HomeMy WebLinkAbout96-01122
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POLiCV"'O
HARRISBURG HOSPITAL
HARRISBURG, PA. 17101
717 - 782-3680
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10: 28 CHEM I I EVAL 10 53: 50 I 53: 50
10' 28 EKG 12 114' 00 I 114' 00
10: 28 CRllTCH TRAINING 90 68: 50 . 68: 50
10' 29 DISPOSABLE CAUTERY 01 16' 50 16' 50
10 :29 ACE BANDAGE 6 01 15: 00 15: 00
10: 29 ORTHOPEDIC COTTON 01 26: 50 26: 50
10,29 GROUNDING PAD 01 20, 00 20, 00
10 :29 X-RAY CASSETTE DRAPE 01 42: 00 42: 00.
10 '29 SPLINT LONG LEG 01 132' 00 132' 00
10 :29 NORM SAL.9 1000 ilL 01 2: 00 2: 00
10' 29 BAS IC SURG SUP-IlINOR 01 102' 50 102' 50
10 :29 ORTH 1ST 1/2 HR 2 01 456: 50 456: 50
10 :29 ORTH ADDL 1/2 HR 2 01 282: 50 282: 50
10,29 MARTIN 6 IN 01 26,50 26, 50
10 :29 NEEDLE COUNT KIT 01 38: 50 38: 50
10' 29 SIllS SUCTION TIP 01 6, 50 6, 50
10: 29 DRESS ING MINOR OR 01 6: 50 6: 50
10 '29 SYNTH CAC SCREW PART 01 42' 00 42' 00
10 :29 SYNTH DRILL BIT 01 67: 00 67: 00
10'29 ARTHRSCP PK 111263 113 01 117' 50 117' 50
10 :29 RECOVERY ROOM 04 231: 00 231: 00
10: 29 COLD PACK 04 3: 50 3: 50
10,29 CHEST PA .. LATERAL 20 99, 90 99, 90
10 :29 ANKLE LIII UNDER 3 VW 20 80: 50 80: 50
10 '29 PORTABLE EXAII SURCHG 20 134' 00 134' 00
10 :29 ANES BASIC MONT II 30 59: 50 59: 50
10 '29 ANES PERS A 30 188' 00 188' 00
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10,29 ANGIO-CATHS 31 10,00 10, 00
10 '29 ANESTHESIA SUP!EQT 31 347' 00 347' 00
10 :29 ADULT BREATHING TUBE 31 21: 00 21: 00
10' 29 DUO THERM PAD 31 33' 00 33' 00
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iF L.ArE Ct<lAROeS IlOR SERVICES
RENDERED OCCuR, YOU WILL
RECE;~E AOOliIO~Al.. a:i.l.il'\iG
TOTALS ~ .su...lls1Ll'A!;f._~___
See Reverse Side If You Have Not Furnished Us
Your Health Insurance Information and/or Forms
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MAKE CHECKS
PAYABLE TO:
:<EF.P ""';5 J)~RT~" ,O:CR ',OUR j:;EC.CRC~. ._ _ _ . _ _
:::~ACH A!I,:;' J::ET...,Ro.;l'H;S PCR!-CN;.'...., PAVI.!~S!'
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, 264 RIOGE HILL RD HARRISBURG, PA. 17101
, IIECH PA 17055 717- 782-3680
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,,:;;;~'~~: IKR!'IIER. ::;'-/" t~9~~~:-~~~~;;'~~i~;'r~~~~;1 I,R,S, i~:O;~,:~~~ON
DATi Ci5CR;~~ci;..-- . r TO;,l1.. C""iROE T -,S" CO-~eRAaE"'T-a"'-OCO\iERAOi - )RD cO~eR"OE t AVCLi"",T
SOIZIAL SECURITY NO. - 191-46-187lO--'~"u-r-~' ;"-r- ---:--- -...- ~--.
