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Home My WebLink About03-1262MOFFITT HEART & VASCULAR VS. ROBERT L. BARBOUR BETTY KNAUB BARBOUR IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW No. 02 - 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. 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 1-800-990-9108 MOFFITT HEART & VASCULAR ROBERT L. BARBOUR BETTY KNAUB BARBOUR : CIVIL ACTION - LAW : No. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COMPLAINT AND NOW, this __ day of March, 2003 comes Moffitt Heart & Vascular, above-named Plaintiff, by and through its attorney, Gall Guida Souders, Esquire, and respectfully avers the following: 1. Plaintiff is a corporation having offices at 1000 North Front Street, Wormleysburg, Pennsylvania 17403. 2. Defendant Robert L. Barbour is an adult individual residing at 2144 Market Street C101, Camp Hill, PA 17011. 3. Defendant Betty Knaub Barbour is an adult individual residing at 2144 Market Street C 101, Camp Hill, PA 17011. 4. At the specific instance and request of Robert L. Barbour, Plaintiff provided medical services to Defendant at the times, amounts, and the prices for these services are indicated in Plaintiff's Statement of Account, a true and correct copy of which is attached hereto, marked Exhibit A, and made part thereof. 5. The prices charged by Plaintiff were fair, reasonable, and market prices that prevailed at the times of the transactions. 6. Defendant Betty Knaub Barbour was married to Defendant Robert L. Barbour at the time services were rendered. 7. Although Defendant Robert L. Barbour was the Plaintiff's patient, Defendant Betty Knaub Barbour is also responsible for payment of said services pursuant to 23 Pa.C.S.A. §4102. 8. Plaintiff avers that the balance due amounts to $8,047.00, which is above the limit for mandatory arbitration. 9. As of February 21, 2003, the interest at the legal rate of six percent a year is $241.41. 10. Although repeatedly requested to do so by Plaintiff, Defendant has willfully failed and refused to pay the aforesaid balance or any part thereof to Plaintiff. WHEREFORE, Plaintiff respectfully requests that judgment be entered in favor of Plaintiff and against Defendant in the amount of $8,288.41 with interest and costs. Respectfully submitted, Gail Guida Souders, Esquire Guida Law Offices 503 North Front Street Harrisburg, PA 17101 717-236-6440 Attorney for Plaintiff Supreme Court ID #68740 PLEASE DO NOT :~ :~:'~)i ~' ~: c C; i:di':D Z "1 .... :" STAPLE '? 2 IN THIS " AR EA H ;J. d d 1 e't:. o w r',, I:::' f.'..l .1. 7 0 5 7 ~ ~ P~CA .'L !.;J 2 3 [:) 21. 2 B HEALTH IN~UHANL;I= UI. AIM I"VI"llW 1.1 MEDI CARE MEDICAID CHAMPUS CHAMPVA GROUP FEDA OTHER la. INSURED'S i.D. NUMBER (FOR PROGRAM IN ITEM ~ HEALTH PLAN r---I BLK LUNG[-~'-] 2. PATIENT'S NAME (Lam Name, First Name, Middle Initial) $. PATIENT'S BIRTHY.Y DATE ~ SEX F ]--""J ;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) 21/.,.4. IIFIRKET S'I" C1[;)1 sa"l×ts~°"aeLJcM'dl I °t"erI 214/.,. HF1RKET S'T CtL'I1 CITY I STATE 8. PATIENT STATUS CITY STATE C~.::lffJp J-'[:iL.L_ ' ~.. _J J::'~J~'J Single[:] Married)-'--) OtherI J C~:JFJP H':[:L.I .... ZiP CODE TELEPHONE (include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) Full-Time 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 .. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH M r-~ SEX F OTNER'NSU"ED'S POL,DY OR GROUP NUMSER I--qYES 7."i'"' '' " b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME b. OTHER INSURED'S DATE OF BIRTH ., SEX MM.OD. YY I Mi----I FF--I YSS c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME 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 eulhorize 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 benalfts either to myself or to the party who accepts assignment services described below. below. SlGNE~ -S:[Glqf:YI"URE ON r---IL..E DATLD.c) 20 02 S~GNED .:,I.:~I~RIJM:. ON F'ZLE': 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 MM IDD I YY~ INJURY(Accident)OR GIVE FIRST DATE MM I DD I YY FROM MM IDD ~ YY TO MM! DD! YY I I PREGNANCY (LMP) I I I I , 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17e. I.D. NUMBER OF R~-~-~HRING PHYSICIAN 18. HOSPITALJZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES E3YES FqNo ;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. t. I 4 1 4..,, (:_~) 2 CORONRRY R'I'HE:I;~OSC 3. I__4' J 23. PRIOR AUTHORIZATION NUMBER 4. t__ 24. A B O D E F G R I J K DATE(S) OF SERVICE Ploa~:e T~fpe PROCEDURES, SERVICES, OR SUPPLIES DAYS t=~Sb~ RESERVED FOR From "i'D . (Excla n Urluaual Circumstances) DIAGNOSIS S CHARGES OR Family EMG OCS LOCAL USE MM DD YY MM DD YY Service Service OPTIHOPDS J MOD F ER OODE UNITS Plan I 2¢. FEDERAL TAX I,D, NUMBER SSN EIN 2B. PATIENT'S ACCOUNT NO, 27. AOu;-P¥ ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. SALANCE DUE (For gsvt ¢lslms sss bask) r~l. SIGNATURE OF PHYSICIAN OR SUPPLIER r42. NAME AND~ADDRESS OF FACILITY WHERE SERVICES WERE B~. PHYSICIAN'S, SUPPLIER'8 BILLING NAME, ADDRESS, ZIP CODE INCLUDING DEGREES OR 8REDENTIALS RENDE~EDilf olher than home or offllBs & PHONE # (l~srltythsthssetemsntslmthersvsrss ]~OF'FI"rT I-4EFiR"I" [~: VRSCUI...RR I1OF:'F:'ZT'T' HERRT 5 VRSCUI._F.1Ft spply I~ t~ls bilk end m's roads e psrt lhsresl,) '1.000 NORTH F:RONT S']"REE:T l[.