HomeMy WebLinkAbout99-00762
I~X0055
RNESTHESIA ASSOCHlTES OF PENNSYLVANIA, L TO.
INDIVIDUAL INQUIRY
PATIENT DATA
-------------------------------------~------------------------------------------
08/12/'37
PAGE: ~::
f.1CCOUNT ' NO
ACCOUNT TYPE
NnME
ADDI'lES,;
: 72833
: ONE TIME (~:)
: '~lil~.tt~WI$$'~:~JaF.l..IiJ;a&:l.:LU.i(s.a,~"
. ..0000c""''''''''A"o''DR';''',
.;""=r.lY.i~.r.Ilial......,
PHONE NO
SSN
BIRTH DATE
EMPLOYER
DCCUPATION
WORK PHONE
PROVIDER
REFERRING
LOCATION
MED REC II
CRAIG E. LAHAR MD LAH)
HARRISBURG HOSPITAL-INPT IP)
GUARANTOR NO
SEX
r~AR ITAL STATUS
PATIENT CLASS
LAST INS LEVEL
SCHEDULED APPT
FIRST VISIT DATE
L.AST V I S IT DATE
LAST ADM IT DATE
D I SCHr-1RGE DATE
DATE FIRST SEEN
THIS YEAR
ENTERED BY
ENTERED DATE
UPDATED BY
UPDATED DATE
72833
M
r~
1
05/1.\/'37
DRM
05/1'3/'37
ACTIVITY DATA
---------------------.------------------------------------------------------------
, D. O. S.
PROCEDURE
DESCRIPTION
ACCT NO: 72833
BAITSELL SR
BRUCE
LVL PRV SPR LOC
AMOUNT
BALANCE
~~9:?'JtJ1:',iZI7110 SIMPLE EXTRACTIONiSI SLF DUM HOW IP 700.00 700.00
' POSTED:05/1'3/'37 BY:DRM D/U:014 DX:144.'3 MALIGNANT NEO~~ASM, MOUTH
CLAIM BALANCE 0.00 Ll 094527
TIME 21:15-23:45 BASE: 3.00 TIME:10.00 CALC: 14. 0121 TYP:l PS-3
E
'3'3140 EMERGENCY SLF HOW
POSTED:05/19/'37 BY:DRM D/U:iZl02 DX:144 .'3
CLAIM BALANCE 0.00 Ll 0'34527
TIME 00:iZl0-00:00 BASE: 2.00 TIME: 0.00 CALC:
IP 100.iZIiZI 8iZ10.00
MALIGNANT NEOPLRSM, MOUTH
2. iZIiZI TYP: 1 1:'8-
BILLED COM-HEALTHPLAN SERVICE 0'34627 HOW 800.00 800.00
,BIL,LED SLF-GUARANTOR CD- 05 800.00 800.00
, ,
~Yl /21/'37 BILLED SLF-GUARANTOR 2ND-DUN 800.00 800.00
08/05/'37 PAW PAYMENT NIP-NO INSURANCE PAYMENT 0'34627 HOW 0.00 800. 0e,
PAW CDt~MENT ONLY MEM IS ELIGIBLE HOW 0.00 800.00
COMMENT STMT REQ CD-03 HOW 121.00 ~~I(.I/'
'f\;li"'~;'
5-11~98 Payment $60.00
BALANCE $740.00
Exhibit A
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