BI~TH ~ATE - 04/30/50 "I':
SEX - I'
~ITA STATUS - S '
RAe! - W I
ATTEND NG DOCTOR - 65009 RUBIN i' RTON L I'DOl0217E
DR~ CO E - 219 :
DIACNO IS - P 824.0
DI~GNO IS - 5 E906.8
PROCED RE - P 79.36
PRtNCI AL PROCEDURE DATE - 10/2~/93 ,
PRINCI AL SURGEON - 6.5009 RUBIN ~ORTON L
AD/IINI TRATION CLASS - 3-ELECTI!VE :
DISCH CE STATUS - 011012031055065'
, '
POLICY HOLDER EIIPLOYER - SELF-E PLOYED
PO~ICY HOLDER - NOT ENTERED.
GRACE AYS - 0
CO~ERE DAYS - 000
TREATII{NT AUTHORITY -
AP~ROV 0 FROII -
APPROV 0 THRU -
IN5UR CE COVERAGE
~O. Al'tE - NOT ENTERED.
/99':1
: GR UP NO': - NONE.
rOLf NO.: -
OT ENTERE
,
" LATE C..A,l=IOES '0'1 SE~'iCES
RE"oCEREJ CCCL.l=I. YO... W':.~
RECE'.E ACO;TIONAL, a,U.i",a
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TOTALS ~ !
See Reverse Side If You Have Not Furnished Us
Your Health Insurance Information and/or Forms
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'------'-..--
7.17. ~ 782-3680
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HARRISBURG HOSPITAL
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GARHANS [:~~:t]
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RAY KRAMER
264 RIDGE HILL RD
HECH PA 17055
HARRISBURG HOSPITAL
HARR ISBURG. PA. 17101
717 - 782-3680
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CATE I CESCFllPT10N - ~ rOTAI.-C;'ARGEi -T+';31" CQVF.;;lAOE CiND CO'JERAGE"TJRO c6~e~AaE ~ j AMOuNT
10,29 TScHEDULE-ORUG INJECTh.';;O I ... ~ 00 r-- .... " -~ --r-- .~ 9: 00
10 :29 I ~~AL HEDS 40 2: 88 I I, 2: 88
10 ' 29 ORAL HEDS 40 4. 00 4' 00
10 : 29 ORAL HEDS 40 4: 00 4: 00
10 '29 ORAL HEDS 40 16' 00 16' 00
10: 29 INJECTABLE KED 41 24, 48 24: 48
10'29 IV-ADlfIXTURE 41 132' 06 132' 06
10 : 29 PREP FEE 59 55: 50 I 55: 50
10: 29 ICE PACK CONSTANT 70 16' 50 I 16: 50
10,29 OBS PT 151 HR 82 14i 00 ' 147,00
10 :29 OBS l'T 2ND UR 82 63; 00 63: 00
10'29 OBS P1 lRD UR 82 31' 50 3l' 50
10 :29 OBS PT 4TH HR 82 21: 00 21: 00
10 '29 OBS PTIHR 5TH-24TH 82 251' 93 251' 93
10: 29 INCENTIVE SPIROMETER 92 50: 00 SO: 00
10: 29 INCENT SP IROHETER II 92 84' 00 84: 00
10 ,30 ORAL HEDS 40 4: 00 4, 00
10 : 30 ORAL HEDS 40 4: 00 4: 00
10 '31 ORAL HEDS 40 2' 88 2' 88
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--------- --------- --------- --------- ---------
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TOTAL
,
,
CHARGES
917' 97
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917' 97
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~~i,~~E~cg~~tR.il.Y~~'~'~ TOTALS... 1_._~__~_____l_~".___________L _____..-'-__....L.__________
See Reverse Side If You Have Not Furnished Us
Your Health Insurance Information and/or Forms
7JJ ~ 7!l2-3680
.;.:EE;' 1'''''5 I:lCq-"-C,,- ;::::~ -"'0,,'1 ~E::CI:D5
c;;-.:.::,~ .1'.:; OlE"",;;!'>. '"...,5 i":;;:=l"C", .';~"" ;;I:"i','E".j~
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MAKE CHECKS
PAYABLE TO:
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01 15 96 10 29 93
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917.97'
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HARRISBURG HOSPITAL
.10 ]0 93
~evsToNe t-<eAL Tt-< NO
MeDICARe PATIeNTS
BLUe CROSS CONTRACT NO
SUBSCRIBER ....
