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HomeMy WebLinkAbout96-01589 ~ \! J Q)o- ex:, \rj . ....../ ~; , i ~., \ I I \ i , \ '",\ .' / / \ ~ ': I L / .~ i ~; , Jhll>1V"! , ; , . I~. TilE i_" IJ i.: H 'I.' I) i.' l'l 1 ~P\ll r j p I. [.; l\ :-i CUr.IBElH.Ai'lU (,OlJ~j'l',{, I'E~.jN:j'{r.IJt\~JI CrVlL t\C'I'[UN - Li\\".; ~l () . IIt\HH(~;nlJHG IlCl:iPlT^L, p [. ^ r WI' I F 1-' v IJt\NI F.f. SPH^GIJE, DEFE~D^~T -:\ (, - \ I ~, ~ .~ ...., ,-~... - \.~ fC- e 0 ~1 P L ^ ...~'~ .... ~ N T , '----- f- ~" , , ", I ARTHUR A, KUSIC ATTORNEY Ar LAW ,1l0 1 (i1\IM'j Mill R'J.\l) PO Br).( fifO'S H.",!;i;:;,: ;,;'-, Ptfj~rjrIJJ.~j:.~ 171(!fS-7015 1/17) S.l'; S6\'.' !m I I . .,,__. ,I. .i&:-:.:~ t "'~;C~<L l1u.'~~~~~~r'O:~"-"r"~~'08. OUTP. :: : : L ;'J~- ,~",~.~,~"!,_L____ t 711 PEAR ST APT 3 ~ LEHOYNE PA 17043 L ~ GARHANS t=,~'1.. -, SEIDLE HEHORIAL HOSPITAL P.O. BOX 2332 HARRISBURG, PA. 1710S 717 - 782-3680 222807097 ISPRAGUE I .aaM,at '~'t;rrE,!L-li9"~~-=-1 I.R,S.23-1352215 DANIEL II 06.14,94 06, IS ,94 .~n.NT CATI C"CRl~ON .' TOTA~ CrtARaE~ COVERAGe --2ND CO"EAAM~RO COIJERAGE A OUNT 06,13 PHLEBOTOHY 10 7,00 7, 00 , , 06: 13 HEHOGLOBIN-HCT 10 20: 00 20: 00 , , , 06 '14 OR LEVEL 2 01 729' 00 729' 00 , il6 :14 TOURNIQUET PER USE 01 9: 00 9: 00 , , 06'14 OR HONITOR CHARGE 01 lOS' 00 lOS' 00 , 06 :14 VIDE~~5TiK--- . 01 3S: 00 3S: 00 , , 06/14 ACE~n2111\02 3' 00 3' 00 I , , , 06 14 RH 102 136, 00 136, 00 / 06 14 POST_l H01DIrl/2d, . 04 140: 00 140: 00 , , 06 14 PRE.qp, PRU ..".. 04 130, 00 130, 00 , 06 14 GENERAL RICOVDY H1l 04 290: 00 290: 00 , , , 06 14 TISSUI GROSS ONLY 10 70' 00 70' 00 , , , 06 14 ANESTR GEM LEVEL 2 30 249: 00 249: 00 , , I , , / 06 14 ANESTHESIOLOGIST 30 430' 00 430' 00 , , , 06 14 12: 00 , , , , ANESTHESIA KASKS 31 12,00 , , , 06 14 PHARH-SEIDLE SURGSVC 41 424' 04 424: 04 , , , 424: 85 , , , 06 14 HEDICAL , SURG SUP 70 424, 8S , , , 06,14 BREATHING CIRCUIT-AD 70 is: 00 15: 00 , , , , , , 06 '14 IV ANGIOCATH 70 S' 00 5, 00 , , , 06 :14 IRRIGATION 500 CC 70 3: 00 3: 00 , , , , , , 06 '14 SUCTION CONN TUBING 70 9' 00 9' 00 , , , 06 :14 SLIPPERS FOAl! 70 3: 00 3: 00 , , , , , , 06 '14 DRESS STOCKINETTE 70 3: 00 3' 00 , , , , , , , , 06,14 IRRIGATION 1000 CC 70 3,00 3, 00 , , , 06: 14 n 1000 CC 70 24: 00 24: 00 , , , , , , 06' 14 IV ANE$TH SET 2C0127 70 7, 00 7, 00 , , , 06: 14 RESP 02 KASK 70 2: 00 2: 00 , , , , , , 06' 14 SURGI PAD EACH 70 l' 00 l' 00 , , , 06: 14 RESP HUHIDIFIER 70 9: 00 9: 00 , , , , , , 06' 14 ICE PACK CHEHICAL 70 l' 00 l' 00 , , , 06 :14 , , , , I RAZOR 70 1. 