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Home My WebLink About03-0400MOFFITT HEART & VASCULAR MARY E. JOHNSON ROBERT JOHNSON VS. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NOTICE TO DEFEND You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. 1F YOU !)O 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 1-800-990-9108 MOFFITT HEART & VASCULAR MARY E. JOHNSON ROBERT JOHNSON IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA : : CIVIL ACTION - LAW : No. 03 - WoO COMPLAINT AND NOW, this c~)x day of January. 2003 comes Moffitt l leart & Vascular, abovc-named PlaintitT~ by and through its attorney, Gall Guida Souders, Esquire, and respectfully avers the follou, ing: 1. Plaiutifl'is a corporation having offices at 1000 North Front Strect, Wormlc) sburg. Pcnnsylvania 17403. 2. Del~ndant Mary E. Johnson is an adult individual residing at 81 Betty Nelson Court 122, Carlisle, Pennsylvania 17013. 3. Delbndant Robert Johnson is an adult individual residing at 81 Betty Nclson Court 122, Carlisle, Pennsylvania 17013. 4. At the specific instance and request of Det~ndant, Plaintiff provided medical scrx ices to Dclbndant at the times, amounts, and the prices tbr these scrvices arc indicated in Plaintifffs Statement of Account. a true and correct copy o1' xqfich is attached hereto, marked Exhibit A, and made part thereof. 5. Thc prices charged by Plaintiff were thir, reasonable, and market prices that prevailed at the times of the transactions. 6. Del'cndant Robert Johnson was married to Defendant ,lacquelinc l?,ccrs at thc time services were rendered. 7. Although Defendant Mary E. Johnson was the PlaintiWs patient, Defendant Robert Johnson is also responsible ~br payment of said services pursuant to 23 Pa.('.S.A.§4102. 8. Plaintifl'avers that the balance due amounts to $7,778.80, which is above thc lilnit for mandatory arbitration. 9. As el'November 14, 2002, the interest at the legal rate o£six percent a year is $961.45. 10. Although repeatedly requested to do so by Plaintiff, Del'endant has willl'ullx failed and refused to pay the aforesaid balance or any part thereof to Plaintifl: Wl t EREFORE, Plaintiff respectfully requests that judgment be entered in Ihvor of Plaintil]' and against Defendant in the amount of $8,740.25 with interest and costs. Respectlitlly submitted, Gall Guida Souders, [~;squire Guida Law Offices 503 North Front Street Harrisburg. PA 17101 717-236-6440 Attorney lbr Plaintiff Supreme Court ID ~68740 ~LEASE,, DO NOT STAPLE IN THIS AREA '?25 hl~ilq:)l.o F,!O,~ci ", t"l;J, dd:L (}!'t:.Ob,ll'l , I::)l::) '~ 'i' ('] :~ . MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) i (Medicare #) [~ (~,,~,r~,d ,) F~ (spon$or,$ SSN) E~ (VA Fi,, #) ~HEALTHPLANr~SLKLUNGF~--'i I Irss~o,~o~ I IrsS~~ IXlaD) 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. MMPATIENT'S. DDBIRTH. yyDATE .~ [] SEX F [] 4. INSURED'S NAME (Last Name, First Name, Middle Initial) 5, PATIENT'8 ADD~E~8 (Nm, 8lreet) ~, PATIENT ~E~TIONSHIP TO IN~U~ED 7. IN~UHED'8 ADD~E~8 (No., cITY STATE B. PATIENT STATUS Ol~ ~TATE g. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RE~TED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER c. EMPLOYER'S NAME OR SCHOOL'NAME c. OTHER ACCIDENT? c. INSURANCE P~N N~E OR PROGRAM N~E d. INSURANCE P~N NAME OR PROGRAM NAME 10d; RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT P~N? ' ' ~ YES ~ NO If y~, return to end ~mpl~e ~em 9 R~D BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATINAS OR AUTHORIZED PERSON'S SIGNATURE I a~hodze the relate of ~y medi~ or other Info~ation ne~ payment of m~ical benefits to the undemlgned physician or supplier for : 14, DATE OF CURRENT: ~ ILLNESS (Flint symptom) OR 15, IF PATIENT HAS H~ S~E OR ~IMI~ I~NESS. 1~, DATES PATIENT UNABLE TO WORK IN CURRE~ OCCUPATION 17, N~E OF REFERRING PHYSICIAN OR OTHER SOURCE 17a, I.D. NUMBER OF ~PEHHING PHYSICIAN 18. HOSPITALI~TION DATES RE~D TO CURRENT SERVICES 19. RESERVED FOR LOCAL USE 20. OUTSIDE ~B? $ CHARGES 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RE~TE ~EMS 1,2,3 OR 4 TO ITEM 24E BY UNE) j ~. MEDICAID RESUBMISSlON CODE ORIGIN~ REF. NO. 23, PRIOR AUTHORI~TION NUMBER PI~ T~ PROCEDURES SERVICES OR SUPPLIES DAYS i~D'I RESERVED FOR 27 ACCEPT ASSIGNMENT? $ 31.81~NATUR~ OF PHYSIOlAN O~ SUPPLIER 32. NAME AND ADDRE88 OF FAOILI~ WHER~ B~RVlOE8 WERE 33. PHY~IOIAN'S, 8UPPLI~R'S BILUN~ NAME, ADD~ES~, ZiP OODE ]. 1 ;L ~;, O U T H F R O N T S"I N.E:E; T J.. {. 3 ~] N O R T H F' R O N T SS TR E:E: T APPROVED OMB~0938-0008 FORM HCFA.1500 (12-90), FORM RRB45OO, (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-1215-0055 FORM OWCP-1500. APPROVED OMB-0720~3001 (CHAMPUS) _P, LEASE, . t DO NOT P I~]~iii J:~ L. I!!] !~; !~].; (]; F~ E] I) ][ T ~..,"? ~" STAPLE ,,, IN THIS r ...... I'f~:~'~1:::, t.(-) , . . ,~ AREA I'I :J. d d .'~ ~h't:. o b,~ r~, P ~::~ ]. 7 0 5 7 ~ 1, MED CARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S I,D. NUMBER (FOR PROGRAM IN ITEM 1) ._J (Medl~are #) r~ (Medlcald #) E'-~ (Spon$or's SSN) ['--~ (VA File #) ~HEALTHPLANr'~BLKLUNSr'-~'~ L_Jrss~ortD) L_j~*~~) 4. INSURED'S NAME (Last Name, First Name, Middle Initlat) 2, PATIENT'S NAME (Last Name, First Name, Middle In[rial) i3. MMPATIENT'S, SDBIRTH,YyDATE ~] SEX F $. PATIENT'E AODRES$ (No,, Streaf) E, PATIENT RELATIONSHIP TO INSURED ?, INSURED'B ADDRESS (No., Slreal) CITY STATE 8, PATIENT STATUS CiTY STATE YORK .'.".:;Ftl:iIIqGS Pr'-1 sincer--] aarrlo~[--] OtherI 'YC)I:~I'( SPRII~.IGS ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) ii). OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER a, EMPLOYMENT? (CURRENT OR PREVIOUS) a. OTHER INSURED'S POLICY OR GROUP NUMBER __ __ a, INSURED'S DATE OF BIRTH b. AUTO ACGIDENT? b, OTHER INSURED'S DATE OF E!RTH SEX pLACE (S~nte) b, EMPLOYER'S NAME OR SCHOOL NAME MM . DD YY [~YES ~NO e, EMPLOYER'S NAME OR SCHOOL NAME c, OTHER ACCIDENT? c, INSURANCE PLAN NAME OR PROGRAM NAME d. INSURANCE PLAN NAME OR PROGRAM NAME 10d, RESERVED FOR LOCAL USE d, IS THERE ANOTHER HEALTH BENEFIT PLAN? IXl YES I I NO If yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13, tNSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authalze the release of any medical or other information necassa~ payment of medical benefits to the undersigned physician or supplier for to prccess this claim. I also request payment of govemment benefits either to myself or to the pally who e, ccepts assignment services described below. 14. DATE OF CURRENT: ~ ILLNESS (First syn~ptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR iLLNESS. 1S. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION M.~ i E..~ i ~~ INJURY(Accident) OR GIVE FIRST DATE MM DD YY MM DD YY MM DD YY .:~. 7 0 PREGNA.CY(LMP) ', ', FROM I I TO ', 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES ~-]YES [-~NO J 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1.2.3 OR 4 TO ITEM 24E BY LINE) / 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1. L/+.l.[)../I. 0 FII RC, U"fE O"i-H ];iqt:::E 3. L__ 23. PRIOR AUTHORIZATION NUMBER 24. A B C D E F G H I J K i P ace T PROCEDURES SERVICES. OR SUPPLIES DAYS EPSDT FromDATE(S) OF SERVICE To I of Ofy~e (Explain [l'nusual Circumstances) DIAGNOSIS RESERVED FOR MM DD 'fY MM DD YY :Service Ser~ce DPT/HCPCS ~ MODIFIER CODE $ CHARGES OR Family EMG COB LOCAL USE UNITS Plan ~1 (:l ', ]. 2.,' (:)0 ,' ,' 2 .'L II ;1. g ......... 