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HomeMy WebLinkAbout99-00960 5, Plaintiff agrced to providc Dcfcndants with thosc mcdical scrviccs and spccifically provide Lorrainc T, Hull with thosc mcdical scrviccs providcd that Dcfcndants pay for thosc medical services, 6, In accordance with the agrccmcnt cntercd into bctween the parties, Plaintiff began providing medical serviccs to Defendant Lorrainc T, Hull on or about September 12, 1994, and continucd to provide those services through March, 1997, Attached hereto and marked as Exhibit A is a true and correct copy of the patient ledger indicating the dates of treatmcnt and the costs for those treatments, 7, Under the terms of the agreement between Plaintiff and Defendants, Defendants were responsible for all medical services provided by Plaintiff whether or not Defendants' respective health insurance carrier would cover any of the costs of the treatment received by Defendant Lorraine T. Hull, 8, After applying the various credits for paymcnts received by Plaintiff from Defcndants' health insurance carrier, there is an outstanding balance due and owing to Plaintiff in the amount of $20,972.25, 9, Despite repeated demands by Plaintifflo Defendants, Defendants have failed or refused to pay for the medical serviccs received by Defendants, 10, Defendants breached their agreement with Plaintiff as a result of their failure to pay for the medical services provided by Plaintiff to Defendant Lorraine T, Hull in accordance with the agrccmcnt reachcd by the parties, 2 '[ledger] cente)W~~: ;p , Trindle Renab M~dicine PATIENT LEDGER GUARANTOR #:hulllo-Ol PATIENT #:hulllo-01 ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST Pl).Y $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J 1 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho INSURED~ -1(J7)~ "LAN 1 "OLICY :;ROUP :Attorney Angio & #:194288043 PLAN 2 POLICY #: GROUP # : :lATE 11/28/94 Jl/05/98 11/28/94 11/28/94 11/28/94 11/29/94 Jl/05/98 11/29/94 11/29/94 11/29/94 12/01/94 01/05/98 12/01/94 12/01/94 12/01/94 12/05/94 01/05/98 12/05/94 12/05/94 12/05/9,~ 12/06/94 01/05/98 12/06/94 12/06/94 12/09/94 01/05/98 12/09/94 12/09/94 # : Rovner FR: **/**/** TO: **/**/** BILL # DR. CPT/PROCEDURE CHECK #:PLAN 150480 pt Pt: pt pt OFFICE: 40 150605 pt pt pt pt OFFICE: 40 150930 pt pt pt pt OFFICE: 40 150968 pt pt pt pt OFFICE: 40 150991 pt pt pt OFFICE: 40 151058 pt 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97128-0ld Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97022-PT Whirlpool 97128-01d Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97128-0ld Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97128-0ld Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97128-0ld Code-Do Not Use DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 9 ld Code-Do Not Use (15) FR: TO: POS CHARGE 0 20.00 0.00 0 35.00 0 60.00 0 70.00 185.00 <------ 0 20.00 0.00 0 20.00 0 60.00 0 70.00 170.00 <------ 0 20.00 0.00 0 35.00 0 60.00 0 70.00 185.00 <------ 0 20.00 0.00 0 35.00 0 60.00 0 70.00 185.00 <------ 0 20.00 0.00 0 35.00 0 60.00 115.00 <------ 0 40.00 0.00 0 35.00 0 60.00 (15) (15) (15) '[ ledger] Trind1e Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hu111o-01 PATIENT #:hull1o-01 ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 I?LAN 1 I?OLICY 3ROUP . : Attorney Angio & #:194288043 #: PLAN 2 POLICY #: GROUP # : Rovner FR:**/**/** TO:**/**/** DATE Bn~L # DR. CPT/PROCEDURE CHECK #:PLAN 12/09/94 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 12/12/94 151145 pt 97010-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/12/94 pt 97124-PT Massage 12/12/94 pt 97128-0ld Code-Do Not Use 12/12/94 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 Dx:8470-Cervica1 sprain/str 12/13/94 151250 pt 97010-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/13/94 pt 97124-PT Massage 12/13/94 pt 97128-0ld Code-Do Not Use 12/13/94 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical sprain/str 12/15/94 151315 pt 97010-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/15/94 pt 97124-PT Massage 12/15/94 pt 97128-01d Code-Do Not Use 12/15/94 pt 97110--Physica1 Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical sprain/str 12/19/94 151532 pt 97010-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/19/94 pt 97124-PT Massage 12/19/94 pt 97128-0ld Code-Do Not Use 12/19/94 pt 97145-Physica1 Therapy 1 Area Each 15 Min 12/19/94 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervica1 Sprain/str 12/20/94 151606 pt 97010-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/20/94 pt 97124-PT Massage 12/20/~4 pt 97128-01d Code-Do Not Use 12/20/94 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervica1 Sprain/str PAGE: 2 DATE : 07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: POS CHARGE 0 70.00 205.00 <------ 0 20.00 0.00 0 35.00 0 60.00 0 70.00 185.00 <------ 0 40.00 0.00 0 35.00 0 60.00 0 70.00 205.00 <------ 0 20.00 0.00 0 35.00 0 60.00 0 70.00 185.00 <------ 0 40.00 0.00 0 35.00 0 60.00 0 30.00 0 70.00 235.00 <------ 0 20.00 0.00 0 35.00 0 60.00 0 70.00 185.00 <------ '[ ledger] Trindle Rehab Medicine Center PATIENT LEDGER -------------- GUARANTOR #:hulllo-Ol PATIENT #:hulllo-01 ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY :;ROUP :Attorney Angio & #:194288043 # : PLAN 2 : POLICY #: GROUP #: Rovner FR: **/**/** TO: **/**/** LJATE BILL # DR. CPT/PROCEDURE CHECK #:PLAN 12/22/94 151723 pt 97010-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/22/94 pt 97124-PT Massage 12/22/94 pt 97128-0ld Code-Do Not Use 12/22/9'4 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical sprain/str 12/28/94 151933 pt 970l2-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 12/28/94 pt 970l0-PT Hot/Cold Packs 12/28/94 pt 99070A-Electrodes- Disposable 12/28/94 pt 97ll8-PT Therapeutic Exercise 12/28/94 pt 97128-0ld Code-Do Not Use OFFICE: 40 DX:8470-Cervical sprain/str 12/29/94 151961 pt 970l0-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/29/94 pt 97ll8-PT Therapeutic Exercise 12/29/94 pt 97128-0ld Code-Do Not Use 12/29/94 pt 97l45-Physical Therapy 1 Area Each 15 Min 12/29/94 pt 97ll0--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 01/03/95 152207 pt 97010-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 01/03/95 pt 97118-PT Therapeutic Exercise 01/03/95 pt 97128-0ld Code-Do Not Use OFFICE: 40 DX:8470-Cervical sprain/str 01/04/95 152229 pt 97010-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 01/04/95 pt 97ll8-PT Therapeutic Exercise 01/04/95 pt 97128-0ld Code-Do Not Use 01/04/95 pt 97l10--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical sprain/str 01/05/95 152243 pt 970l0-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 PAGE: 3 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: POS CHARGE 0 40.00 0.00 0 35.00 0 60.00 0 70.00 205.00 <------ 0 35.00 0.00 0 40.00 0 52.00 0 90.00 0 60.00 277.00 <------ 0 20.00 0.00 0 90.00 0 60.00 0 60.00 0 70.00 300.00 <------ 0 20.00 0.00 0 45.00 0 30.00 95.00 <------ 0 40.00 0.00 0 90.00 0 60.00 0 35.00 225.00 <------ 0 40.00 0.00 '[ ledger] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hulllo-Ol PATIENT #:hulllo-Ol ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 POLICY 3ROUP Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 , :Attorney Angio & #:194288043 PLAN 2 : POLICY #: GROUP # : DATE 01/05/95 01/05/95 01/05/95 01/09/95 01/05/98 01/09/95 01/09/95 01/09/95 01/09/95 01/10/95 01/05/98 01/10/95 01/10/95 01/10/95 01/12/95 01/05/98 01/12/95 01/12/95 01/12/95 01/12/95 01/16/95 01/05/98 01/16/95 01/16/95 01/16/95 01/16/95 01/17/95 01/05/98 # : Rovner FR:**/**/** TO: **/**/** BILL # DR. CPT/PROCEDURE pt pt pt OFFICE: 40 152351 pt pt pt pt pt OFFICE: 40 252366 pt pt pt pt OFFICE: 40 152501 pt pt pt pt pt OFFICE: 40 152703 pt pt pt pt pt OFFICE: 40 152799 pt CHECK #:PLAN 97118-PT Therapeutic Exercise 97128-01d Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97128-01d Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97128-01d Code-Do Not Use Dx:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97128-01d Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97128-01d Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 (15) (15) (15) (15) PAGE: 4 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho POS o o o 260.00 o o o o o 295.00 o o o o 225.00 o o o o o 260.00 o o o o o 260.00 o FR: TO: CHARGE 90.00 60.00 70.00 <------ 40.00 0.00 35.00 90.00 60.00 70.00 <------ 40.00 0.00 35.00 90.00 60.00 <------ 40.00 0.00 35.00 90.00 60.00 35.00 <------ 40.00 0.00 35.00 90.00 60.00 35.00 <------ 40.00 0.00 GUARANTOR #:hulllo-01 PATIENT #:hu111o-01 ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 :Attorney Angio & POLICY,#: 194288043 3ROUP #: , [ledger] DATE 01/17/95 01/17/95 01/17 /95 01/17/95 01/19/95 01/05/98 01/19/95 01/19/95 01/19/95 01/23/95 01/05/98 01/23/95 01/23/95 01/23/95 01/23/95 01/24/95 01/05/98 01/24/95 01/24/95 01/24/95 01/26/95 01/05/98 01/26/95 01/26/95 01/26/95 01/30/95 01/05/98 01/30/~5 Trindle Rehab Medicine Center PATIENT LEDGER Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 Rovner FR:**/**/** TO:**/**/** PLAN 2 POLICY #: GROUP # : BILL # DR. CPT/PROCEDURE pt pt pt pt OFFICE: 40 152934 pt pt pt pt OFFICE: 40 153051 pt pt pt pt pt OFFICE: 40 153208 pt pt pt pt OFFICE: 40 153294 pt pt pt pt OFFICE: 40 153463 pt CHECK #:PLAN pt 97124-PT Massage 97l18-PT Therapeutic Exercise 97128-0ld Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97128-0ld Code-Do Not Use DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97128-01d Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physica1 Therapy, Initial DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs (15) (15) (15) (15) PAGE: 5 DATE :07/13/98 D.O.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 , DR:cho pas o o o o 260.00 o o o o 225.00 o o o o o 260.00 o o o o 170.00 o o o o 180.00 o o FR: TO: CHARGE 35.00 90.00 60.00 35.00 <------ 40.00 0.00 35.00 90.00 60.00 <------ 40.00 0.00 35.00 90.00 60.00 35.00 <------ 20.00 0.00 35.00 45.00 70.00 <------ 20.00 0.00 35.00 90.00 35.00 <------ 35.00 0.00 40.00 '[ ledger] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hulllo-01 PATIENT #:hulllo-01 ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : ' 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 HUll, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY :;ROUP :Attorney Angio & #:194288043 PLAN 2 : POLICY #: GROUP # : JATE 01/30/95 31/30/95 01/30/95 01/31/95 01/05/98 01/31/95 :l1/31/95 01/31/95 01/31/95 02/02/95 01/05/98 02/02/95 02/02/95 02/02/95 02/02/95 02/06/9'5 01/05/98 02/06/95 02/06/95 02/06/95 02/06/95 02/07/95 01/05/98 02/07/95 02/07/95 02/07/95 02/07/95 02/09/95 # : Rovner FR: **/**/** TO:**/**/** BILL # DR. CPT/PROCEDURE pt pt pt OFFICE: 40 153575 pt pt pt pt pt OFFICE: 40 153757 pt pt pt pt pt OFFICE: 40 153824 pt pt pt pt pt OFFICE: 40 153875 pt pt pt pt pt OFFICE: 40 153979 pt CHECK #:PLAN 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physical Therapy, Initial Dx:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physical Therapy, Initial Dx:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97012-PT Traction, Mechanical (15) (15) (15) (15) (15) PP.GE: 6 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho POS o o o 190.00 o o o o o 190.09 o o o o o 190.00 o o o o o 190.00 o o o o o 190.00 o FR: TO: CHARGE 35.00 45.00 35.00 <------ 35.00 0.00 40.00 35.00 45.00 35.00 <------ 35.00 0.00 40.00 35.00 45.00 35.00 <------ 35.00 0.00 40.00 35.00 4.5.00 35.00 <------ 35.00 0.00 40.00 35.00 45.00 35.00 <------ 35.00 , [ledger,] Trindle Rehab Medicine Center PATIENT LEDGER -------------- GUARANTOR #:hulllo-01 PATIENT #:hulllo-01 ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY ~ROUP :Attorney Angio & #:194288043 #: PLAN 2 : POLICY #: GROUP # : Rovner FR: **/**/** TO: **/**/** DATE BILL # DR. CPT/PROCEDURE CHECK #:PLAN 01/05/98 PAYMENT-THANK YOU 0000 n/09/95 pt 97010-PT Hot/cold Packs 02/09/95 pt 97118-PT Therapeutic Exercise 02/09/95 pt 97110--Physica1 Therapy, Initial (15) OFFICE: 40 DX:8470-cervical Sprain/str 02/13/95 154287 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/13/95 pt 97010-PT Hot/Cold Packs 02/13/95 pt 97124-PT Massage 02/13/95 pt 97118-PT Therapeutic Exercise 02/13/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-cervical sprain/str 02/14/95 154310 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/14/9,5 pt 97010-PT Hot/Cold Packs 02/14/95 pt 97124-PT Massage 02/14/95 pt 97118-PT Therapeutic Exercise 02/14/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical sprain/str 02/16/95 154436 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/16/95 pt 97010-PT Hot/Cold Packs 02/16/95 pt 97124-PT Massage 02/16/95 pt 97032-PT Electric stim,manual Each 15 Mins 02/16/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical sprain/str 02/20/95 154598 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/20/95 pt 97010-PT Hot/Cold Packs 02/20/95 pt 97124-PT Massage 02/20/95 pt 97032-PT Electric stim,manual Each 15 Mins 02/20/95 pt 97110--Physica1 Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical sprain/str PAGE: 7 DATE :07/13/98 D.O.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: pos CHARGE 0.00 0 40.00 0 45.00 0 35.00 155.