GROUP NO
.............-..-1
...- .----------
PATlENT'S BIRTt-<DATE ..__....__..__. -
BLue CROSS GROUP NO .
IENCLose AUTt-<ORIZATION)
MEDICAL ASST PATIENTS
PLEAse COMPLeTe oueST IONS BeLOW AND SIGN ANY OUESTlONS CONTACT t-<OSPITAL AT
182,3660
YOU MUST BRING YOIJR CARD Wt-<ICt-< ReLATES TO Tt-<e DATe OF seRv;ce TO t-<ARRISBURG
t-<OSPITAL CUsrOMeR seRVICE OF. Ice
FORWARD A SIGNeD INSURANce CLAIM FORM FOR PROCeSSING
ReTURN COMPLeTeD AND SIGNeD FORM ALONG WITt-< copy OF CARDS
COMMeRCIAL INS,
Ct-<AMPUS
MeDICARe ~ MeDICARe
seCONDARY PAYOR COMPLeTe" .......,-.
eFFeCTive DATe
PART A t-<OSPIT AL
PART B MeDICAL ,....____
_~___~_._._..~._.____._____._..____u_.__ ._uw_.
1.
IS Tt-<e PATieNT OR PATieNT'S spouse eMPLoyeD? yes NO IF yes. COMPLeTe A.
~ IS Tt-<e PATIeNT eNTITLeD TO MeDICARe ON Tt-<e BASIS OF eND STAGe ReNAL DISeASe? ,....... yes
IF yes. COMPLETe C
IS Tt-<e PATieNT coveReD BY AN eMPLOyeR GROUP PLAN?
IF Yes. NAMe OF GROUP PLAN' ___.._,_...__.._... ..-..
...... NO
yes
NO
_. _~_._ .~.~____._..____..~.__._.. ______..._.__~~_._________._..___________..._...~____ ..n__.___'.__'"
2. Does PATieNT t-<Ave ReNAL DISeASe OR t-<AD A ~IDNeY TRANSPLANT? yes ...__, NO IF Yes, COMPLeTe C,
ra IS PATIeNT eNTITLeD TO MeDICARe SOLeLY ON Tt-<e BASIS OF ReNAL DISeASe? ___, yes -... NO
IS Tt-<e PATIeNT coveReD BY AN eMPLOyeR ClROUP PLAN? ...'n. yes _-.. NO
IF yes NAMe OF GROUP PLAN __.._...__.._..........'___..____._ ..,..__,. ...-- ..--, ..u.._.......__ ---,..-
t-<AS PATieNT COMPLeTeD Tt-<e TWeLve (121 MONTt-< COORDINATION peRIOD?
_.._ Yes, STOP MeDICARe PRIMARY NO see ABove GROUP INS PLAN
--_..__.__._~-----_._----_._----- ...-- ...-. ..-------------...-----..-- ----_._----~---_.
3. ARe seRVices ReLATED TO OR Due TO AN AUTO ACCIDeNT OR OTt-<eR LIABILITY INCIDeNT?
_. yes ....._ NO IF Yes. COMPLeTe B.
~ WHAT TYpe OF ACCIDENT CAuseD Tt-<e ILLNeSS,INJURY?
__ AUTOMOBILe, INSURANce COMPANY AND CLAIM NO
___ OTHeR, speCIFY __..___,,___,___'__"'_____'"
--.----.------------------.--..--.-....--. --- .----- ----..------------.--------------.---.--...-
WAS ANOTHeR PARTY ReSPONSIBLE FOR THIS ACCIDENT?
