likelihood that the Plaintiff will recover judgment, including interest and costs, in the amount of $114,000.00. n^*jcxk7\\ To be Signed by the PlaintifT[br Affiant) (in case of a corporation or partnership, a duly authorized officer or partner shall sign.) State of New Hampshire, County of Merrimack This instrument was acknowledged before me on byO'Ofu My Commission Expires Ql Affix Seal, if any Case Name: Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman Case Number: MOTION TO ATTACH WITH NOTICE NOTICE TO THE DEFENDANT THE PLAINTIFF INTENDS TO ATTACH YOUR PROPERTY, AS SET FORTH IN THE ABOVE MOTION FOR PERMISSION TO DO SO, TO SECURE ANY JUDGMENT OR DECREE THE PLAINTIFF MAY OBTAIN IN THIS ACTION. YOU HAVE THE RIGHT TO OBJECT TO THE ATTACHMENT, AND TO HAVE A HEARING AS TO WHETHER IT SHOULD BE MADE. IF YOU DO WISH TO OBJECT AND HAVE A HEARING,-YOU ' 1 SHOULD FILE A WRITTEN OBJECTION DETAILING THE REASONS THEREFOR, TOGETHER WITH A REQUEST FOR A HEARING, WITH THE CLERK OF COURT NOT LATER THAN 30 DAYS AFTER YOU HAVE BEEN SERVED WITH THE MOTION TO ATTACH. IF YOU FAIL TO OBJECT BY THAT DATE, YOU WILL BE DEEMED TO HAVE WAIVED ANY OBJECTION. IF YOU TRANSFER ANY PROPERTY AFTER RECEIVING THIS NOTICE, AND BEFORE THE ATTACHMENT, IF ALLOWED, IS MADE, YOU WILL BE SUBJECT TO THE PROVISIONS OF RSA 511-A:6. EVEN IF YOU DO NOT OBJECT TO THE ATTACHMENT, YOU SHOULD FILE AN APPEARANCE AND ANSWER WITH THE CLERK OF COURT BY 30 DAYS AFTER YOU HAVE BEEN SERVED UNLESS YOU ARE WILLING THAT THE PLAINTIFF HAVE JUDGMENT BY DEFAULT. Plaintiffor Plaintiffs Lawyer ORDER <U+25A1> The motion to attach is denied. <U+25A1> The Plaintiff is granted permission to make the above attachment(s) within ______days. Date Justice BELKNAP COUNTY SHERIFF'S DEPARTMENT TURN OF SERVICE BELKNAP, SS 01/18/2016 I have this day served the within named TERRENCE J COYMAN a copy of a Summons and Complaint by delivering to him in the following manner: IN HAND, at 23 DROUIN DR, BELMONT, NH, at 11:08am. Deputy JSherirv Scott G Corbett Deputy 'Sheriff Belknap County Sheriff's Department Service 25.00 Post & Hand 1.00 Travel 8.40 Prepayment 0.00 Total 34.40 Ki X> n5 CO c r> ~o fO Si CD ip f • THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: _____ 'l^>u2_Lp S (XT C.d(~\\T L—_____ Case Name: ______ Cm earyj CoZft'fAl V J Coy via^ Case Number: ____________ ZAV.— ~ Cif - C>oOQC______________ (if known) ANSWER Requested: <U+25A1> Jury Trial (as allowed by law) <U+25A1> Bench Trial 1. Name of person answering: l S Coy ____________ (Relationship to case):______________ _____________________________________________ ______________ 2. I am answering the Complaint filed by (fitclyK&l 3 Answer each paragraph in the Complaint in corresponding numbered paragraphs, including any affirmative defenses you are asserting: 1. Paragraph 1 Answer: . __________________ x_ (klM ^ Cuf^vO^-i Of |Q?tyr 2. Paragraph 2 Answer: L Gym ka> - Dili- T (ytX^c<<£>-- 3. Paragraph 3 Answer:• \\ pJA’y /'/C/jUAPcJ » (/^ £'&U&r(? jMf {w Cyci<LOiCC'J.^h_C _ Continue on using separately numbered paragraphs (attach additional sheets if necessary) , _________ YvU jo rf^uc^t n'lI CtC /upf rtu'gj-p a./<J -V uj -Volt) X C\\joctc3 Y'^-C'i-VcZ-C/-£ I certify that on this date I provided a copy of this document to the parties who have filed an appearance for this case by: Hand-delivery OR JXl US Mail OR <U+25A1> Email (only when thereprim agreement of the parties to use this method of service). t-25 - \\fo Date Signature of Defendant or Defendant's Attorney Attorney's Printed Name ' Attorney's Address NH Bar Number NHJ8-2689-S (06/04/2015) 5 • • THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: So(jMLv'dy-' Cow~+- Case Name: fe,pv/ Cop ^ Case Number: C \\J - 0600 £, \\ (if known) APPEARANCE/WITHDRAWAL APPEARANCE Type of appearance (Select One) Q Appearance <U+25A1> Limited Appearance (Civil cases only) If limited appearance, scope of representation: Select One: <U+25A1> As Counsel for: (Name) (Address) (Telephone Number) (Name) (Address) (Telephone Number) (Name) (Address) (Telephone Number) I will represent myself (self-represented) WITHDRAWAL As Counsel for Type of Representation: (Select one) <U+25A1> Appearance: <U+25A1> Notice of withdrawal was sent to my client(s) on:______________ at the following address: <U+25A1> A motion to withdraw is being filed. D Limited Appearance: (Select one) <U+25A1> I am withdrawing my limited appearance as I have completed the terms of the limited representation. <U+25A1> The terms of limited representation have not