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 20.00 0 35.00 0 45.00 0 35.00 170.00 <------ DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: 5 5 #:194-28-8043 CLASS: 11 DR:cho '[ ledg'er) Trindle Rehab Medicine Center PATIENT LEDGER -------------- GUARANTOR #:hulllo-Ol PATIENT #:hulllo-Ol ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY: 12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY :;ROUP :Attorney Angio & #:194288043 PLAN 2 : POLICY #: GROUP # : # : Rovner FR:**/**/** TO:**/**/** DATE BILL 11 DR. CPT/PROCEDURE CHECK 1I:PLAN 02/21/95 154619 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/21/95 pt 97010-P~ Hot/cold Packs 02/21/95 pt 97124-PT Massage 02/21/95 pt 97032-PT Electric stirn, manual Each 15 Mins 02/21/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-cervical Sprain/str 02/24/95 154720 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/24/95 pt 97010-PT Hot/cold Packs 02/24/95 pt 97124-PT Massage 02/24/95 pt 97032-PT Electric stirn, manual Each 15 Mins 02/24/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical sprain/str 02/28/95 155033 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/28/95 pt 97010-PT Hot/Cold Packs 02/28/95 pt 97124-PT Massage 02/28/95 pt 97032-PT Electric stirn,manual Each 15 Mins 02/28/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 Dx:8470-cervical Sprain/str 03/01/95 155175 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 03/01/95 pt 99070A-Electrodes- Disposable 03/01/95 pt 97010-PT Hot/Cold Packs 03/01/95 pt 97124-PT Massage 03/01/95 pt 97032-PT Electric stirn, manual Each 15 Mins 03/01/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 03/02/95 155193 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 03/02/95 pt 97010-PT Hot/Cold Packs 03/02/95 pt 97124-PT Massage PAGE: 8 FR: TO: EQ2 CHARGE 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 52.00 0 40.00 0 35.00 0 45.00 0 35.00 242.00 <------ 0 35.00 0.00 0 40.00 0 35.00 '[ledg'er] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hulllo-01 PATIENT #:hulllo-01 ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T HUll, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 I?LAN 1 I?OLICY 3ROUP :Attorney Angio & #:194288043 # : Rovner FR: **/**/** TO:**/**/** PLAN 2 . POLICY #: GROUP # : DATE BILL # DR. CPT/PROCEDURE CHECK #:PLAN 03/02/95 pt 97032-PT Electric stirn, manual Each 15 Mins 03/02/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 Dx:8470-Cervical sprain/str 03/06/95 155333 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 03/06/95 pt 97010-PT Hot/Cold Packs 03/06/95 pt 97124-PT Massage 03/06/95 pt 97032-PT Electric stirn,rnanual Each 15 Mins 03/06/9,5 pt 97035-PT Ultrasound, Each 15 Min 03/06/95 pt 97110--Physica1 Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical sprain/str 03/07/95 155545 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 03/07/95 pt 97124-PT Massage 03/07/95 pt 97010-PT Hot/Cold Packs 03/07/95 pt 97032-PT Electric stirn, manual Each 15 Mins 03/07/95 pt 97035-PT Ultrasound, Each 15 Min 03/07/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 Dx:8470-Cervical sprain/str 03/09/95 155598 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 03/09/95 pt 97010-PT Hot/Cold Packs 03/09/95 pt 97124-PT Massage 03/09/95 pt 97032-PT Electric stirn,manual Each 15 Mins 03/09/95 pt 97035-PT Ultrasound, Each 15 Min OFFICE: 40 DX:8470-Cervical sprain/str 03/13/95 155752 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 03/13/95 pt 97010-PT Hot/cold Packs 03/13/95 pt 97124-PT Massage 03/13/95 pt 97032-PT Electric stirn, manual Each 15 Mins 03/13/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-cervical sprain/str PAGE: 9 DATE :07/13/98 D.O.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASs: 11 DR:cho FR: TO: POS CHARGE 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 30.00 0 35.00 220.00 <------ 0 35.00 0.00 0 35.00 0 40.00 0 45.00 0 30.00 0 35.00 220.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 30.00 185.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ . [ledger] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hulllo-Ol PATIENT #:hulllo-Ol ASSIGNMENT :yes-yes LART PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 aull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY GROUP ':Attorney Angio & #:194288043 # : PLAN 2 . POLICY #: GROUP # : DATE 03/14/95 01/05/98 03/14/95 03/14/95 03/14/95 03/14/95 03/16/95 01/05/98 03/16/95 03/16/95 03/16/95 03/16/95 03/16/95 03/20/95 01/05/98 03/20/95 03/20/95 03/20/95 03/20/95 Rovner FR: **/**/** TO: **/**/** BILL # DR. CPT/PROCEDURE 155817 pt OFFICE: 155948 OFFICE: 155981 OFFICE: 03/21/95 156155 01/05/98 03/21/95 03/21/95 03/21/95 03/21/95 03/21/95 I Payment Notes: OFFICE: 40 pt pt pt pt pt CHECK #:PLAN pt pt pt pt 40 pt pt pt pt pt pt 40 pt 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 970l0-PT Hot/Cold Packs 97032-PT Electric stim,manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min 97110--Physical Therapy, Initial (15) DX:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97032-PT Electric Stim,manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min 97110--Physical Therapy, Initial (15) DX:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97032-PT Electric Stim,manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min 97110--Physical Therapy, Initial (15) DX:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97032-PT Electric Stim,manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min 97110--Physical Therapy, Initial (15) Patient received settlement DX:8470-Cervical Sprain/str pt pt pt pt 40 pt PAGE: 10 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: POS CHARGE 0 35.00 0.00 0 40.00 0 45.00 0 30.00 0 35.00 185.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 30.00 0 35.00 220.00 <------ 0 35.00 0.00 0 40.00 0 45.00 0 30.00 0 35.00 185.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 30.00 0 35.00 I 220.00 <------ [ ledger] GUA~NTOR #:hulllo-03 PA~IENT #:hulllo-03 ASFIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 :US Healthcare POLICY #:KGDR1020 :;ROUP .,#: Rehab Medicine Assoc,Mechbrg PATIENT JJEDGER -------------- Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 1125 PLAN 2 : POLICY #: GROUP # : FR:**/**/** TO: **/**/** DATE BILL # DR. CPT/PROCEDURE CHECK #:PLAN 04/22/96 176q84 pt 97035-PT Ultrasound, Each 15 Min 01/05/98 PAYMENT-THANK YOU 0000 04/22/96 pt 97032-PT Electric stirn, manual Each 15 04/22/96 pt 97010-PT Hot/Cold Packs OFFICE: 30 DX:7231-Cervicalagia/Cervic 04/23/96 176085 pt 97032-PT Electric Stirn, manual Each J.5 01/05/98 PAYMENT-THANK YOU 0000 04/23/96 pt 97124-PT Massage 04/23/96 pt 97010-PT Hot/Cold Packs 04/23/96 pt 97018-PT Paraffin Bath, Fluidotherapy OFFICE: 30 DX:7231-Cervicalagia/Cervic PAGE: 1 DATE : 07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho FR: TO: POS CHARGE 0 60.00 0.00 Mins 0 180.00 0 20.00 260.00 <------ Mins 0 180.00 0.00 0 35.00 0 20.00 0 40.00 275.00 <------ 1ft 1(4& Last statement printed on 06/30/98 for~l~.~~ ~~~for Hull, Lorraine T Balance for Plan Patient Plan CURRENT 0.00 0.00 031-060 0.00 0.00 061-090 0.00 0.00 Qll=.120 0.00 0.00 ' 120+ 535.00 0.00 535.00 0.00 '( ledger] Trindle Rehab Medicine Center PATIENT LEDGER -------------- GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT: **/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 E'LAN 1 E'OLICY :;ROUP . : US Heal thcare '# : KGDRl02 0 #: DATE 01/18/96 01/05/98 01/18/96 01/18/96 01/18/96 01/18/96 01/22/96 06/11/96 06/11/96 01/05/98 01/22/96 pt 06/11/96 01/22/96 pt 06/11/96 OFFICE: 40 01/24/96 170568 pt 06/11/96 06/11/96 01/05/98 01/24/96 pt 06/11/96 01/24/96 pt 06/11/96 01/24/96 pt 06/11/96 OFFICE: 40 01/25/96 170609 pt 06/11/96 06/11/96 01/05/98 01/25/96 pt 06/11/96 HUll, Lorraine T HUll, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 1125 PLAN 2 . POLICY #: GROUP # : FR: **/**/** TO:**/**/** BILL # DR. CPT/PROCEDURE 170206 pt pt pt pt pt OFFICE: 40 170410 pt CHECK #:PLAN PlI13E: 2 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS:7 DR:cho POS Q0103-PT Eval: Medicare,W/C,Auto - Initial 0 PAYMENT-THANK YOU 0000 QOl04-PT Eval: Medicare,W/c,Auto - Re-eval 0 97032-PT Electric Stirn, manual Each 15 Mins 0 99070A-Electrodes- Disposable 0 970l0-PT Hot/Cold Packs 0 Dx: 723l-cervicalagia/Cervic 306.00 97032-PT Electric Stirn, manual Each 15 Mins 0 PAYMENT-THANK YOU 37898933:US Healthcare 1125 Perferred Provider:Us Hea1thcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage 0 Perferred Provider:US Healthcare 1125 97010-PT Hot/Cold Packs 0 Perferred provider:us Hea1thcare 1125 Dx: 723l-cervicalagia/Cervic 15.00 97032-PT Electric Stirn, manual Each 15 Mins 0 PAYMENT-THANK YOU 37898933:US Healthcare 1125 Perferred provider:Us Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage 0 Perferred Provider:us Healthcare 1125 97010-PT Hot/Cold Packs 0 Perferred provider:Us Healthcare 1125 97012-PT Traction, Mechanical 0 Perferred Provider:Us Healthcare 1125 DX:7231-Cervicalagia/Cervic 15.00 97032-PT Electric Stim,manual Each 15 Mins 0 Perferred Provider:US Healthcare 1125 PAYMENT-THANK YOU 37898933:US Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage . 0 Perferred Provider:US 'Healthcare 1125 FR: TO: CHARGE 50.00 0.00 30.00 180.00 26.00 20.00 <------ 45.00 35.00- 10.00- 0.00 35.00 35.00- 20.00 5.00- <------ 90.00 50.00- 40.00- 0.00 35.00 35.00- 20.00 20.00- 35.00 20.00- <------ 180.00 130.00- 50.00- 0.00 35.00 35.00- '[ ledg'er] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 POLICY .:3ROUP Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PAGE: 3 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 :US Healthcare 1125 #:KGDR1020 # : FR: **/**/** TO: **/**/** PLAN 2 POLICY #: GROUP # : DATE 01/25/96 06/11/96 01/29/96 06/11/96 01/05/98 01/29/96 06/11/96 06/11/96 01/29/96 06/11/96 01/31/96 06/11/96 01/05/98 01/31/96 06/11/96 06/11/96 01/31/96 06/11/96 01/31/96 06/11/96 02/01/96 06/11/96 06/11/96 01/05/98 02/01/96 06/11/96 02/01/96 06/11/96 02/01/96 06/11/96 BILL # DR. CPT/PROCEDURE pt OFFICE: 40 170845 pt pt pt OFFICE: 40 170992 pt pt pt pt OFFICE: 40 171246 pt CHECK #:PLAN POS pt pt pt 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 1125 Ox: 7231-Cervicalagia/Cervic 97110--Physical Therapy, Initial (15) PAYMENT-THANK YOU 37898933:US Healthcare PAYMENT-THANK YOU 0000 97032-PT Electric stirn,rnanual Each 15 Mins 0 PAYMENT-THANK YOU 37898933:US Healthcare 1125 Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 1125 Ox: 7231-cervicalagia/Cervic 97110--Physical Therapy, Initial (15) PAYMENT-THANK YOU 37898933:US Healthcare PAYMENT-THANK YOU 0000 97032-PT Electric Stim,rnanual Each 15 Mins Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 37898933:US Healthcare 1125 97124-PT Massage 0 Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 1125 Ox: 7231-Cervicalagia/Cervic 97032-PT Electric stirn,rnanual Each 15 Mins Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 37898933:US Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 97110--Physical Therapy, Initial Perferred Provider:US Healthcare o 15.00 o 1125 o 15.00 o 1125 o o 15.00 o o o 1125 (15) 1125 o FR: TO: CHARGE 20.00 5.00- <------ 35.00 35.00- 0.00 180.00 15.00- 165.00- 20.00 5.00- <------ 35.00 35.00- 0.00 180.00 165.00- 15.00- 35.00 35.00- 20.00 5.00- <------ 180.00 130.00- 50.00- 0.00 35.00 35.00- 20.00 20.00- 35.00 20.00- '[ledger] Trindle Rehab Medicine Center PATIENT LEDGER PAGE: 4 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LsT PLN PAY:02/04/97 LsT PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY 3ROUP :US Healthcare 1125 #:KGDR1020 # : FR:**/**/** TO:**/**/** PLAN 2 POLICY #: GROUP # : DATE CHECK #: PLAN POS BILL # DR. CPT/PROCEDURE OFFICE: 40 02/05/96 171305 pt 06/11/96 06/11/96 01/05/98 02/05/96 06/11/96 02/05/96 06/11/% 02/07/96 06/11/96 01/05/98 02/07/96 06/11/96 06/11/96 02/07/96 06/11/96 02/07/96 06/11/96 02/12/96 06/11/96 01/05/98 02/12/96 06/11/96 06/11/96 02/12/96 06/11/96 02/12/96 06/11/96 pt pt OFFICE: 40 171997 pt pt pt pt OFFICE: 40 172027 pt pt pt pt OFFICE: 40 02/13/96 172044 pt DX:7231-cervicalagia/cervic 97032-PT Electric stirn, manual Each 15 Mins Perferred provider:Us Healthcare 1125 PAYMENT-THANK YOU'37898933:US Healthcare 1125 PAYMENT-THANK YOU 0000 97122-PT Traction, Manual, Each 15 Min Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs Perferred Provider:US Healthcare 1125 DX:7231-Cervicalagia/cervic 97012-PT Traction, Mechanical PAYMENT-THANK YOU 37898933:US Healthcare PAYMENT-THANK YOU 0000 97032-PT Electric stirn,rnanual Each 15 Mins Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 37898933:US Healthcare 1125 97124-PT Massage 0 Perferred provider:Us Healthcare 1125 97010-PT Hot/Cold Packs Perferred provider:Us Healthcare 1125 DX:7231-cervicalagia/Cervic 97012-PT Traction, Mechanical PAYMENT-THANK YOU 37898933:US Healthcare PAYMENT~THANK YOU 0000 97124-PT Massage 0 PAYMENT-THANK YOU 37898933:US Healthcare 1125 Perferred provider:Us Healthcare 1125 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 1125 97032-PT Electric stirn, manual Each 15 Mins Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 97032-PT Electric stirn,manual Each 15 Mins 15.00 o o o 15.00 o 1125 o o 15.00 o 1125 o o 15.00 o FR: TO: CHARGE <------ 180.00 130.00- 50.00- 0.00 30.00 30.00- 20.00 5.00- <------ 35.00 35.00- 0.00 180.00 165.00- 15.00- 35.00 35.00- 20.00 5.00- <------ 35.00 35.00- 0.00 35.00 15.00- 20.00- 20.00 20.00- 180.00 165.00- <------ 180.00 GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 '[ledg'er] Trindle Rehab Medicine Center PATIENT LEDGER PhGE: 5 -------------- Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 DATE : 07/13/98 0.0.B:07/19/36 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 OR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 1125 PLAN 2 : POLICY #: GROUP # : FR: TO: PLAN 1 POLICY GROUP . :US Healthcare 'j/: KGDR1020 # : FR:**/**/** TO:**/**/** DATE 06/11/96 06/11/96 01/05/98 02/13/96 06/11/96 02/13/96 06/11/96 02/13/96 06/11/96 02/15/96 06/11/96 06/11/96 01/05/98 02/15/96 06/11/96 02/15/96 06/11/96 02/15/96 06/11/96 02/19/96 06/11/96 06/11/96 01/05/98 02/19/96 06/11/96 02/19/96 06/11/96 02/19/96 06/11/96 02/20/96 BILL # ~ CPT/PROCEDURE CHECK #:PLAN POS CHARGE pt pt pt PAYMENT-THANK YOU 37898933:US Healthcare 1125 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 0 Perferred provider:US Healthcare 1125 97124-PT Massage 0 Perferred provider:US Healthcare 1125 97012-PT Traction, Mechanical 0 Perferred provider:US Healthcare 1125 Ox: 7231-cervicalagia/cervic 15.00 97032-PT Electric stim,manual Each 15 Mins 0 PAYMENT-THANK YOU 37898933:US Healthcare 1125 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 97010-PT Hot/cold Packs 0 Perferred Provider:US Healthcare 1125 97012-PT Traction, Mechanical 0 Perferred provider:US Healthcare 1125 97012-A-Traction - Pelvic - Mechanical 0 Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 15.00 .97032-PT Electric stirn, manual Each 15 Mins 0 PAYMENT-THANK YOU 37898933:US Healthcare 1125 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage 0 Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs 0 Perferred provider:US Healthcare 1125 97012-A-Traction - Pelvic - Mechanical 0 Perferred provider:US Healthcare 1125 DX:7231-Cervica1agia/cervic 15.00 97110--Physical Therapy, Initial (15) 0 50.00- 130.00- 0.00 20.00 20.00- 35.00 35.00- 35.00 20.00- <------ 180.00 50.00- 130.00- 0.00 20.00 20.00- 35.00 