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HomeMy WebLinkAbout03-3234 . TABAS & ROSEN, P.C. BY: LEWIS C. TRAUFFER I.D.1f60267 22nd Fl.,1845 walnut Street Phila. PA 19103 (215) ~69-S050 Plaintiff(s) THE MILTON S. HERSHEY MEDICAL CENTER P.O. Box 853 Hershey, PA 17033 ATTORNEY FOR Plaintiff vs D~fendanrs(s) GINNY REID PRICE 353 Old Stonehouse Road Boiling Springs, PA 17007 CIVIL ACTION NOTICE You have been sued in court. Ifyoll wish to defend against the claims set forth in the following pages. you must take action within twenty (20) days after this complaint and notice are served. by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE. GO TO OR TELEPHONE THE OFFICE SET FORTH BELOWTO FINDOUTWHERE YOU CAN GET LEGAL HELP. COURT OF COMMON PLEAS DIVISION CUMBERLAND COUNTY TERM. > No. 03 -~3L( G'od~~ I COMPLAINT AVISO Le han demandado a usted en la corte. Si usted quiere defenderse de estas demandas cxpuestas en las paginas siguientes, usted tiene veinte (20) dias de plalO al partir de la feeha de la demanda y la notificacion. Haee faha asentar una eomparencia escrita 0 en persona 0 con un abogado y entrega r a la corte en forma eserita sus defensas 0 sus objeeiones a lasdemandas en contra de su persona. Sea avisado que si usted no se defiende.la corte tomara medidas y puede continuar la demanda en contra suya sin previo aviso 0 notificacion. Ademas, la corte puede decidir a favor del demandante y re4uiere que usted cumpla con todas Ius provisiones de esta demandu. Usted puede perder di,nero 0 sus propiedades 0 otros derechos importantes para usted. LLEVE ESTA DEMANDA A UN ABOGADO I~MEJ)IArAMENTE. 51 NO TIENE ABOGADO 0 51 NO T1ENE EL DINERO SlJFIClENTE DE PAGAR TAL SERVICIO. VAYA EN PERSONA 0 I.I.AME POR TEl.EFONO A LA OFICINA CUVA DIRECCION SE ENClIENTRA [SeRITA ABAJO PARA AVERIGUAR DONDF SE PUEDE CONSEGUIR ASISTENCIA LEGAL CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 (717)249-3166 or (800)990-9108 COMPLAINT - CIVIL ACTION THE MILTON S. HERSHEY MEDICAL CENTER VS. GINNY REID PRICE 1. Plaintiff is a non-profit corporation located at the address indicated in the caption hereof. 2. Defendant is an individual who resides at the address indicated in the caption hereof. 3. At all times material hereto, defendant was the spouse of Bobby Ray Price, Deceased. 4. As the result of a certain medical condition, defen- dant's spouse was admitted to the plaintiff hospital for medical care on October 19, 2000 thru January 19, 2002. 5. The amounts, quantities and nature of the medical care rendered, the da.te on which said medical care was rendered, and the charges therefore are set forth in Exhibit "A" which is incorporated herein as if set forth at length. 6. Said medical care was commensurate with the condition of defendant's spouse and was necessary for the health and welfare of defendant's spouse. 7. Defendant's spouse is deceased. 8. Defendant is financially able to pay for the medical care of the deceased spouse. 9. By virtue of the marital relationship, the Act of 1937, June 24, P.L. 2045, ~3, as amended, 62 Pa. Cons. Stat. Ann. ~1973 and Article 1, ~28 of the Pennsylvania Constitution and all other applicable statutes, laws and ordinances, defendant has a duty to support defendant's spouse. THIS DOCUMENT IS BEING USED IN CONNECTION WITH THE COLLECTION A DEBT; ANY INFORMATION OBTAINED MAY BE USED FOR THAT PURPOSE. 