3 :l 2 5 I 2 6 ', .1., 2 ':" c INCLUDING DEGREES OR CREDENTIALS RENDERED (Il other than home or office) & PHONE # {APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB~0938-0008 FORM HCFA-1500 (12-90), FORM RRB-IS00, APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-O7E0-0001 (CHAMPUS) PLEASE -, 4, ' DO NO7' ' ' : STAPLE I L.J .M. I ...:: C; I:,.' Ii ZD iI. T Z~ "~ UJ IN THIS 'Z'"I:;;,;::,.. Fh?~p t.e /',.,:.... ~ I r ~-- , ~-- AREA PIJ (:idZ(:r(ow ' , PFi .'J..'?(; !:~;'? ~ ~1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 2. PATIENT'S NAME (L~t Name, First Name, Middle Initial) 8. PATIENT'S BIRTH DA~ 4. INSURED'S N~E (~t Name, Fl~t Name, Middle Inifia) CiTY STATE 8. PATIENT STATUS CJ~ STATE 1 0 M,', s~,¢. Married ZIP 0ODE TELEPHONE (Include Area Code) ZIP CODE [ TELEPHONE (INCLUDE AR~ CODE) 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RE~TED TO: 1. INSURED'S POLICY GROUP OR FECA NUMBER e. EMPLOYMENT? (CURRENT OR PREVIOUS) SEX b. OTHER INSURED'S DATE OF BIRTH D, AUTO ACCIDENT? , P~CE (~) b. EMPLOYER'S' NAME (:){:l~ 00J 0000' J c, EMP~OYER'~ NAME OR SCUOQL~NAME c. OTHER ACCIDENT? IxI YES I [ NO Ifyes, return to and complete Item 9 a-d. R~D BACK OF FORM BEFORE ~MPLETING & SIGNING THIS FORM. 13. INSURED'S OR A~HORIZED PERSON'S SIGNATURE I a~hodze 12. PATIENT'S OR AUTHORIZED PER~N'S SJGNA~RE I a~hodze the ml~ of any medi~ or other inflation n~ payment of medi~ benefits to the undersigned physici~ or supplier for 14. DATE OF CURRENT: ~ ILLNESS (Fir~ sym~om) OR 15, IF PATIE~ HAS H~ ~ME OR SIMI~R ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRE~ OCCUPATION .J. j~,l [[J 71 [] L) ~ PREGNANCY (LMP) I I FROM I I TO I I 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITAU~TION DA~S RE~D TO CURRE~ SERVICES 19. RESERVED FOR LOCAL USE 20. OUTSIDE ~B? $ CHARGES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RE~TE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) / 22. MEDICAID RESUBMISSION CODE ORIGIN~ REF. NO. [ 28. PRIOR AUTHORI~TION NUMBER 24. A B C D E F 6 H I J FroDATE(S)m OF SERVICE To Placeof TY~ PROCEDURES SERVICES, OR SUPPLIES DAYS EPSDT ZOi].3;O0 i ; 21 01 83543 i ].,2 t25',,t: : il I I I II ~ 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 25~ FEDERAL TAX LD. NUMBER SSN FIN 26. PATIENT'S ACCOUNT NO. (For go~. claims see back) 29. AMOU~ PA~D 30. BA~NCE DUE ~ply tO his bill and are made a pad hereof.) I'"IR R I;~ Z S :B U IR G . q '- ', 'r SIGNED (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB~0938-0008 FORM HCFA-1500 (12-90), FORM RRB-1500, APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS) ~LEASE,. DO NOT ' .: STAPLE IN THIS 7 '~ [:.; J"IEi [;::,.]. E~ F~,bF" AREA ..... 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S I.D. NUMBER ' (FOR PROGRAM IN ITEM 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle InifiaJ) ~. PATIENT'S ADDRESS (No., Street) S. PATIENT RELATIONSHIP TO INSURED :7. INBURED'S ADDRESS (No., Street) CiTY STATE S. PATIENT STATUS CiTY STATE ZIP CODE TELEPHONE (Include Area Code) ZIP CODE J TELEPHONE (INCLUDE AREA CODE) 9. OTHER INSURED'S NAME (L~t Name, First Name, MiddJe Initial) 10. IS PATIENT'S CONDITION RE~TED TO: 11. INSURED'8 POLICY GROUP OR FECA NUMBER 30F.II-q~;0N, ROJ~E:R'T' P ~. OTHER INSURED'8 POMOY OR GROUP NUMBER ~ ~ a, INSURED'S DATE OF BIRTH a. EMPLOYMENT?(CURRENTOR PREVIOUS)iiYES IXINa MM . DD . YY M~ S~ (.:~(:-t C ] 9 3 5 0 5 2 5 5 .'l b. OTHER INSURED'S DATE OF BIRTH b. AUTO ACCIDEN~ P~CE (~e) b. EMPLOYER'S NAME OR SCHOOL N~E d. INSURANCE PLAN NAME OR PROGRAM NAME 10d, RESERVED FOR LOCAL USE d. IS THERE ANOTHER H~LTH BENEFIT P~N? ~YES [ ~ NO ffy~, tatum to and ~mplete item 9 a-d, READ SACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize StGUED .: [..:~ ,RIUF.k. ON F:IL.E DAT~]~ Q~ 01. StGNED ....... 14, DATE OF CURRENT: j ILLNE~ (Flint ~mptom) OR 15. IF PATIENT HAS H~ SAME OR SIMI~R I~ESS. 16. DATES PA~E~ UNABLE TO WORK JN CURRENT OCCUPATION ., ', ~0 PREGNANCY (~P) , J FROM 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17~. I.D. NUMBER OF REFERRING PHYStCI~ 18. HOSPITALI~TION DATE8 RE~TED TO CURRENT SERVICES ~.. ~ES~WD FOR LOCAL USE ~0. OUTSt~E ~ ~ CH~S~S 21. DIAGNOSIS OR ~TURE OF ILLNESS OR INJURY. (RE~TE ITEMS 1,2,3 OR 4 TO ~EM 24E BY LINE) / ~. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 24. A B C D E F PR~EDURES, SERVICES, OR SUPPLIES DIAGNOSIS DAYSI MM DD ~ MM DB YY Se~l~ ~ C~dm~PCS, MODIFIE~ UNITS P~n , 27, ACCEPT ASSIGNMENT? 25. FEDERAL TAX I,O, NUMBER 8SN EIN 26, PATIENT'S ACCOUNT NO. (For g~. claims cee back) 28, TOTAL CHARGE 2g, AMOUNT PAID ~. BA~NCE DUE 31, SIGNATURE OF PHYSICIAN OR SUPPLIER a2, NAME AND ADDRESS OF FAOILI~ WHERE SKRVICES WERE 33, PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-1500 (12-90), FORM RRB-1500, APPROVED OMB-1215-0055 FORM OWCP-1S00, APPROVED OMS-0720-0001 (CHAMPUS) .RLEASE , DO NOT' STAPLE IN THIS '? 2 [i I1 ~:!~ I:) 'L e F! ':,;~ 1 1, MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la, INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Inlit~l) 5. PATIENT'S ADDRESS (No,, Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'8 ADDRESS (No,, Street) '?I!i? L..(::IT:][:PiOF]E: R:D SelfF-~SP°u""F--]Ch"d~ Otberl CITY STATE 8. PATIENT STATUS CITY STATE ZIP CODE TELEPHONE (include Area Code) ZIP CODE TELEPHONE (iNCLUDE AREA CODE) 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'8 POLICY GROUP OR FECA NUMBER - EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH ~. OTHER INSURED'S POLICY OR GROUP NUMBER b. OTHER INSURED'S DATE OF BIRTH b. AUTO ACCIDENT? 0[], [1(:), (](:It:lEi I I c. EMP~'OYER'~ NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME YES I No d NSURANCE PLAN NAME OR pROGRAM NAME 10d. RESERVED FOR LOCAL USE d. JS THERE ANOTHER HEALTH BENEFIT pLAN? I~,~IYES I I NO If yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13, INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authonze the release of any medical or other information ~ecessa~ payment Of medical benetits to the undersigned physician or supplier for to process this claim. I also request beyment of government benefits either to myself or to the party who accepts assignment services described below. below, 14. DATE OF CURRENT: · ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION M~I,.~'.z. , DD ~ ,YY · INJURY(ACCIdent)OR GIVE FIRST DATE MM , DD , YY MM , DD , YY MM , DD , YY (ii 71 I:j ~} ~1 PREGNANCY (LMP) I I FROM I I TO I I 17, NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D, NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM , DD , YY MM , DD , YY 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) / 2,?. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 24. A B C D E F G H I d K OF SERVICE To Ploa~e T~oe PROCEDURES SERVICES, OR SUPPLIES DAYS I EPSDT FromDATE(S) (Exelaln [J'nusual Circumstances) DIAGNOSIS RESERVED FOR MM DD YY M~t DD YY Service Servicei~f CPT/HCPCS ! MODIFIER CODE $ CHARGES OR Family EMG COB LOCAL USE UNITS Plan i 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE [:! [!i [:) f~l (:) } DATE PIN# IGRP# SIGNED (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0g38-0008 FORM HOFA-1S00 (12-90), FORM RRB-1500, APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS) ,7'LEASE. ' , DO NOT PEERLESS CREDIT STAPLE ?"-~5, .:. Maple Road IN TRIS l']J dd~ e'town, PA AREA [~ PiCA ~- _. ='~-,-U .J H + lib/AL I r-I II~l~Ul'I/~l~l~r' I~,L,AIIVI I'Ul~llVl P~OA ~ ~ il. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP ~ECA OTHER la INSURED'S I,D, NLIMBER fFOR PROGRAM IN iTEM 1 5. PATIEN1 'S ADDRESS (No,, Street) 6, PATIENT RELATIONSHIP TO INSURED 7, INSURED'S ADDRESS (No,, Slreet) CARLISLE PR Single~ Marded~ Other~ CRRLZSL. E PR JOHNSON, ROBERT ~ N/A ~vEs ~NO e < ~YES ~ NO If yes, return to and comptete item 9 a-d. SIGNATURE ON FILE DAT¢I 28 01 SZGhlATURE ON FiLE SIGNED SIGNED ~ M~ll ~71 ~0~ INJURY(Accident) OR GIVE FIRST DATE MM r DD I YY MM DB YY MM DD YY i I PREGNANCY (LMP) I ~ FROM ~ : TO : , NOLT,JEFFREY FROM ~81 ~1' ~O TO [~O~ ~61 ~O ~ L414.Oi__ CORONARY ATHEROSC a.