been completed. A motion to withdraw is beina filed. y I certify that on this date I provided a copy of this document to the parties who have filed an appearance for this case by: <U+25A1> Hand-delivery OR <U+25A1> US Mail OR <U+25A1> Email (only when there is prior agreement of the parties to use this method of service). \\ - 2 ? ~ ( (o Date Signature X? fe&AtV 0*2 T-e/w^-xci \"X Coy a Mailing3 Addr Address Printed Name Email Address Telephone NH Bar ID # if attorney NHJB-2318-S (03/24/2014) 4 # • THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Telephone: 1-855-212-1234 TTY/TDD Relay: (800) 735-2964 http://www.courts.state.nh.us SUMMONS IN A CIVIL ACTION Case Name: Concord Hospital v Terrence J Coyman Case Number: 211-2016-CV-00006 Date Complaint Filed: January 11,2016 A Complaint has been filed against Terrence J Coyman in this Court. A copy of the Complaint is attached. The Court ORDERS that ON OR BEFORE: February 25, 2016 Concord Hospital shall have this Summons and the attached Complaint served upon Terrence J Coyman by in hand or by leaving a copy at his/her abode, or by such other service as is allowed by law. March 17, 2016 Concord Hospital shall file the return(s) of service with this Court. Failure to do so may result in this action being dismissed without further notice. 30 days after Defendant Terrence J Coyman must file an Appearance and Answer or other is served responsive pleading form with this Court. A copy of the Appearance and Answer or other responsive pleading must be sent to the party listed below and any other party who has filed an Appearance in this matter. Notice to Terrence J Coyman: If you do not comply with these requirements you will be considered in default and the Court may issue orders that affect you without your input. Send copies to: Michael J. Fontaine, ESQ Welts White & Fontaine PC 29 Factory Street PO Box 507 Nashua NH 03061-0507 BY ORDER OF THE COURT January 11,2016 Abigail Albee Clerk of Court (296) NHJB-2678-S (10/23/2013) • • THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH SUPERIOR COURT Belknap Superior Court Telephone: 1-855-212-1234 64 Court St. TTY/TDD Relay: (800) 735-2964 Laconia NH 03246 http://www.courts.state.nh.us NOTICE OF DECISION File Copy Case Name: Concord Hospital v Terrence J Coyman Case Number: 211-2016-CV-00006 Enclosed please find a copy of the court’s order of February 19, 2016 relative to: Motion to Attach with Notice February 19, 2016 Abigail Albee Clerk of Court (480) C: Terrence J Coyman; Michael J. Fontaine, ESQ NHJB-2503-S (07/01/2011) • • File: 15-185 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.iih.us Court Name: BELKNAP COUNTY SUPERIOR COURT Case Name: Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman Case Number: (if known) MOTION TO ATTACH WITH NOTICE The' Plaintiff requests permission to make the following attachfnehts' in' the above-\" referenced civil action. Category of Property to be attached .Name of Defendant Real Estate Other Description Amount of Attachment Terrence J. Coyman XX All real estate $114,000.00 In support of this Motion, the Plaintiff certifies that: The plaintiff believes there is reasonable likelihood that the Plaintiff will recover judgment, including interest and costs, in the amount of $114,000.00. To be Signed by the PlaintifTfor Affiant) (in case of a corporation or partnership, a duly authorized officer or partner shall sign.) State of New Hampshire, County of Merrimack This instrument was acknowledged before me on \\\\\\lp(/5 byDlOIU Expires ^(/ My Commission Affix Seal, if any J% ¦ COMMISSION : EXPIRES : SEPTEMBER 18, 2018 %;q <U+2666> Case Name: Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman Case Number: MOTION TO ATTACH WITH NOTICE NOTICE TO THE DEFENDANT THE PLAINTIFF INTENDS TO ATTACH YOUR PROPERTY, AS SET FORTH IN THE ABOVE MOTION FOR PERMISSION TO DO SO, TO SECURE ANY JUDGMENT OR DECREE THE PLAINTIFF MAY OBTAIN IN THIS ACTION. YOU HAVE THE RIGHT TO OBJECT TO THE ATTACHMENT, AND TO HAVE A HEARING AS TO WHETHER IT SHOULD BE MADE. IF YOU DO WISH TO OBJECT AND HAVE A HEARING, YOU SHOULD FILE A WRITTEN OBJECTION DETAILING THE REASONS THEREFOR, TOGETHER WITH A REQUEST FOR A HEARING, WITH THE CLERK OF COURT NOT LATER THAN 30 DAYS AFTER YOU HAVE BEEN SERVED WITH THE MOTION TO ATTACH. IF YOU FAIL TO OBJECT BY THAT DATE, YOU WILL BE DEEMED TO HAVE WAIVED ANY OBJECTION. IF YOU TRANSFER ANY PROPERTY AFTER RECEIVING THIS NOTICE, AND BEFORE THE ATTACHMENT, IF ALLOWED, IS MADE, YOU WILL BE SUBJECT TO THE PROVISIONS OF RSA 511 -A:6. EVEN IF YOU DO NOT OBJECT TO THE ATTACHMENT, YOU SHOULD FILE AN APPEARANCE AND ANSWER WITH THE CLERK OF COURT BY 30 DAYS AFTER YOU HAVE BEEN SERVED UNLESS YOU ARE WILLING THAT THE PLAINTIFF HAVE JUDGMENT BY DEFAULT. Plaintiff or Plaintiffs Lawyer ORDER <U+25A1> The motion to attach is denied. The Plaintiff is granted permission to make the above attachment(s) within days. Date lb o orf - ' Justice 'I A- £ THE STATE OF NEW HAMPSHIRE SUPERIOR COURT BELKNAP, SS DOCKET NO. Concord Hospital, Inc. d/b/a Concord Hospital v. Terrence J. Coyman COMPLAINT NATURE OF THE ACTION 1. This is a breach of contract and/or unjust enrichment action for failure to pay for professional healthcare services and/or supplies. JURISDICTION 2. This Court has jurisdiction over this matter as the Plaintiffs principal place of business is located within this County and/or the Defendant resides within this County. PARTIES 3. The Plaintiff, Concord Hospital, Inc. d/b/a Concord Hospital, is a New Hampshire corporation with a principal place of business at 250 Pleasant Street, Concord, NH 03301. 4. The Defendant, Terrence J. Coyman, is an individual with a last known address of 23 Drouin Drive, Belmont, New Hampshire, 03220. COUNT I IN A PLEA OF ASSUMPSIT AGAINST TERRANCE J. COYMAN ,--r >«-£ tr * 5. Plaintiff incorporates herein by reference the allegations set forth in paragraphs 1- 4 above. 6. Plaintiff provided professional healthcare services and/or supplies to Defendant on or about September 7,2014 through October 2,2014, account numbers 1425000260 and 1427200149, incurring a bill totaling $141,899.38 and any payments, adjustments and/or credits applied to the same have reduced the balance to $85,139.63. 7. Defendant received these professional healthcare services and/or supplies and promised or is obligated to pay. 8. Defendant signed a Treatment Authorization and Administrative Acknowledgement, agreeing to pay for services rendered by Plaintiff. 9. Plaintiff sent several itemized bills and numerous letters, offered to consider payment plans and advised Defendant of charitable care options. 10. Plaintiff has made proper demand for payment on Defendant, but payment has not been provided. 11. Upon information and belief, Defendant is also presently pursuing a personal injury action and Plaintiff has offered to refrain from collecting this bill until Defendant resolves his/her personal injury case provided Defendant agrees to pay the bill from the personal injury action but Defendant refused. 12. Defendant is currently indebted to Plaintiff in the amount of $85,139.63 for said professional healthcare services and/or supplies, plus actual attorney’s fees pursuant to the Treatment Authorization and Administrative Acknowledgement signed by the Defendant. COUNT II 13. Plaintiff incorporates herein by reference the allegations set forth in 2 t paragraphs 1-11 above. 14. Plaintiff provided professional healthcare services and/or supplies to Defendant onorabout September 7, 2014 through October 2, 2014, account numbers 1425000260 and 1427200149, including a bill totaling $141,899.38 and any payments, adjustments, and/or credits applied to the same have reduced the balance to $85,139.63. 15. Defendant received the benefit of these services, promised or is obligated to pay therefore, and/or has been unjustly enriched thereby. WHEREFORE, Plaintiff respectfully requests that this Honorable Court issue Judgment against the Defendant in the sum of $85,139.63, plus actual attorney’s fees pursuant to the Treatment Authorization and Administrative Acknowledgment signed by the Defendant, and provide such other and further relief as this Court deems just and equitable. Respectfully submitted, Concord Hospital, Inc. d/b/a Concord Hospital By and through its attorneys Welts, White & Fontaine, P.C W42 3 "Common words in complaint pages
tf_idf by nature of suit
The words with high tf_idf are important to each nature of suit. What distinguishes one nature of suit from the rest within the collection of court documents are the proper nouns, the names of people and places. This is the point of tf-idf; it identifies words that are important to one document within a collection of documents.
tf_idf by county
The words with high tf_idf are important to each county. What distinguishes one county from the rest within the collection of court documents are the proper nouns, the names of people and places. This is the point of tf-idf; it identifies words that are important to one document within a collection of documents.