10. Defendant refuses to pay the balance due although plaintiff has made demand that defenant do so. 11. Defendant is liable for the medical care rendered to defendant's spouse. 12. As a result of the foregoing, there is due and owing from defendant to plaintiff the sum indicated in Exhibit "A". WHEREFORE, plaintiff demands judgment against defendant for the sum of $13,534.25 plus six percent (6%) interest per annum from the date of discharge to the date of judgment, record costs and non-record costs. TABAS & ROSEN, P.C. ~ c...4 -> LEWIS C. Tap({FFER, ESQUIRE THIS DOCUMENT IS BEING USED IN CONNECTION WITH THE COLLECTION OF A DEBT; ANY INFORMATION OBTAINED MAY BE USED FOR THAT PURPOSE. MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1292175 Date I Svc Code I Description I Units I Debits Credits 02/02/01 8347 CC OUTPATIENT VISIT E 1 30.00 02/02/01 310516 CT THORAX ENHANCED 1 1129.00 02/02/01 310521 CT ABD UNENH & ENH SA 1 1241.00 02/02/01 310567 CT PELVIS ENHANCED 1 885.00 02/02/01 310641 CT LOCM 300-399 MG 1 90.00 02/07/01 920029 MEDICARE NON-COVERED -1 90.00- 03/01/01 902003 MEDICARE PAY HOSP -1 156.39- 03/01/01 920015 MEDICARE CONT ADJ. 0/ -1 2554.23- 03/04/01 900011 PATIENT PAY CHECK -1 9.65- 05/09/01 902003 MEDICARE PAY HOSP 0 38.22- 05/09/01 920015 MEDICARE CONT ADJ. 0/ 1 17.77 08/31/01 980090 HOSPITAL BAD DEBT W/O -1 544.28- 08/31/01 980091 HOSPITAL BAD DEBT PLA 1 544.28 10/10/02 980092 RETURN HOSPITAL BAD D -1 544.28- 10/10/02 980093 RETURN FROM B/D HOSP 1 544.28 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 544.28- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 544.28 -------------------------------------------------------------------------------- * - Not posted Balance: 544.28 I P - I MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1498374 Date I Svc Code I Description I Units I Debits Credits 05/04/01 8348 CC OUTPATIENT VISIT E 1 24.00 05/04/01 104033 CHOLESTEROL TOTAL 1 7.00 05/04/01 104096 LDH 1 10.00 05/04/01 105656 CBC W/PLT CNT, NO DIF 1 22.00 05/04/01 109804 BLOOD COLLECTION 1 11.00 05/04/01 310516 CT THORAX ENHANCED 1 1129.00 05/04/01 310521 CT ABD UNENH & ENH SA 1 1241. 00 05/04/01 310567 CT PELVIS ENHANCED 1 885.00 05/04/01 310641 CT LOCM 300-399 MG 1 90.00 05/07/01 920029 MEDICARE NON-COVERED -1 90.00- OS/28/01 902003 MEDICARE PAY HOSP -1 305.25- OS/28/01 920015 MEDICARE CONT ADJ. 0/ -1 2545.14- 09/10/01 902003 MEDICARE PAY HOSP 0 83.41- 09/10/01 920015 MEDICARE CONT ADJ. 0/ 0 25.48 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 420.68- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 420.68 * - Not posted Balance: 420.68 I A-;L MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 10264 101003 101005 102183 102184 104013 104014 104016 104026 104042 104065 104067 104096 104106 104129 104156 104398 104585 105017 105052 105059 105657 106011 245490 246177 246478 246614 246841 250530 251719 273266 621034 626078 670330 670334 10264 79628 79629 105657 191023 191030 Description P PRIV MED/SURG RM ABO BLOOD GROUP RH