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Home My WebLink About97-02002 ~ ~ \!. ~ ~ ~ '.....,..... ", .~ ) .I f t,r " ~. .,;," " l ~ o <:) ~ ~ I' f. I , ~. ! -:~ (., ,. (" 't~-\": ('\ r;;. (..';. -, ::;,..{ ~')~~ '.):'- .7, . ~~ . In, ,'/'. . ~/. '.:-\\'(j ,;.10,.. ". .' ~. - ~... ~:.. ." " ,:., .) '.' ~ ,-' n ~ c.:.:. ~ ."p -;:OJ U , ".. " <'(;, \I L) ! ,,,. TIMOTHY BEVERLY BYRNE, Plaintiff v. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 97-2002 CIVIL TERM : IN CUSTODY BARBARA ANN BYRNE, Defendant ORDER OF COURT AND NOW, this ;It) day of ""~ ' 1999, upon consideration of the attached Complaint, It Is hereby directed that the parties and their respective counsel appear before \\i:.("\ \ "{ b\$o,\ ' Esq.. the C~ncillator. at ..\r ~"'~\.(\.l.'{\"n\1\c\\$ .C\U\lr{)j.:)C on the .,,< 11J day of,7iLlv , . J 1999, at t) ::0 II.M., for a Pre-Hearing Custody Conference. At such conference, an effort will be made to resolve the issues In dispute; or If this cannot be accomplished, to define and narrow the issues to be heard by the Court, and to enter Into a temporary order. Failure to appear at the Conference may provide grounds for entry of a temporary or permanent order. FOR THE COURT, BY:~\~'i~~~, Custody Conciliator Ul ~-\r (\);:)~ The Court of Common Pleas of Cumberland County Is required by law to comply with the Americans with Disabilities Act of 1990. For Information about accessible facilities and reasonable accommodations available to disabled Individuals having business before the Court, please contact our office. All arrangements must be made at least 72 hours prior to any hearing or business before the Court. You must attend the scheduled conference or hearing. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (717) 249-3166 " , , ;' I~ I' . .' " o.i (. " ::;: ~,2 ~ ~ .' '. 'l~.: I.Jl;""I;.~., : ,:L' ,,', .<.," I , ; I , ~.;Jt;.'l'l jV/ ~~ /1fj~ ~ 4 ~/ .J.//'71 71:.,.110 /11;/~ z. /4 n.dc.e .f'II'~?) ~I';P ~~.-/ '--'I. -;I .~?'-' # . , , i p,.. TIMOTHY BEVERLY BYRNE, Plaintiff v. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 97-2002 CIVIL TERM BARBARA ANN BYRNE, Defendant : IN CUSTODY PETITION TO MODIFY 1. The parties h8reto are the natural parents of Andrew Thomas Byrne, born February 26,1989 and Connor Lee Byrne, born July 6,1992. 2. On or about January 13, 1999, the parties entered into a Custody Agreement whereby the parties would alternate custody of the children on a week on, week off basis. 3. The mother, Barbara Ann Byrne entered into this Agreement based on an oral understanding from the father, Timothy Beverly Byrne that he would change his workshift from 3-11 to another shift allowing him to spend significantly quality time with his children. As of the date of this petition, this has not been done and consequently the basis for the Custody Agreement no longer exists. 4. The mother, Barbara Ann Byrne, has been the primary custodian of the children since their birth and is pr8pared to resume primary custody based on the father's inability to change his workshift. 5. The best interest of the children will be served by a change in custody allowing the mother to retake primary physical custody as she is at home at all times and is available to care for the children as opposed to a third party caregiver which the father must utilize based on his work shift. WHEREFORE, for all the above reasons, the mother, Barbara Ann Byrne, respectfully requests this Court to set a hearing and, after hearing, award her primary physical custody. I ! I I .:n I ~/7/7) Date \ \ on Turc, Esquire 32 South Bedford Street Carlisle, PA 17013 (717) 245-9688 Attorney for Defendant r: I') ,~) ~ .J :, ., : 0 '. J , f.., ...J '., , 1 'J I n ..-! ".' ::. ~ , " -.:." I . i I : TIMOTHY BEVERLY BYRNE, Plaintiff : IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - LM1 BARBARA ANN BYRNE, Defendant NO. 97-2002 CIVIL TERM IN CUSTODY STIPULATION 11HEREAS, the parties have reached an agreement as to the custody and visitation of NlDREl\' THOMAS BYRNE, and CONNOR LEE BYRNE, born to the parties, TIMOTHY BEVERLY BYRNE and BARBARA ANN BYRNE, and wish a Court Order to reflect that agreement; THEREFORE, with due consideration for the welfare of said children, both parties hereby agree as follows to wit: 1. Shared legal and physical custody of the children, ANDREl1 THOMAS BYRNE and CONNOR LEE BYRNE, shall be determined by an agreement executed by the parties hereto, attached hereto as Exhibit "A", and made a part hereof and incorporated herein by reference. 2. It is contemplated and requested by the parties hereto that this agreement be adopted by Order of Court. WITNESS: a1"'7cY~U"'<1, ~ tdtM< YJ1%m~ (. , '-'\ -, ~~;nf1r- , , '. I. .! CUSTODY AGREEMENT ! .~ () V.,,'( I 1'1"1"( THIS AGREEMENT, made this I 3'~ day of Deeembe.., 1998, by and between TIMOTHY BEVERLY BYRNE of 107 Helen Ave., Shippensburg, Cumberland County, Pennsylvania and BARBARA ANN BYRNE, of , F ,. ,I 159 Meadow Drive, Shippensburg, cumberland county, Pennsylvania. WITNESSETH: WHEREAS, the parties were married on March 17, 1989, in Queens, New York; and WHEREAS: Two children were born of this union and marriage, namely ANDREW THOMAS BYRNE, born on February 26, 1989; and CONNOR LEE BYRNE, born on July 6, 1992. WHEREAS, the parties have reached an agreement with regard to custody and visitation of said children; NOW THEREFORE, in consideration of the mutual covenants herein made, as well as other good and valuable consideration, the receipt of which hereby is acknowledged, the parties hereto, intending legally to be bound hereby, do covenant and agree as follows: A. Shared legal and physical custody of the aforesaid children, during minority, hereby is given to both parents, with both children residing with mother :or one week commencing at 6:30 P.M. on sunday and ending on the following sunday at 6:30 P.M. and children residing with the father on the alternating Sunday from 6:30 P.M. and ending on the following sunday at 6:30 P.M. . B. The parties further agree to meet at an agreed upon location for the pick up and drop off of the children. E/r/1thrt "II f C. The parties shall take all reasonable measures to foster a feeling of affection between themselves and the children. Neither party shall do anything to hamper or impair the children's love and respect for the other party. D. With respect to the major holidays consisting of New Year's Day, Easter, Memorial Day, Fourth of July, Labor Day, and Thanksgiving, the parties hereby agree that they will alternate physical custody of the children on said holidays. E. with respect to the Christmas holiday, the parties shall share Christmas with one party having visitation from 12:00 noon on December 24th until 12:00 noon on December 25th while the other party shall have visitation from 12:00 noon on December 25th until 12:00 noon on December 26, 1998. This schedule shall alternate commencing with Christmas of 1998 and this schedule is further subj ect to the work schedule of Timothy Beverly Byrne. In the event that Timothy Beverly Byrne is required to work on December 24 and/or December 25, the parties agree to make arrangements for him to have visitation as close to Christmas as possible. F. It shall be the responsibility of each parent to keep the other advised of the address where the children will be living and of any medical emergencies concerning the children. G. TIMOTHY BEVERLY BYRNE and BARBARA ANN BYRNE agree that in making this agreement there has been no fraud, concealment, over- reaching, imposition, coercion, or other unfair dealing on the part of the other. H. TIMOTHY BEVERLY BYRNE and BARBARA ANN BYRNE hereby agree and therefore stipulate that it is their intent and request that the Court of Common Pleas of Cumberland County, PennsYlvania adopt this agreement as a decree and Order of Court. IN WITNESS WHEREOF, the parties hereto have executed this the day and year first above written. WITNESS: ?R~0:~~-:'1~ (SEAL) nCT :I () 1998 hi? TIMOTHY BEVERLY BYRNE, PlainlifT v IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LA W BARBARA ANN BYRNE, Defendant NO. 97.2002 CIVIL IN CUSTODY '" COURT ORDER AND NOW, this .;l. qt day ofOctobcr, 1998, the Conciliator being advised that the parties have reached an agreement, the Conciliator relinquishes jurisdiction. BY THE COURT, Hubert X. Gilroy, Esquire Custody Conciliator i i i ! i I i , \ ,:,;''/\It";.\,'\=];j 't... ".-. -. .... ''''''" 1\. i. . ... ',nl \) ... . ", -, . "',1 f'" U I :r::/ ';;1 (.- "U".:::J ).b"~l:, -".", . . 4 f!. :.:::; 3::i::CHJ3lJ , . ! BARBARA ANN BYRNE, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUl/TY, PENNSYLVANIA V. TIMOTHY BEVERLY BYRNE, Defendant CIVIL ACTION - LAW NO. 97-2002 CIVIL TERM IN RE: CUSTODY ORDER OF COURT AND NOW, this 8th day of October, 1998, after meeting with counsel, Defendant's request for psychological evaluation by Stanley Schneider, M.E.D., is granted. Both parties are directed to cooperate with Dr. Schneider for the appropriate evaluations. The cost of this evaluation to be borne by Defendant. p pleadings in this action shall be amended to provide that mother is the Plaintiff and father is the Defendant to avoid any This request is granted under the express understanding that Dr. Schneider will have a report written and will be prepared to testify sometime in November. Various confusion. By the Court, Edward E. Guido, J. Ron Turo, Esquire For the Plaintiff Co~U:'" '?'~:.l ;O/9/riS' If ,.l ri'- Anthony L. DeLuca, Esquire For the Defendant :lfh ~ ~ 2f ~~ ~ ~r' J \ pi .'r.'> BARBARA ANN BYRNE, plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. TIMOTHY BEVERLY BYRNE, CIVIL ACTION - LAW Defendant NO. 97-2002 CIVIL TERM IN RE: CUSTODY ORDER OF COURT AND NOW, this 30th day of September, 1998, this hearing is continued until 12:30 p.m. on October 22nd, 1998. The parties are each directed to attend and pay for The Seminar for Separating Families put on by Inner Works. Said seminar must be completed within three months of today's date. By Edward E. Guido, J. Ron Turo, Esquire For the Plaintiff ~d"'-~ ()I'-;"~C<l'( IO/~fqK. ,.s. ? Anthony L. DeLuca, Esquire For the Defendant :lfh I am firmly convinced that the matter is now ripe for your disposition and would object to any evaluation that would take place into November. Moreover, based on the timetable outline, you would not even be able to have this matter presented until probably later in November consistent with your schedule. I believe that Mrs. Byrne has clearly proven her relocation case under Pennsylvania law and do not see any need for a hearing on October 22, 1998 based on the fact that no psychological evaluation will be completed by that date. Therefore I respectfully request that you allow Mrs. Byrne to relocate at this point and deny Mr. Byrne's request for custody. RTlkad ,.Slnn ,. /,2/JL 1- I l RON TURO, ESQUIRE cc: Anthony Deluca, Esquire Barbara Byrne , i; Honorable Edward E. Guido Court of Common Pleas October 6, 1998 Page 2 The sessions on October 20, 26, 27, 28 would be applicable to the mother and father, and possibly to the significant others. A report would be issued approximately two (2) weeks after all sessions have been completed and necessary data obtained. I would respectfully request that, based upon the above time frame, a psychological evaluation be conducted. It would appear that the evaluation would be done in a timely manner and not create any great delay. The evaluation will allow the introduction of a report by an independent party that may be critical to the best interests of the children. I am available for either a telephone or chamber conference at your convenience. Very'truly yours" ~ 0 ~ ~~~ A~~n~ MeLu~ ALD:mad CC: Ron Turo, Esquire I Il-I/I)~. 1'1':1:: 101: L' /I ",-,1,:': :'''1.' ..111111111, I {'I."ll' ,. '",II 1-,,',1 III .- ANrIlONY L. DELUCA A'I"1'UlttlEV AND COUNSELLOR A'I' LAW 113 FRONT STREET P.O. UOX 15R BOILINC SPRTNGS, PA 17007 (717) 258-6844 YAX (717)-25B-J90~ TRJ\NSMnWTl'tI 1"1'1-:: cV('f<":Jb-tJI'I."/-/.lry TO: _\:J-UAA' FcI'l'.:JNJ ,E. ulIld^ FAX NO, 2ft) - 'f..U FROM: II .}).(: 1. (f r' .J CONFIDEtlTIALITY NOTICE 1 THIS TRANSMIS::I()N If, INTENDED ONl.Y FUK THE USE or THF. INDIVIDUAL Oil ENTITV TO WH \.:'J! IT I~; ADDRESSJ:;D, MID MAY CONTAltl COllFTDEN'I'IAI. INFORMATION BILOUGING '1'0 THE SENDEK WHICII Hi f'ROTF.C'I'EU 8'( All ATTORNEY-Cl Ht:" I'IUVII,r.GE. IF YOO ARE NOT THr. TtI'I'EIlDJ:;O RF.CIPHIl'I', YOU ARE Hr.RE';', il()'I'TFTEO 'I'IlAT ANY D15CLC)~;tlRr.. CO!'YltlG, 01STHIULlTTON OR THE TAl< II;' 'JF ANY ACTION IN RJ::[.T ANCE ON THF. CO 11'1' EN'!,:,i Of TlIl~; INFORMATION ,; STRIC'I'LY PROHIUI'l'EI). If 'lOll HIIVF. RI:CI::IVW Till" 'I'RANSMISSIOt: ": 1':1<1<01<, IMMF.OTATI::LY IH)'l'TfY I:~: 11'( 'rfr.r.rIlOIIl:. toR T1':' RETURN. TIlI"1f '{')lJ. This cover ,...",. is on..' ur _ ? __ 1101qes buinq trilnsmlttl"ld. r PATIENT: BYRNE BIRTH: 092862 PHARMACY LAbORATORY LABORATORY EIIERGEHCY ROOM CLAIH . 71992063000 I Capital mJ.,cross l'l'nnsylvania U1ucShield lodependef1lllufl\'" 01 the lIlu. Croll J;nIj Diu. Shl.ld Ancd'lion I I SERVICE. DATES I"'I-! NO. I \ ,_ tv .. lives B GROUP: 023111 O~ 7 0250 0611~ 7 0301 o 697 0305 I I I ! i ::e'i.1 \~..: l: ~I .~~ I' 7bo 100 000 ~I 311pO 311~. 0 ObO 000. 87~0 87,00 0'00 0001. r. 0 g ngl f II I. I +, r r r> r> (') r. (', ,", MM EXPLANATION OF CODES 753 Our rocords show tho patient was not eligiblo for benefits at the tiae these ,., f~t II . 'Capital BlueCross ~ ; ". Pennsylvania BlueShield ... II '............. Uc_.' .... DI... _.... Oluo ShI.I. Au.d.lI.. . . COIIP 1 CENTER DEPARTHEHT 778988 HARRISBURG, PA 17177-8988 . 1".111".1.,1,1,1.1.1",11.,1,..1.1"1.1,1.,111..,1,,,1,1,1,1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-82211 . ... EXPLANATION OF BENEFITS COMPREHENSIVE AND WRAPAnOUNO MAJOR MEDICAL PROGRAMS r ------ UBSCnlUEFl 15 . lilt ana' '~O>>A...'II!!\T'I . LIII PlIOR I 'ALLOIlAIICI I ALLOlIAHl:I IIIISlAOI' JlW,IOIILI 'hJlOlJllAllCt;"I':Jov=i=5:f'cARr~:~~vw~~p!.r' IUlleRDIII ' A/lllllllT CODIt .. I 0,00 .