[__729'5 PAIN ZN&ZM CODE,~ ORIGINAL REF. NO. ~ 786.58 CHEST PAIN UNSPEC 410.40 MI ACUTE OT z 2.1 4.[-- ~ 24. A 8 I C D E F G H I [ J K ~ ~ O ] ' ' ' I ' o 1ii SOUTH FRONT STREET iOOO NORTH FRONT STREET GUTIEiRREZ, FEiLIX, MD HARRISBURG,, PA 17]_~! WORMLEYSBURG, PA 17'343 APPROVED OMB-0938-0008 FORM HCFA-1500 (1290) FORM RRB 1500, tAPPFIOVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PL~-~/~SE PRINT OR TYPE APPROVED OMB 1215-0055 FORM OWCP-1500, APPROVED OMB 0720-0001 fChAk4PLJS~ RLEASE 'DO NO'F STAPLE IN THIS AREA I I I PICA .1. t::, 2 ~,. ,:, u u u ,:~ n,-/~, i n ii~Ul~/~i~f- ~l-/~ii¥i I-~/rtl¥i PiCA I I 1. MEDICARE MEDICAID CHAMPUS OHAMPVA GROUP FEOA OTHER la, INBURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 2. PATIENT'S NAME {gaat Name, Flrs~ Name, Middle Initial) 8. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (~st Name, Flint Name, Middle Initial) 5. PATIENT'S ADDRESS (No.. Street) 6, PATIE~ RE~TIONSHIP TO INSURED 7. INSORED'S ADDRESS (No,. Strew) CITY STATE 8, PATIENT STATUS CI~ STATE ZIP CODE TELEPHONE. . (include Are~ Code) . Full-Time PGA-Time ZIP CODE TELEPHONE (INCLUDE AR~ CODE) JOHIqSON, I,.)J:E:F, f C ' MMI DD I M~ S~ QF:~CJf~35052E;5 ].]~ 2~ ..951~ ~ c. EMP~OYER'~ NAME OR SCHOO~ N~ME c, OTHER ACCIDE~? c. INSU~NCE P~ NAME OR PR~M NAME ' ' '' ~ ' ' : ' ' ~YES .1. ].1 [] 'FI 0 ~) ~ PREG~NCY (LMP) I I FROM I I TO I I NOL..]:~ DE:F:'F:'REY S., Pi.D. FROM ].0I, 11I, 00 TO ].0~ 1E~I, '?29.5 FhqlIq IN L. IMt/ 3.[~._ ~ ~ CODE $ CHARGES OR Family EMG COB i 1 ~pytohsb a.daremedeapa, thereo.) H~..I~:.I..,.S:BUI'~G HC, Ed:)IT'F:I] .... MCd::'F:'I;'T"T', F'IEF:~SE: 8: LIN 11[ SOUTH F:'RONT S-['REINF 100~ FIORTHI RON-f'r'' S'T'[~EE"I" :I:',I:::IC:H:]:HE;KY ,, WIL. I._IFIH :., I-..IF~t:~R:I: ._ ~.,:., ~: .. , SIGNED {J [{} 0 ~ CJ 1, OA~ PIN~ [GRP~ (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM NCFA-1500 (12-90), FORM RRB-1500, APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS) , PLEASE, . DO NOT . .............. I .I.k.[.i: ......... CREZ[)]]T z. = STAPLE ,,, 1. MEDICARE MEDIDAID CHAMPUS OHAMPVA GROUP FECA OTHER re, INSURED'8 ].D, NUMBER (FOR PROGRAM IN ITEM i (M6dlcare #) ~ (Medtcald #) ~'-] ($poneor,$ $$N) F~ (VA File #) F----~HEALTHPLANI-"~BLKLUNDr--~'~ I I(S$No-O)I I($$~) 2, PATIENT'S NAME (Leer Name, First Name, Middle Initial) $, PATIENT'S SIRTH DATE SEX 4. INSURED'B NAME (Last Name, Firat Name, Middle Initial) D,.¢, YY 5. PATIENT'S ADDRESS (No., 8treat) 6. PATIENT RE~TIONSHIP TO INSURED 7. INSURED'8 ADDRESS (No., 8trot) OITY STATE B, ~ATIENT STATUS CITY STATE ZIP CODE TELEPHONE (Include Area Cede) ZIP CODE TELEPHONE (INCLUDE AR~ CODE) Full.Time Pa~-Tlme 9. OTHER INSURED'8 NAME (L~I Name, First Name, Middle Initial) 10, IS PATIENT'S CONDITION RE~D TO; 11. INSURED'S POLIOY GROUP OR FEOA NUMBER :E)I'"IN S:;O N , RO ]~E:RT C QR('] (:15r]5265 b. OTHER INSURER'S DATE OF BIRTH b. AUTO AOOIDENT? P~OE (~e) b. EMPLOYER'S NAME OR SOHOOL NAME c, EMPLOYER'S NAME OR SCHOOL NAME c,OTHER AOOIDE~? c. INSU~NOE P~N NAME OR PROG~M NAME d, INSURANCE PLAN NAME OR PROGRAM NAME 10d, RESERVED FOR LOCAL USE d, [S THERE ANOTHER H~LTH BENEF~ P~N? ~Xl YES ~ J NO ffyes, return to ~d complete item 9 a-d. R~D BACK OF FORM BEFORE COMPLE~NG & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize SIGNED S'[GNRTURE ON I::ZLE DAT~:)[~ ~EI [~]. SIGNED SZGIqFYf'Ut~'E: ON F'ZL.E 14, DA~ OF CURRENT: ~ ILLNESS (Fire symptom) OR 15. IF PATJE~ H~ H~ ~ME OR SIMI~R ILLNESS. 16. DATES PATIE~ UNABLE TO WORK IN OURRE~ OCCUPATION ~i, t~'~i, ~(}~ PREGNANOYI~URY(A~Ident) OR(LMP) GIVE FIRST BATE MM ,I DD I ' ~ FROM MM I~ OD 17, NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17~ I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPffALI~TION DATES RE~TED TO CURRENT SERVICES MM DD YY MM DD 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RE~TE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) / ~. MEDICND RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUT~ORI~TION NUMBER 24. A B C D E F PROCEDURES'(F.~nmm SERVICES' OR SUPPLIES~ DIAGNOSIS DAYS EPSDT DATE(S) OF SERVICE Plmea¢ T~y~ E lain Unu ual Circumstance CODE $ CHARGES OR Family EMG COB Fmm To RESERVED FOR MM DD ~ MM DD ~ Sewim ~oe CP~'~PCS ~ MODIFIE~ LOCAL USE , I 27. ACCEPT ASSIGNMENT? ~. A~OUNT PAID 80, BA~NOE DUE 25, FEDERAL TAX I.D. NUMBER SSN~EIN~ ~6, PATIENT'S ACCOUNT NO. (FOryESgO~, claims NoSee back) 28. TOTAL CHARGE $ INCLUDING DEGREES OR CREDENTIALS RENDERED (If other tha~ home or ~fl~) & PHONE ~ 1 0 0 [) NOIR"I"I'"I F:'RONT .,) I M .E. F 1 0 0 0 NC)IR1 H F:'RONT ST REET (APPROVED BY AMA COUNCIL ON MEglCAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0938~0008 FORM HCFA-1500 (12-90), FORM RRB-tS00, APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB.0720-0001 (CHAMPUS) PLEASE. DO NOT 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'8 I.D. NUMBER FOR PROGRAM IN ITEM I (Medtcare ~) (Medicaid #) (Sponsor's SSN) (VA File #) (SSN or ID) (SBN) (/DJ 2. PATIENT'S NAME (Last Name, First Name, Middle initial) 3, PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) MM i DD , YY~r~ FJ . 5. PATIENT'S ADDRESS (Ne., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) CITY STATE 8. PATIENT STATUS CITY STATE YORI.*; !~;Fh:~;[:lq(-)F..; F'R SInglo~] Marrtsd[~ OtherJ yC)RK ZIP CODE J TELEPHONE (include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) 9, OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10, IS PATIENT'S CONDITION RELATED TO: 11, INSURER'S POLICY GROUP OR FEOA NUMBER :%) Htq :L:;O INI ,, RO :BE:F~T C a. OTHER INSURED'8 POLIOY OR CROUP NUMBER a. INSURED'S DATE OF BIRTH a. EMPLOYMENT? (CURRENT OR PREVIOUS) ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME 'OTRERNSURED'SDATEOES'"TR SEX RrqMM . DD · yy ", "AUTO WES c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME d. INSURANCE PLAN NAME OR PROGRAM NAME 1Od. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? I?~1 YES I I NO If yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM, 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE J authorize 12. pATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authodze the release of any medic~ or other Information necessary pByment of medical benefits to the undersigned physlcaln or supplier for to process this alalm. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. 14, DATE OF CURRENT: ~ ILLNESS (First symptom) OR 15, IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 116. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION i ,N URY(,.alda.,OR CIVB RIRSTDATE MM, DD i YY MM DD . 7 0 PREGNANCY (LMP) I ' FROM II I TO I II 17, NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a, LD, NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM I DD I MM t DD I YY 19. RESERVED FOR LOCAL USE SO, OUTSIDE LAS? $ CHARGES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) ~ 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 2.1 '?~: f'_' .50 CHE;.?.;T pF'q..'(;N UNSIoEC 4,[ 414.0t CORONRRY I::yT' 24. A B C D E F FromDATE(S) OF SERVICE To Plgde rYo~ p(~E/x lain Unu[uel Clrcumst ..... $ CHARGES UNITsOR FamilYPlanEMG MM DD YY MM DD YY Service Serdce C ~°~ PCS MODIFIE~ CODE 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZiP CODE SIGNED (}[~ [}[i~ 0.].. DATE PIN# IGRP# (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0938-000§ FORM HCFA-1500 (12-90), FORM RRB-1500, APPROVED OMB-1215-0855 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS) , PLEASE DO NO']' ' PEERLESS '~F- STAPLE INTHIS 725 Haple Road AREA ~t J.