HAMEiADDRESS OF RESPONSIBLE PARTY,LIABILITY INSURER,
.._.. YES __ NO
_...___.'__.____... ..____u__._.___..______________
4. IS Tt-<IS ILLNESS OR INJURY WOR~ RELATEDIBLACK LUNG?
IF YES EMPLOYER NAME AND ADDRESS AND TELEPt-<ONE NO
_ YES
NO
____.u___. _ ____________._____.______._.__..____ ~----
____.__._____.___._._._ ___ ._________._.~_________u_.
5. DOES Tt-<E PATIENT t-<AVE VA t-<eAL TH BENEFITS THRU CARD" I O,I114?
r-------..------.....--...... ' ,-,..--,--- ,..... ....- ,...,.
I 6. IS Tt-<E PATIENT A DISABLED MEDICARE BENeFICIARY UNDeR AGE 85?
1_...'__.._.______ H_
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YES
,__ NO
,___ YES
........ NO
MEDICARE ASSIG~MEIITfQf!PJI,
I REoueST PAYMENT OF AUTt-<ORIZED MEDICARE BENEFITS TO ME OR ON MY BEt-<ALF FOR ANY SERVICES FURlllSHED TO ME BY OR IN
t-<ARRISBURG HOSPITAL INCLUDINCl Pt-<YSICIAN SERVICES I AUTHORIZE ANY HOLDER OF MEDICAL AND OTHF.R INFORMATION ABOUT ME TO
MEDICARE AND ITS AGENTS ANY INFORMATION NEEDED TO DETeRMINE THESE BENEFITS OR BENEFITS FOR REcATED SERVICE
SIGNED
DATE
.__1
------- --~
PATieNT'S BIR.HDATe
B~Ue CROSS GROuP NO
KEYSTONe HEA~TH NO
MeOICARe p.~neNTS
BLue CROSS CONTRACT NO
SUBSCRIBeR
GROUP NO
._. leNCLose AUTHORIZATION)
I
I COMMeRCIA~ INS
l~~;::::" -" ~it:,~:""OO.""'" '" ;;~~~~~,'" .""", """:".,::---=--
I 1. IS THe PATieNT OR PATiENT'S SPOUSE EMPLOVED?
i
i fA' IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE?
I 1._.1 IF VES, COMPLETE C.
I :: ::: :~~~N~FC~~~:~Dp~:N ~M~L~~ER GR~.U~LAN~_.=- V~....~~~'..~~_
r-;."-~~~;~:~;E~~::;RENAL DI~~~E OR :~~-~'~'DNE~~RA~~PLANT--;'-"'_~~:~~~;-'~","':=-NO
I :~j IS PATIENT ENTITLED TO MEDICARE SO~E~V ON THE BASIS OF RENAL DISEASE? __ VES
I IS THE PATiENT COVERED BV AN EMP~OVER GROUP PLAN? __- VES -- NO
~ ~A~E:~~:~~ ~~~:~~:~~H~ ~~~C~;~2;-~~~TH C~~~;;;ATION PERI;~;-----'
_. VES, STOP MEDICARE PRIMARV .....__ NO, SEE ABOVE GROUP INS. PLAN
_.,_~,._,_..._.."._,_'_hO'_"_ ...,...,.....,.._...........,_. ...,-..--.......--........'..'
3. ARE SERVICES RELATED TiJ OR DUE TO AN AUTO ACCIDENT OR OTHER LIABI~ITV INCIDENT?
_... VES __ NO IF VES COMPLETE B.
PLEASE COMPLETE QUESTIONS B&:LOW AND SIGN ANV OUESTIONS CONTACT HOSPITAL AT
792,3880
MEDICA~ ASST PATIENTS
VOU MUST BRING VOUR CARD WHICH RELATES TO THE DATE OF SeRVICE TO HARRISBURG
HOSPITA~ CUSTOMeR SERVICE OFFICE
FORWARD A SIGNED INSURANCE CLAIM FORM FOR PROCESSING
.., YES
NO
IF VES, COMPLETE A,
..._ VES
_NO
IF VES, COMPLETE C,
_NO
,..-..,
l.IIi WHAT TYPE OF ACCIDENT CAUSED THE ILLNESStlNJURY?
.._.... AUTOMOBILE INSURANCE COMPANY AND CLAIM NO
.__" OTHER SPECIFY ____...____ .------..----,...--,--..........---
WAS ANOTHER PARTY RESPONSIBLE FOR THIS ACCIDENT?