-'-~iOO 0'00 75;~W--'~-_ ~"\ 000 0;00 oeo 753 .. 0100 000 O,uO 753 i ' .~~ ~g _-D~ 2SL ;-- o or f.1otJ1Cilto III alnounls .:lm o 000 ~ covUfilgU may ed propmly. , Olper\ses ... h Iho addlhonHI M' 51 bo comp!Cled mo Ocnchts' Of ,idor lho unpaId were rendered. This expense is net eligible. or. chmo malllmum "cnl ma.imurn , DEFENDANT'S r EXHIBIT Jmber provldod. to .110 questions rlL ' CONCERNING ~',.'. . ,PI.~'J"",11tlS8TATIHINT FOR YOUR RICOIlD8..' .'. !'..":.!'lil'~~~;!~~l,,,~Mm.XT.~,OHAL. X~R~T.IOH,~~,':..pt.18.~~r~"~:.. ' SUBSCRIBER: T B BYRNE CONTRACT' H27q662016 NOTICE DATE 07/21/1997 CHECK . QUESTION CONCERNING THE ABOVE CLAIMlS)? TELEPHONE INQUIRIES: WRITTEN INQUIRIES: PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEMENT. MAIL TO: TOLL-FREE TOD UNITS 1-800-222-33Ql THE COMP I CF.NTER 1-800-2Q2-Q809 DEPARTMENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8:00 AM - 6:00 PM F.ST H Q106 .-- ..~ 1", ...., .. -- . . . . . . . . . . '" I~ ') \, .... Capital lIIucCross I'cnnsyhnnia U1ucShield 11l&h,..nWnlllun.... GIlh. Blue C,o.. and DIu. Shl.ld AUoKl.llon I SERVIC~ IlATlS '\"'1 ~ ! 110'1 TOTAL I LESS AIIOUHT I ,ALI.OlIAILI. I. LI!.SS 'f '. .' .~.. .' ..f.PlI... ;',;.~tO "" ~ ....C;IIAlIiIL. :{"~WULJL ._.AlIOlICl..:.:.<< BYRNE B GROUP:00279 092862 i 19pO 1900 30,00 30~0 3~g 3~Ug 127,00 12'1/10 20:illJl, 20liQ!l 42500 42 00 +, .: PATlENT: BIRTH: PHARKACY KED/SURO SUPPLIES LABORATORY LADORATORY WADIOLOGY EIlERGtKCY ROGK CLAIM . 1722820503500 PHARKACY 1. V. SOLUTION KED/SURO SUPPLIES LABORATORY LABORATORY EIlERGEIlCY ROGK CLAIM' 1722820503600 2 0250 2 0258 2 0270 2 0301 2 0305 CLAIM TOTAL PATlENT TOTAL , , I I I \ .. EXPLANATION OF CODES . 769 The subscribor did not respond to our inquiry on othor covorago, wo prosu.o that anot PaYMont for this cIa!. and all futuro clat.s wil1 be denied until the subscribor pro vi 293 The specific condition roported does not qualify for pay.ent undor YOUR o.orgency ben~ I I THE 1997 DEDUCTIBLE SATISFIED THE 1997 COPAYHENT SATISFIED THE 1997 BENEFIT PAID LIFETIME BENEFIT PAID FOR BARBARA IS FOR BARBARA IS FOR BARBARA IS FOR BARBARA IS . .. 'Capital BlueCross " . " Pennsylvania BlueShield ..~ II ,............ U,onu.. .,... .,~ c.... ond .,~ Ihl.'d A.......I... . . COIIP I CENTER DEPARTMENT 778988 HARRISBURQ, PA I7177-89Ba . . 1,"11111I1,,1.1,1,1,1,"11,,1",1,1,,1,1,1..111,"111I1,1,1,1 T B BYRNE 107 HELEN AVENUE SIIIPPENSBURG PA 17257-8224 . . 0.00 OF 250.00 0.00 OF 3,000.00 96,00 0.00 OF 1,000,000.00 " ;7 '--' ..~ ... "" ... ... .. . . . . . . BJ (8'9.$1 -- .. ~ ., ti '0 Capllal 81ucCrnss · , PCllnsylvania lIIucShlcld Independeol L1ttn.... vI If.. !lIve Cfon .nd DIu. Shl.ld A"IKI.llon ~.:".. "" U::I,Ce.D~{~' 1"1":'-!s~L PATIENT: BYRNE B GROUPI00279 BIRTH I 092862 ~~~~~~~-r--~ t"&RG ROO" "tDlCAL VISIT 0 ~.I.~.l~J~,:r~~~ CLAIH . 72181493500 PATIENT TOTAL TOTAL I LEU AIIOUIIT L' ALLOIIABU, CtWlQll._.. .. ~HQ.WJllU!... ,.,.NllllIIT.,'..o.. LlU..; 96,00 -~O , ~ I I I I ,..... II EXPLANATION OF CODES 293 The specific condition reported does not qualify for pay.ont under YOUR eaorgency THE 1997 DEDUCTIBLE SATISFIED THE 1997 CO PAYMENT SATISFIED TilE 1997 BENEFIT PAID LIFETIME BENEFIT PAID , I 1-- .- 1\ I I I I I I I , I I I I FOR BARBARA IS FOR BARBARA IS FOR BARBARA IS FOR BARBARA IS 0.00 OF 250.00 0.00 OF 3,000.00 96.00 0.00 OF 1,000,000.00 . 'Capital BlueCross fl ; '. Pennsylvania BlucShield ~ g '-. U""'M' .".. D'.. c.... ... DIuo .....,. "'_,..,... . . CO/IP I CENTER DEPARTMENT 778988 HARRISBURG, PA 17177'8988 1,.,"1."1,.1,1,1,1"""",,.,,1,',,1.',1,,111.,,'11,1,1,',1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-822q i / I I I 1 I / I' , EXPLANATION OF BENEFITS COMPREHEtlSfVE AND WRAPAROUND MAJOR MEDfCAL PROGRAMS , usa OTHfR ~m .~AYIllJtT J LfSS ,nOR I ALLIlWAItCI I ALLIlWAItC! 11I!8SAGE & IHEL1l!18LE ". lWA ~IX I -..IT:. . mull PAlJI TO 'ROVJDE....TO GU8SCRl..&Il.I..., lIllUII~I!!I.~.; PROVIDER I (436791) RWC CORP EMER MEDICINE ;UDSCRIBER IS ,.. 000 o o 0 ~e or Mcdic.lro 293 ,- 'lJr ml ilrT10unts are ~- III. ,.. ~ ,.... \0 coverage milY sod properly. ,", j expenses. lm~ Ih tho additional r fit. "'b 1St be completed . . :aro Dcnohls. or iider the unpaid . I ar Icllme maximum Ct. menl maximum umber provldod. ro arc questions ;TIC ; CONCERNING I , I I ;THE [l'HE I , '. 1997 FAMILY DEDUCTIBLE SATISFIED IS 0.00 OF 500.00 1997 FAMILY COPAYMENT SATISFIED IS 0.00 OF 6,000.00 . . PLEASE KEEP THIS STATEMENT FOR YOUR RECORDS. . .:v~.!~~;,!I_~~~~,~~~.~~~~.:t~.Dl.Tl.~~~~I~f~~T~~.1B.~~!..~~}.!..l!!M..P..!~1;~._ SUBSCRIBER: T B BYRNE CONTRACT' H274662016 NOTICE DATE 08/06/1997 CHECK . QUESTION CONCERNING THE ABOVE CLAIHIS)? TELEPHONE INQUIRIES: WRITTEN INQUIRIES: PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TOI TOLL-FREE TDD UNITS 1-800-222-3341 THE COMP I CENTER 1-800-242-4809 DEPARTMENT 77-8988 HARRISBURG, PA. 17177-8988 .I HOURS 8:00 AM - 6:00 PM EST H 4406 -II . " ,'" ," ..~ ... ... III .. . . . . . .. ... BJ 15.'\)4) t,.-J -t , CapilallllueCruss .' Pennsylvania U1l1eShicld Ind.pend."1 Ue.n.... 01 Ih. UhM Cron .,ld Diu. 5111,101 Allodlllon , . I :lnVICE DATeS I"'I-! 110, I .. ,ROlt . TO "" ~ PATIENT: BYRNE B GROUP:00279 BIRTH: 092862 -;;:;r,:;r,-:;rn;;r.:;j;;:;-r-;- ABOO"IHAL ULTRASOUHO ~ITJ~ '167~~ 1 CLAIH . 1720510386700 CLAIM TOTAL . CHAII8I. ,.lll\lUOlll.l., \ .'. - 119(l0 1190 00 00' 1l~0 0 0 ~ ! I , ;. I VASCULAR DIAD PROCEDURE :~_ttt1~~~-~ __~5fl0 CLAIH . 1720610307700 CLAIH TOTAL 6 0 COHSULTATIOH HOSPITAL VISIT HOSPITAL DISCHARGE VISIT CLAIM I 1721210501700 1 99254 1 1 99231 2 CLAIM TOTAL OFFICE/OUTPATIENT VISIT CLAIM' 1721710358700 1 CLAIM TOTAL I. V. SOLUTIOH "ED/SURO SUPPLIES RESPIRATORY SERVICE PULftOHARY FUHCTIOH CLAIM . 1720720090400 CLAIM TOTAL PATIENT TOTAL o '" o o o .. EXPLANATION OF CODES 769 Tho subscribor did not respond to eur inquiry on ethor ceverage, we presu.e that Paymont fer this clai. and al1 future claias wil1 be denied until the subscriber TilE 1997 DEDUCTIBLE SATISFIED TilE 1997 COPAYMENT SATISFIED TIlE 199'1 BENEFIT PAID LIFETIME BENEFIT PAID FOR BARBARA IS FOR BARBARA IS FOR BARBARA IS FOR BARBARA IS . 'Capital BlueCross i ~ '. Pennsylvania B1ueShield ~ ~I L1clnHM 01 the Blue CIon and Blue ShI,kI AnoclaUon . . CDI1P I CENTER DEPARl"ENT 778983 HARRISBURG. PA 17177-8983 ..., 1",111",1"1,1,1,1,1,"11"1,,,1,1,,1.1,1,,111,,,1,..1,1,1,1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-822q .1 j 0.00 OF 250.00 0.00 OF 3,000.00 96.00 0.00 OF 1,000,000.00 EXPLANATION OF BENEFITS COMPREHENSIVE ANO WRAPAROUND MAJOR MEDICAL pnOGRAMS i I , I l:Lba OTllD.,. ~.~'COP'1'lClfT1 uss "U0I1 AUOIIAltCI l' ALLOIIAItCI ./ /llWll.I . ;lNILZ.O ml I j~""AHCe~I;JoVr:;~i =9~~C Rl~f~V~G Jg ~Cll .; A/IllUlIT.tClDl... . ~- ~L~ 1; -= ~;: ---{;'" - I IJ I PROVIDER: (632095) CARLISLE IMAGING ASSOC 11]:0 ---~!~~ '_ t OOG 000 0 0 PROVIDER: (579795) CARLISLE DIGESTIVE DIS ASSOCS LTD O~O OuO r " .----..--- UW;CRlUEfl IS ,.., ,.' or M..cJICiHO lU.' 101 ,Ul1ounls <lfU ~ "f-__. t COVl'rtlgo mily ('d property, PROVIDER: (153146) YELLOW BREECHES 0,00 -000 0 PROVIDER: (390151) CI/AMBERSBURG I/O FAM PRAC CTR 769 TT (!.o:pCn'if!S "nfJ , lhl! ilddlllonal .~ " bo cornr1tHtld . .' are Benoltls' or Idor tho unpaid TOTALS 000 000 arl ~lime maximum er insurer has first liability and allows Coverage for this service. ides other ceverage infor.ation. I I I I I I I ~ I i I I ('"L nont ma_lmum Imber provldp.d (I are questions .TIC CONCERNING 1997 FAMILY DEDUCTIBLE SATISFIED IS 0.00 OF 500.00 1997 FAMILY COPAYHENT SATISFIED IS 0.00 OF 6,000.00 (:'~"~'!'~Y~~~~~J~';~~~!~~~~~'~;~.~;fi;,t;t~!~~t:';' . SUBSCRIBER: T B BYRNE CONTRACT' H274662016 NOTICE DATE 08/12/1997 CHECK . QUESTION CONCERNING THE ABOVE CLAIM(S)? TELEPHONE INQUIRIES: WRITTEN INQUIRIES: PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEMENT. HAIL TO: TOLL-FREE TDD UNITS 1-800-222-3341 TilE COMP I CENTER 1-800-242-4809 DEPARTMENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8:00 AM - 6:00 PM EST H 3182 ,.., ,..., ('. ('~ f,", ""' '1 ... ... + '0 Capital B1ncCruss '.' Pcnnsylvania lIIucShicld . . Indlp.ndenl Linn.... Pllhel USERVicEMduATfSI',I::,'"=! 110. I . . .. _., .. f8llll~ _, . .TO - ~\Q . . PATIENT: BYRNE B GROUP:00279 BIRTHI 092862 OFFICE/OUTPATIENT VISIT 1 ALLlIIIABU I LESSJ . .A/IOUI\T,.,. ~ I , TOTAL I LESS AIlOUHT I ,tllAlliI. .' .1HIiI-lUItLE. 3~.e _O~ 3000 0000 000 I 000 ~~eo 3 0 , (-J i' CLAIH . 1723400912800 INTESTINAL XRAY i I '~j 8r.e 8 00 CLAIH . 1723400912900 HOSPITAL VISIT HOSPITAL DISCHARGE VISIT CLAI" . 1723400913000 LABORATGRY 1 10600 J 10800 19300 ..~ CLAI" . 1723320070700 CLAI" TOTAL PATIENT TOTAL ... i i ! I I ss EXPLANATION OF CODES I' 989 $ 10.00 Tho aaount(s) shown abovo represents tho office visit copaymont and is tho subscribo~ 409 Those services wore provided by a Pro.ier Blue Provider. The amount in tho "ALLOWABLE ,_ providod any DEDUCTIBLE er COPAYMENT aaounts are paid to the provider WITHIN 60 DAYS~ ' 769 The subscriber did not respond to eur inquiry on other covorage, we prosu.e that ano Paymont for this clot. and 011 future claims will be denied until tho subscriber pro , I I I ... ... .. . THE 1997 DEDUCTIBLE SATISFIED THE 1997 COPAYMENT SATISFIED THE 1997 BENEFIT PAID LIFETIME BENEFIT PAID FOR BARBARA IS FOR BARBARA IS . FOR BARBARA IS FOR BARBARA IS 0.00 OF 250.00 0.00 OF 3,000.00 429.00 333.00 OF 1,000,000.00 . .. ... . 'Capital BlueCross . " Pennsylvania BlueShield ".~ 0 '_' u,_.......... c._... e,.. ....,. A_I"I.. . . COIIP I CENTER DEPARTKENT 7789&a HARRISBURG, PA 17177-89&a >4 , , 1,..111..,1..1,1.1.1.1..,11,.1...1,1,,1,1.1..111..,1.,,1,1,1.1 T B BYRNE 107 IIELEN AVENUE SIIIPPENSBURG PA 17257-8224 B3 (tl'9.a1 EXPLANA TION OF BENEFITS COMPREHENSIVE AND WRAPAROUND MAJOR MEDICAL PROGRAMS r .. L. US OTHER ~UI tllI'A'"UU I LnS PRIOR i A1.LOIIAIlC! i ALLOIIAIlC! ~ HESSAGE . INELIGIBLE ' JIGWIAHcf., I ~ I -.wI AHOUIIT PAID TO PROVIDER TO SUllSCRlI!lI A/IOUIll ClIDeS _" , PROVIDER,' C 153146) Y LLOW BREECIl S FAM PRAC TR uuscnlOEn IS "'" Of 0 20fO o 2000 , PROVIDER, (632095) CARLISLE IMAGING ASSOC Of,O O!~O 44fo _ -- ~OO 409 000 0 4 00 000 (153146) YELLOW BREECIlES FAM PRAC CTR Oe 989 00 o or Medlcaro, g L ilmounts 1110 ~ ~-1 (~. , ~ o 0 ,.. ~ COVOI'90 m.y !d properly tn 769 oll:ponso!J. "'9 , the additional ~ it be complclcd ... ore Oonollls' or ider lhu unpaid r> r 'a responsibility. AMOUNT" coluan will bo acceptod by tho providor as payaont in full froa tho date of this notice. her insuror has first liability and allows coverage for this service. ides othor covorage inforaation. an 31imo malelmum ""', nonl maximum Imbor provided. Dare quostions Tit CONCERNING THE 1997 FAMILY DEDUCTIBLE SATISFIED IS 0.00 OF 500.00 THE 1997 FAMILY COPAYMENT SATISFIED IS 0.00 OF 6,000.00 PLEASE KEEP THIS STATEHI!NT FOR YOUR RI!CORDS. SEI RI!VERS8 SIDI! FOR ADDITIONAL INFORMATION ABOUT THIS STATEHBNT '~...'. ",#,......_,_.~._..d" .~..'4..... . ........ "" .. ..q.........,' ~. ,,, l ------.-------. c SUBSCRIBER: T B BYRNE CONTRACT' H274662016 NOTICE DATE 08/22/1997 CHECK . QUESTION CONCERNING THE ABOVE CLAIHCS)? TELEPHONE INQUIRIES: WRITTEN INQUIRIES: PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO: TOLL-FREE TDO UNITS 1-800-222-3341 THE COMP I CENTER 1-800-242-4809 DEPARTMENT 77-8988 HARRISBURG. PA. 17177-8988 .~ HOURS 8:00 AM - 6:00 PM EST '-" H101119 "-' EXPLANATION OF 8ENEFITS COMPREHENSIVE AND WRAPAROUND MAJOR MEDICAL PROGRAMS ~.: LESS OTIIU tEll COPAYIt:IIT I LESS PUO. I ALLOlIAIlCE I ALLOlIAHCE I HESSAQE . lNELIQlILE .~~J/IIIUR'.IlC'.." II - .' AHOUIIT PUll TO PROVIDE. TO fiUasc.UClI,., A/lOUllT. CODEI __ PROVIDER: (436791) RWC CORP EMER MEDICINE ~O O~O 000 O~O 0100 769 "I' 0100 J 0;00 0,00 0 00 0,00 PROVIDER: (436791) RWC CORP EMER MEDICINE ~ _I. ~~~ O~O obo I~~~ ~i~~ 0";; ";0.0 0100 0,00 -~il -opil OpO PROVIDER: (632095) CARLISLE IMAGING ASSOC 0 0 o 0 000 80fO OE 409 Ii 0 000 0 00 80;00 DiDO PROVIDER: C6320951 CARLISLE IMAGING ASSOC o 0 0100 Of 0 4t ~E 409 ul' ~OO 0;00 ~OO 4 00 0;00 PROVIDER: (579795) CARLISLE DIGESTIVE DIS ASSOCS LTD ~O ora 0 0 g~ 124bo O~O 409 , ~~~ ~~~ 9 "~ 80,00 ~~~ 12~~ ~,og 0,00 ~g 2* ~g 0,00 398:00 TOTALS 39a.OO ~-O her insurer has first liability and allows covorago for this sorvice. ides other coverago information. cUt. AMOUNT" column wil1 be acceptod by the provider as payment in full from the date of this notico. i I I ITHE 1997 FAMILY DEDUCTIBLE SATISFIED IS 0.00 OF 500.00 ITHE 1997 FAMILY COPAYMENT SATISFIED IS 0.00 OF 6,000.00 i PLEASE KEEP THIS STATEMENT FOR YOUR RECORDS; i . SE.I! 'UIV~SI 81DE POR ADDITIONAL ItlFORHATlON ABOUT THIS STATEMEMT '--"'..~............~.P ".",", .. "_ d" ,-" ,'.. ......" ... ."" .." ..._.~.. I .......,.. '.,;",,~. ...... SUBSCRIBER: T B BYRNE CONTRACT' H274662016 NOTICE DATE 08/22/1997 CHECK . QUESTION CONCERNING THE ABOVE CLAIHCSI? TELEPHONE INQUIRIES: WRITTEN INQUIRIES: PLEASE FOllOW THE ~ INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO: TOLL-FREE TDD UNITS 1-800-222-3341 THE COMP I CENTER 1-800-242-4809 DEPARTMENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8:00 AM - 6:00 PM EST H10148 "" UUSCRIOER IS " o or M~dtcmo ~.\ III amounts mil ~-l ~. ,.. "" ,.... J coverago may led properly. (', Ollpcnsos, 09 , tho additional b II bo completed " Bro Bonollls. or Idor tho unpaid an. Jllmo rni1llimum ...... nonl maximum Imber provided. e are questions [It CONCERNING ~ ~ '--' III I~' , ' Capilal B1ueCross Pennsylvania D1ueShleld kMSeptndlnt L1UnM" .,Ihel 8Si:VicE~ATEShl'II::I":C':::=! NO. I ,101I TO 0'" sves . PATIENT" BYRNE B GROUP,00279 BIRTH, 092862 ''-] , ; r;\ r-;- EIlERG ROO" "EDICAL VISIT 0720197 07t0971~ W90261~ CLAIH . 1808000918900 PATIENT TOTAL TOTAL CHARGE I LESS AHOUHT I ALLOWABLE I LESS. I INELIOIBLE AI10UNT ~EllUCTIILq I I-~ ------1- 9600 3600 1 I 96lio -'--s6.0 0 , . 