¢ldl e4- o~jr~, PR i624.40994 HEALTH INSURANCE CLAIM FORM ~. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la, INSURED'S ID NUMBER (FOR PROGRAM IN I1 2 PATIENT'S NAME (Last Name, First Name, Middle initial) 3 PATIENT'S BIRTH DATE SEX 4 JNSURED'S NAME (Last Name, First Name, Middle Initial) 3OHNSON P!ARY M~J-.i ?4; tYg~IME~ F XL..~ DOHNSON,IIRRY E 5 PATIENT'S ADDRESS (No,, Stree0 6 PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No,, Street) Sl ET'rY [ ELSOi CT ¢122 8i ETTY NELSON CT CiTY STATE B, PATIENT STATUS CITY STATE ZIP CODE TELEPHONE (IRclude Area Code) ZiP CODE TELEPHONE (INCLUDE AREA CODE) Em Io e FuIFTime Part-Time i7013 {717)1-25E1-5546 "Yd~StuOenl ~Studont ~ 17813 ((7]_5)--258--66/,6 9 OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11, INSURED'S POLICY GROUP OR FECA NUMBER JOHNSON, ROBERT C a OTHER INSURED'S POLICY OR GROUP NUMBER a, EMPLOYMENT? (CURRENT OR PREVfOUS) a, INSURED'S DATE OF BIRTH SEX bi AUTO ACCIDENT? YES NO d. INSURANCE PLAN NAME OR PROGRAM NAME 10d, RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? ~YES ~ NO If yes, return to and complete item 9 a-d SIGNATURE ON FILE ~1 2B ~1 SIGNATURE ON FILE ~, ~, ~~ PREGNANcyINJURY(AcoJdent) OR(LMP) GIVE FIRSTDATE MM ~1 DB ; YY FROM MM ~ DD [ YY TO MM ~ DD ~ YY NOLT, DEFFREY I ,ROM ~Mi~ ~7~ ~O 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)r 22, MEDICAID RESUBMISSION ~i~. Oi CORONARY R-fHEROSC ~ll . 1 ~:O~O~R~% ~Y CODE I ORIGINALREF NO 786.50 CHEST PAIN UNSPEC 729.5 PAIN IN Lit1 24, A B O D E F G H I J K IMM OD YY MM DD YY Service Service CP~/~POS [ MODIFIE~ CODE $ CHARGES UNiTsOR Familplan EMG COB LOCAL USE il,07 00 ~ , 21 01 93010 , i,:),3 ~0,.O0 l Zll SOUTH F'RONi' STREET 1080 NORTH F:"RONT STREET ,~'.~TIE~;h;E/_, FELIX, ~',D HRRRZSSURG, FR 17101 L~ORI'!LEYS~URG, PR 17043 11 20 O1 (APPR¢)VED B'~ AMA COUNC;iL O14 MEDICAL SERVICE 8/88~ PLEASE PRINT OR TYPE APPROVED ON1B-0938 0008 FORM HCFA-1500 (12-[0) FORM RRB 1500 APPROVED OMB 1215 0055 FORNt OWCP 1500 APPROVED OIvlS 0720-0001 fCHAMPUS) PLEASE / IL, Ltd_[ ........ STAPLE 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 2. PATIENT'S NAME (Laat Name, Flrat Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Lest Name, First Name. Middle Initial) 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RE~TIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) CITY STATE B, PATIENT STATUS Ol~ STATE ZIP CODE TELEPHONE (Include Area Cede) ZIP CODE TELEPHONE (INCLUDE AR~ CODE) 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RE~TED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER a. OTHER INSURED'S POLICY OR GROUP NUMBER ~ ~ a. INSURED'S DATE OF BIRTH a. EMPLOYMENT? (CURRENT OR PREV,OUS)~ ~ YES ~X ~ NO MM DD . YY., ,. J, M~ SEX F~ CJRC193505255 :l. ,l. ~ 24 b. OTHER INSURED'S DATE OF BIRTH b. AUTO ACCIDENT? ~CE (~ b. EMPLOYER'S NAME OR SCHOOL NAME 0 {] 0 000 [] {] II I M F YES NO c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE P~N NAME OR PROGRAM N~E ~I INSURANCE PLAN NAME OR PROGRAM NAME 10d' RESERVED FOR LOCAL USE d' IS THERE ANOTHER HEALTH BENEFIT P~N? ~YE8 ~NO If yes, r~urn to and compl~o ltem S s.d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM, 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIE~'S OR AUTHORI~D PERSON'S SIGNA~RE I aulhofi~ the release of ~y m~l~l or other In~rmatlon n~W payment of medlca benefits to the undemlgned physician or supplier for to pmc~ this clam. I al~ request payment of government benefl~ e~h~ to myself or to the pa~ who accepts ~signment sewtces described below. SIGNED SI. GNRTURE OIq FILE: DA~g[* 0t 02 SIGNED SZGIqR'I*LJI;~E: ON F:'ZME 14. DATE OF CURRE~: 4 ILLNESS (First a~ptom) OR 15. IF PATIENT HAS HAD SAME OR SIMI~ ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 17. NAME OF Rb~HHING PHYSICIAN OR OTHER SOURCE 17a. LO. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALI~TION DATES RE~TED TO CURRENT SERVICES 19. RESERVED FOR LOCAL USE 20. OUTSIDE ~? $ CHARGES 2% DIAGNOSIS OR NATURE OF ILLNESS OR ImURV, (RELATE ITEMS 1,2,3 OR 4 TO ImM 24E BY LINE) ~ 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO, 1,1[~ ]. 4. ,,. [)~L COIROINIF:~I:~Y R'I"HIEROSC ~.1 788.50 CHE:S'f' N 23, PRIOR AUTHORIZATION NUMBER Fm~ATEIS)OFSERVICE P~e T[~e PROC~DURE8 SERVICES ORSUPPLE8lAY , 27. ACCEPTyEs ASSIGNMENT?No '~ 0 0 0 $ ~ Ii. 25. FEDERAL T~ I,D. NUMBER SSN~EIN~ ~6. PATIENT'S ACCOUNT NO. (For go~. claims see back) 28. TOTAL CHARGE 29, AMOUNT RAID 30. BALANCE DUE 31. SIGNATURE OF PHYSICIAN OR SUPPLIE~ 32, NAME AND ADDRESS OF FACILITY WHER~ SERVICES WERE 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP COD~ 1 ]. 1 S O U'I"H F:' R OIq"r' S T RE:E T 1. 0 O O Iq O R TI'-I F' R ON'T' S T F',]EE T SIGNED [) /1' El 1. 0 2 DATE PINe (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-Og38-O008 FORM HCFA-1E00 (12-90), FORM RRB-1500, APPROVED OMB-1215-0D55 FORM OWCP-150D. APPROVED OMB-0720-OOOl (CHAMPUS) .PLEASE, t DO' NOT J::)liE[E RI... JiB fi~ ',i~; (:; !';?iE ]) ! 'f' i;i!', ,~' STAPLE ,,, IN THIS "? ":" ~ .:: Fh: [: 167 I',~C,,:' · ~ Cl ~, ., . ,,,-~: AREA Fl:i..dE! 'L<~:~, Lo/.Jt"~ ,, I::h::l 'l /' "!';; ;:' ~ 1, MEDICARE MEDICAID DHAMPUS CHAMPVA GROUP FECA OTHER Jla. INBURED'B I.D, NUMBER (FOR PROGRAM IN ITEM _J (Medlcere #) O (Medlcald #) E'q (Spor~or'$ SSN) E~ (VA FIle #) J'----IHEALTHPLANr--'--IBLKLUNGr-~--I J Ir$$NOrlD) J JrSSN) ',L~. (/D) 2, PATIENT'S NAME (Leal Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4, INBURED'S NAME (Last Name, Flrai Name, Middle Initial) MM , DD , YY B, PATIENT'8 ADDRESS (No., Street) 8, PATIENT RELATIONSHIP TO INBURED 7, INBURED'S ADDRESS (No., 8treet) CITY STATE $, PATIENT STATUS CITY STATE ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) B, OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S OONDmON RELATED TO: 11. INSURED'8 POLICY GROUP OR FEOA NUMBER a, OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH b. AUTO ACCIDENT? PLACE (8~ae) b. EMPLOYER'S NAME OR SCHOOL NAME ~3. OTHER INSURED'S DATE OF BIRTH MM.DO.YY BEX I--I Iq CF1 EMPLOYER'S NAME OR SOHC~OL NAME. c. OTHER ACCIDENT? d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. iS THERE ANOTHER HEALTH BENEFIT PLAN? IXIYES J I NO If.I/e& return to and complete item 9 a-cl. READ BACK OF FORM BEFORE COMPLETING & SIGNING TMIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize t2. PA31ENT'S OR AUTHORIZED PERSON'S SIGNATURE I auth~rize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to pi'ce, ess this claim. I also request payment of government benefits either to myself or to the pariy who accepts assignment services described below. 14. BATE OF CURRENT: · ILLNEBS (Flrai $ymptom) OR 15, IF pATIENT HAS HAB SAME OR SIMILAR ILLNESS. 18. BATES PATIENT UNABLE TO WORK IN OURRENT OCCUPATION 'C:I ,.JURY(AooIde.t O.p. EGNA.Oy .p) GIVE F,RST DATE MM ,' OO ,I EROM MM I' DD ,' TO MM 'l DD I YY 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18, HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES 21. DIAGNOSIS OR NATURE OF lU.NESS OR INJURY. (RELATE ITEMS t,2,3 OR 4 TO ITEM 24E aY LINE) / 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. [ 23. PRIOR AUTHORIZATION NUMBER 2[ 24. A B C D E F FROOEDURES, SERWCES, OR SUPFUES D~AGNOS~S DAYS EPSDT BATE(S) OF SERVICE FIBre. CeTofeYP fE x~lEx lan Unusual Oircumstancess) CODE $ CHARGES OR Family EMG COB LOCAL USE From To RESERVED FOR MM DD YY MM DD YY Sen/ice Service CPTIHOPCS J MODIFIE~ UNITS Plan 27. ACC/PT ASSIGNMENT? $ 1 1 1 SOU'TH F RC)N'T' S"]'F;,'E:ET 1 O 0 O N()R"I'H F:'F!