~OO NORTH FRON'T' STREET CHRNG DF4V.TD Fi);) L~ORt'IL.I:'-.'.YSBURG, PF] 1704.3 L~ORHLEY'..~.~.URG I:-'FI 1 04.3 TYPE APPROVED OMB-0938-0008 FORM HCFA-1500 (12-9B), FORM RRB-lEO0, PLEASE DO NOT "~ ......... r; I:::' F.:' T'~ "?' F i:::. E. R L. E:.' E; S il; T STAPLE 72). 5 I"{ ~::~ t:) ]. e. F~(:) ~ d IN THIS '"' AREA M:J. ddle'(.ot, tr', F:h:'.l ].. r L ..~ ' 1, MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la, INSURED'S I.D, NUMBER (FOR PROGRAM IN ITEM 2, PATIENT'S]~] ~:~ R ]~ oNAMEu ~ (~at Name, First.. Name, MIddlel:;~lnltlal)O ]~1E }:'~ 'T' 3, M~PATIENT'S{]I[ ~9BIRTHll ~. YDATE~] 3 ~ ~ S~ F ~ 4,]jjlNSURED'S¢~ F~ ]~J O uNAME~7~ / (L~tF~ c)Name';[] E J~FIrm"J" Name,L.. Middle Initial) 5, PATIENT'S ADDRESS (~,, Street) 6, PATIENT RELATIONSHIP TO INSURED 7, INSURED'S ~DRE88 (No,, Street) CITY I STATE 8, PATIENT STATUS Cl~ STATE ZIP CODE TELEPHONE {Include Area Cede) ZiP CODE TELEPHONE (INCLUDE AREA CODE) _ . _ ~ FulPTIme ~Pad-Tlme ~ 9, OTHER INSURED'S NAME (L~t Name, First Name, Middle Initial) 18, IS PATIENT'S CONDITION RE.TED TO: 11, INSURED'S POLICY GROUP OR FEOA NUMBER Iq ,, R ,, a. OTHER INSURED'S POLICY OR GROUP NUMBER 8. EMPLOYMENT? (CURRE~ OR PR~IOUS) ~. INSUR~D'S DA~ OF Blah b, OTHER INSURED'S DA~ OF BIRTH b, A~O ACCIDENT? P~CE (~e) b, EMPLOYER'S NAME OR SCHOOL NAME I ~ ~ f YES NO c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDE~? c, INSURANCE P~N NAME OR PROGRAM NAME ..... ~YES ~NO d, INSURANCE P~N NAME OR PROGRAM NAME 1Od. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT P~N? ~YES ~NO If ~s, return to and com~ete item 9 a.d. READ BACK.OF FORM BEFORE COMPLYING & SIGNING THIS FORM, 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE ~ ~tho~e 12. PA~ENT'S OR AUTHORIZED PERSON'S SIGNATURE I ~horize the rae~ of any ~dical or other info~ation necessaff payment of m~ical benefits to the undemtgned ph~ician or supplier for to ~oc~s this dam, Iaso requ~t pa~ent of g~emment benellts either to m~elf or to the p~ who a~pts ~signmenl sewices de~dbed below. bel~. SIGNED S',[GI'.IFq'TURE ON FILE DAT~) 20 02 SIGNED SIGNRTUI~E ON F:;[L. IE 14. DATE OF CURRENT: J ILLNESS (First s~ptom) OR 15, IF PA~ENT HAS HAD SAME OR 81MI~R ILLNESS. 16. DA~S PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM IDD I ~~ INJURY (~cldenl)OR GIVE FIRST DATE MM ~ DD I ~ MM IDD m ~ MM DD YY I I PREGNANCY (LMP) I I FROM 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN lB. HOSPITAM~TION DATES RE~TED TO CURRENT SERVICES MM DD ~ MM DD YY oAXE. NR ., IqA RE:N FROM II 19. RESERVED FOR LOCAL USE 20, OUTSIDE ~B? $ CHARGES 21. DIAGNOSIS OR NATURE OF I~NE~ OR INJURY. (RE'TN ~EMS 1,2,3 OR 4 TO ITEM 24E BY LINE) ~ : ~, MEDICAID RESUBMISSION 1.[794...31. R]~I',IORM ELECTROCRR a.I 4.].4:.~12 COROhlRr,~Y+ ~-~" CODE ~ ORIGIN~REF. NO. ~. PRIOR A~HORI~TION NUMBER 2.14.14..._01 CORON¢4RY. RTHERosc 4,1 4.].4..~04. C)OROIqRRY R"[' DIASNOSIS RESERVED FOR FrDATE(S)~ Of SERVICE To T~of PROCEDURES' SERVICES, OR SUPPLIES EPSDT fExplain Unusu~ Clmumstan~) $ CHARGES OR Family EMG COB MM DD YY MM DD YY Sewlce ~ce C~/HCPCS ~ MODIFIER CODE UNITS Plan LOCAL USE ' I 03 ']1 ,02 , r 22 01 g3544 1,2,3 ~.00~..00 .1 I I '11'02 * ' 22 O1 g353gi~J~°n~°" o 3, , , , -. ~d;hc ca~[. i, 2,3 ~o o,,.. o o i I r I I .I I I I I I I I I I I I I II I I I I I t I I I I I I I~ I I 28. FEDERAL TAX f.D. NUMBER 88N EIN ~B, P~TIENT'8 AOOOUNT NO, ~1 AOOEPT A88 CN~ENT? ~8, TOTAL OHAR6E Ce, A~OUNT ~AID ¢O, BA~NOE DUE 31, SIGNATURE OF PHYSICIAN OR SUPPLIER ~. NAME AN~ADDRESS OF FACILI~ WHERE SERVICES WERE 83. PHYSICIAN'S, 8UPPLIER'S 81LLING NAME. ADDRESS, ZIP CODE INCLUDING DEGREES OR CREDENTIALS N E qfq err 8 omeoro~o~ Icedlfythatthestatemenlsonlhereverae I--~S~U~ ["IO.5~:[]"RL--' M~F-F'IT"r HEPE'T apply to his bill and sre made a pa~ hereof,) 111 EOU'I'H FRONT STREET 10Il0 I',IOR'I'H F'RONT STI;~EE'T' CI-.IF:II',.IG, I)F¢¢ZL~, 11]} I--IRRI;~IS]~:URG, PR 17101 bJORI1L. IEYSBURG, F:'R ].7L.+,::, {:I g 2 0 0 2 I 818NEB BATE PINe .................................................. m~ ~'a D= DD¢~' ~D 'f'VD.-- APPROVED OMB-093B-O008 FORM HCFA-1500 (12-90), FORM RRB-1500, PLEASE DO NOT PE:; E F~ I.,.. E E E:. C:. F'?E:]] I 'T' Z STAPLE ,. J,O,. t .. IN THIS 72 AFIEA 1'1 I I PICA ..I.. ~.:J :~ ~-:I U ,:...I. ,,:. 191:/41. 119 IN~I,119/41~11.,,1: I,,,I.,/411Vl rUIllVl PICA I 1, MED CARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la, INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM I'-"-'l HEALTH PLAN r~l BLK LUN{3~"'~'"I '~(Medl~are#)~-'~(Medlcald#)~($pon$or'a$$N) [~(VAF#s#) L_J($$NorlO) L.~($$N) ~[~.~(IO) 2, PATIENT'S NAME (Lam Name, First Name, Middle Initial) 3, PATIENT'S BIRTH DATE 4. INSURED'S NAME (Last Name, Ftrat Name, Middle Initial) tl F'I t::.] ]"J C) U IR I::?O]iJELF.,~T U~[)il ~.c)j ].9::]~l~ :[3¢.:.'II:;~:Ii~C)L.JIR ., F;!C)3F. JF(-Y'f" L. 5, PATIENT'S ADDRESS (Ns,, S!reet) 6, PATIENT RELATIONSHIP TO INSURED 7, INSURED'S ADDRESS (No., Street) '' B'"EE]B,°""E]°""C] I ,...:;T CITY STATE 8, PATIENT STATUS CITY STATE C;F:./r'tF:) I...lIl...l .... :)F4 SlnDIsi'~] MerrledFq Ofher['--~ CI::~i"'IF) H'ZL.L. ::~r::~ ZiP CODE TELEPHONE (include Aras Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) Full-Time (1'. 7* .]. '~ ) -' 7 ~} ]. '"'/.,. 5 [ii liSt,dent r'~ .~ 7 o ]..]