35.00- 45.00 30.00- <------ 180.00 50.00- 130.00- 0.00 35.00 35.00- 20.00 20.00- 45.00 30.00- <------ 35.00 OFFICE: 40 172109 pt pt pt pt OFFICE: 40 172217 pt pt pt pt OFFICE: 40 172309 pt GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $: 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED # 1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 [ ledger] Trindle Rehab Medicine Center PATIENT LEDGER Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PAGE: 6 DATE :07/13/98 D.O. B: 07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 :US Healthcare 1125 POLICY #:KGDR1020 :;ROUP # : PLAN 2 . FR:**/**/** POLICY #: TO:**/**/** GROUP #: OATE BILL # DR. CPT/PROCEDURE CHECK #: PLAN 01/23/97 01/05/98 02/20/96 01/23/97 01/23/97 02/20/96 01/23/97 02/20/96 01/23/97 02/21/96 01/23/97 01/23/97 01/05/98 02/21/96 01/23/97 02/21/96 01/23/97 02/26/96 01/23/97 01/23/97 01/05/98 02/26/96 01/23/97 02/26/96 01/23/97 02/26/96 01/23/97 02/27/96 01/23/97 01/05/98 OFFICE: 40 172420 pt OFFICE: 40 172656 pt OFFICE: 40 172749 pt PAYMENT-THANK YOU 39674836:US Healthcare 1125 PAYMENT-THANK YOU 0000 97032-PT Electric Stim,manual Each 15 Mins Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 39674836:US Healthcare 1125 97124-PT Massage 0 Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 15.00 97032~PT Electric Stim,manual Each 15 Mins 0 PAYMENT-THANK YOU 39674836:US Healthcare 1125 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 1125 97124-PT Massage Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/cervic 97032-PT Electric Stim,manual Each 15 Mins Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 39674836:US Healthcare 1125 PAYMENT-TfUlliK YOU 0000 97010-PT Hot/Cold Packs Perferred Provider:US Healthcare 1125 97124-PT Massage Perferred provider:US Healthcare 1125 97012-PT Traction, Mechanical Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 97110--Physical Therapy, Initial (15) PAYMENT-THANK YOU 39674836:US Healthcare PAYMENT-THANK YOU 0000 pt pt pt pt pt pt pt pt POS o o o o 15.00 o o o o 15.00 o 1125 FR: TO: CHARGE 35.00- 0.00 180.00 165.00- 15.00- 35.00 35.00- 20.00 5.00- <------ 180.00 50.00- 130.00- 0.00 20.00 20.00- 35.00 20.00- <------ 180.00 130.00- 50.00- 0.00 20.00 20.00- 35.00 35.00- 35.00 20.00- <------ 35.00 35.00- 0.00 , [ledger] Trindle Re~ab Medicine Center PATIENT LEDGER -' - ,-. .... .j. PJ\iGE: 7 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS:7 DR:cho Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY ::;ROUP :US Healthcare 1125 #:KGDR1020 FR:**/**/** #: TO:**/**/** PLAN 2 . POLICY #: GROUP # : DATE 02/27/96 01/23/97 01/23/97 02/27/96 01/23/97 02/27/96 01/23/97 02/28/96 01/23/97 01/23/97 01/05/98 02/28/96 01/23/97 02/28/96 01/23/97 03/04/96 01/23/97 01/23/97 01/05/98 03/04/96 01/23/97 03/04/96 01/23/97 03/04/96 01/23/97 03/06/96 01/23/97 01/23/97 01/05/98 03/06/96 CHECK #:PLAN POS BILL # DR. CPT/PROCEDURE pt pt OFFICE: 40 172825 pt OFFICE: 40 173263 pt OFFICE: 40 173331 pt pt 97032-PT Electric stim,manual Each 15 Mins 0 Perferred Provider:US Healthcare 1125 PAYMENT-THANK YOU 39674836:U8 Healthcare 1125 99070A-Electrodes- Disposable 0 Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs 0 Perferred provider:US Healthcare 1125 DX:723l-Cervicalagia/Cervic 15.00 97032-PT Electric Stim,manual Each 15 Mins 0 PAYMENT-THANK YOU 39674836:US Healthcare 1125 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 0 Perferred provider:US Healthcare 1125 97012-A-Traction - Pelvic - Mechanical 0 Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 15.00 97032-PT Electric stirn, manual Each 15 Mins 0 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 39674836:US Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage 0 Perferred provider:US Healthcare 1125 97010-PT Hot/cold Packs 0 Perferred provider:US Healthcare 1125 97012-A-Traction - Pelvic - Mechanical 0 Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 15.00 97032-PT Electric Stim,manua1 Each 15 Mins 0 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 39674836:US Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage 0 pt pt pt pt pt pt FR: TO: CHARGE 180.00 165.00- 15.00- 26.00 26.00- 20.00 5.00- <------ 180.00 50.00- 130.00- 0.00 20.00 20.00- 45.00 30.00- <------ 180.00 130.00- 50.00- 0.00 35.00 35.00- 20.00 20.00- 45.00 30.00- <------ 180.00 130.00- 50.00- 0.00 35.00 [ledger] Trindle Rehab Medicine Center PATIENT LEDGER PAGE: 8 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS:7 DR:cho Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST P~ PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 POLICY :;ROUP :US Healthcare #:KGDR1020 # : EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 1125 PLAN 2 . POLICY #: GROUP # : FR:**/**/** TO: **/**/** CHECK #:PLAN DATE BILL # DR. CPT/PROCEDURE 01/23/97 03/06/96 pt 01/23/97 03/06/96 pt 01/23/97 OFFICE: 40 03/11/96 173479 pt 01/23/97 01/05/98 03/11/96 pt 01/23/97 01/23/97 03/11/96 pt 01/23/97 OFFICE: 40 03/12/96 173675 pt 01/23/97 01/23/97 01/05/98 03/12/96 pt 01/23/97 03/12/96 pt 01/23/97 03/12/9,6 pt 01/23/97 OFFICE: 40 03/13/96 173698 pt 06/11/96 06/11/96 01/05/98 03/13/96 pt 06/11/96 03/13/96 pt POS Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 1125 97012-A-Traction - Pelvic - Mechanical Perferred provider:US Healthcare 1125 Ox: 7231-Cervicalagia/Cervic 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 39674836:US Healthcare PAYMENT-THANK YOU 0000 97032-PT Electric Stim,manua1 Each 15 Mins Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 39674836:US Healthcare 1125 97124-PT Massage 0 Perferred provider:US Healthcare 1125 Ox: 7231-Cervicalagia/Cervic 15.00 97032-PT Electric Stim,manual Each 15 Mins 0 PAYMENT-THANK YOU 39674836:US Healthcare 1125 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 97012-A-Traction - Pelvic - Mechanical Perferred provider:US Healthcare 1125 97124-PT Massage Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 1125 Ox: 7231-Cervicalagia/Cervic 97032-PT Electric stim,manual Each 15 Mins Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 37898933:US Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs o o 15.00 o 1125 o o o o 15.00 o o o FR: TO: CHARGE 35.00- 20.00 20.00- 45.00 30.00- <------ 20.00 20.00- 0.00 135.00 105.00- 30.00- 35.00 20.00- <------ 135.00 50.00- 85.00- 0.00 45.00 45.00- 35.00 35.00- 20.00 5.00- <------ 135.00 85.00- 50.00- 0.00 35.00 35.00- 20.00 '[ledger] Trindle Rehab Medicine Cente~ PATIENT LEDGER ------------_.- GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 ?LAN 1 ?OLICY ;ROUP JATE :>6/11/96 :>3/13/96 :>6/11/96 :>3/13/96 06/11/96 03/18/96 01/23/97 01/23/97 01/05/98 03/18/96 01/23/97 03/18/96 01/23/97 03/18/96 01/23/97 03/19/96 01/23/97 01/05/98 03/19/96 01/23/97 01/23/97 03/19/96 01/23/97 03/19/96 01/23/97 03/19/96 01/23/97 03/27/96 06/11/96 01/05/98 :US Healthcare #:KGDR1020 # : Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PAGE: 9 DATE : 07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 1125 PLAN 2 . POLICY #: GROUP # : FR: **/**/** TO:**/**/** BILL # DR. CPT/PROCEDURE OFFICE: 40 174034 pt pt pt pt OFFICE: 40 174291 pt pt pt pt pt OFFICE: 40 174518 pt CHECK #:PLAN POS pt pt Perferred Provider:US Hea1thcare 1125 97012-A-Traction - Pelvic - Mechanical Perferred Provider:US Healthcare 1125 97110--Physica1 Therapy, Initial (15) Perferred provider:US Healthcare 1125 DX:7231-Cervica1agia/Cervic 97032-PT Electric Stirn, manual Each 15 Mins Perferred Provider:us Healthcare 1125 PAYMENT-THANK YOU 39674836:US Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage Perferred Provider:Us Healthcare 1125 97010-PT Hot/Cold Packs Perferred Provider:Us Healthcare 1125 97012-A-Traction - pelvic - Mechanical Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 97110--PhysicalTherapy, Initial (15) PAYMENT-THANK YOU 39674836:US Healthcare PAYMENT-THANK YOU 0000 97l24-PT Massage 0 PAYMENT-THANK YOU 39674836:US Healthcare 1125 Perferred Provider:US Healthcare 1125 97012-A-Traction - Pelvic - Mechanical Perferred provider:Us Healthcare 1125 97032-PT Electric Stirn, manual Each 15 Mins Perferred Provider:US Healthcare 1125 97010-PT Hot/Cold Packs Perferred Provider:Us Healthcare 1125 DX:723l-Cervicalagia/Cervic 97010-PT Hot/Cold Packs . Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 o o 5.00 o o o o 15.00 o 1125 o o o 15.00 o FR: TO: CHARGE 20.00- 45.00 45.00- 35.00 30.00- <------ 135.00 85.00- 50.00- 0.00 35.00 35.00- 20.00 20.00- 45.00 30.00- <------ 35.00 35.00- 0.00 35.00 15.00- 20.00- 45.00 45.00- 135.00 135.00- 20.00 5.00- <------ 20.00 5.00- 0.00 , [ ledger] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 POLICY ;:;ROUP Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PhGE: 10 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 :US Healthcare 1125 #:KGDR1020 FR:**/**/** #: TO:**/**/** PLAN 2 : POLICY #: GROUP # : DATE 03/27/96 06/11/96 03/27/96 06/11/96 06/11/96 03/27/96 06/11/96 03/28/96 01/05/98 03/28/96 03/28/96 03/28/96 04/01/96 01/05/98 04/01/96 04/01/96 04/03/96 01/05/98 04/03/96 04/03/Q6 04/03/96 04/04/96 01/05/98 04/04/96 04/04/96 04/08/96 01/05/98 04/08/96 BILL # DR. CPT/PROCEDURE pt OFFICE: 40 174572 pt pt pt pt OFFICE: 40 174927 pt pt pt OFFICE: 40 174969 pt pt pt pt OFFICE: 40 175084 pt pt pt OFFICE: 40 175229 pt pt Q0104-PT Eval: Medicare,W/C,Auto - Re-eva1 Perferred Provider:US Healthcare 1125 Q0103-PT Eval: Medicare,W/C,Auto - Initial Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 37898933:US Healthcare 1125 97110--Physical Therapy, Initial (15) 0 Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97032-PT Electric stirn, manual Each 15 Mins 97110--Physical Therapy, Initial (15) 97012-A-Traction - Pelvic - Mechanical DX:7231-Cervicalagia/Cervic 97012-A-Traction - Pelvic - Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97032-PT Electric Stim,manual Each 15 Mins DX:7231-Cervicalagia/cervic 97012-A-Traction - Pelvic - Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/COld Packs 97032-PT Electric Stirn, manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min DX:7231-Cervicalagia/Cervic 97032-PT Electric stirn, manual Each 15 Mins PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97012-A-Traction - Pelvic - Mechanical DX:723l-Cervicalagia/cervic 97012-A-Traction - Pelvic - Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs CHECK #:PLAN pt pt POS o o 15.00 o o o o 235.00 o o o 200.00 o o o o 260.00 o o o 200.00 o o FR: TO: CHARGE 30.00 30.00- 50.00 20.00- 30.00- 70.00 70.00- <------ 20.00 0.00 135.00 35.00 45.00 <------ 45.00 0.00 20.00 135.00 <------ 45.00 0.00 20.00 135.00 60.00 <------ 135.00 0.00 20.00 45.00 <------ 45.00 0.00 20.00 '[ledger] Trindle Rehab Medicine Center PATIENT LEDGER Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED..J!.l Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 .-.... .. "", ..~" ... PAGE: 11 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 :US Healthcare 1125 POLICY .'#: KGDRI020 3ROUP # : FR:**/**/** TO:**/**/** PLAN 2 POLICY #: GROUP # : DATE BILL # DR. CPT/PROCEDURE CHECK #:PLAN 04/08/96 pt 04/08/96 pt OFFICE: 40 04/09/96 175236 pt 01/05/98 04/09/96 pt 04/09/96 pt 04/09/96 pt OFFICE: 40 04/10/96 175262 pt 01/05/98 04/10/96 pt 04/10/96 pt 04/10/96 pt OFFICE: 40 04/17/96 176044 pt 01/05/98 04/17/96 pt 04/17/96 pt OFFICE: 40 04/18/96 176060 pt 01/05/98 04/18/96 pt 04/18/96 pt OFFICE: 40 04/24/96 176281 pt 01/05/98 04/24/96 pt 04/24/96 pt 04/24/96 pt OFFICE: 40 04/30/96 176607 pt 01/05/98 97032-PT Electric Stirn, manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min DX:7231-Cervicalagia/Cervic 97035-PT Ultrasound, Each 15 Min PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97032-PT Electric Stim,manual Each 15 DX:7231-Cervicalagia/Cervic 97032-PT Electric stirn, manual Each 15 PAYMENT-THANK YOU 0000- 97035-PT Ultrasound, Each 15 Min 97012-A-Traction - Pelvic - Mechanical 97010-PT Hot/Cold Packs Ox: 7231-Cervicalagia/Cervic 97035-PT Ultrasound, Each 15 Min PAYMENT-THANK YOU 0000 97032-PT Electric Stirn, manual Each 15 97010-PT Hot/Cold Packs DX:7231-cervica1agia/Cervic 97035-PT Ultrasound, Each 15 Min PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs . 97032-PT Electric Stirn, manual Each 15 Mins DX:7231-Cervicalagia/Cervic 97110--Physical Therapy, Initial (15) PAYMENT-THANK YOU 0000 97018-PT Paraffin Bath, Fluidotherapy 97010-PT Hot/Cold Packs 97032-PT Electric stirn, manual Each 15 Mins Dx:7231-Cervica1agia/Cervic 97032-PT Electric Stim,manual Each 15 Mins PAYMENT-THANK YOU 0000 POS o o 260.00 o 0 0 Mins 0 250.00 Mins 0 0 0 0 260.00 0 Mins 0 0 215.00 0 o o 260.00 o o o o 275.00 o FR: TO: CHARGE 135.00 60.00 <------ 60.00 0.00 20.00 35,00 135.00 <------ 135.00 0.00 60.00 45.00 20.00 <------ 60.00 0.00 135.00 20.00 <------ 60.00 0.00 20.00 180.00 <------ 35.00 0.00 40.00 20.00 180.00 <------ 180.00 0.00 [ledger] Trindle Rehab Medicine Center PATIENT LEDGER --------------- PAGE: 12 DATE :07/13/98 0.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, .'Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF 00CTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY 3ROUP :US Healthcare 1125 #:KGDRl020 # : FR: **/**/** TO: **/**/** PLAN 2 : POLICY #: GROUP # : DATE BILL t DR. CPT/PROCEDURE CHECK #:PLAN 04/30/96 04/30/96 04/30/96 05/01/96 01/05/98 05/01/96 05/01/96 05/01/96 pt pt pt OFFICE: 40 176926 pt pt pt pt 40 pt pt pt pt 40 rb OFFICE: 05/06/96 176933 01/05/98 05/06/96 05/06/96 05/06/96 OFFICE: OS/20/96 178128 01/05/98 OS/20/96 OS/20/96 OS/20/96 OFFICE: OS/23/96 178138 01/05/98 OS/23/96 OFFICE: OS/23/96 178904 01/05/9? OS/22/96 OS/22/96 OS/22/96 OS/23/96 OS/23/96 rb rb rb 40 rb 97035-PT Ultrasound, Each 15 Min 97010-PT Hot/Cold Packs 97018-PT Paraffin Bath, Fluidotherapy DX:7231-Cervicalagia/cervic 97032-PT Electric stirn, manual Each 15 Mins PAYMENT-THANK YOU 0000 97035-PT ultrasound, Each 15 Min 97018-PT Paraffin Bath, Fluidotherapy 97010-PT Hot/Cold Packs DX:7231-Cervicalagia/cervic 97032-PT Electric stirn, manual Each 15 Mins PAYMENT-THANK YOU 0000 97035-PT Ultrasound, Each 15 Min 97018-PT Paraffin Bath, Fluidotherapy 97010-PT Hot/Cold Packs DX:7231-cervicalagia/Cervic Q0103-PT Eval: Medicare,W/C,Auto - Initial PAYMENT-THANK YOU 0000 97032-PT Electric stirn, manual Each 15 Mins Q0104-PT Eval: Medicare,W/C,Auto - Re-eval 97010-PT Hot/Cold Packs DX:8470-Cervical sprain/str 97032-PT Electric stirn, manual Each 15 Mins PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs DX:8470-Cervical sprain/str 97032-PT Electric Stirn, manual Each 15 Mins PAYMENT-THANK YOU 0000 97018-PT Paraffin Bath, Fluidotherapy 97010-PT Hot/Cold Packs 97032-PT Electric stirn, manual Each 15 Mins 970l8-PT paraffin Bath, Fluidotherapy 97010-PT Hot/cold Packs rb 40 rb rb rb rb rb rb POS o o o 270.00 o o o o 270.00 o o o o 270.00 o o o o 260.00 o o 110.00 o o o o o o FR: TO: CHARGE 30.00 20.00 40.00 <------ 180.00 0.00 30.00 40.00 20.00 <------ 180.00 0.00 30.00 40.00 20.00 <------ 50.00 0.00 90.00 100.00 20.00 <------ 90.00 0.00 20.00 <------ 70.00 0.00 35.00 60.00 140.00 35.00 30.00 [ledger] Trindle Re~ab Metlicine Center PATIENT LEDGER -------------- GUARANTOR #:hu1110-03 PATIENT #:hul11o-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1., : US Heal thcare POLICY ff:KGDR1020 3ROUP # : DATE OS/28/96 01/05/98 OS/28/96 OS/29/96 OS/29/96 OS/29/96 OS/28/96 05/31/96 01/05/98 05/31/96 05/31/96 06/03/96 01/05/98 06/03/96 06/03/96 06/05/96 01/05/98 06/05/96 06/05/96 06/07/96 01/05/98 06/07/96 06/07/96 06/10/96 01/05/98 06/10/96 06/10/96 1125 PLAN 2 POLICY #: GROUP # : FR: **/**/** TO: **/**/** BILL # DR~ CPT/PROCEDURE OFFICE: 40 178905 rb rb rb rb rb rb OFFICE: 40 178906 rb rb rb OFFICE: 40 179189 rb rb rb OFFICE: 40 179249 rb rb rb OFFICE: 40 179281 rb rb rb OFFICE: 40 179408 rb CHECK #: PLAN rb rb DX:8470-Cervica1 Sprain/str 97032-PT Electric Stim,manual Each 15 Mins PAYMENT-THANK YOU 0000 97110-PT Therapeutic Exercise, Each 15 Min 97018-PT Paraffin Bath, Fluidotherapy 97010-PT Hot/Cold Packs 97032-PT Electric Stim,manua1 Each 15 Mins 97010-PT Hot/Cold Packs DX:8470-Cervica1 Sprain/str 97018-PT Paraffin Bath, Fluidotherapy PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97032-PT Electric Stim,manua1 Each 15 Mins DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97018-PT Paraffin Bath, F1uidotherapy 97014-PT Electric Stim,unattended nx:8470-Cervica1 Sprain/str 970l0-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97014-PT Electric stim,unattended 97018-PT Paraffin Bath, Fluidotherapy DX:8470-Cervical Sprain/str 97018-PT Paraffin Bath, Fluidotherapy PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97014-PT Electric stim,unattended DX:8470-Cervica1 Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97014-PT Electric Stim,unattended 97018-PT Paraffin Bath, Fluidotherapy P1(GE: 13 DATE :07/13/98 D. O. B: 07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho FR: TO: POS CHARGE 370.00 <------ 0 140.00 0.00 0 35.00 0 35.00 0 60.00 0 140.00 0 60.00 470.00 <------ 0 35.00 0.00 0 60.00 0 140.00 235.00 <------ 0 60.00 0.00 0 35.00 0 140. 00 235.00 <------ 0 60.00 0.00 0 140.00 0 35.00 235.00 <------ 0 35.00 0.00 0 60.00 0 140.00 235.00 <------ 0 90.00 0.00 0 140.00 0 35.00 GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 . INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 '[ledger] Trindle Retlab Medicine Center PATIENT LEDGER -------------- Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PAGE: 14 DATE : 07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPL't': S S #:194-28-8043 CLASS:7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 :US Healthcare 1125 POLICY #:KGDR1020 3ROUP # : DATE PLAN 2 : FR:**/**/** POLICY #: TO:**/**/** GROUP #: FR: TO: POS 265.00 0 0 0 235.00 0 0 0 235.00 0 0 175.00 0 0 0 235.00 0 Min 0 105.00 0 BILL # DR. CPT/PROCEDURE CHECK #:PLAN OFFICE: 40 06/17/96 179751 rb Jl/05/98 06/17/96 rb 06/17/96 rb 40 rb OFFICE: 06/19/96 179903 01/05/98 06/19/96 06/19/96 OFFICE: 06/21/96 179948 01/05/98 06/21/96 OFFICE: 06/24/96 180106 01/05/98 06/24/96 06/24/96 OFFICE: 06/26/96 180156 01/05/98 06/26/96 OFFICE: 06/28/96 180514 01/05/98 06/28/96 OFFICE: 07/01/96 180685 01/05/98 07/01/96 OFFICE: 07/03/96 180722 rb rb 40 rb DX:8471-Thoracic Sprain 97014-PT Electric Stirn, unattended PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97033-PT Iontophoresis DX:8471-Thoracic Sprain 97018-PT Paraffin Bath, F1uidotherapy PAYMENT-THANK YOU 0000 97010-PT Hot/cold Packs 97014-PT Electric Stirn, unattended DX:8471-Thoracic Sprain 97018-PT Paraffin Bath, F1uidotherapy PAYMENT-THANK YOU 0000 97014-PT Electric Stirn, unattended DX:8471-Thoracic Sprain 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97014-PT Electric Stirn, unattended 97033-PT Iontophoresis DX:8471-Thoracic Sprain 97018-PT Paraffin Bath, Fluidotherapy PAYMENT-THANK YOU 0000 97110-PT Therapeutic Exercise, Each 15 DX:8471-Thoracic Sprain 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97110-PT Therapeutic Exercise, Each 15 Min Dx:8471-Thoracic Sprain 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97110-PT Therapeutic Exercise, Each 15 Min DX:8471-Thoracic Sprain 97110-PT Therapeutic Exercise, Each 15 Min o 65.00 o rb 40 rb rb rb 40 rb rb 40 rb rb 40 rb o 65.00 o rb 40 rb gHARGE <------ 140.00 0.00 60.00 35.00 <------ 35.00 0.00 60.00 140.00 <------ 35.00 0.00 140.00 <------ 60.00 0.00 140.00 35.00 <------ 35.00 0.00 70.00 <------ 30.00 0.00 35.00 <------ 30.00 0.00 35.00 <------ 35.00 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS:7 DR:cho '[ ledger] Trindle Rehab Medicine Center PATIENT LEDGER -------------- GUARANTOR #:hUlllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT: **/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: O. 00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 HUll, Lorraine T HUll, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY ::;ROUP :US Healthcare 1125 PLAN 2 : #:KGDR1020 FR:**/**/** POLICY #: #: TO:**/**/** GROUP #: DATE BILL # DR. CPT/PROCEDURE CHECK #:PLAN POS 01/05/98 PAYMENT-THANK YOU 0000 07/03/96 rb 97010-PT Hot/Cold Packs 0 OFFICE: 40 DX:8471-Thoracic Sprain 65.00 07/05/96 180737 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 01/05/98 PAYMENT-THk~K YOU 0000 07/05/96 rb 97010-PT Hot/Cold Packs 0 OFFICE: 40 DX:8471-Thoracic Sprain 100.00 07/08/96 180904 rb 97010-PT Hot/Cold Packs 0 01/05/98 PAYMENT-THANK YOU 0000 07/08/96 rb 97110-PT Therapeutic Exercise, Each ].5 Min 0 OFFICE: 40 DX:8471-Thoracic Sprain 65.00 07/10/96 180955 rb 97010-PT Hot/Cold Packs 0 01/05/98 PAYMENT-THANK YOU 0000 07/10/96 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 OFFICE: 40 DX:8471-Thoracic Sprain 65.00 07/12/96 181160 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 01/05/98 PAYMENT-THANK YOU 0000 07/12/96 rb 97010-PT Hot/Cold Packs 0 OFFICE: 40 DX:8471-Thoracic Sprain 65.00 07/15/96 181306 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 01/05/98 PAYMENT-THANK YOU 0000 07/15/96 rb 97010-PT Hot/Cold Packs 0 OFFICE: 40 DX:8471-Thoracic Sprain 65.00 07/17/96 181452 rb 97010-PT Hot/Cold Packs 0 01/05/98 PAYMENT-THANK YOU 0000 07/17/96 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 OFFICE: 40 DX:8471-Thoracic Sprain 65.00 07/19/96 181501 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 01/05/98 PAYMENT-THANK YOU 0000 07/19/96 rb 97010-PT Hot/Cold Packs 0 I Payment Notes: Patient received settlement OFFICE: 40 DX:8471-Thoracic Sprain 65.00 PAGE: 15 FR: TO: CHARGE 0.00 30.00 <------ 70.00 0.00 30.00 <------ 30.00 0.00 35.00 <------ 30.00 0.00 35.00 <------ 35.00 0.00 30.00 <------ 35.00 0.00 30.00 <------ 30.00 0.00 35.00 <------ 35.00 0.00 30.00 I <------ GUARANTOR #:hulllo-oO PATIENT #:hulllo-OO ASSIGNMENT :yes-yes LAST PAY DT:08/07/96 LAST PAY $: 200.00 LST PLN PAY:05/15/95 LST PLAN $: 125.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 . . [ledger] PLAN 1 POLICY GROUP DATE 11/30/94 01/05/98 12/08/94 01/05/98 12/08/94 12/08/94 12/28/94 01/05/98 12/28/94 01/26/95 01/05/98 02/16/95 01/05/98 03/01/95 01/05/98 03/09/95 01/05/98 03/09/95 03/09/95 Rehab Medicine ~ssoc,Mechbrg PATIENT LEDGER -------------- Hull, Lorraine T HUll, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:479 Young, William W INSURED #2 :Attorney Angio & #:194288043 # : Rovner FR: **/**/** TO: **/**/** PLAN 2 : POLICY #: GROUP # : BILL # DR. CPT/PROCEDURE CHECK #:PLAN 150577 cho OFFICE: 30 154385 cho 99214-0V L3, Subsequent PAYMENT-THANK YOU 0000 DX:8470-Cervica1 Sprain/str 95904-Sensory NCV, Each Nerve rt median/ulnar/radial PAYMENT-THANK YOU 0000 95900-Motor NCV Each Nerve Without F-wave rt median/ulnar 95860-EMG- One Extremity RUE DX:8470-Cervica1 Sprain/str 20610-Arthrocentesis-Mjr.Jt.,hip,shldr It knee PAYMENT-THANK YOU 0000 99213-0V L2, Subsequent DX:8470-Cervical Sprain/str 99214-0V L3, Subsequent PAYMENT-THANK YOU 0000 Dx:8470-Cervical Sprain/str 99214-0V L3, Subsequent PAYMENT-THANK YOU 0000 DX:723.4-Cervical/upper Lim 99214-0V L3, Subsequent PAYMENT-THANK YOU 0000 DX:723.4-cervical/upper Lim 95904-Sensory NCV, Each Nerve bil median/ulnar/radial PAYMENT-THANK YOU 0000 95900-Motor NCV Each Nerve Without F-wave bil median/ulnar 95861-EMG- Two Extremities BUE DX:723.4-Cervical/upper Lim OFFICE: 30 151161 gri gri gri OFFICE: 30 151844 cho cho OFFICE: 30 153245 cho OFFICE: 30 155271 cho OFFICE: 30 155858 gri gri gri OFFICE: 30 PAGE: 2 DATE :07/13/98 D. O. B: 07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #: 194-28-8043 CLASS: II DR:cho FR: TO: POS CHARGE 3 60.00 0.00 60.00 <------ 3 180.00 0.00 3 120.00 3 200.00 500.00 <------ 3 70.00 0.00 3 40.00 110.00 <------ 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 360.00 0.00 3 240.00 3 300.00 900.00 <------ . . [ledger] Rehab Medidine Assoc,Mechbrg PATIENT LEDGER -------------- GUARANTOR #:hu11lo-00 PATIENT #:hull1o-00 ASSIGNMENT :yes-yes LAST PAY DT:08/07/96 LAST PAY $: 200.00 LST PLN PAY: 05/15/95 LST PLAN $: 125.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:479 Young, William W INSURED #2 PLAN 1 POLICY GROUP :Attorney Angio & #:194288043 # : PLAN 2 : POLICY #: GROUP #: Rovner FR:**/**/** TO:**/**/** DATE BILL # DR. CPT/PROCEDURE CHECK #:PLAN 03/22/95 156137 cho 99214-0V L3, subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:723.4-cervical/upper Lim 04/11/95 157292 cho 99214-0V L3, subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-Cervica1agia/Cervic 05/03/95 158312 cho 99214-0V L3, subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-cervica1agia/Cervic 06/16/95 159973 cho 99214-0V L3, subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-Cervicalagia/cervic 07/19/95 161811 cho 99214-0V L3, subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-cervica1agia/Cervic 08/04/95 162722 cho 99214-0V L3, subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-Cervica1agia/Cervic 08/30/95 163740 cho 99214-0V L3, subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-cervica1agia/Cervic 09/29/95 165427 cho 99214-0V L3, subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-Cervica1agia/Cervic 11/26/96 188516 cho 09102-Medica1 Records ( initial Chg) 01/05/98 PAYMENT-THANK YOU 0000 I Payment Notes: pt recieved settlement OFFICE: 30 DX:723l-cervicalagia/Cervic 'o. PAGE: 3 DATE : 07/13/98 D.O.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: POS CHARGE 3 60.00 0.00 60.00 <-----.. 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 17.25 0.00 I 17.25 <------ I .1 'I , , ;1 " , I I I j' . . (ledger] Rehab Medi6ine hssoc,Mechbrg PATIENT LEDGER GUARANTOR #:hulllo-OO Hull, Lorraine T PATIENT #:hulllo-OO Hull, Lorraine T ASSIGNMENT :yes-yes 5235 Meadowbrook Drive LAST PAY DT:08/07/96 Mechanicsburg, PA 17055 LAST PAY $ . 200.00 . LST PLN PAY:05/15/95 EMPLOYER NAME: LST PLAN $ : 125.00 REF DOCTOR:479 Young, William W AT COLLECTN: 0.00 INSURED #1 INSURED #2 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 :Attorney Angio & Rovner PLAN 2 . . POLICY #:194288043 FR:**/**/** POLICY #: 3ROUP #: TO: **/**/** GROUP #: DATE BILL # DR. CPT/PROCEDURE CHECK #: PLAN pAGE: 4 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: POS CHARGE Last statement printed on 06/30/98 for 2447.25 Balance for Hull, Lorraine T 2247.25 Balance for Plan 0.00 Patient Plan CURRENT 0.00 0.00 031-060 0.00 0.00 061-090 0.00 0.00 091-120 0.00 0.00 120+ 2247.25 0.00 :':o- r--. , ~ ,':: '" I::; '. .. , " ' ) C\J ~ :- (. , .' !! -' ::::' (. '-.. ';~~-:! 1 C);: (0 (":/} (i;;' I.., , l)) ;' ,I'i''::'~ '- ,: !.u :~}O:I w.. 0,.;,; I I. CJ'I ::s c., 0'\ 0 . .. A.) '..f, l 0'\) \ '--:::r' r:') [\~:..., ~--':';I-,. ,~ \ <~~ c\~ -- \ ?! ,J IX:) " "'J r-I -\),~ ~ " ~\ . '~ ~~ G: .~;.... 0< ;; fJl ~ " ,. ~ ~ ~ ~ ~ ~ :i ~ > ~ - ~ ' < i: Ul H ~ ~ z ~ _ Z >< z. g ~ ~ " 0 .t 0 :tl .J '" ~ ~ ~ ~ g ;: v " .... ~ ~ ~ ~ ~. [ledger] GUARANTOR #:hulllo-01 ~ATIENT #:hu111o-01 ASSIGNMENT :yes-yes LA~T PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 POLICY :;ROUP :lATE 11/28/94 01/05/98 11/28/94 11/28/94 11/28/94 11/29/94 01/05/98 11/29/94 11/29/94 11/29/9.4 12/01/94 01/05/98 12/01/94 12/01/94 12/01/94 12/05/94 01/05/98 12/05/94 12/05/94 12/05/94 12/06/94 01/05/98 12/06/94 12/06/94 12/09/94 01/05/98 12/09/94 12/09/94 :Attorney Angio & #:194288043 # : ~w~ r Center ~ PAGE: rr Trind1e Rehab Medicine PATIENT LEDGER Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED Rovner FR: **/**/** TO: **/**/** PLAN 2 : POLICY #: GROUP # : BILL # DR. CPT/PROCEDURE 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97128-01d Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97022-PT Whirlpool 97128-01d Code-Do Not Use 97110--Physical Therapy, Initial Dx:B470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97128-01d Code-Do Not Use 971l0--Physical Therapy, Initial Dx:B470-Cervical Sprain/str 97010'-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97128-01d Code-Do Not Use 97110--Physica1 Therapy, Initial Dx:B470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97128-01d Code-Do Not Use Dx:B470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 9 ~ ld Code-Do Not Use 150480 pt pt pt pt OFFICE: 40 150605 pt pt pt pt OFFICE: 40 150930 pt pt pt pt OFFICE: 40 15096B pt pt -~ P'- pt OFFICE: 40 150991 pt pt pt OFFICE: 40 151058 pt CHECK #:PLAN 1 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho #2 1{J9)~ (15) FR: TO: POS CHARGE 0 20.00 0.00 0 35.00 0 60.00 0 70.00 185.00 <------ 0 20.00 0.00 0 20.00 0 60.00 0 70.00 170.00 <------ 0 20.00 0.00 0 35.00 0 60.00 0 70.00 185.00 <------ 0 20.00 0.00 0 35.00 0 60.00 0 70.00 185.00 <------ 0 20.00 0.00 0 35.00 0 60.00 115.00 <-.