(:)NT .c_:;TF:'IEET SIGNED [)(!i ('iii [].~, DATE PiN# IGRP# (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB*0938-0008 FORM HCFA-150B (12-90}, FORM RRB-1500, APPROVED OMB-1215-0055 FORM OWCP-15O0, APPROVED OMB-0720-0001 (CHAMPUS) PLEASE 'DONOT' STAPLE IN THIS AREA I't:i Cid] e'LO(;J["~., F':'t:l '. '?, ' ,l:' :,, 1, MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) 2. PATIENT'S NAME (Lest Name, First Name, MIridle InJMal) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) CD, YY ;::10 i' tl,.! fZ:.; 0 I',1 I"ll:::l I:'~ Y 1 .Li ,.. -,, 8. PATIENT'S ADDRESS {No,, Street) E. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No,, Street} '/fii'? L..FFT':I;I10F~E: FCD self spouse hlld OtherU '?67 L.I'-?FI"IliOI.,fl::: R1) CITY STATE 8. PATIENT STATUS CITY STATE ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE)r 9, OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) ~ 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER - a. OTHER INSURED'S POLICY OR GROUP NUMBER MM YY SEX a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH b. OTHER INSURED'S DATE OF BIRTH b. AUTO AOOIDENT? pLACE (State) 13. EMPLOYER'S NAME OR SCHOOL NAME .M,DD. MI--: SEX FFq FLYER I:q.O , c. EMPLOYER'S NAME OR SCHOOL NAME c, OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME YES F NO d, INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? ~?~YES I I NO If yes, return to and complete item 9 a-cl. READ BACK OF FORM BEFORE COMPETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'8 SIGNATURE I authorize ,12. PATIENT'S OR AUTHORIZED PERSON'8 SIGNATURE I authorize the release of a.y medacal or other information necessary payment of medical benefits to the undersigned p~ysicisn or supptier for to process this claim. I also request paymeot of govemmeot benefits either to myself or to the party who accepts esalgnmeot services described balow, below. SIGNED S:[:(3J',J~)TU~ ON J::"J[L.E: DATI~](!) 08 J:):[. SIGNED ~:;:[[.SJ~-J~"J'UJ~E L')I',J 14~jATE OF CURRENT: · ILLNESS (Firm symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN OURRENT OCCUPATION DD . YY J INJURY (Accident) OR · GiVE FIRST DATE MM DD YY MM I DD YY MM DD YY J' J-I 0 '~'] {."l {:} I PREGNANCY (LMP) I I FROM I I TO I I 17. NAME OF REFERRING PHYSICIAN OR OTHER 8OURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICE8 MM DD YY MM DD YY 15. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHABCES YES I 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) /, 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. '-,( i:, ~,, '~'/ J 23. PRIOR AUTHORIZATION NUMSER Z 2. L__ 4. L__ _O ~4. A E C D E F G N ~ J K ~" Pl~ce TYo~ PFIOOEDUR[S S[RViCES, OR SUPPLIES DAYS EPSDT PromBATE(S) OF SERVICE To of (Explain ~nu~u~l Olrcumstsnoes) DI^DNOSI$ RESERVED POR MM DO YY MM OD ¥¥ Service ~e~ce OPTIROPOS / MODIFIER CODE $ CHARGES OR Family EMG OCS LOCAL USE ~ O I ~r' I O I Z I '?" ' ~ ': ? "J "':" ~:~ I~¥$s I---INa$ - ' "' (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-15OO (12-90), FORM RRB-1500, APPROVED OME-12tS-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS) .PLEASF~. DO NOT PEERLESS CREI)ZT Z STAPLE IN THIS 725 ]laple Road AREA ~'[J..ddl6~+.o~,Jr'~, PR 17057 1524.4-8994- 1 MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la INSURED'S I,D, NUMBER (FOR PROGRAM IN ITEM I(Med,care #) F~ (Medicaid #) ~ (Sponsor's $SN) ~ (VA File #) ~-~ ~%/NLo] rH/;)LAN ~ ~SI;N~UNG~-] fiD) ~ 2 PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4, INSURED'S NAME (Last Name, First Name, Middle ~nitlal) JOHNSON IIRRY ¥4.;] FI X[ -t ,:- , 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURER'S ADDRESS (No,, Street) 81 ]BETTY I"IEI_SON CT *:122 seifr~spouser-~Child~ Other~] 8]. ]BETI'-Y NELSON CT #122 CITY STATE 8, PATIENT STATUS CITY STATE CARET SEE PA single ~ Married ~1 OtherI CP~RLZ E, LE zip CODE TELEPHONE (include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) ~. Employed ~-~ FuIFTime ~Pad'TJmoIStudent Student 170 JJL 3. ~ 17813 717)) - 25 El - 864- 6 (( 71 ) - 258 - 00 9 OTHER INSUREB'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11 INSURER'S POLICY GROUP OR FECA NUMBER 3OHNSON, I1RRY E a, OTHER INSURER'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a, INSURER'S DATE OF BIRTH 7101353972 ~YES [-~NO M,~J$1 D~i Y.~SI, M~ SEX AUTO ACCIDENT? c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c, INSURANCE PLAN NAME QR PROGRAM NAME E~YES [~NO d, iNSURANCE PLAN NAME OR PROGRAM NAME 10d, RESERVED FOR LOOAL USE d, IS THERE ANOTHERFi1 HEALTH BENEFIT PLAN? /~'-~YES ~ NO I~y~, return to and complete item 9 READ BAOK OF FORM BEFORE COMPLETING & SIGNING THIS FORM, 13, INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12r PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE f authorize /he release of any medical or other inlorm~ttion necessary payment of medical benefits to the u~dersigned physician or supplier for SIGNED SZGNATURE ON FZLE DAT~i 20 D1 SIGNED S.'f,:GNF1TURE ON FZLE 14, DATE OF CURRENT: · ILLNESS (First symptom) OR 15~ IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16~ DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION M.~l~ ~7~ '0'lB ~lNJURY(Accident) OR GfVE FIRST DATE MM DB YY MM DC YY MM DD YY 17. NAME OF HbI-~IRING PHYSICIAN OR OTHER SOURCE 17B, I,D. NUMBER OF REFERRING PHYSICIAN 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY NOLT, 3EFFREY FROM I, I TO I, 19 RESERVED FOR LOCAL USE 20, OUTSIDE LAB? $ CHARGES E~YES E~NO I I 21. DIAGNOSIS OR NATURE OF iLLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)/ 22 MEDICAID RESUBMISSION 4-1L,.01 CORONARY ArH,_RO.¢.¢ 729.5 PAZN ZN~ NO. 23. PRIOR AUTHORIZATION NUMBER 786.50 CHEST PRIN UNSPEC 2.]. 4. L__ 24, A B C D E F I G H i J K Place T e PROCEDURES, SERVICES, OR SUPPLIESI DAYs EPSDT FromDATE(S) OF SERVICE To of ~ofp Ex lain Unusual Circumstances DIAGNOSIS RESERVED FOR NlM DD YY MM DR YY Service Service CP(~/~PCS I MODIFIE~ CODE S CHARGES OR Family EMG COB LOCAL USE UNITS Plan 23-1864-722 14915 ~YES [~]NO s J-101- BE , 75,.00 doert,fythaltflestatemenlsonth ........ tI~P~ ~H~ ~ VR..,DULHR ~?~Z'I'T HEf~RT :~ VflSCLJLF~R GROI 977 gFE._NV'I ~OTTOPf ROF4~ lB00 IqORTH FRONT STREET 20 01 SIGNED DATE PIN~ IAPPRDVED BY AMA COUNCIL ON MEDICAL SERVICE 8/e8) PLEASE PRINT OR TYPE APPROVED OMB~0938-0008 FORM HCFA 1500 (12-90), FORM RRB-1500, APPROVED OMB 1215-0055 FERN] OWCPdS00, APPROVED OMB-0720-8001 (CHAMPDS) 'Do'PLEASE'o~ ' t N__' oc:~:' L:-, 'C-C- , r:--~,_E..~._, CRESZT 7 STAPLE - -- ~ IN THIS 725 Maple Roa. d ~ AREA Midd~e4,:o~r~, PR 17057 ~ i6244.0994 I I IPIc^ ....... "' ~'~'~ HEALTH INSURANCE CLAIM FORM 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S I,D. NUMBER (FOR PROGRAM IN ITEM 2, PATIENT'S NAME (Last Name, First Name, Middle Initial) 3 PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME {Last Name, First Name, Middle Initial) OOHNSON MRRY M~ii ~; ~YgSiM~ F~ OOHNSON,MRRY E 81 BETTY NELSON CT ¢i~2 Self~Sp0,,e~Ohlid~ Other[ "l ~TrY NELSO, CT C~TY STATE 8, PATIENT STATUS CITY STATE ZIP CODE TELEPHONE (Include Area Oode) ZIP CODE TELEPHONE (INCLUDE AREA CODE) i7Oi3 P yed~sl~dent ~S'Ude~t i7oi3 ((7i )-258-8646 9 OTHER INSURED'S NAME {Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11, INSURED'S POLICY GROUP OR FECA NUMBER 3OHNSOH, ~ARY E a OTHER INSURED*S POLICY OR GROUP NUMBER a, EMPLOYMENT? {CURRENT OR PREVIOUS) a, INSURED'S DATE OF BIRTH b OTHER INSURED'S DATE OF BIRTH b, AUTO AOOIDENT? P~OE {Slate) b, EMPLOYER'S NAME OR SCHOOL NAME c. EMPLOYER'S NAME OR SCHOOL NAME c, OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME YES NO O, INSURANCE PLAN NAME OR PROGRAM NAME 100, RESERVED FOR LOCAL USE d, IS THERE ANOTHER HEALTH BENEFIT PLAN? ~YES ~ NO Ifye¢, return to and complete Item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM, 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize t~e release of any medica~ er other Information necessaW payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to t~e pa~y w~o acceDts assignment se~ices described below, below. 