. B. OTHER INSURED'$ NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER N. F:.'l. a. OTHER INSURED'8 POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) e, INSURED'S DATE OF BIRTH h. OTHER INBURED'S DATE OF BIRTH b. AUTO ACCIDENT? PLACE (Slate) b. EMPLOYER'S NAME OR SCHOOL NAME ; I ME3 SEXFE] E]YES ED"°' c. EMPLOYER'S NAME OR SDHOOL 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 ~, NO Ifyes, return to and complete item 9 a-d. I----'1 READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. JNSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize Ihs 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 services described below. below. S.TGNF4TLIRE ON F"IL. Fi DAT~Jg 20 ~?. SZGNF'I'FUF-!E C)N F.T.L.,E SIGNED ' SIGNED 14. DATE OF CURRENT: J ILLNESS (Firsl symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16, DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM IDD ~ YY~ INJURY(Accident)OR GIVE FIRST DATE MMI DD 1 YY MM ~ DD I YY MM ~DD I YY I I PREGNANCY (LMP) i I FROM 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. LD. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES · ~ ' MM DD YY MM DD YY SAXE'I',lt=I., I'.1FII"'~E:' N FROM I I TO I I 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGE8 E]YES l--iN° I 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. {RELATE ITEMS 1,2,3 OR 4 TO iTEM 24E BY LINE) ~ 22. MEDICAID RESUBMISSION "(' a' ' '" :'" = " 3.1 414.0."! OOROI'-IF:IF~Y~ R'r' CODE ORIGINALREF, NO, 1. t ? .J 4. ,, ,.,1 RI~IIORII I_I..EC,'rROCFR_~ ~23. PRIOR AUTHORIZATION NUMBER 2. I 4. t 4. .,. E__~):L CC)I:~(.~t*IF~I:~Y R'r'HEROSC .. 4. I 4. I. lt .04. COROI'qF-~F(Y R"1- 24, A B lC D E F G H I d K I'- FromDATE(S) OF SERVl0E To ,,el ~f fExplatn Unueusl Olrcumstences) DIAGNOSIS RESERVED FOR MM DD Y¥ MM DD "fY Service 8e~i~e CPT/HCPO$ ! ~ MODIFIER CODE $ CHARGES UNffsOR FamllYPis~ EMG COB LOOAL USE ~ plac-~e",'l' of' ~-f-,~-/- i ,, [., .:,""' ,'].]. ,'02 ,' ,' 22.. 0'1.Ig2 g B 0 I I .1,2,3 .3 L-i 001.00 ]. ..-z 0:3',i].,'02.. l, ', P. 2.. 01. g35].0,126'" Z31'io- ].,.2,3 600i. 08 ]. [ ' 5g .l. 2 3 "r~0',,,00 '1. 03,~11~,[.:12 ,' I~ 22 01. g3556 26~ , ., ,. ~ O n..¢¢.,~n:4": .~ ' z 03 ,, t1. ,, 02 , , 2;).01 g35/+0 Ii~¢n~usbqnass 1.,2 3 3001.00 1 03 I ].. :t. ,i 0 ?. ,I ,' 2.2. . 0l g3555-I 2El, ...~Tg 1..2., 3 2 '6 il. rJ 0.. 1. 85. FEDERAL TAX I.D, NUMBER SSN EIN 8IL FATIENT'$ ACCOUNT NO, 87, ACCEPT ASSIGNMENT? 88. TOTAL CHARaE 2.8, AMOUNT PAID 30, BALANCE DUE [~ ~---] (For govt, claims see bsoit) '23.--].8F.~4.'722 E, 0384. r~YES F~)No , 4.';"86',. O0 $ 01. OD $ 4786.00 81. SIGNATURE OF PHYSICIAN OR SUPPLIER 8Z. NAME AND~ADDREBS OF FACILITY WHERE SERVICES WERE 88. PHYSIOIAN'8, SUPPLIER'S BILLIN6 NAME, ADDRESS, ZIP CODE INCLUDINS DEGREES OR CREDENTIALS RENDEREI:~flf olher then home or elf losI & PHONE # applyl certlfYo thlethal blllthean,lltstsmsnteai:, made°netheparreVsreethereof.) H [':'~ R I:;] I $ t)t.J IR. C'.) I..t O S P I '1" R l._ t"i C) F: F' 13 "1" 'T' I--.I E F'~ IR'T' [.( V R S C LJ I_ R R G IR C) I .:) ].].l .c:;OUTH F'RONT $']-IRE~EE"F' 1DSO NORT)-I F'rQoIq'l" .?.';TREE-:T CHF::II',IG, I)AV]:D, I"lI) FIRF~E'.IS]JLJF,ZG, PR ].7.1.0].. WOI:(I"II._IEYStIUFiG, PF.~ ].7043 BIGNED I ............................... =~,~, o==w,,',= =,am 131 ~,B~' J~J3~IJU~'/'~ 'J"V.~' APPROVED OMB-OE3B-OO08 FORM HCFA-1E00 (12.B0), FORM RRB-160n, PLEASE C.. I"~ E..L ! T Z DO NOT I:)t'~i:lii~: I:;',L E S ~-:. "'~ ..... ~'" STAPLE 7 2 5 I'l ~'~ i::~ ;1. e Rc>a~ d IN THIS AREA I"l:~. cld ] (?'~:.Ob,H"~ .. J:h:':i J. '7 [) 57 I IP~CA ].,r.,.,12302:L2g HI::ALIH IN~UMANIJI:: ~l../.t, llVl I"I./I~M 1. MED CARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 2. PATIENT'S NAME (L-~t Nsme, First Name, Middle Inttlal) ~, PATIENT'S BIRTH DATE 4, INRURED'S NAME (Lesl Name, First Nsme, Middle Inlllal) M , YY ) J'----'J r C): lE:FU'r 0,,EE×F , .... §. PATIENT'S ADDRESS (No,, $1rsal) 6, PATIENT RELATIONSHIP TO INSURED ?, INSURED'B ADDRESS (Ne., Stresl) Serf Bpouse Child CiTY J STATE 8, PATIENT STATUS CiTY STATE ....I s,n0,eF-] M..d[--] O,hsrI I ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) JJ Full-TIme j'~jPart-Tlms 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 :I:JF~I:~!:BOUR,, RO:IilERT L. ~, EMPLOYMENT? (CURRENT OR PREVIOUS) DATE OF BIRTH a. OTHER INSURED'B POLICY OR GROUP NUMBER ~ a, INSURED'S " b. OTHER INSURED'S DATE OF BIRTH b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR BCHOOL NAME i M[Z] SEX Fi--1 [--1YEB 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 ~]NO If yea, retum to end complete ltsm O a.d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 18, INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12 PAT ENT'S OR AUTHORIZED PERSON'S S GNATURE I euthadze the release al any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I aisc request payment Gl government benefits either lo myself or to the pa,'ly who accepts assignment services described below. below. SIGNED S.[GI',IF/'I*L:JRFZ ON F'T.L:_E DATi~]~] 20 02 SIGNED S:[GNFI-r'L,tRE: ON F::[LE: 14. DATE OF CURRENT: ~ ILLNESS (Flint symptom) OR 15, IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I DD I YYI INJURY(Accident)OR GIVE FIRST DATE MM j DD I YY MM ~ DD ~ YY MM ~ DD i YY I I PREGNANCY (LMP) I ~ FROM 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 tIF1CI'-I]:N SKY: W:[ FROM 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) I 22. MEDICAID RESUBMISStON CODE ORIGINAL REF. NO, ~.L785.5]. PF-I:[Iq PRE:CC)R.'DIRI_ s.I .