00 1,00 , , I 06: 14 SUCTION CANISTERS 70 18' 00 18: 00 , , I , , , 06,14 IRRIGATION 3000CC 70 16,00 16,00 , , , 06' 14 ESIWlK BANDAGE 70. 27' 00 27' 00 , , , n,,' 1#, 1U "TT 7n I ~: nn I,: nn , , , I~ l.A~ c,",.\Roes ~OA SERVICES TOTALS~ I , , , , pATlEr-, T ~AV R~NC REO &CCUA, 'fOu WIL.. , A CElloE AD lieNAL 9lWNQ err "AC1 DAr.r ' , THIS M,'OUNT See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ,I{EEnH1S,POBTION,FOB YOUB llec.OllOs. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DETACH AND RETURN THIS PORTION WIIH PAYMENT '" ",- ".., I-Bee;;" "^'E-rAC',"SS'C'SE"".CE ,-~-- ' ~c;sc-'.oe ~'" ~-T i ' , 1':'~E"''!' ...-: 'c "',..OUNT CuE 'OAU _aSAA MAKE CHECKS PAYABLE TO: AMOUNT PAlO TV" Q' 1Iu. IIh.l.I"-QOAT~' s.U,;~O "iRlCO l ~~~~~ Tl:005 I 00~orT~08 J ________ -T,-' I ,,;;,:rm,1"r!; - 1_'''''''-[ - ,o\'6.il." cJ-~j I:-----------------L--,.,-l....., ..... I I 8_ " L- DANIEL SPRAGUE t 711 PEAR ST APT 3 b LE110YNE PA 17043 L _I GARl'\ANS ~ OAj 1 SEIDLE l1E110RIAL HOSPITAL P.O. BOX 2332 HARR ISBURG. PA. 17105 717 - 782-3680 222807097 ISPRAGUE. DANIEL li~~9"~-~~-li:~~~=9~~~~~i;~~4 j I.R.S, 23'1~~:'~5 - --rOTAI. cI-lARai-- ~~icoiERiai~-cOvIiRAOi 3RO CO\liRAG& AJ"lOUfojT , --r- DATI OiSCRlPTlQN SOCIAL SECURITY NO. - 187-50-5810 , , , , , BI~TH ATE - 10/19/62 , , , , , , , , , I SEX - , , , , , IIAA ITA STATUS - 0 , , , , , , , , , , R~E - W , , , , ATtEND NG DOC'IQa ~ ~103J-IL\MSHEF . , , ~ 0008219E , I JAMES R , , , DR~ CO E -in n'\ , , , , I , , , " I ~~~~:~ ~~ ;! .36: ,; t,,;;," , I , , \ , , , , I , , , , I PROCED RE ..,.c 80.26 . , , , , , PRl)CED RE ~o '80.6 , , , , , , , , , , PRINCI AL 'R.OCEdE DATE - 06/1~/94 , , , , , PRiNCI AL SUlGEON - 97037 IWISHER, JAII~S F , , , , , , , , ADKINI TRATION CLASS - 3-ELECTIVE , , , , DISC~ GE STATUS - ROUTINE , , , , , , , , , , PO~ICY HOLDER El1PLOYER - THE BOll FACTORY /997 , , , , , , , PO~ICY HOLDER - DANIEL/Z , , , , , GR';'CE AYS - 0 , , , , , , , , , , COVERE DAYS - 000 , , , , TRtATM NT AUTHORITY - , , , , , , , , , , APPROV 0 FROM - , , \ , , , AP~ROV 0 lHRU - , , , , , , , , , , IN~URA CE COVERAGE , , , , , : GRe UP NO.: - ~PNE , , , CO. AIlE - H33/COl'\MERCIAL A-Z POLICY NO., - 050948445 , , , , , I , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , illl\,.AT! C"''''Ra~s I:QR SER\1CES TOTALS ~ , , , , PA fl1=~. '1 ...." R!"'CE~eD oc L",R. "OU Wil.l , , , R CEiVe AOOmOl'oA.. all..U~a TH S A',l:J,,',' - See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms ,. - -, . 