NAMEiADDReSS OF ReSPONSIBLe PARTY'LIABILITV INSURER:
.... YES
_. NO
4. IS THIS ILLNES~ OR INJURV WORK RELATED, BLACK LUNG?
. ..__ YES
_...m NO
IF yes eMPLOYER NAME AND ADDRess AND TELePHONE NO
________.___ __..__...____.__ .__~_._____________._________~_.~_ __ .-...-..--_.__-_0---_--
_____.___m________ ._._________.n_____ _.___.__~_________ ____.______.__u_..._____u._
5. Does THe PATIENT HAVE VA HEALTH BeNEFITS THRU CARD .'O,I174? . ._ YES ,.._ NO
r---------------..-- --.---.----.--------~-~------.----.--..--.----.--------.-----~-
i 6. IS THe PATIENT A DISABLED MeDICARe BENeFICIARY UNDER AGE 8~? .... . yes NO
1___"___'" --. ----.. ,-....----......, _n_ -,,-..-..- .m_..___"''' ...-.-... -_._..~,..
! MED1c:AFl.E ~!3S1q~MI:~T I'QI'lM
I ReOUeST PAVMENT OF AUTHORizeD MEDICARe BENEFITS TO ME OR ON MV BEHALF FOR ANY seRVICES FURNISHeD TO Me BV OR IN
HARRISBURG HOSPITAL INCLUDING PHYSICIAN seRVices I AUTHORIZE ANY HOLDER OF MeDICAL AND OTHER INFORMATION ABOUT Me TO
::::'~'" ". ~"" '" "m,~"" """ m ""'M'" '"'" '''''''''' ""'''',::: ,,~'" ":" ..~~... I
HARRISBURG HOSPITAL,
PlaIntIff
IN THt: l:uUHI ()/ COMMON PLEAS
aJMBERLAND COUNTY. PENNSYLVANIA
:
CIVIL ACTION - LAW
NO. 96-1122 Civil Term
II.
RAY E. KRAMER,
f)efendant
CERTIFICATE OF SERVICE
1. Arthur .4. I<U:51C. E:5Qulre. do hereb,v certlf,v that on
ChI:5 4th
d"H of April
. I~j 96 . r placed In the United
SCates Mal I true and correct coore,' of Ten Day Important
Notice.
addressed to fol lOWIng:
Ray E. Kramer
264 Ridge Hill Road
Mechanicsburg, PA 17055
~;
42 1 Crums 1
P.O. Box 11585
Harrisburg, PA 17112
(717) 540-5610
At torne,v for the Pia III ti ff
Supreme Court 1.0. 07207
, .
td
Arthur A. Kusic, Esquire
Supreme Court No: 07207
4201 Crums Mill ROdd
Harrisburg, PA 17112
(717) 540-5610
Attorney for Plaintiff
HARRISBURG HOSPITAL,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNT'f, PENNSYLVANIA
v.
CIVIL ACTION - LAW
NO. 96-1122 Civil Term
"
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RAY E. KRAMER,
Defendant
IMPORTANT NOTICE
TO: RAY E. KRAMER:
DATE OF NOTICE: APRIL 4, 1996
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A
WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING
WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH
AGAINST VOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS
NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND
YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. 'fOU SHOULD
TAKE THIS NOTICE TO A LAWYER AT ONCE. IF 'fOU DO NOT HAVE A LAWYER
OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO
FIND OUT WHERE YOU CAN GET LEGAL HELP:
Lawyer Referral
CUmberland County Court Administrator
4 th FlCXlr
1 Courthouse square
Carlisle, PA 17013
RESPECTFULLY SUBMITTED:
(717) 240-6200
- . :..<_._~-~:-;-~~.~'").
. . / ,~);:.:: U::' A-"" ,."
{A~rf~lJSrC;"ESQUIRF.
THE PURPOSE OF THIS COMMUNICATION IS TO COLLECT A DEBT AND ANY
INFORMATION OBTAINElJ wrr.r. BI-: USED FOI< THAT PUHPOSE.