__4, 2]. PRIOR AUTHORIZATION NUMBER ~.1 .__ ~.1.~ 24. A B C D E F G H I J K Plass Typ~ PROCEDURES, SERVICER, OR SUPPLIER DAYS EPSDT From DATE(Si OF SERVICE Toof of IExolain Unusual Circumstances) DIAGNOSIS $ CHARGES OR Family EMG DOB FIERERVED FOR MM DD YY MM · DD YY Service Service C~TIHDPDS J MODIFIER CODE UNITS Plsn LDOAL USE I 0Iii , ].51 ,~ 02 ~' ,' 11 [11 g3000 J J ~J"'~'~' 1 , , ~0 I I I I I I I 1 25. FEDERAL TAX I,D, NUMBER BEN SIN 26, PATIENT'S ACCOUNT NO, 27. ACCEPT ASSIGNMENT? 28, TOTAL. CHARGE 88. AMOUNT PAID 80. BALANCE DUE (For govt. claims see back) ["IF-] YES E:]NO , S0',..00, 0',..0nIB 50.00 :]i. SIGNATURE OF RHYSIDIAN OR SUPPLIER ~2. NAME AND~ADDRESS OF FACILITY WHERE SERVICE8 WERE ~a. PHYSICIAN'S, SUFPLIER'E BILLING NAME, ADDREBE, ZIP CODE INCLUDING DEGREES OR CREDENTIALS EN~ EIS_I f q Der t j~om or gflice~ ; & P O.N apply to this bill and ars made a part thersol.) C: .... ;) ....... ]. 0 ~ 0 N O R T H F' IR C) I',[T .:', ] f E: E. I' :l. 000 N O IR T H F' 1R O I',t"1" S T F! E E': T :Iid::ICFt]:N,:JI'(¥ t,J:[:L.I._]:i:~M :B L,JOR!"II I'-"'YF-'BIJF.!E~ Pf.:I 1.704-3 I~K)FRIdL_E'¥,S'I3LIRE~ F'R :1.7043 ........................................... ~= o,oo, mt ~a ~,~' ~tat'r/'~ 'r'vD.'" APPROVED OME-093B-0008 FORM HCFA-1500 (12-9D), FORM RRB-1500, PLEASE: DO NOT STAPLE IN THIS AREA / 1. MEDCARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la, INBURED'E hD, NUMBER (FOR PROGRAM IN ITEM ~ HEALTH PLAN r'--I BLK LUNGi-~--I 2, PATIENT'S NAME (Le,,t Name, First Hems, Mldclte Initial) 3. PATIENT'S BIRTH DATE 4, INSURED'B NAME ILast Name, First Name, Middle Initial) ~. PATIENT'S ADDRESS (Ha,, Street) ~. PATIENT RE~TIONBHIP TO INBUHED 7, INSURED'S ADDRESS (No., ~lr~et) CITY I STATE 8, PATIENT STATUS CITY STATE ZIP OODE TELEPHONE (Inoluds Ares Oode) ZIP OODE TELEPHONE (INOLUDE AREA OODE) g. OTHER INSURED'B NANE (Lsat Name, Flret Name, Middle Initial} 10, 18 PATIENT'~ CONDmON RE~TED TO: 11. INDURED'S POLICY GROUP OR FEOA NUMBER N ~"'1 b. OTHER INSURED'S DA~ OF BIRTH b. AUTO ACCIDENT P~CE (~) b, EMPLOYER'S NAME OR SCHOOL NAME c, EMPLOYER'S NAME OR SCHOOL NAME c, OTHER ACCIDEN~ c. INSURANCE P~N NAME OR PROGRAM NAME ~YES ~NO d, INSURANCE PLAN NAME OR PROGRAM NAME 10~, RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT P~N? ~YES ~ NO Ifyes, r~um to and complete Item 9 a-~. RE~ BACK OF FORM BEFORE COMP~TING & SIGNING THIS FORM. i 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authoHze 12. PATtE~'S OR A~HORI~D PERSON'S SIGNATURE ~ authorize the mle~e of a~ m~i~l or o~er Info.etlon necass~ payment of medical ~neflts to the undemlgned physician or supplier for to pmmss this claim. I ~o reque~ payment of government ~nefi~ either to myself or t~ the p~ who accepts ~signment sewices described below. below. S~N~ $IGNRTURE OIq F:'ILE .A~]g 20 02 S~N~ E;ZGNRTURE ON F:ILE 14. DATE OF CURRENT; I ILLNESS (Flint symptom) OR 15. IF PA~E~ HAS H~ ~ME OR SIMI~R ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM IDD i ~~ INJURY(Accident) OR GIVE FIRST DATE MM ~ DD ~ ~ MM DD YY MM DD YY ~ ~ PREGNANCY (LMP) ~ ~ FROM I 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. LC. NUMBER OF REFERRING PHYSICI~ 18. HOSPITA~TION DATES HE~TED TO CURRE~ SERVICES MM DD YY MM DD YY I I TO I I E;tqXENR ~ NRREN FnO~ 19. RESERVED FOR LOC~ USE 2~. OUTSIDE ~B? $ CHARGES 21. DIAGNOSIS OR ~TURE OF ILLNESS OR INJURY. (RE~ ~MS 1,2,~ OR 4 TO ITEM 24E BY LINE) / ~, MEDIC~D RESUBMISSION CODE ORIGIN~ REF. NO. ~, ~HIOH AUTHOHI~TION NUMDEH Fro~ATE(S) OF SERVICE To P~e T~e PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) DIAGNOSIS RESERVED FOR MM DD YY MM DD YY Se~ice ~ce CPT/HCPCS ~ MODiRER CODE $ CHARGES OR FamilyEMG COB LOCAL USE UNITS Plan , I I I I I I I i I I I II I l 25. FEDERAL TAX I.D. NUMBER 8SN EIN 26, PATIENT'S ACCOUNT NO, 27. ACCEPT ASSIGNMEN~ 2B, TOTAL CHARGE 12B. AMOUNT PAID ~01 ~A~ANO~ DUE 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AN~ADDREBS OF FACILI~ WHERE SERVICES WERE 33, PHYSICIAN'S, SUPPL(ER'S BILLING NAME, ADDRESS, ZiP CODE INCLU~NG DEGREES OR CREDENTIALS RENDEREDflf other than home or circe) & PHONE apply to this bill and are maae a pa. thereof.) ~R..~CL L.~E I'IOF:'F ITT HERRT 1000 NORTH F'RONT STREET 1000 IqC)R"I'H FRONT STI;~EE"r' ZOI:dqO~R 3OHIq P~ FID WuRFII...Iz.~._~.BLR6, PR 17043 ~C~k[IL..IrzY.::~.BL. RG ............................. .~,~^, o=~,.,~= o,oo,~t ~'~ ~' ~¢3llw~ ~ ~'vl==' APPROVED OMB-0g3B.0008 FORM HCFA-1E00 (12-i~0), FORM RRB.1500, PLEASE DO NOT STAPLE IN THIS AREA 1. MEDIOARE MEDICAID CHAMPUS CHAMPVA GROUP FEDA OTHER :la, INSURED'S I.D, NUMBER (FOR PROGRAM N TEM 1 r--'l HEALTH PLAN j'~ BLK LUNGr'~ 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 2. PATIENT'S BIRTH DATE 8EX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) 5. PATIENT'S ADDRESS (No.. Slreet) §. PATIENT RELATIONSHIP TO INSURED 7. INBURED'S ADDRESS (No., Slreel) CITY I STATE S. PATIENT STATUS CITY STATE ZIP OODE TELEPHONE (Include Area Gods) ZIP CODE TELEPHONE (INCLUDE AREA CODE) Full-Time .17 [~ '1 .:t ( 7 ]. 7)) - 7 [~1-/.~ 586 Empl°yed F-'lStudentI IStudentr~lPart'Tlme I ~. 7 ['/1.1. I (( 7 ].';;)) - '7 G 1- 4. 