6000 i 000 I 0:00 60.00 I' I 1 ", ') ';I> ." ., ') ") II EXPLANATION OF CODES Q09 The.e .ervice. were providod by a Promior Bluo Provider. Tho providod any DEDUCTIBLE or COPAYMENT aaount. are paid to the allount in tho "ALLOWABLE provider WITHIN 60 DAYS fl ;:, , ') I I . I THE 1997 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1997 OUT-NETWORK DED MET FOR BARBARA IS 0.00 OF 250.00 THE 1997 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1997 OUT-NETWORK COINS MET FOR BARBARA IS 0.00 OF 3,000.00 THE 1997 BENEFIT PAID FOR BARBARA IS 10,910.60 IN-NETWORK LIFETIME BENEFIT PAID FOR BARBARA IS 6,898.60 OF 1,000,000.00 OUT-NETWRK LIFETIME BENEFIT PAID FOR BARBARA IS 6,898.60 OF 1,000,000.00 1 J .. , , 1..J . 'Capital BlueCross i ; . Pennsylvania BlueShield ~ II '_"'n'"....... .111" .,... C,... .... .,... ..,.Id Au.""'" . ., COltP I CENTER DEPARTMENT 778988 HARRISBURG, PA 17177-8988 ) ..) [lJ In }~I 1..,111...1.,1.1.1.1.1...11.,1.,.1.1,.1,1.1..111...1..,1.1.1.1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 172S7-822Q EX PLANA TION OF [JENEFITS COMPREfiENSIVE AND WRAPAnOUND MAJOR MEDICAL PROGRAMS : LESS OTHER ~ tu <OPAYH'Hr I LESS PRIOR I ALLOIIANCE I ALLOIIAHCE I HESSAGE I INELIOIBLE I JNSURANC! I' I AHO,"" AI10UNT PAID TO PROVIDER TO SUIlSCRIBER AI10UNT CODES .. f---- PR.OV~ ~~~6791~~WC CORP ~ MEDICINE._ ---.-.'-'-r I 000. 000 000 6000 000 1109 i : I --ica ----.LIloc ----Ail ----~OO '0100 --'--;-l--j- TOTALS 60,00 000 MOUNT" column will be accepted by the provider as payment in full om the date of this notice. , , , I HE 1997 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS MET. HE 1997 FAMILY OUT-NETWORK DEDUCT MET IS 0.00 OF 500.00 HE 1997 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. ~E 1997 FAMILY OUT-NETWORK COINSUR MET IS 0.00 OF 6,000.00 II PLEASE KEEP THIS STATEHENT FOR YOUR RECORDS. SEE REVERSE SIDE FOR ADDITIONAL INFORHATION ABOUT THIS STATEHENT I I I SUBSCRIBER, T B BYRNE CONTRACT' H2711662016 NOTICE DATE 03/23/1998 CHECK . QUESTION CONCERNING THE ABOVE TELEPHONE INQUIRIES, CLAIMCS17 WRITTEN INQUIRIES. PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEMENT. HAIL TO. TOLL-FREE TDD UNITS 1-800-222-33111 THE COMP I CENTER 1-800-2112-11809 DEPARTMENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8:00 AM - 6:00 PM EST H 9766 r . . ._-~._------ iuuscnlBER I~; 11'orMI'III{;ilW r 'OJ nl ,UI1UllIlb ilW fJ ~ , r r e COW!t;:lgll may cd I'lropt>fly. , - ~ I eJtpenSU5 Jn~ II the additional r."\ .., 51 be completed .,. aro BenefIts- or "ler Iha unpaid an ellrno m;uurnum , C'C nenl maXimum TIC Imber prOVided. '0 <HO quesllOns COI'CERNING '- "-- v 1.,.0 '- . III .+, Capital D1ueCross Pennsylvania B1ueShleld ...,..nden' L1unaen OIIM 81~ c,....nd Blue Shl,ld AuO(I"lon I SERVICE DATES 1"'1 ,....... ! NO. I TOTAL 'ROlf TO ,.,. sues CHARGE PATIENT. BYRNE B GROUP,00279 A~~:I~~L OU~~::S~UNO ol~~~ OirlY~~ 76700 [_~ =~~113~~ ~=_~ 19;00 =_~~-j~~ _~~_~~~~_ CLAIH · 180B00091B500 CLAIH TOTAL 119,00 11900 0,00 0.00 I LESS AItOUHT I ALLOWABLE I LESS I INELIOIBLE AHOUHT PEDUCTIBLq I ,. " VASCULAR DIAD PROCEDURE ,.., CLAIH . 1BOB00091B~00 OFFICE/OUTPATIENT VISIT " CLAIH . 180B00091B600 , 07,15.97 , , r- --_. , 071597 1 99254 1 17900 179.00 0717,97 1 99231 2 14:>'00 142.00 CLAIH TOTAL ~5200 ~ 5 2,0 0 , 000 1 30.00 30,00 , , , CLAIH TOTAL 5000 50,00 000 , , , , 1 8500 8500 000 I , I 8500 85,00 000 , CONSULTATION 07,1597 .-, NOSPITAL VISIT 071697 HOSPITAL DISCHARGE VISIT CLAIH . 180B000918500 " ... INTESTINAL XRAY CLAIH . 1808000918700 ,. . NOSPITAL VISIT NOSPITAL DISCHARGE VISIT . . CLAIH . 1808000918800 I I I . II EXPLANATION OF CODES 875 Our rocords indicate that these services have alroady boen processed. ~.. THE 1997 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1997 OUT-NETWORK DED MET FOR BARBARA IS 0.00 OF 250.00 THE 1997 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1997 OUT-NETWORK COINS MET FOR BARBARA IS 0.00 OF 3,000.00 THE 1997 BENEFIT PAID FOR BARBARA IS 10,910.60 IN-NETWORK LIFETIME BENEFIT PAID FOR BARBARA IS 6,898.60 OF 1,000,000.00 OUT-NETWRK LIFETIME BENEFIT PAID FOR BARBARA IS 6,898.60 OF 1,000,000.00 ... 'l '-~ . 'Capital BlueCross i ; . Penns Ivania BlueShield ,.; 0 '_...-rlk....... ol.ho .,... c.... .... ..... Sh'.,. .....'.11'" . .. COHP I CENTER OEPARTHENT 778988 HARRISBURG, PA 17177-8988 .J .J 1."11I1"1.,1.1,1.1.1."1,,,1.,,1.1,,,,',,,,11,,,,,,"1,,,,.1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-8224 .J f.il ;~ ! t- i LESS OTHER i INSU.ANCe I I I EXPLANA TION OF DENEFITS COMPREHENSIVE AND WIlAPAIlDUNO MAJOR MEDICAL PROGI1AMS ~E" COPAY"INI I LESS PRIOR 1 ALLOWANCE ! ALLOWANCE I MESSAGE' INELIGIBLE .1 "I A"OUNl AItOUNT PAID TO PROVIDER TO SUBSCRIBER AIlllUNT CODES .. PROVIDER, (632095) C RLISLE IMAG NG ASSOC , 000 I 000 , I --;--- -----r- I __~___..;-___ _, I 0:00 0100 0,00 0,00 875 i I ---..--- -----1-- ---..---,-------.-..~.-_. -------..-----t 000 000 000 000 , , PROVIDER. (632095) CARLISLE IMAGING ASSOC --------- ~ _~__>H ----------.~___ .,.ur-- 000 ,000 000 000 000 875 I I . -'---L_ ---.-1--- ------_, __, ------L ___ '-r- 0'00 000 0,00 0,00 OOO!. I PROVIDER, (579795) CARLISLE DIGESTIVE DIS ASSOCS LTD 000 ' 000 87S-r--- 000 000 875 ' I ;UUSCflJUEIl IS l' flt toll'dledl\' r~;, III .1J!1(llml" ill!' N , , PROVIDER, 000 000 I 0,00 000 , PROVIDER, , , 0100 000 I 000 000 , PROVIDER, 000 000 9 co.'crago rl1ay , t!(i properly (153146) YELLOW BREECHES FAM PRAC CTR , , , 0'00 0:00 l'WpenSl'5 000 875 , 0,00 000 0,00 ~n9 h the addIIIOr1.11 , (632095) CARLISLE IMAGING ASSOC 0100 , , .~. ;1 Ill' compleled 000 000 875 " ,Ill' Denl'llls. or I 000 000 0,00 lC1i.!r till.' tlllJ.},IIU I (153146) YELLOW BREECHES FAM PRAC CTR ~OO 000 0'00 875 E 1997 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS MET. 1997 FAMILY OUT-NETWORK DEDUCT MET IS 0.00 OF SOO.OO E 1997 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. E 1997 FAMILY OUT-NETWORK COINSUR MET IS 0.00 OF 6,000.00 PLEASE KEEP THIS STATEMENT FOR YOUR RECORDS. SEE REVERSE SIDE FOR ADDITIONAL INFORMATION ABOUT THIS STATEMENT SUBSCRIaER, T B BYRNE NOTICE DATE 03/23/1998 CONTRACT' H274662016 CHECK . QUESTION CONCERNING THE ABOVE CLAIHCSl? TELEPHONE INQUIRIES, WRITTEN INQUIRIES. PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO, TOLL-FREE TDD UNITS 1-800-222-3341 THE COMP I CENTER 1-800-242-4809 DEPARTMENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8.00 AM - 6.00 PM EST If 9765 Imber prOvidt'd o aro Quesllons TIC CONCERNING "'" ,... f'l_ ..J "" ", (-, . {" '-' . " , " . , ,.. 004 004 .... .... ... .. . ,.. ... , . J bJ IRq.:, , + (QJg ('lIpilal III11C('rnSS '." . I'cllllsylvallia IIIm'Shil'ld . . . ImJ_I,.n"',,' LI'."'..' ,,1110. Ulu" e",., .-114 Ulu. :'h..h1 ^"<I",Ull>ll . . I SERVICE DATES 1'''/ ""'lMlU I NO. I rRDII TO '''' svcs PATIENT: BYRNE B GROUP:002794 BIRTH: 092862 PIIARnACY LABORATORY LABURATORY LABORATORY LABORATORY EIlLRCCIICY ROON CLAIH . 1731820106500 61.!8 4;06 45~6 49"8 17IJ2 63172 187 2 TOTAL CIt.\ROE I LESS AItOUNT I IHELIOJDLE ALLOWABLE I LESS '!..' ~T , ~EOUCTIBL' i 000 0:00, O,O(~ :iiI' 000 0'00 :00:1 0,00 r! I 000' I r....' 000 000 1~00 9,00 84,00 9;1,00 3300 11ll:00, 34 00 1003.97 10.03,97 10'03!97 100:lj97 10'0397 10'0397 10'03197 10'03.97 10:0~'n 10'03~n J 0.03.21. Ja' 5,52 4114 3864 4232 1~18 -!i'l;lll. 16008 2 0250 2 0301 2 0305 2 0306 2 0307 O!ISO._ . CLAIH TOTAL LABORA TOR Y ~~ 9~ 7 CLAIH . 1731820106700 --L 2 0300 10800 . ___d.... __,_ --..-1..- CLAIH TOTAL 10~00 PATIENT TOTAL 45~00 MM EXPLANATION OF CODES 911A $ 5.52, 911B $ 4.14, 911C $ 38.64, 9110 S 42.32, 911E $ 15.18. i.. This exponse excoeds the contract al10wance amount for a participating provider. Th' ,', 943 $ 35.00 The amountCs) shown abovo was appliod to the emorgoncy room deductible or ponalty spc; I ; I" , (~ TilE 1997 THE 1997 TilE 1997 LIFETIHE DEDUCTIBLE SATISFIED COPAYHENT SATISFIED IlENEFIT PAID BENEFIT PAID FOR BARBARA IS FOR BARBARA IS FOR BARIlARA IS FOR BARllARA IS 0.00 OF 250.00 0.00 OF 3,000.00 5,976.35 2,880.35 OF 1,000,000.00 4- 'Capital B1ueCross i ; '. Pennsylvania 81ueShield ~ 0 '.......__,ll",,".. ., ,,,. UI~ e.... ..... .,~ Shi.,d '''o<'.''on . . coup 1 CEHTER DEPARTUEHT 7789BB It.\RRISBURG, PA 17177-8988 1...111.,.1..1,1.1.1.1.,,11..1..,1,1..1.1.1..111,..1...1.1.1.1 T e BYIlNE 107 liE LEN AVENUE SIIIPPENSBUHG PA 17257'8224 '"~ , ~Cfil ...~ , , f " I 1 , Capital DlucCrnss Pcnnsyhania DlucShicld 1 IncM...ndenlllufl.... ul It.. IJlw Crull M\d OhM Shield Anocl,'lon . . I SEIIVICI DATES '"'I:"':'! 110. .1- . TOTAL. I. LESS AllOUIT.I.,.ALLOlIAlLt, 1 LESS , .. . ~ _, ,..... ..,.I.TO , ~, .- ,~,." IIC/.:t8DU.,. "..,:.JIIllIR,....~tf PATIENT: BYRNE B GROUP: 00279 I BIRTH: 092862 EllERO ROO" "EDlCAL VISIT 9 0 1 9 0 9 0 o 0 CLAIM' 1734610143500 o ,.... ~ ."':J'< ..... ~ ~ i I , I I .. EXPLANATION OF CODES I 293 The specific. 'cendition reported does not qualify for pay.ent under ,YOUR e.ergency benj I I , ... .. .. .. .. . THE 1997 DEDUCTIBLE SATISFIED THE 1997 COPAYMENT SATISFIED THE 1997 BENEFIT PAID LIFETIME BENEFIT PAID 0.00 OF 250,00 0.00 OF 3,000.00 6,008.25 2,912.25 OF 1,000,000.00 FOR BARBARA IS FOR BARBARA IS FOR BARBARA IS FOR BARBARA IS . .., "-4 . 'Capital BlueCross i ; <. Pennsylvania BlueShield :A; II 1_'lI'M_ .'Ibo .,... <<....... .,... ....,. A,ooc""M . . COIIP I CENTER DEPARTHENT 77e988 HARRISBURG, PA 17177-8988 , , .) [Ll I ~ ~lll 1".111..,1.,1,1.1,1,1...11.,1..,1.1,.1.1.1,,111,"1...1,1.1.1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-822q EXPlANA TlON OF BENEFITS COMPREHENSIVE AND wnAPAROUND MAJOR MEDICAL PROGRAMS I ! LESS OTIlfR ~EU toPAl1lfllr I LESS PRIOR I ALLOWAllCE I ALLOWAllCE I "ESSAQE . INELIQIBLE IN$UIAIlCE I k I _r AHOUNT PAID TO PROVIOER TO SUBSCRIBER AHOUNT CODES .. PROVIDER: (q36791l RWC CORP EMER MEDICINE ~--"---T '--I'-'- 1'----...'-,' -,--..-- ...-.:... ..'-....-r.. ! Of 0 000 0100 0100 0100 I ----. ''', -I... ------,__._ .. _______... _ _ _______ I . I O,(JO 000 0,00 0;00 0,00 I TOTALS . ---. "']'- ------,- --- 293 j "---r- .----- '''-' " iuoscnUIEn IS " to or Medlcaro, ,.... 'n,~ '11 iHflotlfllsilre ,,- o 0 000 , f'. , --- ,.... ,. ~ cove. ago may !d propcrly. t"\ oxpenses '"0 h Iho ,\(jdlllonal lit. ..... II be comptOled " ilro Bene!lls' or idet tho unp.:Jid l'HE Il'IIE I I i I I I I I I I I I I I I I I I . I 1997 FAMILY DEDUCTIBLE SATISFIED IS 0.00 OF 500.00 1997 FAMILY CO PAYMENT SATISFIED IS 0.00 OF 6,000.00 PLEASE KEEP THIS STATEHENT FOR YOUR RECORDS. SEE REVERSE SIDE FOR ADDITIONAL INFORMATION ABOUT THIS STATEMENT SUBSCRIBER: T B BYRNE CONTRACT' 1127q662016 NOTICE DATE 12/12/1997 CHECK . QUESTION CONCERNING THE ABOVE ClAIMIS)? TELEPHONE INQUIRIES: WRITTEN INQUIRIES: PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEMENT. HAIL TO: TOLL'FREE TDD UNITS l'800-222-33Ql THE COMP I CENTI:R 1'800-2Q2-QR09 DEPARTMENT 7'1-89R8 IIARRISBUIW, I'A. 17177-8988 1I0URS 8:00 AH' 6:00 PM EST II '1~73 ('. ('J ,111 !lllnlu maximum co, nenl minimum Imbof provldod. e .1ro queslions TIC CONCERNING \001 ill I~ '.I: .. EXPLANATION OF CODES 911A S 5.06, 911B $ 9111 $ 5q.28; 911J $ This expense exceods 9q3 $ 35.00 Tho a.ountCs) shown above was applied to the e.ergency roo. deductible or penalty '10 +, "1 Capital D1ueCrllss Pennsylvania D1ueShield Ind....odetllllun.... ullll' Ul~ Cro.. Mld DIu. Shl.ld Anoc:l..lun . . I :=~C~ .~~~S I"" ":.-!:a L PATIENT I BYRNE B GROUPI00279 BIRTH: 092862 PHARKACY KED/SURG SUPPLIES KED/SURG SUPPLIES LABORATORY LABORATORY LABGRATORY LABORATORY IKAGING SERVICES EltEROENCY ROOn OTHER CLAIH . 1731820106800 ,... ~ '" ... , TOTAL I LESS AIIOUtT.1 ALLOIIAlLI. I LESS ! C/tAAllll ". wueJll~'. ". NIlIlIIl' ,.,I/f.DIIl:TUL~ I OP~ 01l0; OIOOi 000' g~~g:. o 0, o 0' 0"0' ~oJ O. ,"It> 11110 38~0 30,,0 5~~0 6~0 9~00 17pO 52~0 118 0 28 6 52 13.80, 17.Q8, 911C $ 3.68 the contract allowance a.ount for a participating provider. 911E S ... lilt .. . . THE 1997 DEDUCTIBLE SATISFIED THE 1997 COPAYHENT SATISFIED THE 1997 BENEFIT PAID LIFETIME BENEFIT PAID FOR BARBARA IS FOR BARBARA IS FOR BARBARA IS FOR BARBARA IS . . . . 'Capital BlueCross i ; '. Pennsylvania BlueShield ~ 0 'ndo"""'" u,_."., 'M 010.. "'... "'" 810.. Sh'... Au.d...... . . COltP I CENTER DEPARTHENT 778988 HARRISBURg, PA 17177-8988 w '4 1",111."1"1,1,1,1.1,.,11,,1,,,1,1,,1,1,1,,111.,,1,,,1,1,1,1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-822Q . .J ) 911D $ 27.1Q, 0.00 OF 250.00 0.00 OF 3,000.00 6,Q97.59 3.Q01.59 OF 1,000,000.00 I i I I I J 30.36, I I Thel spa .. .. . .. w "-I \_-.1 OJ iB9l1 '-' ..J III +, I TOTAL I LUS AI<<QfT I . ALLOIIAlLE /' LEU II _. ..,-.,., ._.; '.......;1 30fO Of-O 30 0 0 Oi' 3000 0 0 Capital U1ueCruss Pennsyhunia U1ueShield In.....wt.nlllt.Il.... of Ih. oh... Croll and DIu. Shl.ld AIIOtllllufl I lIERVICE GAUl ,..,-! NO'1 ' P.IlIIIl .. .....TO ... IIvca PATIENT, BYRNE B GROUPI00279 BIRTMI 092862 OFFICE/OUTPATIENT VIlIIT CLAIH . 1734010410600 1 CLAIM TOTAL ;', r, '"" PNAR"ACY I. V. SOLUTION "ED/SURD SUPPLIES LABORAToRY LABORATORY LABORAToRY E"EROEHCY ROD" CLAIH . 1734720134700 .... CLAIH TOTAL PATIENT TOTAL ''1 ., ~ .. EXPLANATION OF CODES 989 $ 10.00 Tho aMountCsl shown above reprosonts tho office visit copaYMont and is the subscriber 911A $ 8.28, 911B $ 14.72, 911C $ 14.26, 911D $ 17.02, 911E $ 51.06, This exponse exceeds tho contract allowanco aMount for a participating provider. The 943 $ 35.00 I Tho aMountCsl shown above was appliod to the eMergency rOOM doductible or penalty spo .. r~ i I I I I I i I I , I ... ... ... THE 1997 THE 1997 THE 1997 LIFETIME DEDUCTIBLE SATISFIED COPAYHENT SATISFIED BENEFIT PAID BENEFIT PAID FOR BARBARA IS FOR BARBARA IS FOR BARBARA IS FOR BARBARA IS 0.00 OF 0.00 OF 6,678.61 3,582.61 OF 250.00 3,000.00 1,000,000.00 . 'Capital BlueCross r. ; '. Pennsylvania BlueShield :... 1,,,,,,-, "..,,,... ., .... 8'... C.D".... .,... 