711'-" 782-':1680 - - ' 'OETA~~e:N1H~}~e:~J~~~~J~~~~~~~~;MENT- ' ' - ' .' - - - - - -- -- -- -- - - -- - - - - -- , :::~'~::QI1 OPR.r.IlF O:':~'I::" L~.~~~::~-l~~6..~C::':~l 'c WOJ~Ou MAKE CHECKS ._~",~:'.!'!;I~"-i 'UOJ~ 0"0 PAYABLE TO: SEIDLE l1E110R IAL HOSP !TAL i__Qli.':-lic9~ 1l0A'" _2l1i.'" -'" T"tft0l1lu. DISCH OUTP. IINlms ASt)'C tt~.t;5 hOa~~Nr-~~ 08 -I , , I' 'I I I I; ...!......_.. _______'\ INSu~~1 COVI!Ill~~ _'=1_,~~9.up N~~_h_ lII.c~~~"'9___~_; COMMERCIAL A-J' : 7050948445; I . I ! __' _____L--__, J GARI1AN S i ..~. I lie I 8 . DANIEL SPRAGUE I , 711 PEAR ST APT 3 , , LEMOYNE PA 17043 0 L -1 SZIDLE MEMORIAL HOSPITAL P.O. BOX 2332 HARRISBURG. PA. 17105 717 - 782-3680 ~ ',_ I roo TOTALS~! ! I See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms _ _ , , _ " " " " -7IT'" 782'"3"80 " ' - , ' . ,~E~~ THISP08TjON,FOR YOUFl Fl.COFlOS. , , - , , o OETACH AND RETURN THIS PORTION WITH PAYMENT I ':::~~~Q7 I m.r-IfF ':-.'~~':;" I~~:":~':~-,,~~'::~:O:~(~;:l~~. MAKE CHECKS ";:so-,'.q'_;~:E.,, , PAYABLE TO: SEIDLE MEMORIAL HOSPITAL l__06..'..li'9LJ IRae". NO 'c~lmo~c"...,o I.R.S, 23.1352215 222807097 ISPRAGUE DANIEL Ir 106, 14 ,~4 06, IS ,94 P'411ENT DATI 0E1CRiF'Tl~ TOTAL. CHAAG; 1ST COVERAGe 2ND COVERAGe :lRC Coy&RAO& AMOUrr(r 06,14 RESP OXYGEN PULMONAR 92 13, 00 13, 00 , , , , ~-----'--- ------~-- ~----_!.._- ______1..__ 1-_____1..__ , , , , , TOTAL CHARGES 3377> 89 3377' 89 , , , I 1-...__:'.. 1-.....:... 1-.....'-.. !-.....~.. I-.....r-.. , , , , , , , , , , , , / , , , rn ') , , , , , I , I , I , I , I , " I , "t , , , , I , , , , , I , ,"1 .f ,~ , , , , I ,,'I"j:." .~, C. ;~:~., , i ~f;{j .;;;;. , , , , I , "..I.,,' , , , , , , , , , , , , , , , n , , , , , , , , , I , I , , , , , , , , , , , , , , , , , , , , , , - , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , I , , , , , , , , , , , , , , , , , , , , , , , , I , I , , , , , , , , , , , , , , I , I , , , I , , , I , , , I , , I I , I , , , I , , , , , f , I , , I , I , i , , , , , , , I , ! , I OJ. . ~ '. - T".l"" , 'Il' LATE CHARGES Il'OR seRviCU RerllC!REO OCCuR. VOlO w:w.. RECEI....i ADCfnOt.jA~ Blw~Q AMOUNfOU A,,",CUNf AlO 'O'W .2140\ PATIENT'S BIRTHDATE B~UE CROSS GROUP NO, BLUE CROSS CONTRACT NO _____ SUBSCRIBER __ , KEYSTONE HEA~TH NO, GROUP NO ","" u'"'_____ (ENCLOSE AUTHORIZATION) MED'CARE PATIENTS: PLEASE C(JMP~ETE QUESTIONS BELOW AND SIGN, ANY QUESTIONS