28 ~[ SZGNRTURE ON FZLE S~eN~ SZGNRTURE ON FZLE DATe( S~eN~ 14. DATE OF CURRENT; j ILLNESS (First symptom) OR 15. IF PATJENT HAS HAD SAME OR SiMI~R ILLNESS 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ~1 ~1 ~ ~ INJURY {Accident)OR GIVE FIRST DATE MM DD YY MM DD YY MM DD YY , , PREGNANCY (LMP) ~ : FROM 'I ', TO 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. J.D. NUMBER OF REFERRING PHYSICIAN 18 HOSPITALI~TION DATES RE~TED TO CURRENT SERVICES NOLT, JEFFREY MM DD YY MM DD YY 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE fTEMS %2,3 OR 4 TO ~TEM 24E BY LINE)/ 22. MEDICAID RESUBMISSION ~.[4i~.01 CORONARY ATHEROSC 729 5 PA~N ~N ~r~ CODE ORIGINAL REF NO 788.58 CHES"F PRZN UNSPEC MM DD YY MM DB YY ~ice CP~/~ PCS I MODIFIE~ CODE $ CHARGES OR Family EMG COB 05,29,0Z 32 04~78465 [25,. ' ' ' I ; ' ('INCLUDJNG DEGREES OROREDENTIALSceriif,tha, the statements on the reverse (~E"~ l'' ,-,ha,M~Sp~ A='~- '~ ' ~ ~l T'l- HEART D VASCULAR GRO[~ 245 PARKER STREET iOOO NORTH FRONT STREET LINE, DENNIS E, FiD CARLZSLE, PA 17013 I~ORi'ILEYS~URG~ PA 17043 11 20 01 E,PPROVED 8¥ AMA COUNCIL ON MEDICAL SERVICE 8/B8) PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-1500 (12-90), FORM RRB-1500, APPROVED OMB.1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CRAMPUS) PL,EAS~ DONOT PEERLESS CREDIT STAPLE 725 Maple Road IN THIS AREA riiddletown, Pa 16244-0994 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 2 PATIENT'S NAME (Last Name, Firsl Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4 INSURED'S NAME (Lad Name, First Name, Middle Initial) JOHNSON MARY M.~ii ~°4i ~Y951Mr~ F XL~.j :JOHNSON,MARY E 5 PATIENT'S ADDRESS (No,, Street) 6, PATIENT RELATIONSHIP TO INSURED 7 INSURED'S ADDRESS (No., Street) CITY STATE 8, PATIENT STATUS CITY STATE CARLISLE PA s,,¢e~'~ MarriedS1 Othe~I CARLISLE PR ZiP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) Full-Time Part-Time 9 OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. tS PATIENT'S CONDITION RELATED TO'.11 INSURED'S POLICY GROUP OR FECA NUMBER JOHNSON, MARY E a, OTHER INSURED'E POLICY OR GROUP NUMBER a, EMPLOYMENT? (CURRENT OR PREVIOUS) a, INSURED'S DATE OF BIRTH b, AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME b OTHER INSURED'S DATE OF BIRTH SEX c, EMPLOYER'S NAME OR SCHOOL NAME c, OTHER ACCIDENT? c, INSURANCE P~N NAME OR PROGRAM NAME d, INSURANCE PLAN NAME OR PROGRAM NAME 10d, RESERVED FOR LOCAL USE ~d IS THERE ANOTHER HEALTH BENEFIT PLAN? ~YES ~ NO If yes, relurn to and complete item 9 READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM, 13, iNSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12 PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of a~y medicai or other information necessa~ payment of medical benefits to the undersigned ~ysician or supplier for to process this claim, ~ also request payment of government benefits either to myself or to the pady who accepts assignment se~ices described below. below, SZGNRTURE ON FZLE [[ 2~ Bi SZGNRTURE ON FZLE SIGNED DATE SIGNED 14. DATE OF CURRENT: ~ ILLNESS (First symptom) OR 15 IF PATIENT HAS HAD SAME OR SIMI~R ILLNESS16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ~ ~71 ~~ INJURY(Accident) OR GIVE FIRST DATE MM DD YY MM DD YY MM DD YY 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE ~7a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERV}CES MM DD YY MM DD YY NOLT, JEFFREY FROM Il ~ TO ~ 19 RESERVED FOR LOCAL USE 20. OUTSIDE ~B? $ CHARGES 21. DIAGNOSIS OR NATURE OF ILLNESS OR iNJURY. (RE~TE ITEMS 1,2,3 OR 4 TO ~TEM 24E BY LINE~ 22. MEDICAID RESUBMISSION 4~.8! CORONRRY RTHEROSC 729.5 PRIN ~N ~IM CODEr ORIGINALREF, NO 23. PRIOR AUTHORi~TION NUMBER 78G.50 CHEST PR!N UNSPEC 24. A B C D E F G H I J K DATE(S) OF SERVICE PlaceType PROCEDURES. SERVICES. OR SUPPLIES DiAGNOSiS DAYS EPSDT From To of ol p~X lain Unusual Circums ance~ $ CHARGES OR Famil EMG COB RESERVED FOR MM DD YY MM DD YY Service Se~ice C I~PCS I MODIFIE CODE LOCAL USE I I ~(For govt claims see back) 2:3~'i864722 ~ 14915 I~y~s ~NO , i85,.00 ~, 53~'20 23,.8B (~cerlifyl,allnestatementsonth ........ (~q~L~ M~.>~ ~F~L. ~ITT HEART '~, VASCULAR GAO(: "~G PARKER STREET lOOO NORTH FRONT STREET PZ~4Z, ~r, UL A, ~D C¢~RLZSLE, PR 17013 MORF~L. EYS~URG, PA 17043 SIGNED DATE f4PPROVED 8'¢ AMA COUNCIL ON MEDICAL SERVICE 888, PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-1500 /12-90). FORM RRB-1500. APPROVED OVlB- 215-0055 FORM OWCP 1500 APPROVED OMB-O720-00D1 (CRAMPUE) PLEASE STAPLE IN THIS 1, MEDCARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la, INGURED'S I,D, NUMBER (FOR PROGRAM N TEM ~(M~a~)U(M~I~ald~)~(SpOn~Or'e~N) ~(VAFIle~) ~HEALTHPLAN~BLKLUN~ 2, PATIENT'S NAME (La~ Name, First Name, Middle Initial) 3, PATIENT'8 BIRTH DATE a=v 4, INSURED'8 NAME (L~t Name, FI~ Name, MIddle Initial) 5. PATIENT'~ ADDRE88 (No,, Street) ~, PATIENT RELATIONSHIP TO INSURED OITY STATE 8, PATIENT STATUS ZIP CODE TELEPHONE (InoluOe Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) 8, OTHER INSURED'S NA~E (Last Name, First N~me, Middle Initial) ,10, IS PATIENT'S CONDITION RE~TED TO: 11, INSURED'S POLICY GROUP OR FEOA NUMBER J(:)HN S(}N, ROBERT C ~. OTHER INSURED'8 POLICY OR GROUP NUMBE~ a. EMPLOYMENT? (OU~ENT OR PREVIOUS) ~. INSURED'S DATE OF BIRTH c, EMPLOYER'S NAME OR SCHOOL NAME, c, OTHER ACCIDENT? c. INSURANCE P~N NAME OR PROGRAM NAME d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER H~ALTH BENEFIT P~N? . ~ YES ~ NO If yes, return to and complete ~em 9 a-d. R~D BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13, INSURED'S OR AUTHORIZED PERSON'S SIGNATURE J authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I e~horlze the rele~e ~ any m~ic~ or other info~alio~ n~ payment of medi~ ~nefits to the undersigned physician or supplier for to pr~ess this claim. I also r~uest payment of government ~neats either to myself or to the p~ who ac~pts assignme~ se~ices described below, below. SIGNED 14. DATE OF CURRENT: ~ ILLNESS (First symptom) OR ~ 15. IF PA~ENT HAS HAD SAME OR SIMI~R ILLNESS. 16, DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION M~,[ I ~l ~('.)~ I~URY (Acadent) OR GIVE FIRST DATE MM DB YY MM DD YY MM DD YY 1% NAME OF H~RiNG PHYSICIAN OR OTHER SOURCE 17a, I.D. NUMBER OF H~P~HRING PHYSICIAN 18. HOSPITALI~TION DATES RE~TED TO CURRENT SERVICES 19. H~8~HVED FOR LOCAL USE 20. OUTSIDE ~B? $ CHARGES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RE~TE ITEMS %2,3 OR 4 TO ITEM 24E BY LINE) / 22. MEDICAID RESUBMISSION 4. 2 8. O COIqGEST']:VE HERRT ~ CODE I ORIGINAL REF. NO, 2& PRIOR AUTHORI~TION NUMBER 24. A B C D E F G H DATE(S) OF SERVICE PI~e T~ PR~/DURE8 SERVICES OR SUPPLIES DAYS EPSDT From To (Explain ~usual Circumstances) DIAGNOSIS RESERVED FOR MM DD YY MM DD ~ Se~lce Se~ce CPT/HCPCS ~ MODIFIER CODE r 111 SOUTFI F'RONT S"I'I:;~E:ET 1[:]88 NORTH F'ROIqT STF~EE:T .BOKEI...I1F. I,,I ~ TGI)I) R, II]:) I-.I¢~RR:[: S~UR6 ~ PF/ 171 B] ~OIRFIL. EYE;:BUR(3, PF~ ]. 