5/01,.. A._IOI'", . . COHP I CENTER DEPARTHENT 7789aa HARRISBURG, PA 17177-89aa 1,"111".1..1.1,1,1.1...11..1..,1.1..1.1.1,.111.,,1,"1,1,1,1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-8224 EX PLANA TION OF BENEFITS COMPREHENSIVE AND WRAPAnOUND MAJOR MEDICAL Pf10aBAM5 I ~ un OTHER ~lIl toPAYltOOI I usa ~RIOR l ALLOWAIICE l ALLOWAIICE ~"ESSAOE' IHELlOlBLE . IN$URAllCE I II _I AHOUHT ~AlD TO ~ROVIOER TO SUII$CRIBU AllDUHT CODES .. . PROVIDER: C 153146) Y LLOW DRECCII S FAH PRAC TR i ---'-~~~ T-no~o- --- --- ~'O-O -- ---- 2~100' mh -- -o~~o 9-8~--I' -rn r-1 G, . -----0100 ---..Loloo -'---'-0100 - -----i010o ---0;00 - --,--_. ---t -ij PROVIDER: (390058) CARLISLE 1I0SPIT ",. -'------T ----"r---n'--'T- -------'T---"--- g,gg ggg 1~~~ g,gg ~n~ I I 0'00 000 It.74 0'00 911C ' I 0'00 000 1998 0'00 '.I11lJ I opo 0:00 59,94 0,00 911E I 000 000 8611 0,00 911F I I 0:00 O~O _Z8~Z 0,002..1.HLr43 - -r-' 000 000 Iblu2 000 0:00 000 18 '02 0,00 18102 000 , ---0'0;; 000 0'00 0,00 0,00 0,00 .D,OO 000 000 TOTALS 's rosponsibility. l1F $ 7.36, 911G $ 54.28 subscribor is not rosponsible for this amount. ifiod in YOUR coverage. I r I I I HE 1997 HE 1997 FAHILY DEDUCTIBLE SATISFIED IS 0.00 OF FAMILY COPAYMENT SATISFIED IS 0.00 OF PLEASE KEEP THIS STATEMENT FOR YOUR RECORDS. 8!! REVERSE SIDE FOR ADDITIONAL INFORKATION ABOUT THIS STATEHENT 500.00 6,000.00 SUBSCRIBER: T B BYRNE CONTRACT' 11274662016 NOTICE DATE 12/16/1997 CHECK . QUESTION CONCERNING THE ABOVE CLAIHCS)? TELEPHONE INQUIRIES: WRITTEN INQUIRIES: PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO: TOLL-FREE TOO UNITS 1-800-222-3341 TilE COHP I CENTER 1-800-242'4809 DEPARTHENT 77-8988 IIAIlllIS8URG, PA. 17177-8988 HOURS 8:00 AH -- 6:00 PM EST II 6809 UOSCRlllm IS '" (1 or Ml'dICiHl'. 1\1 iHlIounh ,HI! N ..- ,.. "" ,.., ,.. ,-. & cover ago may I'd pforwrly ,.. f'Jptmsos ,.~ h the ,J(ldlllor'lill '. II bl! compleled IV mo Benoflts. or ldor tho unpaid , . Q ro, f""t 0- ,tin ulmlOmilJln1lJm """ ll{jnl nla_lfTlUIn , , Jmber flfO'J,,'cd Ie me qUc~!lOns ,:m CONCERNING .~ v , , , 'THE rl'HE r~~ I I I I I , i I I i I I I i I , , EXPlANA liON OF BENEFITS COMPREHENSIVE AND WRAPAROUND MAJOR MEDICAL PROGRAMS LESS OTIIER ~u. COPAV"_T I LESS PRIOR I ALLONANCE I ALLONANCE I "ESSA'E I INELIGIBLE IH;URAHCE I ~ I A''''''iT AHOUHT PAID TO PROVIDER TO SUBSCRIBER AIIOUHT COOtS .. PROVIDER: 1~367911 RWC CORP EMER MEDICINE . --O~-o --J--'~~-O -----o:00 --'-~I~-'------0100-~09-"---r-'T- ----010'0- .O!OO' -----0;00- --60100 -- uO~O -- ----11--- "", TOTALS bO,OO 0'00 I ,lJlISCRH)En IS 'II or f,lt.d,cafO III ilfllOtm!!; ,1111 N. I. COVorilgfl may I'd pfOperly. , ' lJ.ponses ,"g h Itl!} Mdlllonal AMOUNT" coluan will bo accepted by the provider as payaent in full froa tho date of this notico. ,.... " II bo comploted mo Bonellls' Of Iclm Iho unpaid an ohmu ma.lmum ~tJ nenl maximum Jmber proVided '0 ara quosllons TIC CONCERNING 1997 fAMILY IN-NETWORK DEDUCTIBLE Of 0.00 IS MET. 1997 fAMILY OUT-NETWORK DEDUCT MET IS 0.00 Of 500.00 1997 fAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1997 fAMILY OUT-NETWORK COINSUR MET IS 0.00 Of 6,000.00 PLEASE KEEP THIS STATEMENT FOR YOUR RECORDS. SEE REVERSE SIDE FOR ADDITIONAL INFORMATION ABOUT THIS STATENENT SUBSCRIBER: T B BYRNE CONTRACT' 1127~662016 NOTICE DATE 12/2~/1997 CHECK . QUESTION CONCERNING THE ABOVE CLAIHISI? TELEPHONE INQUIRIES: WRITTEN INQUIRIES: PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEMENT. HAIL TOI TOLL-FREE TDD UNITS 1-800-222-33~1 TUE COMP I CENTER 1-800-2~2-~809 DEPARTMENT 77-8988 UARRISBURG, PA. 17177-8988 '--- HOURS 8:00 AM - 6:00 I'M EST , -' U 7805 II + '0 Capllal D1ueCrllss I ".' Pennsylvania D1ueShleld , . ancNp'rwMl\l L1u,.......r lhe Blut c,....nd llue ~1.14 A...d.ll.lon / ". :: " . ..I..SEIlvm ~TIS 1"'1.-_ !SHll. ..1, ", [', r ~ '0" ;;',;. < ;.,:.1.. fltOtt.....c. TO . \, ' VC3 .i PATIENT. BYRNE B GROUP,00279 t':t~~~y OR~:62 1727'97111~7~712jo;;s;T ..., TAKE HOHE ORUGS ,1127,91.1127.972 ozsLL. CLAIH . 1807920155900 PATIENT TOTAL . TOTAL I Lua A/lOUIT I ., I:Il4IlllE, . j .:IIlELlOllLE. . I 65'00 6500 39.51f ___39.5'1 104,54 104,54 , I I I i ALLlIIIAIILE 1 usa Ii ." NIOIIlT., 1 ; IIEll\1l:m~lIi i 000 I , 000 1 , , , I r I " .., f,\ 1'\ ,'" Ioi i I AA EXPLANATION OF CODES ! 293 Tho .pocific condition roportod doo. not qualify for payaont undor YOUR oaorgoncy bono 454 Duo to .pocial proco..ing roquirod for thi. claia, individual aaount. cannot bo .hown ! , i Ioi ... ... ... THE 1997 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. Ie THE 1997 OUT-NETWORK DED MET FOR BARBARA IS 0.00 OF 250.00 THE 1997 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1997 OUT-NETWORK COINS MET FOR BARBARA IS 0.00 OF 3,000.00 THE 1997 BENEFIT PAID FOR BARBARA IS 10,850.60 It - IN-NETWORY. LIFETIME BENEFIT PAID FOR BARBARA IS 6,815.60 OF 1,000,000.00 OUT-NETWRK LIFETIME BENEFIT PAID FOR BARBARA IS 6,815.60 OF 1,000,000.00 w . 'Capital BlueCross i ; . Pennsylvania BlueShield ~ 0 '.........n' u"...... .1... .,... c.... ond .,... S.",. A....'."~ . . COHP I CENTER OEPARTHENT 778988 HARRISBURG, PA 17177-8988 i T '11 T T .. ~J lij 0'1:, 1,..111",1..1,1.1.1,1...11,.".,1.,.,1,1,1.,111,"1,.,1,1.1,1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-8224 ',,) ,-.J EXPLANA TION OF BENEFITS COMPREHENSIVE AND WRAPAROUND MAJOR MEOICAL pnOGRAMS LESS OTHER h.. cot'AVHfHI I LESS PRlOft l' ALLOlIANCI ! ALLOWANCE I "ESSAllE . INILIDULI., 'J W$URANCI ,,,I H L, AIlOU'n . AItOlMr PAID TO PROVIOEft TO, SUBSCRIBER fJlOUIfT CODES'~ ..;.\ PROVIDER, (999000) BOOKINGS HOS I I ----'-o~ : T .-----~ 000 000 , , I I 000 000 ----- .-----.,-- 293 ' i ! ..-oI00q~~3+_+-f- 0.00 TOTALS colUllns; allounts will appear only on tho "TOTAL" lino. 1997 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS HET. 1997 FAHILY OUT-NETWORK DEDUCT HET IS 0.00 OF 500.00 1997 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1997 FAMILY OUT-NETWORK COINSUR MET IS 0.00 OF 6,000.00 i"(;"",:, 'PL'EASE KEEP, THIS STATEMENT FOR YOUR RECORDS.'" " . "J f:~'>SEE .REVERSE 'SIDI; FORADDITIONALINFORHATIONABOUT THlSSTATEHI'NT-:'.i' _ooJ..'"" ~.,. ,.:.t....;~ -'.~..,,~ ", ..t." ,;.;;: ',;:.::, ..1.; ....:',:,. .;,';;' _'. ,.;.~. ,',i...'. .. ." ,_.> .',-,--~_.,;, .,.,. __,. ,.... . /.' -1_.:'::.~ _. .'" ::.',: ':. .".j.,', _.....:.;:. ,~.,t,_? ;',c'", ,:.~"'_.."';"LlJ SUBSCRIBER, T B BYRNE NOTICE DATE 03/20/1998 CONTRACT. H274662016 CHECK . QUESTION CONCERNING THE ABOVE CLAIH(Sl7 TELEPHONE INQUIRIES, WRITTEN INQUIRIES. PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEMENT. HAIL TO, TOLL-FREE TDD UNITS 1-800-222-3341 THE COMP I CENTER 1-800-242-4809 DEPARTMENT 77-8988 HARRISBURG. PA. 17177-8988 HOURS 8:00 AM - 6:00 PM EST H 6289 I , ~ I . ...-....------- UBSCflUlt.;R IS '" l'lIf t,'f'dIC,HtJ r 11 amounls ilfl! ("L "iI' .J ~ r r. n \' ) coveragl! milY cd properly r ("', e.penses ,ng , lh(! addlllonal r' .'" It bo compleled .. ;HO Benolils. or 'der the unpnid an. Hlmo mmdmum t."tJ, nonl mnl(imum mber prOVided. c are qucslions TIC CONCERNING '- '- ~ -..:. BJ le'):1 +, , Capital U1ucCrllss PClIlIsylvulllu U1l1cShlcld lnd....,td.nllh..,...... ulll.. Ulu. (run Ml4 UIIMI 5hi.ld Auud.tlon I SERVICE DATES I"" "'''-! NO. I TOTAL . .. fRllII. ,TO '''n~. ..... .Clt4KRfi.. PATIENT: BYRNE B GROUP:00279 BIRTH: 092862 EnERO ROOn MEDICAL VISIT 9~r 9 00 I LESS AHOUIfT'l Al.LllIIAILE 1 LESS 'I '..' ..WLIUIDL~. .'.....NWtL.,_..,IlCJlllCUDL. i f ~ I I t " 9J~~ 9 00 1 CLAIM . 1800110438200 CLAIM TOTAL 1I0SPITAL VISIT i , , I Oej 000: , 0; , r':l. ! o 1 CLAIM TOTAL PATIENT TOTAL "" CLAIM . 1800110613700 o o "" ..~ .., ... ... .. EXPLANATION OF CODES .. 293 Tho spocific condition roportod doos not qualify for payaont undor YOUR o.ergoncy bani 409 Thoso sorvicos woro providod by a Pro.ior Bluo Providor. Tho a.ount in tho "ALLOWABLE' ' providod any DEDUCTIBLE or CO PAYMENT a.ounts aro paid to tho providor WITHIN 60 DAYS ... ... ... ... THE 1997 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1997 OUT-NETWORK OED MET FOR BARBARA IS 0.00 OF 250.00 THE 1997 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1997 OUT-NETWORK COINS MET FOR BARBARA IS 0.00 OF 3,000.00 THE 1997 BENEFIT PAID FOR BARBARA IS 6,930.61 - IN-NETWORK LIFETIME BENEFIT PAID FOR BARBARA IS 2,834.61 OF 1,000,000.00 OUT-NETWRK LIFETIME BENEFIT PAID FOR BARBARA IS 2,834.61 OF 1,000,000.00 ... ... .... . 'Capital BlueCross i ; '. Pennsylvania BlueShield ... I,.........., u,........, ... B'~ "'_ .... .,~ Oh'.,. A._I"'... . . CO/IP I CENTER DEPARTHENT 778988 HARRISBURG, PA 17177-8988 . ., ~-j ,.J 1."111",1,,1.1.1,1,1,..11.,1..,1,1,.1,1,1,,111,,.1.,,1,1,1,1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-8224 " EXPLANATION OF [JENEFITS COMI'Il[ltEIlSIV[ Arm WIlAPAnOUIlO MAJOI1 MEIl'CAL 1'1l0GI1AMS USS OTHER ~U. tOl'AYHlHI I LESS rRIOR I ALLOWAHCE I ALLOWANCE I "ESSAGE I INHIOIBLE IHSURANCE I ~ I.......' AIKlUNT rAID 10 PROVIDER TO SUBSCRIBER . All0U1i1 CODES .. PROVIDER: (~36791) RWC CORP EMER M~DICIN~ --- 0100 -r--~I~o _u_ -, -or~o.- ,- .--~r~~--u - -.----or~o ;93'1""-- "-r'- .----0100 J---oloii --.-'--0100- ._'-~oo -----.0100. ---, r-- -I-- PROVIDER: (130360) JAY A TOWNSEND MD ----.-~~~ I-~ro'~. ,.,._~~~- .-~-:l;;~ --_.-'-~'o~I~~~--I--.-I-- -,.- '-o~OO' -0100 0'0'0' 1310'----0100-' - . -,+--. O;QO 0:00 0:00 13 00 01' ' , , ' I l3i~00 0,00[-- -,- .. , , coluan will be accoptod by tho providor as paymont in ful1 date of this Iloticu. 1997 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS MET. 1997 FAMILY OUT-NETWORK DEDUCT MET IS 0.00 OF 500.00 1997 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1997 FAMILY OUT-NETWORK COINSUR MET IS 0, ou or (,,000.00 PLEASE KEEP THIS STATEHENT FOR YOUR RECORDS. SEE REVERSE SIDE FOR ADDITIONAL INFORHATION ABOUT THIS STATEHENT SUBSCRIBER: T B BYRNE CONTRACT' IIZ7~66Z016 NOTICE DATE 01/02/1990 CHECK . QUESTION CONCERNING THE ABOVE CLAIH(S)7 TELEPHONE INQUIRIES: WRITTEN INQUIRIES: PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEMENT. HAIL TO: TOLL-FREE TOO UNITS 1-000-222'33~1 TilE COMP I CENTER l'OOO-2Q2-Q809 m:PAIlTMI:NT Tl-0900 IIAIlIlISIlUIW, PA, 1'I177-89UO 1I0URS 8:00 AM - 6:00 I'M EST II ',...."1; r- lJlI~;CRlIl[n IS f'" I' Of P.lpdlCiUH r I '''1' 11,lIllountS;l!O , , i l cover ago may ~d plOpm1v. ..... erpunSC5 flg, , tho addlllonal ,... .'W. .1 bo complotod .. JrQ Benefits" 01 der lhc unpaid " ,nnl tllmo lniUlmUm "'" 'onl maximum flC ,"bor provided n ,lro questIons CONCERNING ~ '- I i -I! Capllal BlueCross I r., M Pennsylvania B1ueShleld ' ~" "*r:,*nl Lk.nMtI .'IN II... Ct_ Ind I'", W,l. Anoel..lon ..." .. ~fft~~1~~~JiWj!:E~W;=~~~~~!!Fo~~!:~11&J=~lL~'I~I~~)~J~ IIRTHI 092862 -----r I I OUTPATIENT CARE 1 3167 000 3167 000 , PATIENT TOTAL 3167 , 000 I 3167 , , :f. , CLAIH . 1823010061400 000 . . i 1,,,,1 I I , I I ... 0-1 H THE 1997 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1997 OUT-NETWORK OED HET FOR BARBARA IS 0.00 OF THE 1997 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1997 OUT-NETWORK COINS HET FOR BARBARA IS 0.00 OF 3,000.00 THE 1997 BENEFIT PAID FOR BARBARA IS 10,998.Q3 . I - IN-NETWORK LIFETIME BENEFIT PAID FOR BARBARA IS 11,991.21 OF 1,000,000.00 OUT-NETWRK LIFETIME BENEFIT PAID FOR BARBARA IS 11,991.21 OF 1,000,000.00 250.00 , I I , I.. 1'- I 1 I I I I i I '1 , I , I , ) , I , J . 'Capital B1ueCross i ; . Pennsylvania BlueShield OA: g "" "do'" Lk....... .11... ",... c,......II... Ihkl. ....dltlon . . COItP I CENTER DEPARTKENT 778988 HARRISBURG, PA 17177-8988 I T! TI TI T! i , I " \..i 1".111",1"1,1,1,1,1",11,.1",1.1.,1,1,1,.111,,,1,"1,1,1,1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-B22Q OJ IB 9~1 '.J u EXPLANATION OF BENEFITS COMPREHENSIVE AND WRAPARoutlD MAJOR MEDICAL PROGRAMS , ......' r ,------~I UIISCHIllH1IS ~ ------ ,... ItJ.l I'll iHHO\Hlls i11t! I"j -I I r f I \ it ~1~~','I~R~~b~=iU~\.a~~i~ltrJ:.~;=~f.M I 0100 31:67 ~OO \_1 0,00 51i67 0,00 t 51'67 000 It or '.1t~1lIcalO rl r ! co...t:fa~e l11ilV ed properlv_ e_penSll5 J"t. h lht! adc!llIonal .., ;1 be cOl11ph!led me Oenelils' or ider the unpaid .,. ilrl clime nliUlnlUrn ,.~ nelll maxImum ,Tit Imber provided. t! am quesllons CONCERN'NG 1997 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS HET. E 1997 FAHILY OUT-NETWORK DEDUCT MET IS 0.00 OF 500.00 E 1997 FAHILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. E 1997 FAHILY OUT-NETWORK COINSUR MET IS 0.00 OF 6,000.00 ,:Yfi~~~l~~~![i. grJl~l~i~~.~ffl~~~~~~l~~~:~:fi~,~~B.fF.f~~~[~f7JJ,t " . ~ ~.I.O 1!. .~ ,1'Jt.~" ,,' .:w..J.....H'ltiL'. -~'T-db-':;:d,d.iIw.;~c.~~~>>l,tJr~1..u:i.Ji:;o~liw~.3 SUBSCRIBER, T B BYRNE NOTICE DATE 08/18/1998 CONTRACT' H27q662016 CHECK . QUESTION CONCERNING THE ABOVE CLAIHCS>? TELEPHONE INQUIRIES, WRITTEN INQUIRIES, PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEMENT. HAIL TO, " TOLL-FREE TDD UNITS 1-800-222-33Ql THE COMP I CENTER 1-800-2q2-Q809 DEPARTHENT 77-8988 HARRISBURG, PA. 17177-S988 '-- HOURS 8:00 AH - 6:00 PH EST H 6516 '-' r~ , "" +. ~ Capital D1ueCross I " M Pennsylvania 8lueShleld . · "",,"nl Lice,..... .IIM Ilut Ct... .nd Ilue Shield Auodtt\on I LESS AttOUNT I "" , I :::ICE DA~~S 1"'1 "':.'"" ! ~ I C~T:E INELIGIBLE . PATIENT, BYRNE B GROUP,00279 BIRTH, 092B62 --r-r -EL -'-,- EIIERG ROO" "EDICAL VISIT 010498 2 W9026 1 9600 9600 I I, PATIENT TOTAL 96'00- -''9600 , . CLAIM . laO~~105~0200 ALLOWABLE ~ LESS ~ , AIIOIIfT EDUCTIBL . .....--. 000 000 000 000 I f i. ... " " I i ....1 " " .. EXPLANATION OF CODES 293 The .pecific condition reported doe. not qualify for payment under YOUR omer90nc~ bon " .. . .. ,- , .... ., Capital BlueCross i ; . Pennsylvania BlueShield :A: II,............, Lk....... "'M .,.. c_ ond 0'... Sh,.I. .....,",.. . .. CllHP I CENTER DEPARTHENT 778983 HARRISBURG, PA 17177-8983 .. THE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. It THE 1998 OUT-NETWORK OED HEr FOR BARBARA IS 0.00 OF 250.00 THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK COINS MET FOR BARBARA IS 0.00 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS 104.00 " - IN-NETWORK LIFETIHE BENEFIT PAID FOR BARBARA IS 3,293.16 OF 1,000,000.00 OUT-NETWRK LIFETIME BENEFIT PAID FOR BARBARA I~ 3,293.16 OF 1,000.000.00 .. 1 I ... ':--I 1,,,111,,,1,,1,1,1,1,1,,,11,,111,1,1,,1,1,1,,111,,,1,,,1,1,1,1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-8224 u v I [. L. L~ .iO i I- , , I. . o . . .. "" ..., ru I~ <':1 \.J -.J . + , ('apllalllltw('ru\\ '.' I','nn.\yhania IIlu,-Slticld , 11l.......lld.:,1 l lUll..... ullh. 11I11. 