5[:1 [. . .., ' 9. OTHER INSURED'8 NANE (Last Name, First Name, Middle Initial) 10. I$ PATIENT'S CONDITION RELATED TO: tl, INSURED'S POLICY GROUP OR FECA NUMBER a, OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a, INSURED'S DATE OF BIRTH b. OTHER INSURED'8 BA'TE OF BIRTH b. AUTO ACCIDENT? PLACE (BP, ia) b. EMPLOYER'S NAME OR SCHOOL NAME c. EMPLOYER'8 NAME OFt 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? E~YES F~NO If yea, return te and complete ltem B a.d, READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13, INBURED'$ OR AUTHORIZED PERSON'S SIGNATURE I authorize 12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release ef any medical or other Information ne~easary payment cf msdloal benefits to the undersigned physician or supplier for to process this claim, I also request p~Yment of government benefits either to myself er to the party who ac~epf~ assignment cervices described below. below, SIGNED S]:.GI',IA"I'URE ON F'T.I..E: DAT~.']~I 20 02). SIGNED S]:GNI"'qTURE O1',1 I':'YI_tE 14. DATE OF CURRENT; ,~ ILLNESS (FIr~l sy~plem) OR 1E. IF PATIENT HA,9 HAD SAME OR EIMILAR ILLNESS. 1E. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I DD I YYI INJURY (A~eldsnt) OR GIVE FIRST DATE MM I DB I YY MM I DD I YY MM DD YY I I PREGNANCY (LMP) !. ~ FROM I I TOII ~ 17, NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I,D, NUMBER OF REFERRING PHYSICIAN 18, HOBPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY SAXENR ,. NA RE"'N FROM , ~ TO ~ 18. 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) . 22, MEDICAID REBUBMIBSION CODE ORiGiNAL REF. NO. 1.14.14.,,02.__ CORONARY ATHEROSC a.l__ 28. PRIOR AUTHORIZATION NUMBER 2.17~16:,~___~i] CHEST F:'FIZN LIBISPEC 4.1__ O 24. A B C D E F G H I J K I-- PRocEDuRES, SERVICES, OR SUPPLIES DAYS EPSDT FromDATE(S) OF SERVICE To , PloafCe TYofPe (Ex~laln Unusual Circumstances] DIAGNOSIS RESERVED FOR MM DD YY MM DD YY Service Sewlce CPT/HCPCS ! MODIFIER CODE $ CHARGES UNITsOR Famllyplan EMG COB LOCAL USE ' ,u.O ' 22 ' 02 ~ ' 11. 04 784.65 I , s'l-u~L,,/ ]. 2 8[)01,, 00 .'l. z 0 2'',22'02 ' ' ].].. 09 'Rg505 l chlbri~e i. 2 0 O 0 /+ 25, FEDERAL TAX I.D. NUMBER SSNr_.__~ r~--~EIN 26. PATIENT'S ACCOUNT NO. ;'7. (For govt. claIAOCEPT ASSIGNMENT?back) 28, TOTAL CHARGE 25. AMOUNT PAID 80, BALANCE DUE 23--].85/+ 722, '.I IIX, I 5(3384. J-~YES E~]NO ' ~-, '-'~ C,,,, 8 O '~ ':; O r"' $ O,,[b' $ 1596.00 ;31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND~ADDRESS OF FACILITY WHERE SERVICES WERE :3;3. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDEREDilf olher than hams or office) & PHONE # (I cedily thai the statements on the raversa apply to this bill and ..... de a part ,hereof.) M O I::' F' :[ '1' T F'IEA R"I" & VASCULAR M C) F:'F .'[ TT I'-IEA RT .S,' V F-] SC t.)t... A R GROI SIGNED AMA COUNCIL ON MEDICAL SERVICE 81SBt PL~',~.~E PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-1500 (12-90), FORM RRB-1500, PLEASE f DO NOT ........... ) ..... r l .E.l"d....I .""'"" ('" ') ......... .=, :.:, .~ t',~1:::..[) I T' z:~ STAPLE a: 'LU '? "') I:~ _ IN THIS , z ,.. l*'J Et i:) 2, ~ R o !:~ ci ,. AREA M J. d d 1. e;,-t O :,J r'~., P ¢:1 ]. 7 0 ~!} 7 .~ 1. MEDICARE MEDICAID CHAMPU8 CHAMPVA GROUP FEOA OTHER la, INSURED'S LC, NUMBER (FOR PROGRAM IN ITEM ] (Medicare l/) r] (Madl~atd l/) r--] (Spon$or,s $SN) F--] (VA File #) I'--]HEALTHPLANi----IBLKLUNGr~ I I(SSNor/D) L_j($$N) 2. PATIENT'S NAME (Last Name, Flrel Name, Middle Initial) 3, PATIENT'S BIRTH DATE SEX 4, INSURED'S NAME (Last Name, First Name, Middle Inlltal) M 5. PATIENT'S ADDRESS {No., 8treat) 6, PATIENT RELATIONSHIP TO INSURED 7, INSURED'$ ADDREBS (No., Street) CITY I STATE 8, PATIENT BTATUS CITY STATE ZIP CODE TELEPHONE (Include Aras Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) D. 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 N R 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 ADOlDEbrr? PLACE (Stste) b. EMPLOYER'S NAME OR SCHOOL 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 1Od. RESERVED FOR LOCAL USE d, IS THERE ANOTHER HEALTH BENEFIT PLAN? F--lYES ~ NO /lyes, 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 autl3orlzs the release of any medical or other Informalion necessary payment of medical benefits to the urldereigned physician or supplier far to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below, below. SIGNED :3IGIqFq'I'LJF~E: ON F::[L_E DAT~iSi 20 02 SIGNED S'[GI'IFI'I'UF~E C)N t:::'il_lii~. 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 MM ~ DD I YY~ INJURY.(Accident) OR GIVE FIRST DATE MM I DD I YY MM DD YY MM DD YY I t PREGNANCY (LMP). I I FROM 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I,D. NUMBER OF REFERRING PHYSICIAN 118. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY SRXE'.IqR, IqRREN FROM I I TO [ I 19. RESERVED FOR LOCAL USE ~0. OUTSIDE LAB? $ 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, ~.1414..02 CORD)NARY RTHERO.S.;O a.t__ 23. PRIOR AUTHORIZATION NUMBER 24. A B C D E F G H I J K placeTv~ PROCEDURES, SERVICES, OR SUPPLIES DAYS EPSDT FromDATE(S) OF SER¥1CE Toof al (Exolain Unusual Circumstances) DIAGNOSIS RESERVED FOR MM DD YY MM DD YY Sarvtca Series CPTIHCPCS I MODIFIES CODE $ CHARGES UNIT[CFI FamllYPla~ EMG COB LOCAL USE 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27.