----- 0 40.00 0.00 0 35.00 0 60.00 (15) (15) (15) [ledger] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hulllo-01 PATIEN~ #:hulllo-OI ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 L5T PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 HUll, Lorraine T HUll, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY ':;ROUP :Attorney Angio & #:194288043 # : Rovner FR: **/**/** TO: **/**/** PLAN 2 POLICY #: GROUP # : DATE BILL # DR. CPT/PROCEDURE CHECK #:PLl\N 12/09/94 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 12/12/94 151145 pt 97010-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/12/94 pt 97124-PT Massage 12/12/94 pt 97128-0ld Code-Do Not Use 12/12/94 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 12/13/94 151250 pt 97010-PT Hot/cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/13/94 pt 97l24-PT Massage 12/13/94 pt 97l28-01d Code-Do Not Use 12/13/94 pt 97ll0--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 12/15/94 151315 pt 970l0-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/15/94 pt 97124-PT Massage 12/15/94 pt 97128-01d Code-Do Not Use 12/15/94 pt 97l10--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 12/19/94 151532 pt 97010-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/19/94 pt 97124-PT Massage 12/19/94 pt 97128-01d Code-Do Not Use 12/19/94 pt 97145-Physical Therapy 1 Area Each 15 Min 12/19/94 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 12/20/94 151606 pt 97010-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/20/94 pt 97124-PT Massage 12/20/94 pt 97128-01d Code-Do Not Use 12/20/94 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str PAGE: 2 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: 1'05 CHARGE 0 70.00 205.00 <------ 0 20.00 0.00 0 35.00 0 60.00 0 70.00 185.00 <------ 0 40.00 0.00 0 35.00 0 60.00 0 70.00 205.00 <------ 0, 20.00 0.00 0 35.00 0 60.00 0 70.00 185.00 <------ 0 40.00 0.00 0 35.00 0 60.00 0 30.00 0 70.00 235.00 <------ 0 20.00 0.00 0 35.00 0 60.00 0 70.00 185;00 <------ [ledger] Trind1e Rehab Medicine Center PATIENT LEDGER -------------- GUARANTOR #:hulllo-01 PATIENT #:hulllo-01 ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, pA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY ':;ROUP :Attorney Angio & #:194288043 # : PLAN 2 : POLICY #: GROUP # : Rovner FR: **/**/** TO: **/**/** DATE BILL # DR. CPT/PROCEDURE CHECK # : PLAN 12/22/94 151723 pt 97010-pT Hot/cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/22/94 pt 97l24-PT Massage 12/22/94 pt 97128-01d Code-Do Not Use 12/22/94 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 12/28/94 151933 pt 97012-pT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 12/28/94 pt 97010-pT Hot/Cold Packs 12/28/94 pt 99070A-E1ectrodes- Disposable 12/28/94 pt 97118-PT Therapeutic Exercise 12/28/94 pt 97128-01d Code-Do Not Use OFFICE: 40 DX:8470-Cervical Sprain/str 12/29/94 151961 pt 97010-PT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 12/29/94 pt 97118-pT Therapeutic Exercise 12/29/94 pt 97128-01d Code-Do Not Use 12/29/94 pt 97145-Physical Therapy 1 Area Each 15 Min 12/29/94 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 Dx:8470-Cervical Sprain/str 01/03/95 152207 pt 97010-pT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 01/03/95 pt 97118-pT Therapeutic Exercise 01/03/95 pt 97128-01d Code-Do Not Use OFFICE: 40 DX:8470-Cervical Sprain/str 01/04/95 152229 pt 97010-pT Hot/Cold Packs 01/05/98 PAYMENT-THANK YOU 0000 01/04/95 pt 97118-PT Therapeutic Exercise 01/04/95 pt 97128-01d Code-Do Not Use 01/04/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 01/05/95 152243 pt 97010-PT Hot/Cold Packs Ol/05/98 PAYMENT-THANK YOU 0000 PAGE: 3 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS:11 DR:cho FR: TO: POS CHARGE 0 40.00 0.00 0 35.00 0 60.00 0 70.00 205.00 <------ 0 35.00 0.00 0 40.00 0 52.00 0 90.00 0 60.00 277 . 00 <------ 0 20.00 0.00 0 90.00 0 60.00 0 60.00 0 70.00 300.00 <------ 0 20.00 0.00 0 45.00 0 30.00 95.00 <------ 0 40.00 0.00 0 90.00 0 60.00 0 35.00 225.00 <------ 0 40.00 0.00 [ledger] Trindle Rehab Medicine Center PATIENT LEDGER -------------- HUll, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 GUARANTOR #:hu1Ilo-01 PATIENr #:hulllo-Ol ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY .:;ROUP :Attorney Angio & #:194288043 #: Rovner FR:**/**/** TO: **/**/** PLAN 2 : POLICY #: GROUP # : DATE 01/05/95 01/05/95 01/05/95 01/09/95 01/05/98 01/09/95 01/09/95 01/09/95 01/09/95 01/10/95 01/05/98 01/10/95 01/10/95 01/10/95 01/12/95 01/05/98 01/12/95 01/12/95 01/12/95 01/12/95 01/16/95 01/05/98 01/16/95 01/16/95 01/16/95 01/16/95 01/17/95 01/05/98 BILL # DR. CPT/PROCEDURE CHECK #:PLAN pt pt pt OFFICE: 40 152351 pt pt pt pt pt OFFICE: 40 152366 pt pt pt pt OFFICE: 40 152501 pt pt pt pt pt OFFICE: 40 152703 pt pt pt pt pt OFFICE: 40 152799 pt 97118-PT Therapeutic Exercise 97128-01d Code-Do Not Use 97110--Physica1 Therapy, Initial DX:8470-Cervica1 Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97128-01d Code-Do Not Use 97110--Physical Therapy, Initial Dx:8470-Cervica1 sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK yOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97128-0ld Code-Do Not Use DX:8470-Cervical sprain/str 97010-PT Hot/cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 9711U-?T Therapeutic Exercise 97128-0ld Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 971l8-PT Therapeutic Exercise 97128-0ld Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical sprain/str 97010-PT Hot/cold Packs PAYMENT-THANK YOU 0000 (15) (15) PAGE: 4 DATE :07/13/98 D.O.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: POS o o o 260.00 o o o o o 295.00 o o o o 225.00 o (15) o o o o 260.00 o (15) o o o o 260.00 o CHARGE 90.00 60.00 70.00 <------ 40.00 0.00 35.00 90.00 60.00 70.00 <------ 40.00 0.00 35.00 90.00 60.00 <------ 40.00 0.00 35.00 90.00 60.00 35.00 <------ 40.00 0.00 35.00 90.00 60.00 35.00 <------ 40.00 0.00 [ledger] Trindle Rehab Medicine Center PATIENT LEDGER -------------- GUARANTOR #:hulllo-Ol PATIENT #:hull1o-01 ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: . 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 POLICY ':;ROUP Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 :Attorney Angio & #:194288043 # : PLAN 2 POLICY #: GROUP # : DATE 01/17/95 01/17/95 01/17/95 01/17/95 01/19/95 01/05/98 01/19/95 01/19/95 01/19/95 01/23/95 01/05/98 01/23/95 01/23/95 01/23/95 01/23/95 01/24/95 01/05/98 01/24/95 01/24/95 01/24/95 01/26/95 01/05/98 01/26/95 01/26/95 01/26/95 01/30/95 01/05/98 01/30/95 Rovner FR:**/**/** TO:**/**/** BILL # DR. CPT/PROCEDURE pt pt pt pt OFFICE: 40 152934 pt pt pt pt OFFICE: 40 153051 pt pt pt pt pt OFFICE: 40 153208 pt pt pt pt OFFICE: 40 153294 pt pt pt pt OFFICE: 40 153463 pt pt CHECK #:PLAN 97124-PT Massage 97118-PT Therapeutic Exercise 97128-01d Code-Do Not Use 97110'--Physica1 Therapy , Initial DX:S470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97128-01d Code-Do Not Use DX:S470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97128-0ld Code-Do Not Use 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 971lS-PT Therapeutic Exercise 97110--Physical Therapy, Initial Dx:S470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physical Therapy, Initial DX:S470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs (15) (15) (15) (15) PAGE: 5 DATE : 07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho POS o o o o 260.00 o o o o 225.00 o o o o o 260.00 o o o o 170.00 o o o o 180.00 o o FR: TO: CHARGE 35.00 90.00 60.00 35.00 <------ 40.00 0.00 35.00 90.00 60.00 <------ 40.00 0.00 35.00 90.00 60.00 35.00 <------ 20.00 0.00 35.00 45.00 70.00 <------ 20.00 0.00 35.00 90.00 35.00 <------ 35.00 \0.00 40.00 [ledger] Trindle Rehab Medicine Center PATIENT LEDGER -------------- Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 GUARANTOR #:hulllo-01 PATIENT #:hulllo-Ol ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY ':;ROUP :Attorney Angio & #:194288043 Rovner FR: **/**/** TO: **/**/** PLAN 2 : POLICY #: GROUP # : DATE 01/30/95 01/30/95 01/30/95 01/31/95 01/05/98 01/31/9'5 01/31/95 01/31/95 01/31/95 02/02/95 01/05/98 02/02/95 02/02/95 02/02/95 02/02/95 02/06/95 01/05/98 02/06/95 02/06/95 02/06/95 02/06/95 02/07/95 01/05/98 02/07/95 02/07/95 02/07/95 02/07/95 02/09/95 # : BILL # ~ CPT/PROCEDURE CHECK #: PLAN pt pt pt OFFICE: 40 153575 pt pt pt pt pt OFFICE: 40 153757 pt pt pt pt pt OFFICE: 40 153824 pt pt pt pt pt OFFICE: 40 153875 pt pt pt pt pt OFFICE: 40 153979 pt 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physical Therapy, Initial DX:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physical Therapy, Initial DX:8470-Cervical sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physical Therapy, Initial Dx:8470-Cervical sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physical Therapy, Initial Dx:8470~Cervical sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97118-PT Therapeutic Exercise 97110--Physical Therapy, Initial DX:8470-Cervical sprain/str 97012-PT Traction, Mechanical (15) (15) (15) (15) ( 15) PAGE: 6 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: POS, o o o 190.00 o o o o o 190.00 o o o o o 190.00 o o o o o 190.00 o o o o o 190.00 o CHARGE 35.00 45.00 35.00 <------ 35.00 0.00 40.00 35.00 45.00 35.00 <------ 35.00 0.00 40.00 35.00 45.00 35.00 <------ 35.00 0.00 40.00 35.00 45.00 35.00 <------ 35.00 0.00 40.00 35.00 45.00 35.00 <------ 35.00 [ledger] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hulllo-Ol PATIENT #:hulllo-01 ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY ':;ROUP :Attorney Angio & #: 194288043 # : PLAN 2 : POLICY #: GROUP # : Rovner FR:**/**/** TO: **/**/** DATE BILL # DR. CPT/PROCEDURE CHECK #:P~N 01/05/98 PAYMENT-THANK YOU 0000 02/09/95 pt 97010-PT Hot/Cold Packs 02/09/95 pt 97118-PT Therapeutic Exercise 02/09/95 pt 97110--physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 02/13/95 154287 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/13/95 pt 97010-PT Hot/Cold Packs 02/13/95 pt 97124-PT Massage 02/13/95 pt 97118-PT Therapeutic Exercise 02/13/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 Dx:8470-C~rvical Sprain/str 02/14/95 154310 pt 970l2-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/14/95 pt 97010-PT Hot/Cold Packs 02/14/95 pt 97124-PT Massage 02/14/95 pt 97118-PT Therapeutic Exercise 02/14/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 02/16/95 154436 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/16/95 pt 97010-PT Hot/Cold Packs 02/16/95 pt 97124-PT Massage 02/16/95 pt 97032-PT Electric stirn, manual Each 15 Mins 02/16/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 02/20/95 154598 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/20/95 pt 97010-PT Hot/Cold Packs 02/20/95 pt 97124-PT Massage 02/20/95 pt 97032-PT Electric stirn, manual Each 15 Mins 02/20/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str PAGE: 7 DATE :07/13/98 D.O.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: POS CHARGE 0.00 0 40.00 0 45.00 0 35.00 155.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 20.00 0 35.00 0 45.00 0 35.00 170.00 <------ [ledger] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hulllo-01 PATIENT #:hulllo-Ol ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY .:;ROUP . :Attorney Angio & '#: 194288043 PLAN 2 : POLICY #: GROUP # : Rovner FR: **/**/** TO: **/**/** # : DATE BILL # DR. CPT/PROCEDURE CHECK #:PLAN 02/21/95 154619 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/21/95 pt 97010-PT Hot/Cold Packs 02/21/95 pt 97124-PT Massage 02/21/95 pt 97032-PT Electric Stirn, manual Each 15 Mins 02/21/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 02/24/95 154720 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/24/95 pt 97010-PT Hot/Cold Packs 02/24/95 pt 97124-PT Massage 02/24/95 pt 97032-PT Electric stim,manual Each 15 Mins 02/24/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 02/28/95 155033 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/28/95 pt 970l0-PT Hot/Cold Packs 02/28/95 pt 97124-PT Massage 02/28/95 pt 97032-PT Electric Stirn, manual Each 15 Mins 02/28/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 03/01/95 155175 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 03/01/95 pt 99070A-Electrodes- Disposable 03/01/95 pt 97010-PT Hot/cold Packs 03/01/95 pt 97124-PT Massage 03/01/95 pt 97032-PT Electric Stirn, manual Each 15 Mins 03/01/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 03/02/95 155193 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 03/02/~5 pt 97010-PT Hot/Cold Packs 03/02/95 pt 97124-PT Massage PAGE: 8 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: POS CHARGE 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 52.00 0 40.00 0 35.00 0 45.00 0 35.00 242.00 ' <------ 0 35.00 0.00 0 40.00 0 35.00 [ ledger] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hu111o-01 PA'rIENT #:hulllo-'Ol ASSIGNMENT :yes-yes LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1" :Attorney Angio & POLICY #:194288043 ':;ROUP # : Rovner FR: **/**/** TO: **/**/** PLAN 2 : POLICY #: GROUP # : DATE BILL # DR. CPT/PROCEDURE CHECK #:PLAN 02/21/95 154619 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/21/95 pt 97010-PT Hot/Cold Packs 02/21/95 pt 97124-PT Massage 02/21/95 pt 97032-PT Electric Stirn, manual Each 15 Mins 02/21/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 Dx:8470-Cervical Sprain/str 02/24/95 154720 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/24/95 pt 97010-PT Hot/Cold Packs 02/24/95 pt 97124-PT Massage 02/24/95 pt 97032-PT Electric stirn, manual Each 15 Mins 02/24/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 02/28/95 155033 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 02/28/95 pt 97010-PT Hot/Cold Packs 02/28/95 pt 97124-PT Massage 02/28/95 pt 97032-PT Electric Stirn, manual Each 15 Mins 02/28/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 DX:8470-Cervical Sprain/str 03/01/95 155175 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 03/01/95 pt 99070A-Electrodes- Disposable 03/01/95 pt 97010-PT Hot/Cold Packs 03/01/95 pt 97124-PT Massage 03/01/95 pt 97032-PT Electric Stirn, manual Each 15 Mins 03/01/95 pt 97110--Physical Therapy, Initial (15) OFFICE: 40 Dx:8470-Cervica1 Sprain/str 03/02/95 155193 pt 97012-PT Traction, Mechanical 01/05/98 PAYMENT-THANK YOU 0000 03/02/95 pt 97010-PT Hot/Cold Packs 03/02/95 pt 97l24-PT Massage PAGE: 8 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: POS CHARGE 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 35.00 190.00 <------ 0 35.00 0.00 0 52.00 0 40.00 0 35.00 0 45.00 0 35.00 242.00 ' <------ 0 35.00 0.00 0 40.00 0 35.00 [ ledger] Trindle Rehab Medicine Center PATIENT LEDGER Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 GUARANTOR #:hulllo-Ol PATIENT #:hulllo-01 ASSIGNMENT :yes-yes LAST P~Y DT: **/**/** LAST PAY $ : 0.00 LST PLN PAY: 12/27/94 LST PLAN $: 284.11 AT COLLECTN: ' 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 'PAGE: 9 DATE :07/13/98 D.O.