1:'61" anJ Ulu. Shi,ltl Anud.liull . . I SERVICE DATES ''''I "-I NO. I TOTAL FROIl TO - SVCS CHARGE PATIENT: BYRNE B GROUP:00279Q V~~~JL~~ ~1~~8~~EDURE ~_;~~~ffifEI93~71I~_~ -=- ~'E CLAIH . 1800910219700 PATIENT TOTAL 5~0 0,0 " I LESS AIIOIMr I ALLDlIAIILE I LESS lHELlOIII.E AIIOIMr jlEDucTDL ---liO 1000 00 QgpO l- 49j00 . . . .. EXPLANATION OF CODES 409 These sorvices wero provided by a Pre.ior Blue Provider. The a.ount in the "ALLOWABL providod allY DEDUCTIBLE or COPAYMENT a.ounts are paid to the provider WITHIN 60 DAYS . . . TilE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT'NETWORK DED MET FOR BARBARA IS 0.00 OF 250.00 THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT'NETWORK COINS MET FOR BARBARA IS 0.00 OF 3,000.00 TilE 1998 BENEFIT PAID FOR BARBARA IS 49.00 - IN-NETWORK LIFETIME BENEFIT PAID FOR BARBARA IS 2,898.46 OF 1,000,000.00 OUT-NETWRK LIFETIME BENEFIT PAID FOR 8ARBARA IS 2,898.46 OF 1,000,000.00 . 'Capital 81ueCross i ; ". Pennsylvania 81ueShield :Ii II '....'....., U<M..... "'ho .,~ "'M..... .,~ Shl"d ...~I.II"" . ,COHP I CENTER OEPARTHENT 778988 HARRISBURG, PA 17177-8988 1.,.111..,1..1,1.1.1.1..,11,,1...1,1..1.1.1,.111.,.1..,1.1,1,1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-8224 \,US OTHlIl 1IISUllA/lCI EXPLANATION OF OENEFITS COMPREIlENS'VE AIm wnAPARoulm MAJOn MEOICAL PIlOGnAMS ~us c;ap......, I LESS PIlIOIl 1 ALLOIlAIICE 1 ALLOIlAIICE \IUWUE I IHELIOIlLE I I I ......" AIlOUIIT PAID TO PROVIDER TO SUlst1lIHIl AIlOlIIT COOlS .. PROVIDER: (632095) C RLISLE IMAG NG ASSOC r- '---,- -----r-- '--r 000 000 q900 O~O Q09 Jo'o --O~Ofi --410 ---000 Of 0 OpO TOTALS 4900 000 eolu.n will bo aeeoptod by tho providor as pay.ont in full dato of this notieo. 1998 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS MET. 1998 FAMILY OUT-NETWORK DEDUCT MET IS 0.00 OF 500.00 1998 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1998 FAMILY OUT-NETWORK COINSUR MET IS 0.00 OF 6,000.00 PLEASE KEEP THIS STATEMENT FOR YOUR RlCORDS. SEE REVERS! SIDE FOR ADDITIONAL INFORHATION ABOUT THIS STATEMENT SUBSCRIBER: T B BYRNE CONTRACT. 1127Q662016 NOTICE DATE 01/09/1998 CHECK . QUESTION CONCERNING THE ABOVE ClAIMlS)1 TELEPHONE INQUIRIES: WRITTEN INQUIRIES: PLEASE FOllOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEMENT. MAIL TO: TOLL-FREE TOO UNITS 1-800-222-33Ql THE COMP I CENTER 1-800-2Q2-Q809 DEPARTMENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8:00 AM - 6:00 PM EST H QnQ r - SLII\~;Cnlm n I~ ,1\l"O,r,lt'l!lr,lIl' 111'!ll ;1111')111\,,, ,III' Mfl ,1!, ~ lilt' (UVI'IiI~W /II.., S~l'[t propt'r1v :!d lJ.pens(!~ 1011' 11th the ;1I1(IIIIOn;ll .ln1 usl bo completed Icmc Onnell\'; or \5idt~1 Ihl) unp,lltl I\)' illellllll}m,lkllllunl C( yml!f11 mill,mUnl lumber fHOlJldcd !lIC aw questions 'I1' 5 CONCERNING ,. ,.. 4, . "" r' ,... ,-' r ~ /I I "1+' .. Capital D1ueCross Pennsylvania D1ueShleld IndI,-ndtnt L1n",... ollhlll~ ClIN, .nd IllIt ShI,ld Auocbllon I SERVICE DATES 1"'/ ''''''''l NO. I TOTAL PROII TO "" SVCS CHARIlE PATIENT, BYRNE B GROUP,00279 BlRTN, 092B62 ; '~----r , "EDICAL THERAPY 012898 012898 3 90806 1 6500 000 I I I , .L__----1 CLAIH. 1804310114100 PATIENT TOTAL 65,00 0,00 I LESS AItOUHT I ALLOIIA!LE I LESS I INELIOIBLE AItOUHT pEDUCTIBLq ... --r 6500 000 i _1- 65.00 ODD . . ... . ... " EXPLANATION OF CODES 979 $ 10.00 Tho amount<s> shown abovo was appliod to YOUR copay.ont. . . lit .. THE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. lit THE 1998 OUT-NETWORK DED MET FOR BARBARA IS 0.00 OF 250.00 THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK COINS MET FOR BARBARA IS 0.00 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS 1 Oq . 00 lit - IN-NETWORK LIFETIME BENEFIT PAID FOR BARBARA IS 3,293.16 OF 1,000,000.00 OUT'NETWRK LIFETIME BENEFIT PAID FOR BARBARA IS 3,293.16 OF 1,000,000.00 .... .... . 'Capital BlueCross i ; . Penns Ivania BlueShield ~ g '.........J'k........ ,.. 0'.. c._ WId .,.. .....,. A..."".... . . CDltP I CENTER OEPARTHENT na988 HARRISBURIl, PA 171n-89113 , I '.,1 1",111.,.1.,1.1.1.1,1".11.,1...1,1"1.',',,11111,1,,.1.1,1.1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-822q OJ 199:) '_.1 r 000 I l-l 000 , EX PLANA liON OF BENEFITS COMPREIIENSIVE AIm WRAPAnOUlm MAJOR MEDICAL PROGRAMS h.. COPAVHIH, I LESS PRIOR 1 ALLOWANCE ! ALLOWANCE I MESSAGE . INELIOIBLE I · I AIIOIII' AItOlIfT PAID TO PIlOVIDU TO suaSCRIUR A/lllUNT toilES .. PROVIDER. (030736) S LLY ROONEY PIlD I 000 , , . 5500 000 979 I . ---I 55,00 000 0'00 I 000 H- ,. I I .. I t , TOTALS 0,00 5500 0'00 1998 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS HET. 1998 FAMILY OUT-NETWORK DEDUCT HET IS 0.00 OF 500.00 1998 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1998 FAMILY OUT-NETl/ORK COINSUR MET IS 0.00 OF 6,000.00 PLEASE KEEP THIS STATEHENT FOR YOUR RECORDS. SEE'REVERSE'.SIDE FOR ADDITIONAL INFORHATION ABOUT THIS STATEHENT,' .:\ ' ..'.f SUBSCRIBER. T B BYRNE CONTRACT. H27q662016 NOTICE DATE 02/12/1998 CHECK . QUESTION CONCERNING THE ABOVE CLAIHCSl7 TELEPHONE INQUIRIES, WRITTEN INQUIRIES. PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO. TOLL-FREE TDD UNITS 1-800-222-33Ql TilE COMP I CENTER 1-800-2Q2-Q809 DEPARTMENT 77-8988 HARRISBURG, PA. 17177-8988 1l0URS 8:00 AM - 6:00 PM EST II Q856 ,.. ._-~~. ---. SUtJ~;CflIllEn IS ,.. uu or ',\f~dl[;;lItl I'rltanHJUf\lsiUll 111 ("\ r ,~ ,. I, COVOldllo mnl ,ed IlfoPOItv .- 1'''lIufl5u5, On, Ih tho additional .n, sl be completed :JIC Benefits. or lidor Iho unpaid , i1r cllmo malimum to 1wnl mltximum Jmber provided. ~o are quostions Tlr CONCERNING , I , . ( ----..--------. <. '- "- '- ,-. III "II i' ,. Capital D1ueCross · ,~! M Pennsylvania D1ueShleld "~ii ,~l.:,I:r,', '!t:r,\~t~":',""'lsiRVi~i""oATi;""';.r"~:;:; NO. '., TOTAL " . LESS~, ,~LLOlIABLB,< ' LESS , " lpAflEHT";"\i'Y~itELL"~l'i(,L fllOIL,. "'~R'iit;~Oli279! $~a I. ..,J:tM~(. ,.J.lIlul\Ull.d,.....NW!T~.~bQM;JD BIRTH, 092862 '-1 1 I, OFFICll/OUTPATIEHT VISIT 030298 030298 3 99212 1 3200 3200 000 000 " THERAPEUTIC INJECTION Q3.02.2 Q3.02.2 .3.J255Q. _I. 6.0Q 60Q OQ ----D,Q CLAIH. 1806410676900 CLAIH TOTAL 38,00 38.00 0,00 0,00 . , ,,- 900 PHARKACY 010498 010498 2 0250 900 I.V. SOLUTION 01:0498 010~98 2 0258 3200 3200 KEO/SURD SUPPLIES 010498 01.0498 2 0270 3900 3900 . LABORATORY 010498 010498 2 0301 37,00 3700 LABORATORY 01P498 019498 2 0305 37.00 3700 EIIERCEHCY ROOH 010498 010498 2 0450 22100 22100 . EKO/ECO 010498 010498 2 0730 87,00 8700 OlAllIIOSTIC SERVICES lU 022 325,Q 25 CLAIH . 1804420156300 CLAIH TOTAL 787,00 787,00 . 010698 010698 2 0250 , PNASHACY 7500 75,00 000 - I.V. SOLUTION 01:0~98 010698 2 0258 3200 3200 000 . KEO/SURO SUPPLIES 010698 010698 2 0270 4000 4000 000 LABORATORY 010698 010698 2 0301 3700 3700 000 LABORATORY 010698 010698 2 0305 6300 6300 EHERCEHCY ROOH Q 36roo jaQ CLAIH . 1805620151900 CLAIM TOTAL 36500 . PATIENT TOTAL 1190,00 119000 , . ... . 'Capital BlueCross i; . Pennsylvania BlueShield ~ H '-....... ""..... .11'" I'... c....."" l"d.,,1d A....'",,,, . . COI!P I CENTER DEPARTMENT 778988 HARRISBURG, PA 17177'8988 II EXPLANATION OF CODES I.. 769 Tho lubscribor did not rospond to our inquiry on othor covorage, we presul8e that anotr Poy.ont for this clai. and all futuro clail8s will be deniod until the subscriber prov 293 Tho Ipocifie condition reportod doos not qualify for paYllont under YOUR ol8orgoncy bon . I I ! . I ! i l , t I i 1 1 , ~ 250.00 . . tit TilE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK DED MET FOR BARBARA IS 0.00 OF THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK COINS MET FOR BARBARA IS 0.00 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS 219.00 .. - IN-NETWORK LIFETIME BENEFIT PAID FOR BARBARA IS 6,815.60 OF 1,000,000.00 OUT-IIETWRK LIFETIMe BeNeFIT PAID FOR BARBARA IS 6,815.60 OF 1,000,000.00 tIi) ... ~. ,f '.J _1"1111".1.,1.1.1,1,1,"11"1",1,1,,1.1,1"11I11I1,"1,1,1.1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-8224 EXPLANA liON OF IlENEFITS COMPREHENSIVE AtIO WRAPAI10UrlO MAJOn MEOICAL PI10GI1AMS OTHER. . ~UI taPA'"'"'.l Ll$S ~RlO. I . A1LOlIAIlCI. . I ALLOIIAIlCI II1ISUOI. IHIUGULlj' E;~I';Jov~t~ ~;tm'l~~lIlYtd.~&TRlff~~t~Q F~$Cm~IlH~imMIT~IlI...r"'- 000 769 D.OO .1flLr 000 , ~;UB~;cnIBEn 15 ~jl) Of r.I,'dlc.l!C 000 , 000 000 .J,01l 0,01l o.DD- 000 000 0,00 , PROVIDER, (390058) CARLISLE HOSPIT , , 000 000 000 000 000 0,00 000 000 0,00 0,00 000 000 0,00 0,00 0,00 000 000 000 000 000 000 000 000 000 000 000 000 000 OD. ,QD. ,Oil 0 0,00 000 0,00 000 , , PROVIDER, (390058) CARLISLE HOSPIT fll' l!ol alllounl~, illU MI r- 000 293 000 293 000 293 000 769 000 769 000 293 1\00 769 001>- 0,00 t~ CO"I~';\(JP 1n,IY 1-;"11 PH'Pi'lly ,- 000 769 nOD 769 000 769 000 769 0'00 769 ,r,n, III the addiliOnill (11'.~lI'n!;()s 0,00 0,00 0,00 000 i "", Isl be compleled :aw Of'nellt5' Of Sl(h~1 Ihl~ unp;lld I ill Icllt1le fl1illlll1urn .r insuror has first liability and allows covorago for this sorvico. os other covorage inforllation. ' it. c\. menl mJltllllUm r I 1 I I 'I I , ~ 1998 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS MET. 1998 FAMILY OUT-NETWORK DEDUCT MET IS 0.00 OF 500.00 1998 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1998 FAMILY OUT-NETWORK COINSUR MET IS 0.00 OF 6,000.00 1:;:' ': ;': ' \';;, "PLEAS'! 'KEEP THIS 'STATEMENT FOR YOUR RECORDS.;.': '" ": ~", f:,;n \ li:f..E.~~J~J_~~l~~}!I?1J1o.~V~~,~R!'.~!~~!! ~Pw"!.T,: ~.Hl~,~~I~!E,~~'1~;;, [3 I , I , umber pro'o'ulod ro art) quesllOlls ml ; CONCERNING SUBSCRIBER, T B BYRNE CONTRACT' H274662016 NOTICE DATE 03/17/1998 CHECK . QUESTION CONCERNING THE ABOVE TELEPHONE INQUIRIES' CLAIHCSl1 WRITTEN INQUIRIES, PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO, TOLL-FREE TDD UNITS 1-800'222-334\ THE COMP I CENTER \-800-242-4809 DEPARTMENT 77-8988 HARRISBURG, PA. 17177-89B8 HOURS 8:00 AM - 6:00 PM EST H 9354 ,... r, r. , 'P I r j " I I ,\-;1> " I I I ~, ~r!~~~~~~.l;;l'"'""="' "'" ."" ""'""_~ . ~a j l~~ffik~'~! ;:;~~R~~'X:C .(iiaJ kUOll I;; L ~~~!1!Orr7~!~~J; .~CIlARQL2.:I~mILweLd j.Jlj!MfL~"billl&U8L. . BIRTH. 092862 I I ~~~i"~:rON gm~: gm~: ~ mg ~~gg m I LABORATORY 0111898 0111a98 2 0300 1700 000 I LABORATORY lI..1ltll98 .D1JIl9B 2 0300 litO O.OQ. 1_' CLAIH . 1807920153800 PA TI ENT TOTAL 111,45 0,00 0,00 O,OO! . f , ! I A I 000 \ ! f j ODD! .':n I I I t t l l"~l ~i '''1 PATIENT. BYRNE BIRTH 1 022689 NEDICAL THERAPY CLAIH . 1808411390300 6500 65,00 000 000 , 6500 6500 1 PATIENT TOTAL ~., ~ "" "" II EXPLANATIOH OF COOES 9113 $ 35.00 I The llIleuntCs) shown abovo was applied to tho ellergency rooll deductible or penalty spe., 11511 Duo to spocial processing roquired for this claill, individual allounts cannot bo shown I 979 $ 10.00 i Tho 1lIl0untCs) shown abovo was applied to YOUR copaYllont. I I.. 1.- I' I I I I ! I TH' THl- 'ru\ OU'\ ~ 1 ~ , 1 I , I i , I I ~ M ... " ... THE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK DED MET FOR BARBARA IS 0.00 OF THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK COINS HET FOR BARBARA IS 0.00 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS 318.115 - IN-NETWORK LIFETIHE BENEFIT PAID FOR BARBARA IS 6,975.05 OF 1,000,000.00 OUT-NETWRK LIFETIME BENEFIT PAID FOR BARBARA IS 6,975.05 OF 1,000,000.00 250.00 ... ...- . . . 'Capital BlueCross i ; . Pennsylvania BlueShield ~ g '.......... Lk._.... .100 .,.. em. ond .,.. ...,.,. .....,..... . . CDHP I CENTER OEPARTHENT 778988 HARRISBURG, PA 17177-B988 . J !., 1...111...1..1.1.1.1.1...11..1...1.1..1.1.1..111...1...1.1.1.1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-82211 ,,-,I:, EXPLANATION OF BENEFITS COMPREHENSIVE ANO WRAPAROUND MAJOR MEDICAL PROGRAMS . ~~S COP.Y~[r! I. U$S PRlaR '1,; ALLDlfAItCB.!' ALLDlfAItCI lH~~DB I DlBLI~Dl~~ J L..J.:"lO...:.J~ 'AlD. ,TO 'ROVlDEIl . TO.Jlm~WEll. _""NIOLIIIT~!;lllIU.lU.;;ojj PROVIDER. (999000) BOOKINGS HOS I 943 ~ 1645 OrOO 454 II 000 000 000 , , , PROVIDER. (030736) SALLY E ROONEY PHD 000 000 5500 000 979 I i I ' 000 0,00 5500 0,00 , 131,45 0.00 , fied in YOUR coverago. 011 columns; amounts will appear only on the "TOTAL" line. THE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR ANDREW IS SATISFIED. 1998 OUT-NETWORK DED MET FOR ANDREW IS 0.00 OF 250. DO ;no THE 1998 IN-NETWORK COINS OF 0.00 FOR ANDREW IS SATISFIED. 1998 OUT-NETWORK COINS MET FOR ANDREW IS 0.00 OF 3,000.00 1998 BENEFIT PAID FOR ANDREW IS 301.22 NETWORK LIFETIME BENEFIT PAID FOR ANDREW IS 275.00 OF 1,000,000.00 -NETWRK LIFETIME BENEFIT PAID FOR ANDREW IS 275.00 OF 1,000,000.00 1998 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS MET. 1998 FAMILY OUT-NETWORK DEDUCT MET IS 0.00 OF 500.00 1998 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1998 FAMILY OUT-NETWORK COINSUR MET IS 0.00 OF 6,000.00 ~i}}'~~~':~. . EJ~RS:~~~~~"'~~~~At~~~.i~~~lE~~~tR~~~I~~U~~'~$f~~~.~'~!;,;f;~~~~V:~ t.M.!b.....!~>I:.o..........~_!>..'*......_...........d!.i.iU....:..u"C.......:...w_~.1.....~".....~..,.". ,l.~.I_~....Jt....a......~,-,,-..-............,~.... . SUBSCRIBER. T B BYRNE CONTRACT. H274662016 NOTICE DATE 03/25/1998 CHECK . QUESTION CONCERNING THE ABOVE CLAIHCSl7 TELEPHONE INQUIRIES. WRITTEN INQUIRIES. PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO. TOLL-FREE TDD UNITS 1-800-222-3341 THE COMP I CENTER 1-800-242-4809 DEPARTMENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8:00 AM - 6:00 PM EST H 9738 'I ,.. SUOSCRIUEfllS ,... ~le or Mt'dICtlfL' ()l' Hll ill1Hlllllb ,1111 ,...... - ltJ ("'. ,.. IIlICtl\l.",I!I'.I11i1Y ,ml pHljJPrtV r, IC_rJefll.llS 1011 III ItlU iHJcllllOn.11 _.1. 151 tw COlllplelpl1 ;me Bem'lits' or iide' the Ullp.lirl 1m 'clime m"XlfnUITl c, menl milwnum umbfH provided re are qucsllolls ; CONCERNING '. '- II · +. , Capital B1ueCross I r.~, M Pennsylvania B1ueShield I' . '"I'~_, ~: ~'7ndt.~L~',~".'~M.si~cindDATi;I'ld^'-= NO. · ~:~AiiENr. BY~NE'~',.:.....~~.,I flOll '~RO!:!OO~9! ~YCSI BIRTH. 092B62 --:--] I J;J~ I I. LABORATORY 03,02,98 03,0~98 Ce~ .___.. CLAIH . IB07920144300 PATIENT TOTAL '. _ CT::O~.. , 1~~u='I.