[ForACCEPTgovt. ASSIGNMENT?clalms see back) 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE ~ ' $ 0',. $ 300.00 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32, NAME AND~ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN'S, SUPPLIER'8 BILLING NAME, ADDRESS, ZIP CODE INCLUDING DEGREE8 OR CREDENTIAL8 RENDEREDIII other lhan home or office) & PHONE # ~ce,it~ma~t~es,a. .... fac, th ........ MOFFZT'i" HERR'T' ~.~ VfqSOUL. RR MOF'I=ZTT FiERiR"r' 8: VRSOULFiR CRC ]. 000 Iq O IR T H F F.' O N T S T' R [ii:E T ]. 0 [) 0 N O R'T H F' IR O Ixl"[' S T tR E E'l" f:~I:K)I....L.O, kIZI...L. IRM, MI) k~ORML. EYS:BUR(-;, P~.:I 17043 bJORMLE:YE;BURG, PR 2.704.,~t S~NED []!'3 2[] []2 DATE P,N# {GRP~ ....... ,.~ ~,, ~... ~,,~,~. ~. ,~=n,r.^, ~cmu~r.c ,mm ~1 ~1~1= ~l~llM'r !')1~ 'I'V~,~ APPROVED OMB-0938-0008 FORM HCFA-1500 (12-90), FORM RRB-1500, PLEASE DO NOT STAPLE IN THIS AREA 1, MEDICARE MEDIOAID CHAMPUS CHAMPVA GROUP FECA OTHER lm 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) MM ,DD, YY ~'~ Fi 5, PATIENT'S ADDRESS (No., Street) 6, PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) CITY I STATE B. PATIENT STATUS CITY BTATE ZIP CODE TELEPHONE (Include Area Cods) ZIP CODE TELEPHONE (INCLUDE AREA CODE) g. OTHER INSURED'S NAME (Last Name, Firsl Nama, Middle Initial) 10. IS PATIENT'S CONDITION BELATED TO: ~11. IN@URBD'S POLICY GROUP OR PEOA NUMBER a. OTHER INBURED'S POLICY OB GROUP NUMBER a, EMPLOYMENT',; (CURRENT OR PREVIOUS) e. INBURED'B DATE OF BIRTH · OD, J. 93g b. OTHER INSURED'B DATE OF BIRTH b. AUTO ACCIDENT? PLACE (State) b, EMPLOYER'S NAME OR SCHOOL 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 a, IS THERE ANOTHER HEALTH BENEFIT PLAN? F'--]YES ~ NO If yes, return to and complete item 6 e-d, READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM, ,13· INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I 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 undemlgned physician or supplier for to process this claim. I also reqaest payment of government benefits el?lief to myself or to t~e party who accepts assignment services described below. below. SIGNED .r.,:;IGNRTL]I~E OIq FYL. E DATES 2£1 02. S,GNED E;~GI'I(.~"['L,!I:~E ON 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 MM I DD I YY~ N JURY(Accident)OR GIVE FIRST DATE MM ~ DD I YY MM ~ DD I YY MM I DD I YY ~ I PREGNANCY (LMP) ~ I FROM I ~ TO I 17. NAME OF REFERRING PHYS C AN OR OTHER SOURCE 17a. I,D. NUMBER OF REPEPiRING 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) 'I[' 22, MEDICAID RESUBMISBION CODE ORIGINAL REF, NO, 1, I 4, :L 3 ,. 0 R N G :[ N R D E O U .8 .T T U !~; E, I , _ 23, PRIOR AUTHORIZATION NUMBBR ~4, A B C D E Y G H I J K DAYS EPBDT FramDATE(B) OF SERVICE To Place TFo~ PROCEDURES, SERVICES, OR SUPPLIES DIAGNOSIS RESERVED FOR MM DD YY MM DD Y'~ el (Exl31slnUnu~us C mumatancac) $ CHARGES OR Family EMS COS LOCAL USE Sarvlae Sen~=e -CPT/HCPCS ! MODIFIER CODE UNITS Plan I I I I I I 25, FEDERAL TAX I,D. NUMBER SSN EIN 26, PATIENT'S ACCOUNT NO, 27 ACCEPT ASSIGNMENT? 26, TOTAL CHARGE 29, AMOUNT PAID 30, BALANCE DUE IFor govt, claims see back) 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32, NAME AND~ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDI..i,'-~S, ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDE_~EDflf olher than home or office) & PHONE # ( ced ytha tlle statements on the reverse I¥1OI--'F'I'T"T I"IF. PlET E~, ' ' c'" " ¥ ") ..... SIGNED [) !~ 2 Ci ~,] 2 DATE PIN# JGRP# APPROVED OMB-O93B-000E FORM HCFA-1500 (12-90), FORM RRB-1500, 02/18/02 09:19 Account : 60'384 FACE :S H E E T MOFFITT HEART & VASCULAR GR Acct Type: 1 CASH OR CHECK Setup : 06/15/00 Memo On~ : Memo Two : 2/18/02-HAS NO INS! R E $ P O N S I,B L E 1000 NORTH FRONT STREET WORMLE¥SBURG, PA 170~3 ROBERT L BARBOUR 2144 ~/~KET ST C101 CAMP HILL, PA 17011 Pharm: Loc : 1-WORMI~EYSB~G OFFICE Diagl: 414.02-CORONA/%Y ATHEROSCLE Diag2: 272.2-HY~LIPIDEMIA MIXED Diag3: 414.02-CORONAR¥ ATHERO$CLE Aller: Aller: PARTY Char~ : Y sSN : 192 H-Phone: (717)-761-4586 DOB : 10/29 W-Phone: (717)- - Age : 62 S Fax-~um: (717)- - 0~st: 00/00 Doctor : 15 - CHANG, DAVID, MD i 000 NORTH FRONT STR ( 717 ) - 73 RefDoc : 1344-SAXENA,NARENDRA, M V. A. OUTPATIENT C (717)-?~ 25 NORTH 32ND STREET' (717)~7 ~02129 ;1939 · .X: M ;0000 L-OIO1 -9782 ~0-9854 ~0-9782 Marital Status: S M D W S~ou,se' s"Name $Chil iren___ P A T I E N T A U,T It O R I Z A T 'r O N ,, M~DICAL RECORDS RELEASE: I hereby authorize Mof~itt Heart & Vascular Group to OBTAIN any and al'l medical records from other health care providers and facilities and/o~ RE~.~SE any and all of my medical records reNarding my physical or mental condition or treatment to o~her health care providers & facilities. Si~ilature of Patient Date of my INSURANCE AUTHORIEATION: I authorize payment o~ medical benefits ~o Moffitt Heart & Vascular Gro% services rendered. For any services fu,~nished to me by any of the ph~s~ the non-physician professional staff of, Moffitt Heart & Vascular Group, authorize release of any information to. my insurance carrier to determix benefits payable for services re~dered.i I further agree to accept respo! for p~yme~t pf services determine~ to b,e ineligible for insurance benefJ -- ' ' Signature of PatSefi6 - ., ' ___ ?/? '3-----C~ 0 ! for c ~/~s or . 