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY ':;ROUP :Attorney Angio & #:194288043 # : PLAN 2 . POLICY #: GROUP # : Rovner FR:**/**/** TO:**/**/** DATE BILL # DR. CPT/PROCEDURE CHECK #: PLAN 03/02/95 pt 03/02/95 pt OFFICE: 40 03/06/95 155333 pt 01/05/98 03/06/95 pt 03/06/95 pt 03/06/95 pt 03/06/95 pt 03/06/95 pt OFFICE: 40 03/07/95 155545 pt 01/05/98 03/07/95 pt 03/07/95 pt 03/07/95 pt 03/07/95 pt 03/07/95 pt OFFICE: 40 03/09/95 155598 pt 01/05/98 03/09/95 pt 03/09/95 pt 03/09/95 pt 03/09/95 pt OFFI<~E: 40 03/13/95 155752 pt 01/05/98 03/13/95 pt 03/13/95 pt 03/13/95 pt 03/13/95 pt OFFICE: 40 97032-PT Electric stirn, manual Each 15 Mins 97110--Physical Therapy, Initial (15) DX:8470-Cervical sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97032-PT Electric stirn, manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min 97110--Physica1 Therapy, Initial (15) DX:8470-Cervical Sprainjstr 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97124-PT Massage 97010-PT Hot/Cold Packs 97032-PT Electric stirn, manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min 97110--Physical Therapy, Initial (15) DX:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97032-PT Electric Stirn, manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min DX:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97032-PT Electric stirn,rnanual Each 15 Mins 97110--Physical Therapy, Initial (15) DX:8470-Cervical sprain/str PO.Q. o o 190.00 o o o o o o 220.00 o o o o o o 220.00 o o o o o 185.00 o o o o o 190.00 FR: TO: CHARGE 45.00 35.00 <------ 35.00 0.00 40.00 35.00 45.00 30.00 35.00 <------ 35.00 0.00 35.00 40.00 45.00 30.00 35.00 <------ 35.00 0.00 40.00 35.00 45.00 30.00 <------ 35.00 0.00 40.00 35.00 45.00 35.00 <------ [ledger] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hulllo-Ol PATIENT #:hulllo-Ol ASSIGNMENT :yes-yes LART PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:12/27/94 LST PLAN $: 284.11 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 POLICY ':;ROUP Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 :Attorney Angio & #:194288043 # : PLAN 2 . POLICY #: GROUP # : DATE 03/14/95 01/05/98 03/14/95 03/14/95 03/14/95 03/14/95 03/16/95 01/05/98 03/16/95 03/16/95 03/16/95 03/16/95 03/16/95 03/20/95 01/05/98 03/20/95 03/20/95 03/20/95 03/20/95 Rovner FR: **/**/** TO: **/**/** 155817 pt BILL # DR. CPT/PROCEDURE CHECK #:P~N pt pt pt pt OFFICE: 40 155948 pt pt pt pt pt pt OFFICE: 40 155981 pt pt pt pt pt OFFICE: 40 U3/21/95 156155 pt 01/05/98 03/21/95 03/21/95 03/21/95 03/21/95 03/21/95 I Payment Notes: OFFICE: 40 pt pt pt pt pt 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97032-PT Electric stim,manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min 97110--Physical Therapy, Initial (15) Dx:8470-Cervical Sprain/str 970l2-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/cold Packs 97124-PT Massage 97032-PT Electric stim,manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min 97110--Physical Therapy, Initial (15) DX:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97032-PT Electric Stim,manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min 97110--Physical Therapy, Initial (15) DX:8470-Cervical Sprain/str 97012-PT Traction, Mechanical PAYMENT-THANK YOU 0000 97010-pT Hot/Cold Packs 97124-PT Massage 97032-PT Electric Stim,manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min 97110--Physical Therapy, Initial (15) Patient received settlement DX:8470-Cervical Sprain/str PAGE: 10 DATE : 07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho FR: TO: EQg CHARGE 0 35.00 0.00 0 40.00 0 45.00 0 30.00 0 35.00 185.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 30.00 0 35.00 220.00 <------ 0 35.00 0.00 0 40.00 0 45.00 0 30.00 0 35.00 185.00 <------ 0 35.00 0.00 0 40.00 0 35.00 0 45.00 0 30.00 0 35.00 I 220.00 <------ [ledger] Rehab Medicine Assoc,Mechbrg PATIENT LEDGER GUA~NTOR #:hulllo-03 PA'rIENT #: hulllo-03 ASPIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T HUll, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED---1La PLAN 1 POLICY :;ROUP :US Healthcare #:KGDRI020 # : 1125 PLAN 2 : FR:**/**/** POLICY #: TO:**/**/** GROUP #: OATE BILL # DR. CPT/PROCEDURE CHECK #:PLA~ 04/22/96 176084 pt 97035-PT Ultrasound, Each 15 Min 01/05/98 PAYMENT-THANK YOU 0000 04/22/96 pt 97032-PT Electric stim,manual Each 15 04/22/96 pt 97010-PT Hot/Cold Packs OFFICE: 30 DX:7231-Cervicalagia/Cervic 04/23/96 176085 pt 97032-PT Electric stim,manual Each 15 01/05/98 PAYMENT-THANK YOU 0000 04/23/96 pt 97124-.PT Massage 04/23/96 pt 97010-PT Hot/cold Packs 04/23/9,6 pt 97018-PT Paraffin Bath, Fluidotherapy OFFICE: 30 DX:7231-Cervicalagia/Cervic PAGE: 1 DATE : 07/13/98 D.O.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS:7 DR:cho FR: TO: POS CHARGE 0 60.00 0.00 Mins 0 180.00 0 20.00 260.00 <------ Mins 0 180.00 0.00 0 35.00 0 20.00 0 40.00 275.00 <------ 7ft 1(4& Last statement printed on 06/30/98 for~I~.Q~ L -fia:r:::..;;( for Hull, Lorraine T Balance for Plan Patient Plan CURRENT 0.00 0.00 061-090 0.00 0.00 091-120 0.00 0.00 120+ 535.00 0.00 031-060 0.00 0.00 535.00 0.00 [ledger] Trindle Rehab Medicine Center PATIENT LEDGER -------------- GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 POLICY :;ROUP DATE 01/18/96 01/05/98 01/18/96 01/18/96 01/18/96 01/18/96 01/22/99 06/11/96 06/11/96 01/05/98 01/22/96 06/11/96 01/22/96 06/11/96 01/24/96 06/11/96 06/11/96 01/05/98 01/24/96 06/11/96 01/24/96 06/11/96 01/24/96 06/11/96 01/25/96 06/11/96 06/11/96 01/05/98 01/25/96 06/11/96 :US Hea1thcare #:KGDR1020 # : Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PAGE: 2 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS:7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 1125 PLAN 2 . FR:**/**/** POLICY #: TO:**/**/** GROUP #: BILL-1 DR. CPT/PROCEDURE 170206 pt pt pt pt pt OFFICE: 40 170410 pt OFFICE: 40 170568 pt pt pt pt OFFICE: 40 170609 pt CHECK #: PLAN PO!? pt pt Q0103-PT Eval: Medicare,W/C,Auto - Initial 0 PAYMENT-THANK YOU 0000 Q0104-PT Eval: Medicare,W/C,Auto - Re-eval 0 97032-PT Electric Stirn, manual Each 15 Mins 0 99070A-E1ectrodes- Disposable 0 97010-PT Hot/COld Packs 0 Dx: 7231-Cervicalagia/cervic 306.00 97032-PT Electric stirn, manual Each 15 Mins 0 PAYMENT-THANK YOU 37898933:US Healthcare 1125 Perferred provider:uS Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage 0 Perferred Provider:US Healthcare 1125 97010-PT Hot/Cold Packs 0 Perferred Provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 15.00 97032-PT Electric Stirn, manual Each 15 Mins 0 PAYMENT-THANK YOU 37898933:US Healthcare 1125 Perferred Provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage 0 Perferred Provider:US Hea1thcare 1125 97010-PT Hot/Cold Packs 0 Perferred provider:US Healthcare 1125 97012-PT Traction, Mechanical 0 Perferred Provider.:US Healthcare 1125 Dx:7231-Cervicalagia/Cervic 15;00 97032-PT Electric Stirn, manual Each 15 Mins 0 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 37898933:US Healthcare 1125 PAYMENT-THANK YOU 0000 97124-pT Massage 0 Perferred provider:US Healthcare 1125 pt FR: TO: CHARGE 50.00 0.00 30.00 180.00 26.00 20.00 <------ 45.00 35.00- 10.00- 0.00 35.00 35.00- 20.00 5.00- <------ 90.00 50.00- 40.00- 0.00 35.00 35.00- 20.00 20.00- 35.00 20.00- <------ 180.00 130.00- 50.00- 0.00 35.00 35.00- [led"ger] Trind1e Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hulllo-OJ PATIENT #:hu1llo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY ':;ROUP :US Healthcare #:KGDR1020 # : FR: **/**/** TO: **/**/** 1125 PLAN 2 : POLICY #: GROUP # : iJATE BIL~ DR. CPT/PROCEDURE CHECK #:PLAN PAGE: 3 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho POS 01/25/96 pt 97010-pT Hot/Cold Packs 0 06/11/96 Perferred provider:US Healthcare 1125 OFFICE: 40 DX:7231-Cervicalagia/Cervic 15.00 01/29/96 170845 pt 97110--Physical Therapy, Initial (15) 0 06/11/96 PAYMENT-THANK YOU 37898933:US Healthcare 1125 01/05/98 PAYMENT-THANK YOU 0000 01/29/96 pt 97032-PT Electric stirn, manual Each 15 Mins 0 06/11/96 PAYMENT-THANK YOU 378989J3:US Healthcare 1125 06/11/96 Perferred provider:US Healthcare 1125 01/29/96 pt 97010-PT Hot/Cold Packs 0 06/11/96 Perferred provider:US Healthcare 1125 OFFICE: 40 DX:7231-cervicalagia/Cervic 15.00 01/31/96 170992 pt 97110--Physical Therapy, Initial (15) 0 06/11/96 PAYMENT-THANK YOU 37898933:US Healthcare 1125 01/05/98 PAYMENT-THANK YOU 0000 01/31/96 pt 97032-PT Electric stirn, manual Each 15 Mins 0 06/11/96 Perferred provider:US Healthcare 1125 06/11/96 PAYMENT-THANK YOU 37898933:US Healthcare 1125 01/31/96 pt 97124-PT Massage 0 06/11/96 Perferred provider:US Healthcare 1125 01/31/96 pt 97010-PT Hot/Cold Packs 0 06/11/96 , Perferred provider:US Healthcare 1125 OFFICE: 40 DX:7231-Cervicalagia/Cervic 15.00 02/01/96 171246 pt 97032-PT Electric stirn, manual Each 15 Mins 0 06/11/96 Perferred provider:US Healthcare 1125 06/11/96 PAYMENT-THANK YOU 37898933:US Healthcare 1125 01/05/98 PAYMENT-THANK YOU 0000 02/01/96 pt 97124-PT Massage 0 06/11/96 Perferred provider:US Healthcare 1125. 02/01/96 pt 97010-PT Hot/Cold Packs 0 06/11/96 Perferred provider:US Healthcare 1125 02/01/96 pt 97110--Physical Therapy, .Initial (15) 0 06/11/96 Perferred provider:US Healthcare 1125 FR: TO: CHARGE 20.00 5.00- <------ 35.00 35.00- 0.00 180.00 15.00- 165.00- 20.00 5.00- <------ 35.00 35.00- 0.00 180.00 165.00- 15.00- 35.00 35.00- 20.00 5.00- <------ 180.00 130.00- 50.00- 0.00 35.00 35.00- 20.00 20.00- 35.00 20.00- [ledger] Trindle Rehab Medicine Center PA'rIENT LEDGER -----------_._- GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: ' 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 POLICY ':;ROUP DATE 02/05/96 :>6/11/96 06/11/96 01/05/98 02/05/96 06/11/96 02/05/96 06/11/96 02/07/96 06/11/96 01/05/98 02/07/96 06/11/96 06/11/96 02/07/96 06/11/96 02/07/96 06/11/96 02/12/9"6 06/11/96 01/05/98 02/12/96 06/11/96 06/11/96 02/l2/96 06/11/96 02/12/96 06/11/96 02/13/96 :US Healthcare #:KGDR1020 # : pt pt OFFICE: 40 171997 pt pt pt pt OFFICE: 40 172027 pt pt pt pt OFFICE: 40 172044 pt Hull, Lorrai.ne T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PAGE: 4 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS:7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 1125 PLAN 2 : FR:**/**/** POLICY #: TO:**/**/** GROUP #: CHECK #:P~N POS BILL # DR. CPT/PROCEDURE OFFICE: 40 171305 pt DX:7231-Cervicalagia/Cervic 97032-PT Electric Stirn, manual Each 15 Mins Perferred provider:Us Healthcare 1125 PAYMENT-THANK YOU 37898933:US Healthcare 1125 PAYMENT-THANK YOU 0000 97122-PT Traction, Manual, Each 15 Min Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs Perferred Provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 97012-PT Traction, Mechanical PAYMENT-THANK YOU 37898933:US Healthcare PAYMENT-THANK YOU 0000 97032-PT Electric Stirn, manual Each 15 Mins Perferred provider:us Healthcare 1125 PAYMENT-THANK YOU 37898933:US Healthcare 1125 97124-PT Massage 0 Perferred provider:us Healthcare 1125 97010-PT Hot/Cold Packs Perferred Provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 97012-PT Traction, Mechanical PAYMENT-THANK YOU 37898933:US Healthcare PAYMENT-THANK YOU 0000 97124-PT Massage 0 PAYMENT-THANK YOU 37898933:US Healthcare 1125 Perferred provider:Us Healthcare 1125 97010-PT Hot/Cold Packs Perferred provider:us Healthcare 1125 97032-PT Electric Stirn, manual Each 15 Mins Perferred provider:US Healthcare 1125 Dx:7231-Cervicalagia/Cervic 97032-PT Electric Stirn, manual Each 15 Mins 15.00 o o o 15.00 o 1125 o o 15.00 o 1125 o O. 15.00 o FR: TO: CHARGE <------ 180.00 130.00- 50.00- 0.00 30.00 30.00- 20.00 5.00- <------ 35.00 35.00- 0.00 180.00 165.00- 15.00- 35.00 35.00- 20.00 5.00- <------ 35.00 35.00- 0.00 35.00 15.00- 20.00- 20.00 20.00- 180.00 165.00- <------ 180.00 5 PAGE: Trindle Rehab Medicino Center PA'rrEN'l' LEDGER [ledger] -------------- DATE :07/13/98 D.O. B: 07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho null, Lorraine T null, Lorra ine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/*~/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 lliI;lJ.!JiIDLU Hull, Lorraine 'I' 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOVER NAME: REI' DOC'I'OR:065 Cho, Jay J INSURED #2 1125 PLAN 2 : FR:**/**/** POLICY #: '1'0:**/**/** GROUP #: :US nealthcare #:KGDR1020 # : PLAN 1 POLICY ':;ROUp FR: TO: CHARGE POS CHECK #:P~N PJ;lW--1!. Dlh ~~l'l'/PRoclmUR~ DATE 50.00- 130.00- 0.00 20.00 20.00- 35.00 35.00- 35.00 20.00- <------ 180.00 50.00- 130.00- 0.00 20.00 20.00- 35.00 35.00- 45.00 30.00- <------ 180.00 50.00- 130.00- 0.00 35.00 35.00- 20.00 20.00- 45.00 30.00- <------ 35.00 PAVMEN'l'-'rtIANK YOU 37898933 :US Heal thcare 1125 Porforred provider:US Hea1thcare 1125 PA VMEN'l'-'l'nANK YOU 0000 97010-P~' lIot/Cold Packs 0 Perferred provider:US Healthcare 1125 97124-PT Massage 0 Perferred provider:US Healthcare 1125 97012-PT Traction, Mechanical 0 Perferred provider:US Healthcare 1125 Dx:7231-Cervicalagia/Cervic 15.00 97032-PT Electric stirn, manual Each 15 Mins 0 PAYMENT-THANK YOU 37898933:US Healthcare 1125 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 0 Perferred provider:US Healthcare 1125 97012-PT Traction, Mechanical 0 Perferred provider:US Healthcare 1125 97012-A-Traction - Pelvic - Mechanical 0 Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 15.00 97032-PT Electric stim,rnanual Each 15 Mins 0 PAVMENT-TIIANK YOU 37898933:US Healthcare 1125 Perferred Provider:US Healthcare 1125 PI\VMENT-TIII\NK YOU 0000 97124-P'1' Massage 0 Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs 0 Perferred provider:US Healthcare 1125 97012-A-Traction - Pelvic - Mechanical 0 Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 15.00 97110--Physical Therapy, Initial (15) 0 06/11/96 06/11/96 01/05/98 02/13/96 06/11/96 02/13/96 06/11/96 02/13/% 06/11/96 02/15/96 06/11/96 06/11/96 01/05/98 02/15/96 06/11/96 02/15/96 06/11/96 02/15/96 06/11/96 02/19/96 06/11/96 06/11/96 01/05/9fl 02/19/96 06/11/96 