~=L~ ".b~~LJ 10800 10800 ....4-- -._ I 10~00 10BOO 0'00 I 0,00 000 0'00 '.. . . . . . II EXPLAHATION OF CODES 769 Tho .ub.cribor did not ro.pond to our inquiry on othor covorago, wo prO.UNO that anoth PaYNont for thi. claim and all futuro claime will bo deniod until tho .ub.cribor provj . . . . THE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. It THE 1998 OUT-NETWORK DED HET FOR BARBARA IS 0.00 OF 250.00 THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK COINS HET FOR BARBARA IS 0.00 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS 219.00 . - IN-NETWORK LIFETIHE BENEFIT PAID FOR BARDARA IS 6.815.60 OF 1,000.000.00 OUT-NETWRK LlFETIHE BENEFIT PAID FOR BARBARA IS 6,815.60 OF 1.000,000.00 '-J 1".111,.,1..1,1.1,1,1."11"".,1.1.,1.1.1,,111,,,1..,1,1,'.1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-8224 I '11 ~ 1 I I i I , I i .. w . 'Capital BlueCross i ; . Pennsylvania BlucShield ;a; 51 ............,lk...... o/.ho .,... c.... ... .,... ..,... A....l..,~ . .. COIlP I CENTER DEPARTltENT 778988 HARRISBURG, PA 17177-8988 \-:4 e' i~ c,.:, u L I. "1 "1It!ij " I. :. . . . . . Capital B1ueCross Pennsylvania BlueShleld IndepencMnl L1e""....f 1M .1.... Ct... ,nod II~ Wild Auoclulon I LESS AHOUHT I I ;=m DA~~S \"'\''';:'' l~s I i::':iE INELIOIBLe PATIENT, BYRNE B GROUP,00279 :r~~~~~U~~~~~~ VISIT 03'0298~3'g~~li3l99212 1 320;----doo THERAPEUTIC IHJECTIOH Jl3.ll2.98 3.Q2.9 ilJ2550 _---.-1_ __ ,_6.00 5.00 CLAIH I 1808000919000 CLAIH TOTAL 38,00 5,00 AHBULAHCE SERVICE AHBULAHCIl SERVICE AHBULAHCE SERVICE CLAIH I 1807500044900 -----~ ------ 1 1135'00 13 7150 I 113500 7150 57650 61450 I 57650 581,50 CLAIH TOTAL PATIENT TOTAL , . I ALLOlIABLE A/1OUIfT bLESS I EDUCTIBLEl , 3200 000 1.00 .,__000 3500 0,00 , jl I AA EXPLANATION OF CODES 989 $ 10.00 Tho amountCs> shown abovo roprosonts tho offico visit copaymont and is tho subscribor' 1109 Thoso sorvicos woro providod by a Promior Bluo Providor. Tho amount in tho "ALLOWABLE providod any DEDUCTIBLE or COPAYHENT amounts aro paid to tho providor WITHIN 60 DAYS f 119 You did not rospond to our inquiry on other covorago, wo pro~umo that anothor insuror for this claim and all futuro claims will bo donied until YOd provido othor covorago i . . . .. .. THE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK DED HET FOR BARBARA IS 0.00 OF 250.00 THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK COINS MET FOR BARBARA IS 0.00 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS 2112.00 IN-NETWORK LIFETIHE BENEFIT PAID FOR BARBARA IS 6,898.60 OF 1,000,000.00 OUT-NETWRK LIFETIHE BENEFIT PAID FOR BARBARA IS 6,898.60 OF 1,000,000.00 .. ... ..., . 'Capital B1ueCross i ; . Pennsylvania BlueShield ~ H,...........,,,,,..... .".. .,... <".. "'" .,... ShI,'. ..-,..,.. . to CllI1P I CENTER DEPARTMENT 778968 HARRISBURG, PA 17177'8968 ~" 'J 1",111",1"1,1,1,1,1",11"1",1,1,,1,1,1,,111,,.1,,,1,1,1,1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-82211 (:1 -' .' EXPLANA TlON OF OENEFITS COMPREHENSIVE AND WRAPAROUND MAJOn MEDICAL PIlOGIlAMS (55 OTHER hss COPAV"'NI I LESS PRIOR! ALLOWANCE ! ALLOWANCE bltESSAGE I INELIGIBLE RANCE I' I ANOUH! AItOUNT PAID TO PROVIDER TO SUBSCRIBER AItOUNT CODES .. PROVIDER, (153146) Y LLOW BREECH S FAH PRAC TR -,------;-- -----T-~ ----.--..---.---.....--- ------..___.__ , 000: 000 000 2200 :'--_0,00 ---_000 -___0.00 ____ __1.00 ,_ _n,__ 0,00 0,00 000 23,00 0.. --.---j"--___..__ nUT- 000 989 u. _0.00 '109. '.__,___ ,_.__ 000 PROVIDER, (282236) CUHBERLAND VLY /lOSE CO NO 2 ---r- ------~-- , 000 000 000 000 000 0,00 000 000 000 0,00 000 000 000 000 0'00 23,00 TOTALS 2300 0:00 , --~~ ____'. "u__. ,_____. responsibility. OUNT" column will be accoptod by the provider as payment in full oa the dato of this notice. s first liability and allows coverago for this sorvice. Paymont format ion. 1998 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS HET. 1998 FAHILY OUT-NETWORK DEDUCT HET IS 0.00 OF 500.00 1998 FAHILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1998 FAMILY OUT-NETWORK COINSUR HET IS 0.00 OF 6,000.00 PLEASE KEEP THIS STATEHENT FOR YOUR RECORDS. SEE REVERSE SIDE FOR ADDITIONAL INFORMATION ABOUT THIS STATEHENT SUBSCRIBER. T B BYRNE NOTICE DATE 03/23/1998 CONTRACT. H2711662016 CHECK. QUESTION CONCERNIHG THE ABOVE CLAIMCS)? TELEPHONE INQUIRIES, WRITTEN INQUIRIES. PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEMENT. MAIL TO. TOLL-FREE TOO UNITS 1-800-222-33111 1-800-2112-11809 THE COMP I CENTER DEPARTHENT 77-8988 IfARRISBURG, PA. 17177-8988 HOURS 8.00 AM - 6:00 PM EST H 9767 ,.. -... -.-----.-.--- ~iUll:jCflUllH l~) ,.. HI' III ',ll'<10C,1I11 t'JlI ,trfHHIIll'.illl' f"1., -' ~u ,..., r: L. r Itl co....erage may ~;ed propmly ~. j e~pHn',es 0111 Ih tile nddillollal .rn~ IsI bo complelrct :are UenolllS' or iidor lhu unpaid tar ft.'linwrtla:lIrTlurll cc.. men! m,wmum limber provided. re are quesllons 'T1r , CONCERNING <, I. ... 1 EXPLANA liON OF OENEFITS COMPREHENSIVE AND WllAPAnOUND ' '. MAJOI1 MEDICAL PflOGI1AMS lmsortff:~',','l. i~ ~Of'AYKPfT.I'; LESS '"RIDR .1i~,';ALLDlIAHCI : .1" ALLOIWClI. .:j." EWJlI.., Dlmll~\~l 1ii\I~IU.l'~!!!/!fl~L~ll'1l1~': .,TO,PJIOVIOER;: tlUIaKlWIi& 1;j.:A!IlMft;~.. 'T" . PROVIDER. (39998q) D kOTA SURGIC L SUUSCfllDER IS ~ 21900 DE 529 000 219,00 000 , (39998q) DAKOTA SURGICAL 000 000 MOO ~ 0100 000 6000 ,00 (39998q) DAKOTA SURGICAL 000 10000 000 000 10000 000 (39998q) MEDICAL XRAY CE 000 9000 000 529 0,00 90,00 0,00 0,00 469100 ~OO 46 00 ClOD [JO or MudlCiHtl. )111 amounls 0:0 IN I~ I o coverage may wd proporly. "r mber provillcd. Dare queslions CONCERNING I cKponsos. 'nc< h tho additional n9 5t be completed are Benefits' or ider tho unpaid ovided. Providers that arc members with the local PIan have agreod to ot YOUR responsibility. car- :ttimc mnximum COI nenl maximum 1998 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS MET. 1998 FAMILY OUT-NETWORK DEDUCT MET IS 0.00 OF 500.00 1998 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1998 FAMILY OUT-NETWORK COINSUR MET IS 0.00 OF 6,000.00 ~,~~~~i~R~~!~~~~~~t;J1i~1M~!~~~~J~~]j~!~~Ji;,~f~y~~~~~;m~ SUBSCRIBER, T B BYRNE NOTICE DATE 07/09/1998 CONTRACT. H27q662016 CHECK . QUESTION CONCERNING THE ABOVE CLAIM(S>? TELEPHONE INQUIRIES. WRITTEN INQUIRIES, PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEMENT. HAIL TO. TOLL-FREE TDD UNITS l-aOO-222-33ql THE COMP I CENTER 1-800-2Q2-Qa09 DEPARTMENT 77-898a HARRISBURG, PA. 17177-8988 HOURS 8:00 AM - 6:00 PH EST H 7358 EXPLANA TlON OF BENEFITS COMPnEIfENSIVE Arm wnAPAnOUNO MAJOn MED'CAL pnOGnAMS '""'\ ,... iUUScnlBER IS crrltl~;:~i~~W()V LI$I:rUOR J:'~~~=~"i I~.::.a:r=.: PROVIDER, ~2~BkOOKINGS MEDic . relpondbility. ,.., JO or Medlcaro. 000 0100 38811 5 5 0100 989 ~OO 000 000 000 )PiI Int amounts are N. r r "' I o coverago may lod proporly. :t OlponS89. .J"\; lh tho additional 51 bo completed . 11 :oro Benehls' or lidor the unpaId " I ar fclime mtudmum menl maximum umbor provided. to are quesUons ,TIl I CONCERNING OF 0.00 IS HET. 250.00 OF 500.00 0.00 IS SATISFIED. SUBSCRIBER. NOTICE DATE 08/11/1998 CONTRACT . CHECK . QUESTION CONCERNING THE ABOVE CLAIHCS)? TELEPHONE INQUIRIES. WRITTEN INQUIRIES. PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO. TOLL-FREE TOD UNITS 1-800-222-33111 THE COMP I CENTER 1-800-2112-11809 DEPARTMENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8:00 AM - 6:00 PM EST H 6321 ~/ III .. ~! Capllal D1ueCross I, Pennsylvania BlueShleld ... '., . ~r.e~Lk,'~t'..'J.~'IU.Ct""~'IU.Il;:'~!I~~uocl'llon., ,_ f" l~~~~~~~~t;ft;:l'! ~\~~:'f ";':m.~~~~i!;X~~l~ 110".) 'I,' IIRTH. 092862 VEHIPUHCTURE 042998 04 998 3 36415 C" VEHIPUHCTURE 060~8 060~8 3 36415 PATHOLOGY/ILOOD TEST CLAIH . 1122010104000 TOTAL".,;,,'. LI$S AHDWT;ijiALLOIlAILI:, b~ 1;_ ,_., . . UA ';~;)~~~~~11 , 30~ ~OO 3,00 300 0,00 0,00 000 , , !Ii I I' ! ; I' I ,,,,I f' fl .1 f' .' .' 4 I 4 , i \ .. .. THE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. . THE 1998 OUT-NETWORK DED HET FOR BARBARA IS 250.00 OF 250.00 THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK COINS HET FOR BARBARA IS 5.70 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS 4,947.36 .- - IN-NETWORK LIFETIHE BENEFIT PAID FOR BARBARA IS 10,628.57 OF 1,000,000.00 OUT-NETWRK LIFETIHE BENEFIT PAID FOR BARBARA IS 10,628.57 OF 1,000,000.00 1\ ~ I' i' ~-I . 'Capital BlueCross i ; . Peons Ivania BlueShield :AI II" '" ._1 Lk_ oI.he ",.. 01_ .... ",.. ..~,. A",".lI.. . . COltP I CENTER DEPARTHENT 778988 HARRISBURG, PI. 17177-1988 'I 'I 7. ~ .4 l.) I.,"" 1",111,,,1,,1,1.1,1,1,,,11,,1,,,1,1,.1.1,1,,111,,.1.,.1,1,1,1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-8224 0' js.<).tj EXPLANATION OF OENEFITS COMPREHENSIVE AND WRAPAROUND MAJOn MEDICAL PROGRAMS ,. JBSCRIBER IS LJU,C1JH. ,~ Pt~Y LISI r~I~;I}~=Il:,I~~~tall~fi~,1:mr..w PROVIDER. ~23~ OkOOKINGS MEDic ODD 300 ODD $0 .0 @o --; 000 000 , , or Modlcare. 1ilV It amounts are I. ,.. DIDO 'f' ,... I "1' I ..... , I covongo may I d proporly. ('. 1"' expenses. "9 tho addllional (' . .., be complotod to Denolils- or Jor Iho unpaid ant timo maximum .u> enl maximum '10' nber provided. . Bro questions :ONCERNING ,.J 1998 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS MET. 1998 FAMILY OUT-NETWORK DEDUCT MET IS 250.00 OF 500.00 1998 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1998 FAMILY OUT-NETWORK COINSUR MET IS 5.70 OF 6,000.00 , )1~'f;tT~~~~Z~~Hs'~~,,'g~~~~~l~~tf ft~~~FO~~A;.~~~}iMt~Jtit~.~jll SUBSCRIBER. T B BYRNE NOTICE DATE 08/10/1998 CONTRACT' H27q662016 CHECK' '" QUESTION CONCERNING THE ABOVE CLAIH(S)1 TELEPHONE INQUIRIES. WRITTEN INQUIRIES. PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO. TOLL-FREE TDD UNITS 1-800-222-33Ql THE COMP I CENTER 1-800-2Q2-Q809 DEPARTMENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8:00 AM - 6:00 PM EST H 651Q 1-.\ '. " " ", , .., I ' . , ~ 004 ... .... ..... ..... .. ~. . 4 k.l 1_,1 OJ (B"9~J ..... III II Capital D1ueCro55 I r.. Pennsylvania BlueShleld . ! ....,.ndtnt Lk.......r ,I'M .1... ".., .,wI..... W.ld Au.I'llon . "l -:; .'<f.;tql'il......JN.rr...n"lj.ti.,-I~ Mn'Jt:I~I'~'rHQ~, '~~~~':'~~~';' 1:~~:~;;',1i1!,M~~i~~1}~u~~m~~_J BIRTH I 092862 , PHARKACV 0~0~8 0~1l~8 2 0250 TREATllEHT ROOK 0~~8 0~0~8 2 0760 24 El\EJlaEHCV ROOK 0(\0~8 0~0~8 2 0450 KED/SURO SUPPLIES 060~8 0~0~8 2 0270 LABORATORY CLAIM' 1B20220224800 PATIENT TOTAL 48a86 000 431;08 ~OO 81,00 0,00 6 15 0,00 143 39 000 0,00 ') II EXPLANATION OF CODES 943 $ 70.00 The ..ountC.) .hown abovo wa. appliod to tho o.ergoncy roo. deductible or ponalty .po 454 Due to .peeial proeo..ing required for thi. ela~, individual a.ount. cannot be .hown THE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK DED HET FOR BARBARA IS 250.00 OF 250.00 THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK COINS HET FOR BARBARA IS 5.70 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS 4,776.15 - IN-NETWORK LIFETIME BENEFIT PAID FOR BARBARA IS 10,457.36 OF 1,000,000.00 OUT-NETWRK LIFETIME BENEFIT PAID FOR BARBARA IS 10,457.36 OF 1,000,000.00 . 'Capital BlueCross i ; . Pen Ivania BlueShield ;A: II I~Lk__' 01"" .,.. c...... .,.. "'.,. A.....,,1on . . COKP I CENTER DEPARTMENT 178m HARRISBURG, PA 17177-8988 1",111,"1"1,1,1,1.1",11"1.,,1,1,,1,1.1,,111,,,1,,,1,1,1.1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-8224 J EX PLANA nON OF BENEFITS COMPREHENSIVE AND WRAPAROUND MAJOR MEDICAL PROGRAMS if.u:Wnl~~..~~fDJ;lg;'~=; ;,'r.....r'~.tJJ,"fe.I' .;1!Ill!fa~flJ . PROVIDER, (gm'~"MiADttINaS]I~-s~ QIl 1,....J ti ,..., .------ ;UW,CflrOErl IS r. ~,! or t.1I'(lIc.II" IfJ ']-1 9q3 'I);' 'n! illl1otml5 illl~ 000 , 126 13 126 13 000 qSq 000 f"; r r l! cO'o'm,lHu mill' w'J PlOpurly r :! 1!~pt'l1~l'S (ln~ Il, !he illlfJlllon.11 r I , 1ified in YOUR coverage. lin all coluana; a.ounta will appoar only on tho "TOTAL" line. I I i I ..... 51 hu complclod :are OU/IUflls. or lldot Iho unp.Hd '. I ar Il'Imlt.! milumum C!. mon! maWllwn lJfllt)f~1 pro'.lded ro .HO questIOns m, : CONCERNING 1998 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS MET. 1998 FAMILY OUT-NETWORK DEDUCT MET IS 250.00 OF 500.00 1998 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1998 FAHILY OUT-NETWORK COINSUR MET IS 5.70 OF 6,000.00 f1WJjf.J'flJrlmsil~'K.liEp rfHls':o.$T~T,~Ii'i1~~FQ~l~\!~R;;:lllcb~p.I~i:!),;~~:F~ pi.! ~~ ~1!~~illM.~;.L!!~R,!Cm.Yt!M!!WIJI1': fA . SUBSCRIBER, T B BYRNE NOTICE DATE 07/31/1998 CONTRACT. H27q662016 CHECK . QUESTION CONCERNING THE ABOVE TELEPHONE INQUIRIES, CLAIH(S17 WRITTEN INQUIRIES. PLEASE FOLLOW TNE INSTRUCTIOHS PROVIDED ON TNE REVERSE SIDE OF TNIS STATEHENT. HAIL TO. TOLL-FREE TDD UNITS '-800-222-33q, 1-800-2Q2-Q809 THE COMP I CENTER DEPARTHENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8.00 AH - 6.00 PM EST H 660Q ..... :: ,II'~\'~':\~"~~~'~I~"E~~~!,~~~~~tDlrn, ~~,I'i,!I'~I~,,'~1,~ikTaTAL'l '"' ......" ,,,,.....,. I' ,...., ,II 'A,~ ',,".. ,""I"'\l'1:fu.'" ,'j{."i", " .", ~ik"~ .~l~C; . ".I:"Cw.IIQa:.:~ ,;JIWJQJIl.IllJ.ii:l..MllMII~1 PATIEHT, BYRHE B GRDUP,00279 BIRTH' 092862 ' I BEllI-PRIVATE ROOK 06,1598 061598 1 0120 1 3qOOO 000 3qOOO 0'0000 BPECIAL CHARllEll 0~1598 0~1598 1 0220 qOOO 000 qOOO 00'00 PHARIIACY 0615,98 0~1598 1 0250 28JqO 000 28840 , KED/BURO BUPPLIES 06,1598 0~1598 1 0270 77,70 000 77,70 ~OO LABORATORY 061598 061598 1 0300 1q1;10 000 1Q110 0,00 EIlEROEICCY ROOK "511 3U,on OQll UZ ---D.QQ CLAIH . IB21800041200 PATIENT TOTAL 120420 000 120420 000 '" -- ! .. .'''' ~ "" ... ... ... ... .. '" I I I I ~ I ' I I I I I I , I ... THE 1998 IN-NETWOR~ DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. .... THE 1998 OUT-NETWORI( DED HET FOR BARBARA IS 250.00 OF 250.00 THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK COINS HET FOR BARBARA IS 5.70 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS 6,190.QO .. - IN-NETWORI( LIFETIHE BENEFIT PAID FOR BARBARA IS 11,871.61 OF 1,000,000.00 OUT-NETWRI( LIFETIHE BENEFIT PAID FOR BARBARA IS 11,871.61 OF 1,000,000.00 ... ... . 'Capital BlueCross i ; . Pen Ivania BlueShield .. 