15 O1 12: 18p 71'7'702200'7 p.4 o2/2§/20o3 o8'45 FAX 23BBSff9 GUIDA LA~ OFFICES ; , ~00¢/007 MOFFITT HEART & VASCULAR ¥$. ROBERT L. BARBOUR BETTY KNAUB BARBOUR IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PP..NNSYLVANJA CIVIL ACTION - LAW No. V£RIFICA'I'IQN I VERIFY TI-IAT THE STATEMENTS MADE iN ]'HIS COMPLAINT ARE 'FRUF: AND CORRECT, I UNDERSTAND TIIAT THE STATEMEN I'S HEREIN ARE MADE 5UB.IEC'F TO THE PENALTIES OF 18 PA.C.S.A. SECTION 4904 RELA'I'IN(.J TO UN.gWORN FAI,SH-'ICATiON TO AUTHORITIES. ~/Signat~e- Printcd l~lame Title Date RECEIVED TIMEFEB, 25. ll'41AM PRINT TIMEFEB, 25. ii'43AM MOFFITT HEART & VASCULAR VS ROBERT L. BARBOUR BETTY KNAUB BARBOUR : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION - LAW : : NO. 03-1262 Civil Term CERTIFICATE OF SERVICE ! hereby certify that on March 27, 2003 I served the Civil Complaint upon the person and in the manner indicated below: Personal service by James Stamos: Robert L. Barbour 2144 Market Street, CI01 Camp Hill, PA 17011 Gail Guida Souders ~'~ Guida Law Offices, P.C. 503 North Front Street Harrisburg, PA 17101 717-236-6440 Dated: March 31, 2003 MOFFITT HEART & VASCULAR ROBERT L. BARBOUR BETTY KNAUB BARBOUR : 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. 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 COUN3rY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 1-800-990-9108 -7"I , MOFFITT I~,ART & VASCULAR Plaintiff VS. ROBERT L. BARBOUR and BETTY KNAUB BARBOUR Defendants : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : CML ACTION - LAW : : NO. 03-1262 CIVIL TERM : : JURY TRIAL DEMANDED DEFENDANTS' ANSWER AND NEW MATTER TO PLAINTIFF'S COMPLAINT AND NOW, this ~4,~. day of April, 2003, comes Robert L. Barbour and Betty Knaub Barbour, through their legal counsel, Austin F. Grogan, of Coyne & Coyne, P.C., and aver the following: 1. Defendants are without sufficient knowledge to admit or deny the allegation. If an answer is required, Defendants deny the allegation and strict proof is demanded. 2. Admitted. 3. Admitted. 4. Defendants are without sufficient knowledge to respond to the averment. If an answer is required, Defendants deny the allegation and strict proof is demanded. Defendant Robert L. Barbour acknowledges he has been and continues to be under the care of Moffitt Heart & Vascular. 5. The Defendants are without sufficient knowledge to respond, therefore, Defendants deny the allegation and strict proof is demanded. 6. Admitted. 7. No answer is required. If an answer is required, Defendants deny the allegation and strict proof is demanded. 8. Denied. Compulsory arbitration limits are set above Plaintiff's requested compulsory arbitration should be scheduled at an appropriate time following discovery. the Defendants entered into an agreement to pay the agreed upon amount. 9. it is denied. amount and Furthermore, The Defendants are without sufficient knowledge to respond to the averment and, therefore, Furthermore, the Plaintiff is not entitled to receive interest and, therefore, is not authorized to receive interest. 10. Denied. Specifically, strict proof is demanded. Defendants and Plaintiff's agent entered into an agreement to accept Twenty-Five Dollars ($25.00) a month for an agreed upon amount of money. The Defendants were current with payments and continues to make payments. WHEREFORE, the Defendants respectfully request this Honorable Court to dismiss the action with prejudice. NEW MATTER 11. Paragraphs 1 through 10 are incorporated as if fully set forth. 12. Plaintiff's agent Peerless Credit Services, Inc. and Defendants' entered into an agreement to a reduced amount of $2875.93 payable at $25.00 per month; 13. Defendants confirmed in writing with Plaintiff's agent of the understanding; 14. 15. attached). 16. Defendants believe the writing is in possession of Plaintiff or Plaintiffs' agent. Defendants' received confirmation of agreement on or about November 5, 2002 (copy Defendants' continue to make timely payments in accordance with the agreed amount. WHEREFORE, the Defendants respectfully request this Honorable Court to dismiss Plaintiff's action and award reasonable attorney fees. Dated: Respectfully submitted: By: Austin F. Grog~n, Es~re 3901 Market Street Camp Hill, PA 17011-4227 (717) 737-0464 Pa. S. Ct. No. 59020 Attorney for Defendants CERTIFICATE OF SERVICE I, Austin F. Grogan, Esquire, hereby certify that a tree copy of the Defendants' Answer to Plaintiff's Complaint has been served upon the below-referenced individual by sending the same by first class mail, postage prepaid, addressed as follows: Gail Guida Souders, Esquire Guida Law Offices 503 North Front Street Harrisburg, PA 17101 Dated: Austin F. Grogan, l~l~ire 3901 Market Street Camp Hill, PA 17011-4227 (717) 737-0464 Pa. S. Ct. No. 59020 Attorney for the Defendants Nov 5, 2002 PAYMENT REMINDER THIS IS A REMINDER OF YOUR NEXT PAYMENT DUE ACCORDI~TO THE ARR3~NGEMENT o~ ~o~ ~coo~T, ~o~ ~.XT ~.~T I~ ~. ~ ~O,.LO~S~ ~ !