02/19/96 06/11/96 02/19/96 06/11/96 02/20/% pt pt pt OFFICE: 40 172109 pt pt pt pt OFFICE: 40 172217 pt pt pt pt OFFICE: 40 1'12309 pt [ledger] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 POLICY :;ROUP DATE 01/23/97 01/05/98 02/20/96 01/23/97 01/23/97 02/20/96 01/23/97 02/20/96 01/23/97 02/21/9,6 01/23/97 01/23/97 01/05/98 02/21/96 01/23/97 02/21/96 01/23/97 02/26/96 01/23/97 01/23/97 01/05/98 02/26/96 01/23/97 02/26/96 01/23/97 02/26/96 01/23/97 02/27/96 01/23/97 01/05/98 :US Healthcare #:KGDRI020 # : Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PAGE: 6 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS:7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 1125 PLAN 2 . FR:**/**/** POLICY #: TO:**/**/** GROUP #: BILL # DR. CPT/PROCEDURE OFFICE: 40 172420 pt OFFICE: 40 172656 pt pt pt pt OFFICE: 40 172749 pt CHECK #:PlJ!.N POS pt PAYMENT-THANK YOU 39674836:US Healthcare 1125 PAYMENT-THANK YOU 0000 97032-PT Electric stirn, manual Each 15 Mins Perferred provider:US Hea1thcare 1125 PAYMENT-THANK YOU 39674836:US Healthcare 1125 97124-PT Massage 0 Perferred Provider:US Healthcare 1125 97010-PT Hot/Cold Packs Perf erred provider:US Healthcare 1125 Dx: 7231-Cervicalagia/cervic 15.00 97032-PT Electric stirn, manual Each 15 Mins 0 PAYMENT-THANK YOU 39674836:US Healthcare 1125 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs Perferred Provider:US Healthcare 1125 97124-PT Massage Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 97032-PT Electric stirn, manual Each 15 Mins Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 39674836:US Healthcare 1125 PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 1125 97124-PT Massage Perferred provider:US Healthcare 1125 97012-PT Traction, Mechanical Perferred Provider:US Healthcare 1125 DX:7231-Cervicalagia/cervic 97110--Physical Therapy, Initial (15) PAYMENT-THANK YOU 39674836:US Hea1thcare PAYMENT-THANK YOU 0000 o pt pt o pt pt o o 15.00 o o o o 15.DO o 1125 FR: TO: CHARGE 35.00- 0.00 180.00 165.00- 15.00- 35.00 35.00- 20.00 5.00- <------ 180.00 50.00- 130.00- 0.00 20.00 20.00- 35.00 20.00- <------ 180.00 130.00- .50.00- 0.00 20.00 20.00- 35.00 35.00- 35.00 20.00-' <------ 35.00 35.00- 0.00 [lodgur 1 Trindle Rehab Medicine Center PA'!'IEN'!' LEDGER GUARANtOR Hlhul1lo-03 PATIENT H:hulllo-03 ASSIGNMENT :yoA-no LAS'!' PAY 0'1': u/u/u LAS'!' PAY $ : 0.00 LST PL.N PAY: 0~/04/97 LS'!' PL.AN $: !i!i0. 00 NI' CO [,I.EC'1'N : 0.00 ,Ul_SJ.!.B1~JU/.! Hull, Lorralne '1' 5~35 Moadowbrook Drive Mochnnicsburg, PA 17055 I'I.AN 1 1'01,ICY :;ROUP Hull, L.orraine T HUll, Lorraine '1' 5~35 Meadowbrook Drive Mochanicsburg, PA 17055 PAGE: 7 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 :US Honlthcare 1125 H:KGDRI0~0 FR:**/**/** H: TO:**/**/** PLAN 2 . POLICY #: GROUP # : QAT..~ 0~/27/96 01/23/97 01/~3/97 02/27/96 o 1/~ 3/97 0~/~7 /96 01/23/97 02/28/96 01/~3/97 01/23/97 01/05/98 02/28/96 01/~ 3/97 02/28/96 01/23/97 03/04/9,6 01/23/9'1 01/23/97 01/05/98 03/04/96 01/23/97 03/04/96 01/23/97 03/04/96 01/23/97 03/06/96 01/23/97 , 01/23/9'7 01/05/98 03/06/96 DJl~ ~ CPT/PROCEDURE OFFICE: 40 172825 pt OFFICE: 40 173263 pt OFFICE: 40 173331 pt pt CHECK #:PLAN POS pt 97032-PT Electric stirn, manual Each 15 Mins 0 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 39674836:US Hea1thcare 1125 99070A-Electrodes- Disposable 0 Perferred provider:US Uea1thcare 1125 97010-PT Hot/Cold Packs 0 Perferred Provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 15.00 97032-PT Electric stirn, manual Each 15 Mins 0 PAYMENT-THANK YOU 39674836:US Healthcare 1125 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 0 Perferred Provider:US Healthcare 1125 97012-A-Traction - Pelvic - Mechanical 0 Perferred provider:US Healthcare 1125 Dx: 7231-Cervicalagia/Cervic 15.00 97032-PT Electric stirn, manual Each 15 Mins 0 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 39674836:US Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage 0 Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs 0 Perferred provider:US Healthcare 1125 97012-A-Traction - Pelvic - Mechanical 0 Perferred provider:US Healthcare 1125 Dx: 7231-Cervicalagia/Cervic 15.00 97032-PT Electric Stirn, manual Each 15 Mins 0 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 39674836:US Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage 0 pt pt pt pt pt pt pt FR: TO: CHARGE 180.00 165.00- 15.00- 26.00 26.00- 20.00 5.00- <------ 180.00 50.00- 130.00- 0.00 20.00 20.00- , 45.00 30.00- <------ 180.00 130.00- 50.00- 0.00 35.00 35.00- 20.00 20.00- 45.00 30.00- <------ 180.00 130.00- 50.00- 0.00 35.00 GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 [ledger] PLAN 1 POLICY ':;ROUP Trindle Rehab Medicine Center PATIENT LEDGER Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PAGE: 8 DATE : 07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 :US Hea1thcare #:KGDR1020 # : FR: **/**/** TO:**/**/** DATE 1125 PLAN 2 : POLICY #: GROUP # : BILL # DR. CPT/PROCEDURE POS 01/23/97 03/06/96 01/23/97 03/06/96 01/23/97 OFFICE: 03/11/96 173479 01/23/97 01/05/98 03/11/96 01/23/97 01/23/97 03/11/96 01/23/97 OFFICE: 03/12/96 1731575 01/23/97 01/23/97 01/05/98 03/12/96 01/23/97 03/12/96 01/23/97 03/12/96 01/23/97 OFFICE: 03/13/96 173698 06/11/96 06/11/96 01/05/98 03/13/96 06/11/96 03/13/96 CHECK #:PLAN Perferred provider:US Healthcare 1125 pt 97010-PT Hot/Cold Packs 0 Perferred provider:US Healthcare 1125 pt 97012-A-Traction - Pelvic - Mechanical 0 Perferred Provider:US Healthcare 1125 40 DX:7231-Cervicalagia/Cervic 15.00 pt 97010-PT Hot/Cold Packs , 0 PAYMENT-THANK YOU 39674836:US Healthcare 1125 PAYMENT-THANK YOU 0000 pt 97032-PT Electric Stirn, manual Each 15 Mins 0 Perferred Provider:US Healthcare 1125 PAYMENT-THANK YOU 39674836:US Healthcare 1125 pt 97124-PT Massage 0 Perferred Provider:US Healthcare 1125 40 DX:7231-cervicalagia/Cervic 15.00 pt 97032-PT Electric Stirn, manual Each 15 Mins 0 PAYMENT-THANK YOU 39674836:US Healthcare 1125 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 pt 97012-A-Traction - Pelvic - Mechanical 0 Perferred provider:US Healthcare 1125 pt 97124-PT Massage 0, Perferred provider:US Healthcare 1125 pt 97010-PT Hot/Cold Packs 0 Perferred provider:US Healthcare 1125 40 DX:7231-Cervicalagia/Cervic 15.00 pt 97032-PT Electric Stirn, manual Each 15 Mins 0 Perferred Provider:US Healthcare 1125 PAYMENT-THANK YOU 37898933:US Healthcare 1125 PAYMENT-THANK YOU 0000 pt 97124-PT Massage 0' Perferred provider:US Healthcare 1125 pt 97010-PT Hot/Cold Packs 0 FR: TO: CHARGE 35.00- 20.00 20.00- 45.00 30.00- <------ 20.00 20.00- 0.00 135.00 105.00- 30.00- 35.00 20.00- <------ 135.00 50.00- 85.00- 0.00 45.00 45.00- 35.00 35.00- 20.00 5.00- <------ 135.00 85.00- 50.00- 0.00 35.00 35.00- 20.00 [ledg'er] Trind1e Rehab Medicine Center PATIENT LEDGER Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 GUARANTOR #:hu111o-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechan,~csburg, PA 17055 PLAN 1 POLICY :;ROUP DATE 06/11/96 03/13/96 06/11/96 03/13/96 06/11/96 03/18/96 01/23/97 01/23/97 01/05/98 03/18/96 01/23/97 03/18/96 01/23/97 03/18/96 01/23/97 03/19/96 01/23/97 01/05/98 03/19/96 01/23/97 01/23/97 03/19/96 01/23/97 03/19/96 01/23/97 03/19/96 01/23/97 03/27/96 06/11/96 01/05/98 :US Healthcare #:KGDRI020 # : PAGE: 9 DATE : 07/13/98 D.O.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR: cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 1125 PLAN 2 . POLICY #: GROUP #: FR:**/**/** TO:**/**/** BILL # DR. CPT/PROCEDURE OFFICE: 40 174034 pt pt pt pt OFFICE: 40 174291 pt pt pt pt pt OFFICE: 40 174518 pt CHECK #:PLAN POS pt pt Perferred Provider:US Healthcare 1125 97012-A-Traction - Pelvic - Mechanical Perferred provider:US Healthcare 1125 97110--Physical Therapy, Initial (15) Perferred provider:US Healthcare 1125 Dx: 7231-Cervicalagia/cervic 5.00 97032-PT Electric stirn, manual Each 15 Mins 0 Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 39674836:US Healthcare 1125 PAYMENT-THANK YOU 0000 97124-PT Massage Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 1125 97012-A-Traction - pelvic - Mechanical Perferred provider:US Healthcare 1125 DX:7231-cervicalagia/cervic 97110--Physical Therapy, Initial (15) PAYMENT-THANK YOU 39674836:US Healthcare PAYMENT-THANK YOU 0000 97124-PT Massage 0 PAYMENT-THANK YOU 39674836:US Healthcare 1125 Perferred provider:US Healthcare 1125 97012-A-Traction - Pelvic - Mechanical Perferred provider:US Healthcare 1125 97032-PT Electric stirn, manual Each 15 Mins Perferred provider:US Healthcare 1125 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 97010-PT Hot/Cold Packs Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 0000 o o o o o 15.00 o 1125 o o o 15.00 o FR: TO: CHARGE 20.00- 45.00 45.00- 35.00 30.00- <------ 135.00 85.00- 50.00- 0.00 35.00 35.00- 20.00 20.00- 45.00 30.00- <------ 35.00 35.00- 0.00 35.00 15.00- 20.00- 45.00 45.00- 135.00 135.00- 20.00 5.00- <------ 20.00 5.00- 0.00 GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 [ ledger] , I ,I I 1 I PLAN 1 POLICY ':;ROUP DATE 03/27/96 06/11/96 03/27/96 06/11/96 06/11/96 03/27/96 06/11/96 03/28/96 01/05/98 03/28/96 03/28/96 03/28/96 04/01/96 01/05/98 04/01/96 04/01/96 04/03/96 01/05/98 04/03/96 04/03/96 04/03/96 04/04/96 01/05/98 04/04/96 04/04/96 04/08/96 01/05/98 04/08/96 :US Healthcare #:KGDRI020 # : Trindle Rehab Medicine Center PATIENT LEDGER Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PAGE: 10 DA'l'E : 07/13/98 D.O. B: 07/19/38 CHART: HOME :717-761-7869 EMRG : 717-761-7869 EMPLY: S S #: 194-28-8043 CLASS:7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 1125 PLAN 2 : POLICY #: GROUP #: FR: *1'/**/** TO:**/**/** BILL # DR. CPT/PROCEDURE pt OFFICE: 40 174572 pt pt pt pt OFFICE: 40 174927 pt pt pt OFFICE: 40 174969 pt pt pt pt OFFICE: 40 175084 pt pt pt OFFICE: 40 175229 pt Q0104-PT Eval: Medicare,W/C,Auto - Re-eval Perferred provider:US Healthcare 1125 QOI03-PT Eval: Medicare,W/C,Auto - Initial Perferred provider:US Healthcare 1125 PAYMENT-THANK YOU 37898933:US Healthcare 1125 97ll0--Physical Therapy, Initial (15) 0 Perferred provider:US Healthcare 1125 DX:7231-Cervicalagia/Cervic 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97032-PT Electric stirn, manual Each 15 Mins 9'7110--Physical Therapy, Initial (15) 97012-A-Traction - Pelvic - Mechanical DX:7231-Cervicalagia/Cervic 97012-A-Traction - Pelvic - Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97032-PT Electric stirn, manual Each 15 Mins DX:7231-Cervica1agia/Cervic 97012-A-Traction - Pelvic - Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97032-PT Electric stirn, manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min Dx:7231-Cervicalagia/Cervic 97032-PT Electric stirn, manual Each 15 Mins PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97012-A-Traction - pelvic - Mechanical DX:7231-Cervicalagia/Cervic 97012-A-Traction - Pelvic - Mechanical PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs CHECK #:PLAN pt pt pt POS o o 15.00 o o o o 235.00 o o o 200.00 o o o o 260.00 o o o 200.00 o o FR: TO: CHARGE 30.00 30.00- 50.00 20.00- 30.00- 70.00 70.00- <------ 20.00 0,00 135.00 35.00 45.00 <------ 45.00 0.00 20.00 135.00 <------ 45.00 0.00 20.00 135.00 60.00 <------ 135.00 0.00 20.00 45.00 <------ 45.00 0.00 20.00 [ledger] Trindle Rehab Medicine Center PATIENT LEDGER Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 GUARANTOR #:hul1Io-03 PATIENT #:hulllo-C3 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 POLICY :;ROUP :US Healthcare #:KGDRI020 # : PAGE: 11 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EM PLY : S S #:194-28-8043 CLASS:7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED # 2 1125 PLAN 2 : POLICY #: GROUP # : FR: **/**/** TO: **/**/** DATE BILL # DR. CPT/PROCEDURE CHECK #:PLAN . 04/08/96 pt 04/08/96 pt OFFICE: 40 04/09/96 175236 pt 01/05/98 04/09/96 pt 04/09/96 pt 04/09/9<1 pt OFFICE: 40 04/10/96 175262 pt 01/05/98 04/10/96 pt 04/10/96 pt 04/10/96 pt OFFICE: 40 04/17/96 176044 pt 01/05/98 04/17/96 pt 04/17/96 pt OFFICE: 40 04/18/96 176060 pt 01/05/98 04/18/96 pt 04/18/96 pt OFFICE: 40 04/24/96 176281 pt 01/05/98 04/24/96 pt 04/24/96 pt 04/24/96 pt OFFICE: 40 04/30/96 176607 pt 01/05/98 97032-PT Electric stirn, manual Each 15 Mins 97035-PT Ultrasound, Each 15 Min DX:7231-cervicalagia/Cervic 97035-PT Ultrasound, Each 15 Min PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97124-PT Massage 97032-PT Electric stirn, manual Each 15 Mins DX:7231-Cervicalagia/Cervic 97032-PT Electric Stirn, manual Each 15 Mins PAYMENT-THANK YOU 0000' 97035-PT Ultrasound, Each 15 Min 97012-A-Traction - Pelvic - Mechanical 97010-PT Hot/Cold Packs DX:723l-cervicalagia/cervic 97035-PT Ultrasound, Each 15 Min PAYMENT-THANK YOU 0000 97032-PT Electric stirn, manual Each 15 Mins 97010-PT Hot/Cold Packs DX:7231-Cervicalagia/cervic 97035-PT Ultrasound, Each 15 Min PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97032-PT Electric stirn, manual Each 15 Mins DX:7231-Cervicalagia/Cervic 97110--Physical Therapy, Initial (15) PAYMENT-THANK YOU 0000 97018-PT Paraffin Bath, F1uidotherapy 97010-PT Hot/Cold Packs 97032-PT Electric Stirn, manual Each 15 Mins DX:7231-Cervicalagia/Cervic 97032-PT Electric stim,manual Each 15 Mins PAYMENT-THANK YOU 0000 FR: TO: 1'05 o o 260.00 o o o o 250.00 o o o o 260.00 o o o 215.00 o o o 260.00 o o o o 275.00 o CHARGE 135.00 60.00 <------ 60.00 0.00 20.00 35.00 135.00 <------ 135.00 0.00 60.00 45.00 20.00 <------ 60.00 0.00 135.00 20.00 <------ 60.00 0.00 20.00 180.00 <------ 35.00 0.00 40.00 20.00 180.00 <------ 180.00 0.00 GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02j04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 [ ledger] Trindle Rehab Medicine Center PATIENT LEDGER Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PAGE: 12 DATE : 07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY 3ROUP :US Healthcare #:KGDR1020 # : FR: **/**/** TO:**/**/** 1125 PLAN 2 : POLICY #: GROUP #: DATE BILL # DR. CPT/PROCEDURE CHECK #:PLAN 04/30/96 04/30/96 04/30/96 05/01/96 01/05/98 05/01/96 05/01/96 05/01/96 pt pt pt OFFICE: 40 176926 pt pt pt pt 40 pt pt pt pt 40 rb OFFICE: 05/06/96 176933 01/05/98 05/06/96 05/06/96 05/06/96 OFFICE: OS/20/96 178128 01/05/98 OS/20/96 OS/20/96 OS/20/96 OFFICE: OS/23/96 178138 01/05/98 OS/23/96 OFFICE: OS/23/96 178904 01/05/98 OS/22/96 OS/22/96 OS/22/96 OS/23/96 OS/23/96 rb rb rb 40 rb 97035-PT