10~Lk'''''''''''"''C<Mo'''.I'''''1'0..'''''''lon . . lnlP I CEllTER OEPARTKENT 77B9a& HARRISIlURO, PA 17177-B9a& ..... . I _10001110001001.1.1.10100011,,1110101001.1.10.1110111...1.1.1.1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-822Q [\1 -..:. , ) EX PLANA nON OF BENEFITS COMPRWENSIVE AIm WRAPAflOUND MAJOR MEDICAL PROGRAMS 'GtHl~;;,ill~1 LIS$ m;I",AL~DlIAIltI~,,'1 ~~t':~'=W PROVIDER, ~08) Bkoo~I~OS~I I ~ 3qOOO 0,00 qDOO 000 28SqO 000 71j70 000 1~110 000 ltO llD. 120ft20 0,00 120ft20 000 1998 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS MET. 1998 FAHILY OUT-NETWOR~ DEDUCT HET IS 250.00 OF 500.00 1998 FAMILY IN-NETWOR~ COINSURANCE OF 0.00 IS SATISFIED. 1998 FAMILY OUT-NETWORK COINSUR HET IS 5.70 OF 6,000.00 ~{\!t',V,~~;!f,{1:~tP~'m'i "~I~~~THi:'srs'iATIHEilt~FORYvoiiR 'fJiECORii,Wl~~WJ~~. '.~ . Ii&;" ~"IlS"-' ~.D{ti!:2!t1~~~n,o~!,'~"f,.RI!.t't II it,.,. :r'rllt"" II I . I SUBSCRIBER, T B BYRNE NOTICE DATE 08/12/1998 CONTRACT' H27q662016 CHECK · QUESTION CONCERNING THE ABOVE CLAIH(Sl7 TELEPHONE INQUIRIES. WRITTEN INQUIRIES. PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO, TOLL-FREE TDD UNITS 1-800-222-33q1 THE COHP I CENTER 1-800-2Q2-Q809 DEPARTHENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8.00 AH - 6.00 PH EST H 5961 ,... L ';UII'iCfllllrn IS ! , r ',IIJ'i III t,l,.dICilW " Ih'llt ,llllll111l1!l iHn H.lfl I I i. ; \, ..j r '1 'I' \"". COV<"i1U" milY ~;sl!d prupl!lly ~'d mptlllses 'If' 11th tho ,HHhllonal .SII US! he completed lcaw UenelllS" or 'sider tht.! unpaid jlelllTle malllmum .- " l r {/1lt!nl mallimurn lUmtJor prOVided. , . . HO ure questions , CONCERNING '-' !. ... ~ .... .... ..... ..... ..... .... .... ... THE 1998 IN-NETWORI DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORI DEn MET FOR BARBARA IS 250.00 OF 2SD.00 THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK COINS MET FOR BARBARA IS 5.70 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS 2,6qS.01 IN-NETWORK LIFETIME BENEFIT PAID FOR BARBARA IS 8,326.22 OF 1,000,000.00 OUT-NETWRI LIFETIME BENEFIT PAID FOR BARBARA IS 8,326.22 OF 1,000,000.00 .. ... ... . 'Capital BlueCross ;, ; . PeRM lvania BlueShield :.Ii I ".'r...1Lk_........'..C_...I1.........A._.ollon . . COI1P I CENTER DEPARTKENT 7789aa HARRISBURG, PA 17177-8'188 ~ . ) 1...111.111..1.1.1.1,1...11..1...1.1,.1.1.111111...1...1.1,1.1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 172S7-822q .. "' (B'lll .' 111 THE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK DED HET FOR BARBARA IS 250.00 OF THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORl COINS MET FOR BARBARA IS 5.70 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS q, 9q7 .36 II - IN-NETWORK LlFETIHE BENEFIT PAID FOR BARBARA IS 10,628.57 OF 1,000,000.00 OUT-NETWRK LIFETIME BENEFIT PAID FOR BARBARA IS 10,628.57 OF 1,000,000.00 i , ~F> I .. f.. I ;',' ~~ !i;_ I i M M M ... .. .. .. w ... '-4 OJ 16"_1~1 'j .., III ~ I Capital B1ueCross II '" Pennsylvania B1ueShield . lndtf'!'ndeNlIul'lM".' IN II..,. CtM' and 1I..,.1h1,ld AuO(.I.tlon Ini~iJli~!~'~)y':%,!,;r;1lf;L~'t\in~; SlIlVJ"'.p.\TI'-'~'I;,jr:~.. ',!\~il.': :'C~' dJi:~ll,ALLOIlAIIL~.; ~1:.:;': "''':':I:E~~t:;:~~;~_::;1<';, \~,:.,.;,.-' : ,,'- ,.; ;!~<''',,:, '.f~~ l]Jl\;~~,~~' - ,"~,"~;v :" " J:?~~.. PATIENT, BYRNE B QROUP,00279 BIRTH, 092862 OffICE/OUTPATIENT VISIT 1 2 CLAIH . 1822010103500 CLAIH TOTAL 26193 000 i f: II . I 3 3 000 ! 3263 3 I 3 000 3 000 3 "'" OUTPATIENT CARE CLAIH . 1822010103600 1 ,.... OUTPATIEHT CARE CLAIH . 1822010103700 1 CLAIH TOTAL .. 1 ~~ PATHOLOOY TEST/CPK PATHOLOOY/BLOOO TEST CLAIH . 1822010103800 CLAIH TOTAL PATHOLOOY TEST PATHOLOOY TEST/THYROXIH CLAIH . 1822010103900 2~q 3361 140'63 CLAIH TOTAL PATIENT TOTAL .. EXPLANATION OF CODES 989 $ 10.00 Tho aaountCa> ahown abovo roprosonts tho offico visit copaymont and is tho i aubscr ibor I, ! 250.00 . U Capital BlueCross ;, ; . Pen Ivania BlueShield ~ 51 1..........~Lk'_.. .,... II.. c.... ... II.. ..kid A...cI...... . . COlIP I CEHTER DEPARTHEHT 778988 HARRISBURG, PA 17177-8988 , I 1 1 'i ~ I 1",111",1,.1,1,1,1,1",11"1."1,1,,1.1,111111,,,1,,,1,1,1.1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 172S7-822q r"' J1J5cnlDEn IS r"' . or ModlCarO. "MV I .1mOunls mo " I' ~. ,. ! covorage may I'd proporly. olponsos. .'!J the addillonal . ! be comploled ", ro Benefl!s. or 10r rho unpaid EXPLANA nON OF BENEFITS COMPnE"Er~SIV[ Mm WrMPA"OUtm MAJOR MEDICAL PROGflAMS li\.~ Offill ,hit ~OI'~YHIH'J 'Llss PftIDft I' ALLOIIANCI, /,' ALLOIIANCI 'I"U~U !!!!~~ULlj F-"I""",:'lt-RI~W'li1f~: Jlf':lt'~1~Ao~!~~~ri!JUlIlacma. ~_~I!I~ 000 1693 000 989 I ODD 1&93 600 , , (196223) BROOKINGS MEDIC 000 ODD 3~63 3 63 , 000 -i 000 (196223) BROOKINGS MEDIC 000 3 63 000 000 00 000 a reaponaibility. 1998 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS MET. 1998 FAHILY OUT-NETWORK DEDUCT HET IS 250.00 OF 500.00 1998 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1998 FAHILY OUT-NETWORK COINSUR HET IS 5.70 OF 6.000.00 '~~!;~f;l~Wlrp.r' '''$'i~KE'i~r,rib,- S;~T,~,l', E)iEHT!'FORi;",O 'lI" '~,!:i~cqO!irP.E $;':,!~,J2~1 '. III Il!i!!ll!~Mf!J:JPJl~ ..u..'1ff!!.~.~~~~ Ar . SUBSCRIBER, T B BYRNE NOTICE DATE 08/10/1998 CONTRACT. H27q662016 CNECK . QUESTION CONCERNING THE ABOVE CLAIH(S)7 TELEPHONE INQUIRIES. WRITTEN INQUIRIES. PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON TNE REVERSE SIDE OF THIS STATEHENT. HAIL TO, TOLL-FREE TDD UNITS '-800-222-33q, THE COMP I CENTER 1-800-2q2-q809 DEPARTHENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8.00 AH - 6.00 PM EST H 6513 dn!, limo maximum AI). ont maximum tlO nber providod. , aro quosfions :ONCERNINCl -------------- EXPLANA TION OF BENEFITS COMPREHENSIVE AND WRAPAROUND MAJOR MEDICAL PROGRAMS P:k'e~&~~!~Wrm~I~~~~~~~~I!~U 000 3 63 Ob 000 3 63 00 3 63 0100 OF 0.00 IS HET. 250.00 OF 500.00 0.00 IS SATISFIED. SUBSCRIBER, CONTRACT . NOTICE DATE 08/13/1998 CHECK . QUESTION CONCERNING THE ABOVE CLAIH(S)7 TELEPHONE INQUIRIES. WRITTEN INQUIRIES, PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO, TOLL-FREE TDD UNITS '-800-222-33q, THE COMP I CENTER 1-800-2q2-q809 DEPARTHENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8:00 AH - 6:00 PM EST H 7862 - \_. ; "r I :, , r r iUOSCRIOER IS '"" Ie or f;1t!(JICiHO ')pt Inl amounls arc I I 'J N r r umber provided. ro aro quoslions HIl . CONCERNING ( '. ,-, l.. I .." I" I Capital BlueCross II "..-' M Pennsylvania B1ueShield "'__~1~_~,f!~~~'~'~~~;'lo,!~.he~,_~lueCt""nd8Iue,!,I!ld~nocl'llon _ _", .; '_, 11,.,; ,^,J,,101i" "in , """"'>>"".'..'j' :~I'llAral 'I"'Ll'f'!O'!', , ,!"HO " 'I' "TOTAL. "I,LI$S ~[ill' "~,LLOlIAIL~"", ~.-1'~i_""--!-<--lt";,,,-,,,~+,,,'h/d;'f~'_'\'~_i!il..:t-J\j/ !.'~" /iiJ1L~JJ)jk _""'- irea: :;,~l ." ,\ "'U.DnC!.i~" . "...al '1''''''1; 'i...t'-,~:, ,-- -. - _.. __'I' "\"....-~... ....,.. -. ,- . _.. ~ ........,.."..;.,.. .MAW.. _..IIfJIIUHl~~. _!tI1.........-.re PATIENT, BYRNE B GROUp,00279 BIRTH I 0921162 PATHOLOOY TEST/CPIC <",I! 5 000 I 000 1 CLAIH . 11122610073400 9,25 CLAIH TOTAL "" VENIPUNCTURE PATHOLOOY PANEL PATH TEST/BLOOO COUNT PATHOLOOY PAHEL TESTS PATHOLOOY/BLOOO TEST CLAIH . 11122610073500 07l2~8 0 ~8 3 3M1S 07l2~8 07i2~8 3 80050 0Ti2~8 07t2~8 3 85023 0712998 0 ~98 3 80058 , 000 000 000 ~OO 000 0'00 300 1q63 12;03 10,81 1 1 1 1 300 ,q:63 1~03 10,81 4~05 5 '30 ,..., CLAIH TOTAL PATIENT TOTAL .., ."" H H ... ... r I ... ... THE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK DED MET FOR BARBARA IS 250.00 OF 250.00 THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK COINS MET FOR BARBARA IS 5.70 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS 6,278.33 IN-NETWORK LIFETIME BENEFIT PAID FOR BARBARA IS 1',959.Sq OF 1,000,000.00 OUT-NETWRK LIFETIME BENEFIT PAID FOR BARBARA IS 1',9S9.Sq OF 1,000,000.00 ... ... ~ ~ I I I I , I , . , i , , ... . V Capital B1ueCross i ; . Pennsylvania BlueShield :A: II '............. Lk_.. .. ,he .,.. c:... .... .,.. ...~l. A....'..... . II COItP I CEHTER DEPARTMENT 778988 HARRISBURG, PA 17177-8988 ... .... 1."111",1"1,1,1,1,1",11,,1,,,1,1,,1,1,1,,11111.1,,,1,1,1,1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 172S7-822q 0' IS911 '~.J j\ EXPLANA nON OF BENEFITS COMPREHENSIVE Arm WRAPAROUND MAJOR MEDICAL PROGRAMS '~U$ UTHlR,:! t1;i~f,ir1i~Blbtrr~~Dl~~ILI!:r~~~R~~ , ' 000 000 925 000 0,00 925 0,00 (196223) BROOKINGS MEDIC 000 000 300 000 000 000 1~63 000 ~OO 0,00 1203 ~OO 0,00 0,00 10,81 0,00 000 000 000 0'00 0'00 ~oo 000 1998 FAMILY IN-NETWORK DEDUCTIBLE OF 0.00 IS HET. 1998 FAHILY OUT-NETWORK DEDUCT HET IS 250.00 OF 500.00 1998 FAMILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. 1998 FAMILY OUT-NETWORK COINSUR MET IS 5.70 OF 6,000.00 "\?~,~,fii:~;lm,',i?f,~iA$' . K,{IP~;Ttii'$lsfATil",'EH1::!FOil';;"OUR:, R,"IiCQR, Dii)r!t;i+~,'Xl~ll'W '" E.o' E!'!lB!!I,'SIQ .':.'l!Ii.~!HTJ,!lt!-,::;J,~fi~~l!MJ.It'bMR\!Ji:~ru!~~!~t~~ SUBSCRIBER, T B BYRNE NDTICE DATE 08/1q/1998 CONTRACT' H27q662016 CHECK . QUESTION COHCERNING THE ABOVE CLAIH(SJ7 TELEPHONE INQUIRIES, WRITTEN INQUIRIES, PLEASE FOLLOW THE INSTRUCTIOHS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO, TOLL- FREE TDD UNITS '-800-222-33q, THE COMP I CENTER 1-800-2q2-q809 DEPARTHENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8:00 AM - 6:00 PM EST H 6686 r- un~;cn1BH~ IS ~, ~-I ! , l! or r.'pdICiHIJ 'U,I 1111 amourllg am N . ~ r l CJvotago mav ud properlv . oxponses. JllrJ h ItlO i1dd!tlonnl .." it be completed '0' illO 0(mOII15' Of idel tho unpaid an cllmo maltlmUm et. nenl maximum ,mber provided. '0 are questions .TIC CONCERNINO ( EXPLANA TION OF BENEFITS COMPREHENSIVE AND WRAPAROUNO MAJOR MEDICAL PIlOGRAMS r' ;1;/1',. nrllLH IS ...., r TOTALS 2800 au 31:69 3169 , ;.. (., ~.' < .. ~,,' ,1J I' 000 989 ~QJl 0,00 00 , 'I), ~~(;l ,ril'lIlllh .lIlt '" '''J -. ~ , i \ , I "" t.' r,; J~'I" .1(11.' '!lilY ,,"l pror~l'rty 1 t'.p"n<;fl~, Jll'. :11 lit\! dLldilillll..1 a reaponaibility. OUNT" coluen will be accopted by the provider aa payment in full roe the date of thia notice. ~,t bi~ Comrll'lnd . l' ;.:lfC Ocne'll~-' or ildl'1 Ill!' unp.1If1 ,ilf '.;'I:1I1t'rJ1il'I/TlUlll u.. tllt'nl IT'd~ltnurT1 (,11'(11'1 Pl()"",lt~(l rll iU,,' qld'~-ll()ns illt i COtJC[RNltJQ HE 1998 FAHILY IN-NETWORK DEDUCTIBLE OF E 1998 FAMILY OUT-NETWORK DEDUCT HET IS E 1998 FAHILY IN-NETWORK COINSURANCE OF SUBSCRIBER, T B BYRNE NOTICE DATE 08/20/1998 CONTRACT' H27q662016 CHECK . QUESTION CONCERNING THE ABOVE CLAIHCSl? TELEPHONE INQUIRIES, WRITTEN INQUIRIES, PLEASE FOLLOW THE INSTRUCTIONS PROVIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO, TOLL-FREE TDD UNITS 1-800-222-33q1 THE CaMP I CENTER 1-800-2q2-q809 DEPARTHENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8:00 AM - 6:00 PM EST ~ H 7qS1 v . II EXPLANATION OF CODES 989 $ 10.00 Tho aaount(a) ahown abovo roprosonta tho offico viait copaYNont and ia tho aubacribor' .., _I- , Capital B1ueCross I i , Pennsylvania B1ueShleld I.. . "'*f:!:ndent L!unM" .1 IN INt c,... .nd IkIIlN.ld Anocl'llon . ~~~~iiJ'Ji\!i!p,1t=11l:lii~lmf:f,iit:.iiM=.1~l~t~'lli:i~ BIRTH' 092862 I -. -,~-"'~ '''' ' ,... '," '" \ tLAIH . 1823910328200 PATlEHT TOTAL 32,00 0,00 . . . . . . . . .. THE 1998 IN-NETWORK DEDUCTIBLE OF 0.00 FOR BARBARA IS SATISFIED. THE 1998 OUT-NETWORK DED MET FOR BARBARA IS 250.00 OF 250.00 THE 1998 IN-NETWORK COINS OF 0.00 FOR BARBARA IS SATISFIED. THE 199B OUT-NETWORK COIHS HET FOR BARBARA IS 5.70 OF 3,000.00 THE 1998 BENEFIT PAID FOR BARBARA IS 10,075.78 .. _ IN-NETWORK LIFETIME BENEFIT PAID FOR BARBARA IS 15,78B.66 OF 1,000,000.00 OUT-NETWRt LIFETIME BENEFIT PAID FOR BARBARA IS 15,788.66 OF 1,000,000.00 III .. . '0 Capital BlueCross i ; . Peons lvanill BlueShield ~ .,.,.,.".i} lk.,...... 1M llue erMl Ilftd llue IhMld Alaocllllon . . COIIP I CENTER DEPARTMENT 778983 HARRISBURG, PA 17177-8983 .. ,n 1".111".1"1,1,1,1,1",11"1",1,1,,1,1,1,,111,,,1,,,1,1,1.1 T B BYRNE 107 HELEN AVENUE SHIPPENSBURG PA 17257-B22q .. :~. '.\.\1 .... EX PLANA TION OF BENEFITS COMPf1EIIHJSIVE MW WflAPMlourw MAJOn M[DICAl rnOGIlAMS , 'J~=1_11~=yj!t~J:~~~1"~tr{F~'!f~'=m~J 000 989 I 0100 0,00 2ze 2~00 2~00 0,00 0'00 r UU~,CIlIOEn IS ! ..... (' 1'llI f.I,'dlc.1I0 'I." III ,1II10un!s aw ]-1 r 'I I I I ,'t';l;. ~ CO'o'elilglJ may l~d properly e.p!:l1ses '"lJ ' tile adtllhol1JI a rosponaibility. ..At .. II be completed ore BenefIts' or idrf tho unpaid an. ~llmc lTIil).il11Utn co, nenl ma_lmum mHler provIded. e iHt' questions TIC CONCERNING 1998 FAHILY IN-NETWORK DEDUCTIBLE OF 0.00 IS MET. 1998 FAHILY OUT-NETWORK DEDUCT HET IS 250.00 OF 500.00 1998 FAHILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. HE 1998 FAHILY OUT-NETWORK COINSUR HET IS 5.70 OF 6,000.00 ~~~~~~~rN~fll~r~J!~gE,rKi" '~ftglsjsrA,T1E,:, '~Hf!'F.Oll, 'tY~~=~ftC,~~~s,'g~l~f}(~IIiJ!~ tt'J:it; L""'~~JO~till!"'~II~..~~f.~~l'd."~lg~fff'Jl~.'-"''-m,,l!..l1t..'-,,M~,mm SUBSCRIBER. T B BYRNE NOTICE DATE 08/27/1998 CONTRACT' H27q662016 CHECK' QUESTIDN CONCERNING THE ABOVE CLAIH(Sl7 TELEPHONE INQUIRIES. WRITTEN INQUIRIES, PLEASE FOLLOW THE IHSTRUCTIONS PROVIDED ON THE REVERSE SIDE DF THIS STATEHENT. HAIL TO. TOLL-FREE TDD UNITS '-800-222-33q, THE COHP I CENTER 1-800-2q2-q809 DEPARTHENT 77-8988 HARRISBURG, PA. 17177-8988 '- HOURS 8:00 AH - 6.00 PH EST H 6992 EXPLANA TJON OF BENEFITS COMPREHENSIVE MIO WRAPAROUND MAJOn MEDICAL PROGRAMS L'~lt11J'~!lta~ff:i!~tfni.gf~I.~~=::~ I I O~ 2600 ~OO q09 000 000 000 000 000 , OUNT" coluen will be accepted by the provider aa payment in full roe the dato of thia notice. E 1998 FAHILY [N-NETWORK DEDUCTIBLE OF 0.00 IS MET. E 1998 FAHILY OUT-NETWORK DEDUCT MET IS 250.00 OF 500.00 E 1998 FAHILY IN-NETWORK COINSURANCE OF 0.00 IS SATISFIED. E 1998 FAHILY OUT-NETWORK COINSUR MET IS 5.70 OF 6,000.00 '!i;i~;~ii.!!lfi.if~iis~f.kp',i;f,IlI'S~'ITA:~~I~!q!~Vilvi'ilmRDI~, ;r-~' *}:rf~~"'~ ,.'l '~1.~~~~Jhg8,~.8P~~.U~.N!.~~~.M~til!!!j.t. ,f flM!i~ SUBSCRIBER, T B BYRNE NOTICE DATE 09/03/1998 CONTRACT. H27q662016 CHECK . QUESTION CONCERNING THE ABOVE CLAIH(S)7 TELEPHONE INQUIRIES, WRITTEN INQUIRIES, PLEASE FOLLOW THE INSTRUCTIONS PRDYIDED ON THE REVERSE SIDE OF THIS STATEHENT. HAIL TO, TOLI.