CONTACT HOSP'TA~ n 1ge,eel0, MEO'CA~ ASST, PATIENTS: YOU MUST BR'NG YOUR CARD WH'CH RELATES TO THE OATE OF SERVICE TO SEIOLE MEMOR'AL HOSPITAL BUSINESS OFFICE, COMMERCIA~ 'NS, FORWARO A SIGN EO INSURANCE CLAIM FORM FOR PROCESSING, CHAMPUS: RETURN COMP~ETED ANO S'GNEO FORM ALONG WITH COPY OF CARDS, MEDICARE MEDICARE SECQNDARY PAYOR ~ COMPLETE '" 1. IS THE PATIENT OR PATIENT'S SPOUSE EMPLOYEO? EFFECTIVE OATE PART A HOSPITAL PART B MEDICA~ _YES _NO IF YES, COMPLETE A, ~ IS THE PATIENT ENTITLEO TO MEOICARE ON THE BASIS OF END STAGE RENA~ OISEASE? _ YES IF YES, COMP~ETE C, IS THE PATIENT COVEREO BY AN EMP~OYER GROUP PLAN? _ YES _ NO 'F YES, NAME OF GROUP PLAN: _NO 2. COES PATIENT HAVE RENAL DISEASE OR HAD A KIONEY TRANSPLANT? [Q] _YES _NO IF YES, COMPLETE C, __ YES _NO _NO IS PATIENT ENTITLEO TO MEDICARE SO~E~Y ON THE BASIS OF RENA~ OISEASE? IS THE PATIENT COVEREO BY AN EMP~OYER GROUP PLAN? _ YES 'F Yes, NAME OF GROUP PLAN: HAS PATieNT COMPLETeo THe TWELve (12) MONTH COOROINAT'ON PERIOO? _ YES, STOP MEOICARE PRIMARY _ NO, SEE ABOVE GROUP INS, PLAN 3. ARE SERVICES RELATEO TO OR OUE TO AN AUTO ACCIDENT OR OTHER LIABI~ITY INCIOENT? _ YES _ NO 'F YES, COMP~ETE B, ~ WHAT TYPE OF ACCIOENT CAUSEO THE 1~~NESSlINJURY? _ AUTOMOBILE: INSURANCE COMPANY ANO CLAIM NO, , _ OTHER: SPECIFY WAS ANOTHER PARTY RESPONS'BLE FOR THIS ACCIOENT? NAME/AOORESS OF RESPONSIBLE PARTY/~IAB'~ITY INSURER: _YES _NO 4. IS THIS I~~NESS OR 'NJURY WORK RELATEO/BLACK LUNG? _YES _NO 'F YES, EMPLOYER NAME ANO ADORESS AND TE~EPHONE NO, 5. DOES THE PATIENT HAVE VA HEA~TH BENEFITS THRU CARO .'0.,1141 8. 's THE PATIENT A O'5Aa~EO MED'CARE BENEFIC'ARY UNOER AGE ee? __ YES _NO YES NO MEDICARE ASSIGNMENT FORM I REQUEST PAYMENT OF AUTHORIZEO MEO'CARE BENEFITS TO ME, OR ON MY BEHALF FOR ANY SERVICES FURN'SHED TO ME BY OR IN SE'D~E HOSPITAL, INCLUOING PHYSIC'AN SERVICES I AUTHORIZE ANY HOLOER OF MEOICAL AND OTHER INFORMATION ABOUT ME TO MEO'CARE AND ITS AGENTS ANY 'NFORMATION NEEOEO TO OETERMINE THEse BENEFITS OR BENEF'TS FOR RELATEO SERVICE, SIGNED OATE , :~ :':' ; j -'1 : "1':\ !iT '1 ;~ f~, h j i-..- r\ ~ /.::, ""tu " , ,;" ! ~ .1<:');' ,io: t; ~ "j i i 'j., ; ,..:11 'rii I ;'~ !_l '.1 1:.':.H.].,. t i' 8n"f ,.I.. S!:'o'f LJ . ' ,\ ! ~ ' ! Ii; " .Jfi !!,- q~ " . " , I ~ f' ,'.N. 1 iii!. I; -,', F- .: r: , .' " .' " '. , " , , 1 i , t ,: :ll' It' ~(.,,'~ ~ 'C. ' ,';:;;.>.">::.,..:<.,-'V"~ , '.' t; c/~t4~/ 0/. n~ '--', "'1!..LtLA... (], Ilt<~ ,1J.'tVj , -..n I 'i' ,"',T,.