TYPE CULTURE, URINE COL CO CULTURE, URINE PRESUM ALBUMIN ALKALINE PHOSPHATASE BILIRUBIN TOTAL CALCIUM CREATININE, BLOOD UREA NITROGEN (BUN), URIC ACID, BLOOD LDH MAGNESIUM PHOSPHORUS, BLOOD SGPT (ALT) ELECTROLYTES GENTAMICIN LEVEL PERIPHERAL SMEAR PARTIAL THROMBOPLAS T PROTHROMBIN TIME CBC/DIFF/PLT COUNT, A URINALYSIS-BASIC & MI SODIUM CHLORIDE 0.9% GENTAMICIN 5 ML SODIUM CHLORIDE 30 ML PREDNISONE 20 MG SODIUM BICARBONATE 50 VINCRISTINE 2MG/2ML ONDANSETRON 8MG TABS CEFEPIME 2GR VIAL I V DEXTROSE 5%-.45 S I V DILUENT DEX 5% 50 IV INFUSION SET, UNIV IV INFUSION SET, UNIV P PRIV MED/SURG RM TISSUE CULT NEOL BLD/ CYTOGENET BM KARYOTYP CBC/DIFF/PLT COUNT, A LVL4 SURGICAL PATHOLO DECALCIFICATION - Continue - f)3 PAGE: 1 Patient: PRICE BOBBY RAY Acct No: 1635548 I Units I 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 24 4 2 2 2 3 1 1 1 1 1 1 1 1 1 Debits 760.00 16.00 15.00 38.00 38.00 9.00 9.00 9.00 9.00 9.00 8.00 8.00 11.00 37.00 9.00 10.00 23.00 67.00 8.00 28.00 18.00 28.00 34.00 5.30 2.25 2.10 2.16 8.40 18.30 123.76 127.60 18.00 8.00 7.00 8.00 760.00 204.00 478.00 28.00 56.00 17.00 Credits MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 191073 191090 191091 245206 245490 245911 246394 246703 246747 246841 247831 273266 310516 310521 310567 310641 600908 600909 621014 621034 661606 10264 83193 101111 101142 101143 101144 101514 104028 104042 104065 104067 104106 104129 104398 105054 105657 245207 245490 245525 245579 Description IMMUNOPEROXIDASE @ GRPl STAIN-MICRO GRP2 STAIN-HISTO LIDOCAINE 10MG/ML SODIUM CHLORIDE 0.9% ALLOPURINOL 300 MG PROCHLORPERAZINE 10 M LORAZEPAM 2 MG RANITIDINE 150 MG SODIUM BICARBONATE 50 ACETAMINOPHEN 325 MG CEFEPIME 2GR VIAL CT THORAX ENHANCED CT ABD UNENH & ENH SA CT PELVIS ENHANCED CT LOCM 300-399 MG NDL BIOP 116 4IN BONE NDL ASPIRAT ILLIN 156 I V DEXTROSE 5%-WATER I V DEXTROSE 5%-.45 S BIOPSY/ASPIR TRAY P PRIV MED/SURG RM CELL SURF MARKER EA POOL BLD PRODUCT PROC PLTS,RANDOM/U IRRADIATE COMPONENT LEUKOREDUCE PLTS PROC PLTS,APHER/U IONIZED CALCIUM CREATININE, BLOOD UREA NITROGEN (BUN), URIC ACID, BLOOD MAGNESIUM PHOSPHORUS, BLOOD ELECTROLYTES PLATELET COUNT CBC/DIFF/PLT COUNT, A LIDOCAINE 1 ML SODIUM CHLORIDE 0.9% HEPARIN SODIUM 1000 U SODIUM CHLORIDE 1 ML PAGE: 2 Patient: PRICE BOBBY RAY Acct No: 1635548 Debits Credits I Units I 1 1 1 1 2 1 2 1 1 5 1 2 1 1 1 1 1 1 3 1 1 1 14 1 6 2 2 1 1 2 2 1 1 1 2 1 1 1 2 1 1 40.00 12.00 13.00 2.10 5.30 2.10 2.26 3.65 2.10 10.50 2.10 127.60 1185.00 1303.00 929.00 95.00 35.00 27.00 18.00 6.00 30.00 760.00 1036.00 21. 00 306.00 86.00 126.00 698.00 66.00 18.00 16.00 8.00 37.00 9.00 46.00 12.00 28.00 2.10 5.30 3.40 2.15 -------------------------------------------------------------------------------- - Continue - fi-If MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 245911 245958 246127 246273 246478 246841 247831 251251 272425 273266 306615 306778 307508 621014 621042 626080 626081 661645 670330 670334 670335 10264 101003 101004 101005 101021 101102 101103 101111 101142 101143 101144 104028 104042 104064 104065 104106 104129 104378 104398 105054 Description ALLOPURINOL 300 MG HEPARIN SODIUM 100 UN DIPHENHYDRAMINE 25 MG METHYLPRED. SOD. SUCC SODIUM CHLORIDE 30 ML SODIUM