- FREE TDD l'NITS '-800-222-33q, THE COHP I CENTER 1-800-2q2-q809 DEPARTHENT 77-8988 HARRISBURG, PA. 17177-8988 HOURS 8:00 AH - 6:00 PH EST H 6520 r-- " r 1}[J~;f;HIBER IS "" I' ()f t,l"i!lc,U{J. "lJ.l' L dftlOlJ/lI'i <lIt' II ,." I' wH'fayn Itlay :t~lJ pfOpl'rly , , (!Jp"n!.('5 <,,'. tl Uw ,lddl!iOfltll ( ,~ ~l be completed 'u mo BoneMs. or Idt'lr Hl(' Impair:! nn C'!llml'lT1aWnUfn ..... lwnl mi1~tmum IJl1tJr.r plovldcd o iH(l quesllon~ II( COIICERNING ,r J-j ~ .... . BARBARA ANN BYRNE, Plaintiff, v. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 97-2002 CIVIL TERM : CIVIL ACTION - LAW : IN CUSTODY TIMOTHY BEVERLY BYRNE, Defendant ORDER OF COURT AND NOW this tkJ t:A day of U u/ Y ,1998, upon consideration of the Petition for Special Scheduling of Plowman hearing as filed by Plaintiff, a hearing is hereby ordered to be held on the 30 tI7 day of .tinE 1'V'l.b f::/Z, 1998, at C;: 00 A .m. in Courtroom No..scl the Cumberland County Courthouse. BY THE COURT ~ <111 . I ~ .." ~ I .. , ~ ,,),,,,-,( 6 LA, d(J/ V. o.q I rJ-d' v. (\S CD ! l.r.J ' N011tl BARBARA ANN BYRNE, Plaintiff, : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 97-2002 CIVIL TERM : CIVIL ACTION - LAW : IN CUSTODY v. TIMOTHY BEVERLY BYRNE, Defendant PETITION FOR SCHEDULING OF PLOWMAN HEARING 1. Plaintiff is Barbara Ann Byrne, an adult resident of the Commonwealth of Pennsylvania, Cumberland County and the natural mother and primary custodian of her minor children, Andrew Thomas Byrne, born February 26, 1989 and Connor Lee Byrne, born July 6, 1992. 2. Defendant is Timothy Beverly Byrne, the natural father of the children who has partial custody of the children pursuant to a Court Order entered into by the Honorable George E. Hoffer on the 21"t day of April, 1997. A copy of the Court's Order is allached hereto and made a part hereof. 3. Plaintiff and Defendant are currently in the final stages of divorce litigation in Cumberland County and captioned to No. 97-4328 Civil Term. 4. Plaintiff will be marrying her fiance at the conclusion of the divorce litigation. 5. Plaintiffs fiance has received a job opportunity and he is currently employed in the State of South Dakota. This employment opportunity will allow Plaintiff to continue to provide full-time care for her children and will also allow her to significantly increase hers and the children's quality of life in that they will purchase a home in ,I BARBARA ANN BYRNE, Plnintiff, : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : j\ OlJ^ : NO. 97- CML TERM : CML ACTION - LAW : IN CUSTODY : I ~ , v. TIMOTHY BEVERLY BYRNE, Defendant AND NOW, 'W. ~of R , 1997, upon consideration ofthe within Stipulation it is ordered and decreed as fo ws: 1. Andrew Thomas Byrne, born February 26, 1989 and Connor Lee Byrne, born July 6, 1992 are the natural children ofBarhara Ann Byrne and Timothy Beverly Byrne, hereinafter mother and father. 2. Shared legal custody of said child as contemplated by the Act of November 5, 1981, P.L. 322, 23 P.S. Section 1001, et seq" will be in both of the parties, as the natural parents. 3. Primary physical custody of said child shnll be in the mother subject to periods of partial "" , custody with the father at such times and at such places as the parties agree. In the event the parties are unable to agree upon visitation, Timothy B. Byrne, father, shnll have the right of visitation every other week when he has time off work for a period of 48 hours. 4. The parties will alternate partial custody of the children on the holidays of New Year's Day, Easter, Memorial Day, Fourth of July, Labor Day, and Thanksgiving. 5. The parties will share Christmas with one party luiving visitation from 12 noon on December 24 until 12 noon on December 25 while the other party shnll have visitation from 12 noon on December 25 until 12 noon on December 26. This schedule shnll alternate commencing with Christmas of 1997 and this schedule is further subject to Timothy B. Byrne's work schedule. In the event that Timothy B. Byrne is required to work on December 24 and December 25, the parties agree to make arrangements for him to have visitation as close to Christmas as possible. 6. Timothy B. Byrne shnll be entitled to four (4) non-consecutive weeks of visitation each and every swnmer. By the Court, J. 4 - 2 j -t'i1 I.hl, (L ' niJ tl\...LL6.,)l.ls CERTIFICATE OF SERVICE I hereby certify that I served a true and correct copy of the Petition for Scheduling of plowman Hearing, upon Anthony L. DeLuca, Esquire, by depositing same In the United States Mail, first class, postage pre-paid on the --Z-. day of July, 1996, from Carlisle, Pennsylvania, addressed as follows: Anthony L. DeLuca, Esquire P.O. Box 356 113 Front Street Boiling Springs, PA 17007-0356 TURO LAW OFFICES Ron Turo, Esquire 32 South Bedford Street Carlisle, PA 17013 (717) 245-9666 Attorney for Plaintiff I , I I ( I I 'p, C' ',.I"l :...l (") " .. = ..l . '1] I (, , c\ J . , ,) , " , ) :;; .' II .' . (.; -) , ~ ~ 1 ~ lJ ..... "- !;. .0 .OQ ':6' ~ nLED..Q;~;:::;~ (": ~_, :'~',""-"-T""'" .. ' , .),,,,, (1'" S,,"O 2') '''11' C:5 .(J.. :.; _ hli ..1 C'IL' ", ' " r'ot.,,!, L....._. .~_. .,~. .....~.......I'rTl' .:::.....'1..."..//.'.' . I r...1 \ ".) It.\.~. ..:, \ f~;).?f &vi (~ /1~ 7l 4'7/ De~<1 if.do;; '9f )Jtf10 11~?i dtjf . tJ,~.~ to/J7 yUitud ~ I. ~r rt- VS. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW I TIMOTHY BEVERLY BYRNE, Plaintiff BARBARA ANN BYRNE, Defendant NO. 97-2002 CIVIL TERM IN CUSTODY , f I I ! I ORDER OF COURT t:o lOU, Barbara Ann Byrne, have been sued in court to obtain custody of the children: Andrew Thomas Byrne and Connor Lee Byrne. You are ordered to appear in person at Cumberland county Courthouse, Carlisle, Pennsylvania on 1998, at .M., for [ ] a conciliation or mediation conference. [ ] a pretrial conference. [ ] a hearing before the court. If you fail to appear as provided by this order, an order for custody, may be entered against you or the court may issue a warrant for your arrest. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PENNSYLVANIA 17013 (717) 249-3166 AMERICAN WITH DISABILITIES ACT OF 1990 The Court of Common Pleas of cumberland County is required by law to comply with the Americans with Disabilities Act of 1990. For information about accessible facili~ies and reasonable VS. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW TIMOTHY BEVERLY BYRNE, Plaintiff BARBARA ANN BYRNE, Defendant NO. 97-2002 CIVIL TERM IN CUSTODY COMPLAINT FOR CUSTODY 1. The Plaintiff is Timothy Beverly Byrne, residing at 107 Helen Avenue, Shippensburg, Cumberland County, Pennsylvania 17257. 2. The Defendant is Barbara Ann Byrne, residing at 159 Meadow Drive, Shippensburg, Cumberland county, Pennsylvania 17257. 3. Plaintiff seeks custody of the following children: Name Present Residence Age Andrew Thomas Byrne 159 Meadow Drive, Shippensburg, PA 9 Connor Lee Byrne 159 Meadow Drive, Shippensburg, PA 6 Andrew Thomas Byrne was born out of wedlock while Connor Lee Byrne was not born out of wedlock. The children are presently in the custody of the mother, Barbara Ann Byrne, who resides at 159 Meadow Drive, Shippensburg, Pennsylvania. During the past five years, the children have resided with the following persons and at the following addresses: Barbara Ann Bryne and Timothy Beverly Byrne 107 Helen Avenue, Shippensburg, PA 1993-Spring 1997 Barbara Ann Bryne 159 Meadow Drive, Shippensburg, PA Spring 1997 to Present The mother of the Children is Barbara Ann Byrne, currently residing at 159 Meadow Drive, Shippensburg, Pennsylvania. She is married to Plaintiff but a divorce is pending. The father of the children is Timothy Beverly Byrne currently residing at 107 Helen Avenue, Shippensburg, Pennsylvania. He is married to Defendant but a divorce is pending. 4. The relationship of Plaintiff to the children is that of father. The plaintiff currently resides with the following persons: Name Relationship Cheryl A. Hoachlander Girlfriend 5. The relationship of Defendant to the children is that of mother. The Defendant currently resides with the following persons: Name Not Known Relationship 6. Plaintiff has participated as a party or witness, or in another capacity, in other litigation concerning the custody of the children in this or another court. The Court, term and number, and its relations to this action is: Court of Common Pleas in Cumberland County, Pennsylvania to No. 97-2002 Civil Term. There is a pending petition for a Plowman Hearing scheduled for September 30, 1998. Plaintiff has information of a custody proceeding concerning the children pending in a Court of this Commonwealth. The court, term and number, and its relationship to this action is: Court of Common Pleas in Cumberland County, Pennsylvania to No. 97-2002 Civil Term. There is a pending petition for a Plowman Hearing scheduled for September 30, 1998. The Plaintiff does not know of a person not a party to the proceedings who has physical custody of the children or claims to have custody or visitation rights with respect to the children. 7. The best interest and permanent welfare of the children will be served by granting the relief requested because: A. The Defendant has an illness that requires frequent hospitalization and/or medical care which results in Plaintiff caring for said children; B. The Defendant is planning to move to South Dakota where no family is available to assist and/or care for the minor children when she is hospitalized and/or in need of medical care; and C. The Plaintiff has very frequent contact with his children that has resulted in a very strong bond being established with them. 8. Each parent whose parental rights to the children have not been terminated and the person who has physical custody of the children have been named as parties to this action. All other persons, named below, who are known to have or claim a right to custody or visitation of the children will be given notice of the pendency of this action and the right to intervene: Name Address Basis of Claim NONE ~ .:J' ~ C 9 l!-- ~Q 8~ ....:- z 0 :c <: ~~~ 00>: n~ ~~~ ?<;:; CO ' '0- n. :""l~ . 1I1 0- ffi~ "1:. W rt~ f- (f1 LL.. CO :5 0 C1' U Z lIl< <> il-l ,jJ ~>1 il-l ~ >< <l: 'M III I1<lIl , ,jJ '0 0 U Z M ~ ~ 0 ::l ... zz ~ Z.... OJ E-< ~ OM I>: III il-l III .J ==t;; - ~11< ~ ><.-t , OJ 0 W III 11< M 0 U 0 SW~~ o ...:;: Z I>: I-g: " U ><< I-l >< ~ . <(/)><13 tl-l H I-l . 0 .J ~!zlilz 1<< I> I>: III III 1<< 00 H ~ > >- Z Ii! .cr. o U E-< :J: OD. E-< UZ M 5a Z Z Ou.o.:rn g; 0 N III < H 0 1= rl Cl - Z ~H 0 >< < J: <- :J o tOO ~ ~ I-l fa UNO 11< I- ~< IE-< :€ Z !:J r- III 0 III 0 <l: MI-lOl 0 :€ I>: U E-< gjH U H < > . E-< III Z H 0 Z H . . ~ 18199~ v. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : J. M')' : NO. 97- . CIVIL TERM BARBARA ANN BYRNE, Plaintiff, TIMOTHY BEVERLY BYRNE, : CIVIL ACTION - LAW Defendant : IN CUSTODY AND NDW..... t..P.8.r R " , 1997, upon consideration of the within Stipulation it is ordered and decreed as fo ws: 1. Andrew Thomas Byrne, born February 26, 1989 and Connor Lee Byrne, born July 6, 1992 are the natural children of Barbara Ann Byrne and Timothy Beverly Byrne, hereinaller mother and father. 2. Shared legnl custody of said child as contemplated by the Act of November 5, 1981, P.L. 322, 23 P.S. Section 1001, et seq., will be in both of the parties, as the natural parents. 3. Primary physical custody of said child shall be in the mother subject to periods of partinl custody with the father at such times and at such places as the parties agree. In the event the parties are Wl8ble to agree upon visitation, Timothy B. Byrne, father, shall have the right of visitation every other week when he has time olf work for a period of 48 hours. 4. The parties will alternate partial custody of the children on the holidays of New Year's Day, Easter, Memorinl Day, Fourth of July, Labor Day, and Thanksgiving. 5. The parties will share Christmas with one party luiving visitation from 12 noon on December 24 until 12 noon on December 25 while the other party shall have visitation from 12 noon on December 25 until 12 noon on December 26. This schedule shall alternate commencing with Christmas of 1997 and this schedule is further subject to Timothy B. Byrne's work schedule. In the event that Timothy B. Byrne is required to work on December 24 and December 25, the parties agree to make arrangements for him to have visitation as close to Christmas as possible. 6. Timolhy B. Byrne shnll be enlilled 10 four (4) non-conscculive weeks ofvlsiUilion ench nnd every summer. By lhe Court, J. 4. ljri7 jIJ ~,It (L < niJ /I'-&.( ~, .l JUS ~ . v. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : .J (I.L- : NO. 97. U CIVIL TERM \' I BARBARA ANN BYRNE, Plaintiff, TIMOTHY BEVERLY BYRNE, Defendant : CIVIL ACTION. LAW : IN CUSTODY COMPLAINT FOR CUSTODY 1. Plaintiff is Barbara Ann Byrne, an adult individual whose residence is at 107 Helen Avenue, Shippensburg, Cumberland County, Pennsylvania. 2. Defendant is Timothy Beverly Byrne, an adult individual whose residence is at 107 Helen Avenue, Shippensburg, Cumberland County, Pennsylvania. 3. Plaintiff seeks custody of her children, Andrew Thomas Byrne, born February 26, 1989 and Connor Lee Byrne, born July 6, 1992, currently residing at 107 Helen Avenue, Shippensburg, Cumberland County, Pennsylvania. 4. On April 16, 1997, the paries entered into a custody stipulation which is attached hereto a.~ Exhibit A. WHEREFORE, PJaintifTrequests your Honorable Court to order custody rights of Andrew Thomas Byrne, born February 26, 1989 and Connor Lee Byrne, born July 6, 1992, in accordance with the stipulation of the parties. Respectfully submitted, LAW OFFICES OF RON TURO ,/!?h' ? Date .~ 1 , ,,' , 7 / - . -, ' ~//j . .-. '~.- . .,' 0P 0' , /_,:h. ,/~jf~ L Robert J. ?,julderig, Esquire 32 South Bedford Street Carlisle, PA 17013 (717) 245.9688 Attorney for Plaintiff F: '::-.1 ," .,.,....- , N' , "" "I .-," .. ? i..,' I I .0 -J ~ r. ,n 0 ( -J " .~ , , .,-, :'~:1 :; ::J G;;,r~ -.... r'l ;.J ~ ., ,I' . /\::, ;:.~- " "~l (I ~ -J J~ . ~-,: '( ,. 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