-- / >> DuE DAT~. ~/30/02 ~'~"J!l~~,_[/p p >> A~OUNT DUE $2875.93 PLEASE RETURN PROMPT PAYMENT WITH THE TOP STUB TO OUR OFFICE. THANK YOU, MS. GREENE >>CALL OUR OFFICE IF YOU WOULD LIKE TO PAY BY MC/VISA OR CHECK BY PHONE. >>THIS LETTER IS FROM A DEBT COLLECTOR AATD IS AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THIS PURPOSE. YOUR ACCOUNT (S) DUE: Creditor Account # MOFFITT HEART AND VASCULA 60384 TOTAL ALL YOUR ACCOUNTS WITH THIS OFFICE: 1 $ 28?5.93 INCLUDING THE ABOVE. Regarding Amt Owed Serv Date 2s75.93 08/16/o2 >>PAY TO: PEERLESS CREDIT SERVICES, INC. * PO BOX 518 * MIDDLETOWN, PA. 17057 >>QUESTIONS TO: 717-702-2000 OUR ACCT# 135432-2E 9 VERIFICATION The facts set forth in the foregoing are hue and correct to the best of the undersigned's knowledge, information and belief and are verified subject to the penalties for unswom falsification to authorities under 18 Pa. C.S.A. §4904. Dated: ed,- z./ ~ o~ MOFFITT HEART & VASCULAR VS ROBERT L. BARBOUR BETTY KNAUB BARBOUR IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 03-1262 Civil Term TO: Robert L. and Betty Knaub Barbour DATE OF NOTICE: April 17, 2003 IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT AN ANSWER TO Plaintiff's Complaint. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP: CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 1-800-990-9108 Gail Guida Souders Guida Law Offices, P.C. 503 North Front Street Harrisburg, PA 17101 (717) 236-6440 Identification #68740 Attorney for Plaintiff MOFFITT HEART & VASCULAR VS ROBERT L. BARBOUR BETTY KNAUB BARBOUR : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : : CIVIL ACTION - LAW : : NO. 03-1262 Civil Term CERTIFICATE OF SERVICE I hereby certify that I am this 17T" day of April, 2003, serving the Default Notice upon the persons and in the manner indicated below which service satisfies the requirements of Pennsylvania Rule of Civil Procedure, 403: Service b~ First Class U.S. Mail: Robert L. and Betty Knaub Barbour 2144 Market Street, C101 Camp Hill, PA 17011 Gail Guida Souders MOFFITT HEART & VASCULAR GROUP: VS ROBERT L. BARBOUR and BETTY KNAUB BARBOUR IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 03-1262-Civil Term RULE 1312-1. The Petition for Appointment of Arbitrators shall be substantially in the following form. PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: Gail Guida Souders, Esquire, counsel for the plaintiff in the above action, respectfully represents that: 1. The above-captioned action is at issue. 2. The claim of the plaintiff in the action is $8,288.41 plus interest and costs. The following attorneys are interested in the case as counsel or are otherwise disqualified to sit as arbitrators: Austin Grogan, Esquire, 3901 Market Street, Camp Hill, PA 17011. WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. Date: March 8, 2004 Respectfully submitted, Gail Guida Souders Guida Law Offices, P.C. 111 Locust Street Harrisburg, PA 17101 717-236-6440 Identification #68740 Attorney for Plaintiff MOFFITT HEART 8,: VASCULAR GROUP: VS ROBERT L. BARBOUR and BETTY KNAUB BARBOUR iN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 03-1262-Civil Term CERTIFICATE OF SERVICE I hereby certify that on March 11, 2004, I served the Petition for Appointment of Arbitrators upon the person and in the manner indicated below, which service satisfies the requirements of Pennsylvania Rule of Civil Procedure. 403. Service by First Class U.S. Mail to: Austin Grogan, Esquire 3901 Market Street Camp Hill, PA 17011 Gail Guida Souders, Esquire Guida Law Offices, P.C. 111 Locust Street Harrisburg, PA 17101 717-236-6440 Dated: March 11,2004 MOFFITT HEART & VASCULAR GROUP: VS ROBERT L. BARBOUR and BETTY KNAUB BARBOUR IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 03-1262-Civil Term ORDER OF COURT AND NOW, ~/t~4~-~ //~ ,2004, in consideration of the foregoing action as prayed for. By the Court, MOFFIT ROBERT HEART AND VASCULAR GROUP hl The Com~ of Common Pleas of Cumberland P~ntiff County, Pennsylvania No. 03 - 1262 BARBOUR AND BETTY KNAUB BARBOUR Defendant Civil Action - Law. Oath We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United States and the Constitution of this Commonwealth and that we will discharge the duties of our office Donald R. Dorer, Esq. Marylou Matas, Esq. David A. Name (Chairman) Name Name .lmeobs & Associates Griffie & Associates Martson LawFirm LawFirm LawFirm Fitzsimons, Esq. Deardorff Williams Otto 1206 Summit Way 200 N. Hanover Street 10 East, High Street Ad&ess Ad&ess Ad&ess Mechanisburg, PA 17050 ,Carlisle, PA 17013 Carlisle, PA 17013 ciw, zip ciw, z~ ci~, zi~ Award We, theundersignedarbi~ors, havingbeendulyappointedand swom(oraffirmed),makethe foHowing award: (Note:Ifdamages ~rdelayare awarded, they sh~lbesepar~elystmed.) Tho Board finds that a discounted debt of $2,400.93 is due and owing; however, thpro ~ no breach to date, and finds in favor of Defendants. Date of Hearing: Date of Award: ll/10/04 11/10/04 .~s. (Insert name if applicable.),~:[,.~. Arbitrators' compensation to be paid upon appeal: $ /~p o ~onotary PRAECIPE FOR SATISFACTION MOFFITT HEART & VASCULAR GROUP: PLAINTIFF : VS ROBERT L. BARBOUR BETTY KNAUB BARBOUR DEFENDANTS IN THE COURT OF COMMON PLEAS CUMBERLanD COUNTY, PENNSYLVANIA CIVIL ACTION - MONEY JUDGMENT NO. 03-~civil term To Prothonotary: Please SATISFY the judgment against ROBERT L. BARBOUR and BETTY KNAUB BARBOUR as the parties have reached a settlement. Date: January 3, 2005 Respectfully submitted, Gail Guida Souders Guida Law Offices, P.C. 111 Locust Street Harrisburg, PA 17101 717-236-6440 Identification #68740 Attorney for Plaintiff