Ultrasound, Each 15 Min 97010-PT Hot/Cold Packs 97018-PT Paraffin Bath, Fluidotherapy DX:7231-Cervicalagia/Cervic 97032-PT Electric stirn, manual Each 15 Mins PAYMENT-THANK YOU 0000 97035-PT Ultrasound, Each 15 Min 97018-PT Paraffin Bath, Fluidotherapy 97010-PT Hot/Cold Packs Ox: 7231-Cervicalagia/Cervic 97032-PT Electric stirn, manual Each 15 Mins PAYMENT-THANK YOU 0000 97035-PT Ultrasound, Each 15 Min 97018-PT Paraffin Bath, Fluidotherapy 97010-PT Hot/Cold Packs DX:7231-Cervicalagia/Cervic QOI03-PT Eval: Medicare,W/C,Auto - Initial PAYMENT-THANK YOU 0000 97032-PT Electric stirn, manual Each 15 Mins QOI04-PT Eva1: Medicare,W/C,Auto - Re-eval 97010-PT Hot/cold Packs DX:8470-Cervical Sprain/str 97032-PT Electric stirn, manual Each 15 Mins PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs DX:8470-Cervical Sprain/str 97032-PT Electric stim,rnanual Each 15 Mins PAYMENT-THANK YOU 0000 97018-pT Paraffin Bath, Fluidotherapy 97010-PT Hot/Cold Packs 97032-PT Electric stim,rnanual Each 15 Mins 97018-PT Paraffin Bath, F1uidotherapy 97010-PT Hot/Cold Packs rb 40 rb rb rb rb rb rb POS o o o 270.00 o o o o 270.00 o o o o 270.00 o o o o 260.00 o o 110.00 o o o o o o FR: TO: CHARGE 30.00 20.00 40.00 <------ 180.00 0.00 30.00 40.00 20.00 <------ 180.00 0.00 30.00 40.00 20.00 <------ 50.00 0.00 90.00 100.00 20.00 <------ 90.00 0.00 20.00 <------ 70.00 0.00 35.00 60.00 140.00 35.00 30.00 [ledger] Trindle Rehab Medicine Center PATIENT LEDGER GUARANTOR #:hul1Io-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, pA 17055 PLAN 1 POLICY ':;ROUP Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 :US Healthcare 1125 PLAN 2 #:KGDR1020 FR:**/**/** POLICY #: #: TO:**/**/** GROUP #: DATE OS/28/96 01/05/98 OS/28/96 OS/29/96 OS/29/96 OS/29/96 OS/28/96 05/31/96 01/05/98 05/31/96 05/31/96 06/03/96 01/05/98 06/03/96 06/03/96 06/05/96 01/05/98 06/05/96 06/05/96 06/07/96 01/05/98 06/07/96 06/07/96 06/10/96 01/05/98 06/10/96 06/10/96 BILL # DR. CPT/PROCEDURE OFFICE: 40 178905 rb rb rb rb rb rb OFFICE: 40 178906 rb rb rb OFFICE: 40 179189 rb rb rb OFFICE: 40 179249 rb rb rb OFFICE: 40 179281 rb rb rb OFFICE: 40 179408 rb CHECK #:pLAN PAGE: 13 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho FR: TO: POS CHARGE 370.00 <------ 0 140.00 0.00 0 35.00 0 35.00 0 60.00 0 140.00 0 60.00 470.00 <------ 0 35.00 0.00 0 60.00 0 140.00 235.00 <------ 0 60.00 0.00 0 35.00 0 140.00 235.00 <------ 0 60.00 0.00 0 140.00 0 35.00 235.00 <------ 0 35.00 0.00 0 60.00 0 140.00 235.00 <------ 0 90.00 0.00 0 140.00 0 35.00 DX:8470-Cervical Sprain/str 97032-PT Electric Stirn, manual Each 15 Mins PAYMENT-THANK YOU 0000 97110-PT Therapeutic Exercise, Each 15 Min 97018-PT Paraffin Bath, Fluidotherapy 97010-PT Hot/Cold Packs 97032-PT Electric stim,manual Each 15 Mins 97010-PT Hot/Cold Packs DX:8470-Cervical Sprain/str 97018-PT Paraffin Bath, Fluidotherapy PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97032-PT Electric Stirn, manual Each 15 Mins DX:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97018-PT Paraffin Bath, Fluidotherapy 97014-PT Electric stirn, unattended DX:8470-Cervical Sprain/str 970l0-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97014-PT Electric Stirn, unattended 97018-PT Paraffin Bath, Fluidotherapy Dx:8470-Cervical Sprain/str 97018-PT Paraffin Bath, Fluidotherapy PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97014-PT Electric Stirn, unattended Dx:8470-Cervical Sprain/str 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97014-PT Electric Stim,unattended 97018-PT Paraffin Bath, Fluidotherapy rb rb , PAGE: 14 'l'rindle Rehab Medicine Center PATIENT LEDGER [ledi;jer] Hull, Lorraine 'r null, Lorraine T 5235 Meadowbrook Drive Mechnnicsburg, PA 17055 DATE :07/13/98 D.O.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 7 DR:cho GUARANTOR #:hull1o-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN PAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 1125 PLAN 2 : FR:**/**/** POLICY #: TO:**/**/** GROUP #: :US Healthcare #:KGDRI020 # : PLAN 1 POLICY :;ROUP FR: TO: POS 265.00 0 0 0 235.00 0 0 0 235.00 0 0 175.00 0 0 0 235.00 0 Min 0 105.00 0 CHECK #: PLAN CHARGE BILL # DR. CPT/PROCEDUR~ :lATE DX:8471-Thoracic Sprain 97014-PT Electric stirn, unattended PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97033-PT Iontophoresis DX:8471-Thoracic Sprain 97018-PT Paraffin Bath, Fluidotherapy PAYMENT-THANK YOU 0000 97010-PT Hot/Cold Packs 97014-PT Electric Stirn, unattended DX:847l-Thoracic Sprain 97018-PT Paraffin Bath, Fluidotherapy PAYMENT-THANK YOU 0000 97014-PT Electric stirn, unattended DX:8471-Thoracic sprain 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97014-PT Electric stirn, unattended 97033-PT Iontophoresis DX:8471-Thoracic Sprain 97018-PT Paraffin Bath, Fluidotherapy PAYMENT-THANK YOU 0000 97110-PT Therapeutic Exercise, Each 15 DX:8471-Thoracic Sprain 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97110-PT Therapeutic Exercise, Each 15 Min DX:8471-Thoracic Sprain 97010-PT Hot/Cold Packs PAYMENT-THANK YOU 0000 97110-PT Therapeutic Exercise, Each 15 Min DX:8471-Thoracic Sprain 97110-PT Therapeutic Exercise, Each 15 Min <------ 140.00 0.00 60.00 35.00 <------ 35.00 0.00 60.00 140.00 <------ 35.00 0.00 140.00 <------ 60.00 0.00 140.00 35.00 <------ 35.00 0.00 70.00 <------ 30.00 0.00 35.00 <------ 30.00 0.00 35.00 <______ I 35.00 OFFICE: 40 06/17/g'6 179751 rb 01/05/98 06/17/96 rb 06/17/96 rb 40 rb OFFICE: 06/19/96 179903 01/05/98 06/19/96 06/19/96 OFFICE: 06/21/96 179948 01/05/98 06/21/96 OFFICE: 06/24/96 180106 01/05/98 06/24/96 06/24/96 OFFICE: 06/26/96 180156 01/05/98 06/26/96 OFFICE: 06/28/96 180514 01/05/98 06/28/96 OFFICE: 07/01/96 180685 01/05/98 07/01/96 OFFICE: 07/03/96 180722 rb rb 40 rb rb 40 rb rb rb 40 rb rb 40 rb o 65.00 o rb 40 rb o 65.00 o rb 40 rb DATE :07/13/98 D.O. B: 07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMpLY: S S #:194-28-8043 CLASs: 7 DR:cho [ledger] Trind1e Rehab Medicine Center PATIENT J.EDGER GUARANTOR #:hulllo-03 PATIENT #:hulllo-03 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0.00 LST PLN pAY:02/04/97 LST PLAN $: 550.00 AT COLLECTN: 0.00 . INSURED #1 Hull, 'Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 null, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:065 Cho, Jay J INSURED #2 PLAN 1 POLICY ':;ROUP :us Hea1thcare #:KGDR1020 # : PLAN 2 : POLICY #: GROUP #: 1125 FR: **/**/** TO: **/**/** DATE BILL # DR. CPT/PROCEDURE CHECK #:PLA~ POS 01/05/98 PAYMENT-THANK YOU 0000 07/03/96 rb 97010-PT Hot/Cold Packs 0 OFFICE: 40 DX:8471-Thoracic sprain 65.00 07/05/96 180737 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 01/05/98 PAYMENT-THANK YOU 0000 07/05/96 rb 97010-PT Hot/Cold Packs 0 OFFICE: 40 DX:8471-Thoracic Sprain 100.00 07/08/96 180904 rb 97010-PT Hot/Cold Packs 0 01/05/98 PAYMENT-THANK YOU 0000 07/08/96 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 OFFICE: 40 DX:8471-Thoracic sprain 65.00 07/10/96 180955 rb 97010-PT Hot/Cold Packs 0 01/05/98 PAYMENT-THANK YOU 0000 07/10/96 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 OFFICE: 40 DX:8471-Thoracic sprain 65.00 07/12/96 181160 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 01/05/98 PAYMENT-THANK YOU 0000 07/12/96 rb 97010-PT Hot/Cold Packs 0 OFFICE: 40 DX:8471-Thoracic sprain 65.00 07/15/96 181306 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 01/05/98 PAYMENT-THANK YOU 0000 07/15/96 rb 97010-PT Hot/Cold Packs 0 OFFICE: 40 DX:8471-Thoracic sprain 65.00 07/17/96 181452 rb 97010-PT Hot/Cold Packs 0 01/05/98 PAYMENT-THANK YOU 0000 07/17/96 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 OFFICE: 40 DX:8471-Thoracic sprain 65.00 07/19/g6 181501 rb 97110-PT Therapeutic Exercise, Each 15 Min 0 01/05/98 PAYMENT-THANK YOU 0000 07/19/96 rb 97010-PT Hot/Cold Packs 0 I Payment Notes: Patient received settlement OFFICE: 40 DX:8471-Thoracic Sprain 65.00 PAGE: 15 FR: TO: CHARGE 0.00 30.00 <------ 70.00 0.00 30.00 <----;-- 30.00 0.00 35.00 <------ 30.00 0.00 35.00 <------ 35.00 0.00 30.00 <------ 35.DO 0.00 30.00 <------ 30.00 0.00 35.00 <------ 35.00 0.00 30.00 I <------ [ledger] GUARANTOR #:hu111o-00 PATIENT #:hu111o-00 AS!HGNMENT : yes-yes LAST PAY DT:08/07/96 LAST PAY $: 200.00 LST PLN PAY:05/15/95 LST PLAN $: 125.00 AT COLLECTN: 0.00 INSURED #1 Hu11, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 PLAN 1 POLICY ::;ROUP :Attorney Angio & #:194288043 # : ~~ Rehab Medicine Assoc,Hospita1 PATIENT LEDGER . PAGE: 1 -------------- null, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 DATE :07/13/98 D.O.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho EMPLOYER NAME: REF DOCTOR:479 Young, William W INSURED #2 Rovner FR: **/**/** TO:**/**/** PLAN 2 : POLICY #: GROUP # : FR: TO: CHECK #:PLAN POS CHARGE DATE BILL # ~ CPT/PROCEDURE 1 200.00 0,.00 <------ 08/16/95 01/05/98 163136 cho 99253-Consult IP Initial L3 PAYMENT-THANK YOU 0000 OFFICE: 20 DX:7231-Cervicalagia/cervic 200.00 'JUlie 1998 J ,Ju,0... z.-I/I.fUS- ,u O()'1.Ol:l Y'5'J ~.c.Jo --- -ptd g "ZoC17Z,2) J 4cffi /' for~~ Balance for Balance for \\I-~II\o,(, Last statement printed on 06/30/98 Patient Plan CURRENT 0.00 0.00 HUll, Lorraine T Plan 200.00 0.00 031-060 0.00 0.00 061-09Q 0.00 0.00 091-120 0.00 0.00 120+ 200.00 0.00 GUARANTOR #:hu11Io-00 PATIENT #:hu11Io-00 AS8IGNMENT :yes-yes LAST PAY DT:08/07/96 LAST PAY $: 200.00 LST PLN PAY:05/15/95 LST PLAN $: 125.00 AT COLLECTN: 0.00 INSURED #1 HUll, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 [ledger] Rehab Medicine Assoc,11echbrg PATIENT LEDGER . PAGE: 2 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho Hull, Lorraine T Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:479 Young, William W INSURED #2 PLAN 1 POLICY GROUP :Attorney Angio & Rovner #:194288043 FR:**/**/** #: TO:**/**/** PLAN 2 : POLICY #: GROUP # : OAT!:; 11/30/94 01/05/98 12/08/94 01/05/98 12/08/94 12/08/94 12/28/94 01/05/98 12/28/94 01/26/95 01/05/98 02/16/95 01/05/98 03/01/9? 01/05/98 03/09/95 01/05/98 03/09/95 03/09/95 BILL # DR. CPT/PROCEDURE 150577 cho OFFICE: 30 151161 gri gri gri OFFICE: 30 151844 cho cho OFFICE: 30 153245 cho OFFICE: 30 154385 cho OFFICE: 30 155271 cho OFFICE: 30 155858 gri gri gri OFFICE: 30 CHECK #: PLAN 99214-0V L3, Subsequent PAYMENT-THANK YOU 0000 DX:8470-Cervical sprain/str 95904-Sensory NCV, Each Nerve rt median/ulnar/radial PAYMENT-THANK YOU 0000 95900-Motor NCV Each Nerve without F-wave rt median/ulnar 95860-EMG- One Extremity RUE DX:8470-Cervical Sprain/str 20610-Arthrocentesis-Mjr.Jt.,hip,shldr It knee PAYMENT-THANK YOU 0000 99213-0V L2, Subsequent DX:8470-Cervica1 sprain/str 99214-0V L3, Subsequent i'AYMENT-THANK YOU 0000 DX:8470-Cervical sprain/str 99214-0V L3, Subsequent PAYMENT-THANK YOU 0000 DX:723.4-Cervical/upper Lim 99214-0V L3, Subsequent PAYMENT-THANK YOU 0000 DX:723.4-Cervical/upper Lim 95904-Sensory NCV, Each Nerve bil median/ulnar/radial PAYMENT-THANK YOU 0000 95900-Motor NCV Each Nerve without F-wave bil median/ulnar 95861-EMG- Two Extremities BUE DX:723.4-Cervical/upper Llm POS 3 60.00 3 3 3 500.00 3 3 110.00 3 60.00 3 60.00 3 60.00 3 3 3 900.00 FR: TO: CHARGE 60.00 0.00 <------ 180.00 0.00 120.00 200.00 <------ 70.00 0.00 40.00 <------ 60.00 0.00 <------ 60.00 0.00 <------ 60.00 0.00 <------ 360.00 0.00 240.00 300.00 <-.----- [ledg-er] Rehab Medicine Assoc,Mechbrg PATIENT LEDGER GUARANTOR #:hulllo-OO PATIENT #:hulllo-OO ASSIGNMENT :yes-yes LAST PAY DT:08/07/96 LAST PAY $: 200.00 LST PLN PAY:05/15/95 LST PLAN $: 125.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T Hull, Lorrai.ne 'f 5235 Meadowbrook Drive Mechanicsburg, PA 17055 EMPLOYER NAME: REF DOCTOR:479 Young, William W INSURED #2 PLAN 1 POLICY GROUP :Attorney Angio & #:194288043 # : Rovner FR:**/**/** TO:**/**/** PLAN 2 : POLICY #: GROUP # : DATE BILL # DR. CPT/PROCEDURE CHECK # : PLAN 03/22/95 156137 cho 99214-0V L3, subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:723.4-Cervical/upper Lim 04/11/95 157292 cho 99214-QV L3, Subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-Cervicalagia/Cervic 05/03/95 158312 cho 99214-0V L3, Subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-Cervicalagia/Cervic 06/16/95 159973 cho 99214-0V L3, Subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-Cervicalagia/Cervic 07/19/95 161811 cho 99214-0V L3, Subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-Cervicalagia/Cervic 08/04/95 162722 cho 99214-0V L3, Subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-Cervicalagia/Cervic 08/30/95 163740 cho 99214-0V L3, Subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-Cervicalagia/Cervic 09/29/95 165427 cho 99214-0V L3, Subsequent 01/05/98 PAYMENT-THANK YOU 0000 OFFICE: 30 DX:7231-Cervicalagia/Cervic 11/26/96 188516 cho 09102-Medical Records (initial Chg) 01/05/98 PAYMENT-THANK YOU 0000 I Payment Notes: pt recieved settlement OFFICE: 30 DX:7231-Cervicalagia/cervic PAGE: 3 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS:11 DR:cho FR: TO: POS CHARGE 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 60.00 0,00 60.00 <------ 3 60.00 0.00 60.00 <------ 3 60.00 0.00 60.00 <---.;.-- 3 17.25 0.00 I 17.25 <--'---- [ledger] Rehab Medicine Assoc,Mechbrg PATIENT LEDGER . PAGE: . GUARANTOR #:hulllo-OO PATIENT #:hulllo-OO ASSIGNMENT :yes-yes LAST PAY DT: 08/07/96 LAST PAY $: 200.00 LST PLN PAY:05/15/95 LST PLAN $: 125.00 AT COLLECTN: 0.00 INSURED #1 Hull, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 Hull, Lorraine T null, Lorraine T 5235 Meadowbrook Drive Mechanicsburg, PA 17055 DATE :07/13/98 D.0.B:07/19/38 CHART: HOME :717-761-7869 EMRG :717-761-7869 EMPLY: S S #:194-28-8043 CLASS: 11 DR:cho EMPLOYER NAME: REF DOCTOR:479 Young, Wi11iam W INSURED #2 PLAN 1 POLICY ':;ROUP :Attorney Angio & #:194288043 #: FR: TO: PLAN 2 : POLICY #: GROUP # : Rovner FR: **/**/** TO:**/**/** DATE BILL # DR. CPT/PROCEDURE j::HECK #:PLAN POS CHARGE Last statement printed on 06/30/98 for 2447.25 Balance for Hull, Lorraine T 2247.25 Balance for Plan 0.00 Patient Plan CURRENT 0.00 0.00 031-060 0.00 0.00 061-090 0.00 0.00 120.:!: 2247.25 0.00 091-120 0.00 0.00 .....-;' 4 >- ry, "- cr; c: [ ~ - u ; c. , Li.: , , .,.. ,. , C. (,."j; , " - c':: ,~) l; ...1 : ~ ' ,.'I c..: f..:.:'; L; - :.1.. .~ LL ()", , 0 0' (j " . '>- 0' '- b; c:: t:- ~. .~ 1- ~0< LUQ - ::?:~ 0-', ~" ~~{{ c:: ;-."- n ;:,"i.l) CJr~:.. I ) .," 1...:..1:.... ";~lfO ~2:; :>- ~:; l:iJLL - l.L_ 0"\ ::5 0 0.' ,;,) "