7[]4.3 (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8188) PLEASE PRINT OR TYPE APPROVED OMB.0938-0008 FORM HCFA.1500 (12-g0), FORM RRB-1EOO, APPROVED OMB-121E-0055 FORM OWCP. 1500, APPROVED OME-0720.0001 {CHAMPUS) PLEASE, , - DO~ NO:I' :~ ~:.~il :~ .... :~ii F F.; ('_', F,'[E]) I 'T Z ' STAPLE '"' IN THIS 7 ~'~ ,~ I ]~.~d..> i.¢3 Rc>,~%cI AREA I i l.(I ~ ](:=" oU,Uh., FV:::1 17057 162440 g g 4 1. MEDICARE MEDICAID CHAMPUS CNAMPVA GROUP FECA OTHER la, INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE 8EX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) 5, PATIENT'S ADDRESS (No,, Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No,, Slreet) CITY STATE 8, PATIENT STATUS CITY STATE ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) Full-Time Part-Time g, OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10, IS PATIENT'S CONDITION RELATED TO: 11, INSURED'S POLICY GROUP OR FECA NUMBER JOHIq!3Ol'.l, ROI:IEtTT C a. OTHER INBURED'S POLICY OR GROUP NUMBER a, EMPLOYMENT? (CURRENT OR PREVIOUS) a, INSURED'S DATE OF BIRTH b'OTHERINSURED'BDATEGFS~RTHM~x~-] SE× Ffl--~ b. AUTO^CCIDENT? c. EMPLOYER'S NAME OR SO, HOOL NAME c, OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME I--lYES F-lNG d, INSURANCE PLAN NAME OR PROGRAM NAME 10d, RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? F~YES L_J NO If yes, return to and complete item 9 a-d, READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I euth~ize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment sen/icas described below, below. S~GNED SIGNRTURE ON F:'IL.E DAT~9 03 02 SIONF-I'I'UF~E ON FILIE SIGNED ' 14. DATE OF CURRENT: j ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16, DATES PATIENT UNABLE TO WORK iN CURRENT OCCUPATION M~I~I I~?r ~l]"~ INJURY (Accident) OR GIVE FIRST DATE MM DD YY MM DD YY MM DD YY , , PREGNANCY ILM~ Ii : FROM 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. i.D. NUMBER OF REFERRING PHYSICIAN 18, HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 19, RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES ]VES [ NO 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,~,0 OR 4 TO iTEM 24B SY LINE) 22, MEDICAID RESUSMISSION f, LZ,.28.Ol COIqGEST'IVE F'IEFtRT s,I .__ ; CODE I ORIGINALREF, NO. 23, PRIOR AUTHORIZATION NUMBER 24. A B C D E F G H I J K FromDATE(S) OF SERVICE To Pl~e TYO~ PROCEDURES SERVICES OR SUPPLIES DAYS EPEDT Ex lain Unu~uat Clrcumslances DIAGNOSIS RESERVED FOR MM DD YY MM DD YY Servi~e 8~vlce CP~/~gPC$/ MODIFIESR) CODE $ CHARGES OR Family EMG COB LOCAL USE , E~. FEDERAL TAX m. NUMSE. ESN E,N ~E. P.~:T,ENT'S ACCOUNT NO. ~,.(For27' ACCEPTgovt A. laSIGNMENT?.ee bask) $ :[. 61" INCLUDING DEGREES OR CREDENTIALS SIGNED APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-093e-000E FORM HCFA-1500 (12-90), FORM RRB-IS00, APPROVED OMB-121E-0055 FORM OWCP-1500, APPROVED OMB-0720,0001 (CHAMPUS PLEASE 'DO NOT STAPLE IN THIS AREA '? 2 5 I'1~ p 1 e, IR o a d I'l.'J. d d Z ~:~, Lo~,,Y~ r'~, F:'F:'i 1. 7 0 5 7. 1, MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1} L-J (SSN or I0) LJ ($$N) ~ (ID) 2, PATIENT'S NAME (Lest Name, First Name, Mibdle Initial) 3, PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle initial) I I 5, PATIENT'S ADDRESS (No., Slreet) 6, PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No,, Slreef) 8.'J ;Blii:'I""i"Y NE:L..SON C'T' #.1.22 se"IX JspouseLJch,dL_J~ ~ ~ °therE__J CT CITY STATE B, PATIENT STATUS CITY STATE C ZIP CODE TELEPHONE (Include Area Oade) '.IP OOOE TELEPHONE (INCLUDE AREA CODE) Full-Time I 0 ,3 g. OTHER INSURED'S NAME (Lest Name, First Name, Middle Initial) 10, IS PATIENT'S CONDITION RELATED TO: ' 11, INSURED'S POLICY GROUP OR FECA NUMBER C a. EMPLOYMENT? (CURRENT OR PREVIOUS) s, OTHER INSURBD'S POLICY OR GROUP NUMBER __ __ a, INSURBO'B DATE OF BIRTH t3, OTHER INSURED'S DATE OF BIRTH b. AUTO AOOIDENT? PLAOE (Slate) b, EMPLOYER'S NAME OR SCHOOL NAME c, EMPLOYER'S NAME OR SOHOOL NAME c, OTHER ACCIDENT? c, INSURANCE PLAN NAME OR PROGRAM NAME LL d, INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVEC FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? r~YES I I NO If yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'B OR AUTHORIZED PERSON'S SIGNATURE I authorize 12, PATIENT'S OR AUTHORIZEC PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request pey~ent of govem~er~l benefits either to myself or to the pa~ty who accepts assignment services described below, below. SIGHED [..:~NR1LII:.I:. ON F]iI....E DAT~Z~. 01. 02 SIGNED STGNI:~TUF,~E ON F'i;[I_!!:T 14. DATE OF CURRENT: ~ ILLNESS (First symptom) OR 15, IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION l~.~.j, ir ~Jb~' I, [~YJ".II PREGNANcyINJURY(A¢°Ident)OR(LMP) GIVE FIRSTDATE MM,, DD ,1 YY FROM MM : DO : YY TO MM ', DD ', YY t7. HAME OF REFERRING PHYSICIAH OR OTHER SOURCE 17a, I.D. NUMBER OF REFERRING PHYSICIAN 18, HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY ~E. RESERVED FOR LOCAL USE ~0. OUTS~CE LAS? S CHARGES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS t,2,3 OR 4 TO ITEM 24E BY LINE} / 22, MEDICAID RESUBMISSION CODE ORIGINAL REF, NO. 23, PRIOR AUTHORIZATION NUMBER 24, A B C D E F G H I J N DAYS EPSD'J DATE(S) OF SERVICE Pl~ce TYofpe PROCEDURES,_~ ~p~ll SERVICES, OR SUPPLIES~ DIAGNOSIScoDE RESERVED FOR From To of Ex lain Llnu~ual Circumstances $ CHARGES OR Famil EMG COS LOCAL USE MM DD YY MM DD YY Service ~er~ce CI~/t~uPCS~ MODIFIE. UNITS Plan 1,000 HORTH F"RONT S'T'P.E:E'2F Z000 INIORTH F:'RON'T' !:"';'T'REEE:T (:) Z, (] .'[. (:} 2 DATE PIN# I GRP# APPROVED OMB-0938-O00E FORM HCFA-1500 (12-90), FORM RRB-1500, (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED 0MS-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS) PLEASE D~ NOT STAPLE IN THIS AREA l"l J. d d.'l 0 4:.oki ('~ ~ I::) FI 2. 7 (:) !:.~ '?, . MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED+S I.D. NUMBER (FOR PROGRAM IN ITEM 2. PATIENT'S NAME (Last Name, First Name, Middle Rlltlal) 3, PATIENT'S BIRTH DATE 4, INSURED'S NAME (Lest Name, First Name, Middle Initial) yy SEX 5. PATIENT'S ADDRESS (No., Street) 6, PATIENT RELATIONSHIP TO INSURED 7, INSURED'S ADDRESS (No,, Street) CITY STATE E. PATIENT STATUS CiTY STATE ZiP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (iNCLUDE AREA CODE) ~FulRTimestudent ~PamTlme~udent g. OTHER INSURED'S NAME (Lest Name, First Name, Middle Initial) 10, IS PATIENT'S CONDITION RE~TED TO: 11. INSURED'8 POLICY GROUP OR FECA NUMBER ~]OI-INSON~ I'IF~IRY E MM ~D M~ SEX F~ a. OTHER INSURED'S POLICY OR GROUP NUMBER ~ YES ~ NO a. INSURED'S DATE OF BIRTH ~. EMPLOYMENT? (CURRENT OR PREVIOUS) c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c, INSURANCE P~N NAME OR PROGRAM NAME ~. INSURANCE P~N NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE R~ BACK OF FOH~ BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR A~HORI~D PERSON'S SIGNATURE I aulhorize the rNease of any medl~l or other informmton necessa~ payment of medlc~ benefits to the undersign~ physician or supplier for to prooGss this claim. I ~so requ~ payment of government ben,its either to m~elf or to the pa~ who accepts ~lgnmem se~ices described below. below. 14. CATE OF CURRENT: i ILLNE88 (Fimt symptom) OR 1 [, IF PATIENT HAS HAD ~ME OR SIBI~ IL~ES8. 16. DATE8 PATIE~ UNABLE TO WORK IN CURRENT OCCUPATION 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSP~ALI~TION DATES RE~TED TO CURRENT SERVICES MM DD YY MM DD YY 21. DIAGNOSIS OR NATURE OF ILLNESS OR I~URY. (RE~ ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION & CODE ORIGINAL REF. NO. 23. PRIOR AUTHORI~TION NUMBER zL'?06.,50 CHEST PRZN LJIqSPI~EC 4.1 ~4. A ~ C g E OF SERVICE ~27' AOOE~iyES ASSIGNMENT? 31 SIGNATURE OF PHYSIOIA~R ~0~PLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WER~ 33, PHY~I~I'~N"S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE (APPROVED SY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0g38-00O8 FORM HCFA-1500 (12-90), FORM RRB-1500, APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS) PLEASE, DO N C_J']' STAPLE IN THIS AREA 1 d d 1. (a't:. 0 b,~ ri ~ P ¢::1 1 '? [:) {:."i '?, 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) 5. PATIENT'S ADDRESS (No,, Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 91 }!:ETI"Y NEi:L!:'JC)N C, 1" ~UI. 22 se,,Ix IsPou-I IOh"dl IOtherI N ED... F.;C) N C:'T' ~t. 122 CITY STATE B. PATIENT STATUS CITY STATE ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) 9, OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'8 POLICY GROUP OR FECA NUMBER 3C)HIqSON, r.'IRRY E a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. OTHER INSURED'S POLICY OR GROUP NUMBER __ __ a, INSURED'S DATE OF BIRTH P, OTHER INSURED'S DATE OF BIRTH b, AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR BDHOOL NAME c, EMPLOYER'S NAME OR SCHOOL NAME c, OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d, IS THERE ANOTHER HEALTH BENEFIT PLAN? ~YES I J NO If yes, return to and complefe item 9 a~d, READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for ~ePo~,O~ess this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. 14. DATE OF CURRENT: i ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MI '"-- , "" I PREGNANCY (LMP) '1 I FROM 17, NAME OF REFERRING PHYSICIAN OR OTHER SOURCE t7a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY 19. RESERVED FOR LOCAL USE E0. OUTSIDE LAB? $ CHARGE8 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) / 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. ~8. PRIOR AUTHORIZATION NUMBER 24. A S C D E F G H I J K DATE(S) OF SERVICE PIDDle TYo~ PROCEDURES, SERVICES, OR SUPPLIES DiAGNOSiS DAYS EPSD3 From To EX lain Unusual Circumstances $ CHARGES OR Family EMG COB RESERVED FOR MM DD YY MM DD YY Service l ~ervice CP(~/~°~PCS! MODIFIE~ CODE LOCAL USE UNITS Plan ~ ~ cJ77 WF~I.,.NUT .BU l f.,,ql ROAD ,'lCJ00 I',IORTH F:'RC, I',iT S'T'F~EilEUr' (21 4. 0 1. 0 2 DATE P,N8 IIGRP~ (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMS-0938-0008 FORM HCFA-1500 (12-90), FORM RRB-1500, APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS) PLEASE " t · DO NC~T · , STAPLE PE~]ERLF~:i i:; CI:~IEI)Z"t" Z ,¥- AREA l"lJ. ddJ. cr[o~,)r'~, P¢::l ].. '? [] (:,~ 7 ~ 1, MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la, INSURED'S I.D, NUMBER (FOR PROGRAM IN ITEM .2 (Medlcara #) r--~ (Med~aid #) F--l ($poneor'$ SSN) ~-~ (VA FIle #) F-~HEALTHPLAN~BLKLUNBF'~'~ 2. PATIENT'S NAME (Lest Name, Flrlt Name, Middle Initial) 3, PATIENT'S BIRTH DATE 4, INSURED'8 NAME (L~t Name, First Name, Middle Inltla0 5. PATIENT'S ADDRESS (No,, Street) 6, PATIENT RE~TIONSHIP TO INSURED 7. INSURED'8 ADDRESS (No,, Street} CITY , STATE 8, PATIENT STATUS CITY 8TA~ Cfq I:~L :[ '.%.E PF-) Slnglo ~ Mettle, ~ Oth.rI CF[RL, Z SL.E: ':~a ZIP CODE ZIP TELEPHONE (Include Area Code) TELEPHONE (INCLUDE AR~ CODE) Full,Time 9, OTHER INSURED'8 NAME (Last Name, First Name, Middle Initial) 10. 18 PATIENT'S CONDITION RE~TED TO: 11, INSURED'8 POLICY CROUP OR FECA NUMBER 3OHIq ~3ON, Re) ]~E]TT C a. OTHER INSURED'S POLICY OR GROUP NUMBER a, EMPLOYMENT? (CURRENT OR PREVIOUS) a, INSURED'8 DATE OF BIRTH b. OTHER INSURED'8 DATE OF BIRTH c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c, INSURANCE P~N NAME OR PROGRAM NAME d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. 18 THERE ANOTHER HEALTH BENEFIT P~N? ~YES ~ NO ffyes, return to and complete Item 9 a-d. 12. PATIE~'S OR AUTHORI~D PERSON'S SIGNATURE I a~hori~ the rel~ o any m~ ~ or other information necesssw payment of m~ical ben,its to the undersigned physician or supplier for below. SIGNED 14. DATE OF CURRE~: ~ ILLNESS (First symptu,l) OR 15, IF PATIE~ HAS HAD ~ME OR SIMI~R ILLNESS. 16. DATES PATIE~ UNABLE TO WORK JN CURRENT OCCUPATION 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D, NUMBER OF RE~NHING PHYSICIAN 18. HOSP~TALJ~TION DATES RE~TED TO CURRENT SERVICES 19, RESERVED FOR LOCAL USE 20. OUTS)DE ~B? $ CHARGES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, (RE~ I~MS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION ORIGINAL REF. NO, ~. [__428., 0 CONGE: S'T Z VIE HER R'I" 3. I .__ COOE [ 23. PRIOR AUTHORI~TION NUMBER z[4'Z4'-01._ OORONRRY RTHEROSC 4.1 24, A a C ~ E F G Fro~ATE(8) OF SERVICE TO P~¢e T[~ PROCEDURES SERVICES OR SUPPL ES (Ex~lain ~sual Circumstances) DIAGNOSIS DAYS EPSDT MM DB YY MM OD Y~ Se~tcl ~ CPT/HCPCS [ MODIFIER CODE $ CHARGES UNITsOB FamllYplanEMG COB RESERVEDLocAL usEFOR , 977 ~LIqU'I' }]0T'1"O1'I ROF[9 Z0Ol) NORTH F'ROIqT E;'I'RE]ET ]iiRZL. Yl,ROBE:R'f' G, ItJD CFIIRI..ZSL.IE, PR .I. 7]],~" '~ I, iORIILtEYS:[itJRG, DATE PiN* {APPROVED BY AMA COUNCIL ON MEDICAL SERVICE a/88) PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-150D (12-90), FORM RRB-1500, APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMG-0720-0001 (CHAMPUS) Deo 11 02 lO:~Sa GUID^ LAW OFFICES, p.4 ~oo4/oo4 MOFFITT HEART & YASCULAR V$, MARY I-~. ,IOHNSON' ROBERT .IOi4 NSON IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANI~k CIVIL ACTION - LAW No. I VERII:Y THAT THE STATEMENTS MADE IN THIS COMPLAIN'F ARt/ AND ¢:ORRECT. t I. JNDERSTAND TIIAT TIlE S'I'A'I'EMENTS HEREIN ARE MAD[-.' $1JB.IECT TO TI-IE PENALTIES OI-' 18 PA.C.S.A. SECTION 4904 REI.ATING "l'O [)NSWORN I-~ALSii..i(_,A.i.ION TO AIJTHORITIES. ~ig~lature - Printed Name Title RE,SEI~zED, 'TIMEE, EC. !i. l I:44AM PRINT TIMEDEC. Ii. l l:46AM WRIT OF EXECUTION and/or ATTACHMENT COMMONWEALTH OF PENNSYLVANIA) COUNTY OF CUMBERLAND) NO 03-401 Civil CIVIL ACTION - LAW TO THE SHERIFF OF CUMBERLAND COUNTY: To satisfy the debt, interest and costs due JONATHAN RUDY, Plaintiff (s) From JAIME FOLKENROTH, 250 SAMPLE BRIDGE ROAD, MECHANICSBURG, PA 17050 (1) You are directed to levy upon the property of the defendant (s)and to sell . (2) You are also directed to attach the property of the defendant(s) not levied upon in the possession of GARNISHEE(S) as follows: WAYPOINT BANK, GARNISHEE, 269 PENROSE PLACE, CARLISLE, PA 17013 - ANY AND ALL ACCOUNTS OF DEFENDANT and to notify the garnishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from paying any debt to or for the account of the defendant (s) and from delivering any property of the defendant {s) or otherwise disposing thereof; (3) If property of the defendant(s) not levied upon an subject to attachment is found in the possession of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a garnishee and is enjoined as above stated. Amount Due $881.50 Interest Atty's Comm % Arty Paid $37.25 Plaintiff Paid Date: JANUARY 30, 2003 (Seal) REQUESTING PARTY: Name CHARLES RECTOR, ESQUIRE Address: 1104 FERNWOOD AVENUE CAMP HILL, PA 17011-6912 Attorney for: PLAINTIFF Telephone: 71%761-8101 Supreme Court ID No. 39121 L.L. $.50 Due Prothy $1.00 Other Costs $175.00 ATTORNEY FEE CURTIS R. LONG erothonot~ (~ Deputy 5 R. Thomas Kline, Sheriff, who being duly swom according to law, states this writ is returned STAYED. Sheriff's Costs: Docketing 18.00 Poundage 17.63 Advertising Law Library .50 Prothonotary 1.00 Mileage 10.35 Misc. Surcharge 20.00 Levy 40.00 Post Pone Sale Garnishee 9. O0 116.48 Sworn and Subscribed to before me This 7'~ day of 2003 A.D. ~.,., ~ ~ l~tho-notary Advance Costs: Sheriff's Costs: 150.00 116.48 33.52 Refunded to Atty on 3 / 17 / 03 So Answers; R. Thomas Kline, SHeriff By