BICARBONATE 50 ACETAMINOPHEN 325 MG KDUR 20MEG UD MIDAZOLAM IMG/ML 2ML CEFEPIME 2GR VIAL GUIDE WIRE(S) SEDATION IV/IM/INHALA CV CATH PLACE,PERC,<2 I V DEXTROSE 5%-WATER I V SODIUM CHLORIDE 0 I-V DILUENT NML SALIN I-V DILUENT NML SALIN TRAY LUMBAR PUNCTURE IV INFUSION SET, UNIV IV INFUSION SET, UNIV SET IN-LINE FILTER W/ P PRIV MED/SURG RM ABO BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN BLOOD PROCESSING PER LEUKOREDUCE RBCS POOL BLD PRODUCT PROC PLTS,RANDOM/U IRRADIATE COMPONENT LEUKOREDUCE PLTS IONIZED CALCIUM CREATININE, BLOOD GLUCOSE, FLUID UREA NITROGEN (BUN), MAGNESIUM PHOSPHORUS, BLOOD PROTEIN, MISC BODY FL ELECTROLYTES PLATELET COUNT PAGE: 3 Patient: PRICE BOBBY RAY Acct No: 1635548 Debits Credits I Units I 1 2 2 4 1 6 2 1 1 2 2 1 1 2 3 1 1 1 4 1 3 1 1 1 1 4 4 4 1 6 5 1 2 2 1 2 2 2 1 2 1 2.10 4.20 4.20 26.20 2.10 12.60 4.20 4.05 2.10 127.60 148.00 307.00 302.00 12.00 18.00 8.00 8.00 18.00 28.00 8.00 51. 00 760.00 16.00 28.00 15.00 216.00 324.00 176.00 21.00 306.00 215.00 63.00 132.00 18.00 17.00 16.00 74.00 18.00 18.00 46.00 12.00 -------------------------------------------------------------------------------- - Continue - &-5 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date ! Svc Code ! 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 105657 106036 111001 192070 245911 246127 246273 246563 246747 246841 247831 273636 621244 626080 626081 670330 670335 10264 104028 104042 104060 104065 104106 104129 104398 105656 111001 230892 245492 245794 245911 245958 246176 246273 246478 246563 246747 246841 246907 248793 250524 Description CBC/DIFF/PLT COUNT, A CELL COUNT & DIFF, BO GLUCOSE BEDSIDE MONIT SMEARS,CONCENTR,INTER ALLOPURINOL 300 MG DIPHENHYDRAMINE 25 MG METHYLPRED. SOD. SUCC DEXAMETHASONE 4 MG RANITIDINE 150 MG SODIUM BICARBONATE 50 ACETAMINOPHEN 325 MG ONDANSETRON 24MG TABL I V SODIUM CHLORIDE 0 I-V DILUENT NML SALIN I-V DILUENT NML SALIN IV INFUSION SET, UNIV SET IN-LINE FILTER w/ P PRIV MED/SURG RM IONIZED CALCIUM CREATININE, BLOOD GLUCOSE, BLOOD UREA NITROGEN (BUN), MAGNESIUM PHOSPHORUS, BLOOD ELECTROLYTES CBC W/PLT CNT, NO DIF GLUCOSE BEDSIDE MONIT MESNA INJ SALINE 0.9% 500 ML CYCLOPHOSPHAMIDE INJ ALLOPURINOL 300 MG HEPARIN SODIUM 100 UN FUROSEMIDE 10 MG/ML METHYLPRED. SOD. SUCC SODIUM CHLORIDE 30 ML DEXAMETHASONE 4 MG RANITIDINE 150 MG SODIUM BICARBONATE 50 LORAZEPAM 0.5 MG DEXTROSE 5% 150ML SODIUM BICARBONATE 65 PAGE: 4 Patient: PRICE BOBBY RAY Acct No: 1635548 Debits Credits I Units! 1 1 2 1 1 2 1 1 1 5 2 3 3 1 3 3 2 1 2 2 1 2 2 2 2 1 4 14 2 28 1 2 1 2 2 1 2 8 1 4 1 28.00 65.00 44.00 19.00 2.10 4.20 6.55 3.60 2.10 10.50 4.20 185.61 18.00 8.00 24.00 36.00 34.00 760.00 132.00 18.00 8.00 16.00 74.00 18.00 46.00 23.00 88.00 1354.36 10.30 63.56 2.10 4.20 2.10 13 .10 4.20 3.60 4.20 16.80 2.10 8.40 2.10 -------------------------------------------------------------------------------- - COIJ.tinue - H~0 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM PAGE: 5 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1635548 Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 07/12/01 273636 ONDANSETRON 24MG TABL 3 185.61 07/12/01 621244 I V SODIUM CHLORIDE 0 2 12.00 07/13/01 10264 P PRIV MED/SURG RM 1 760.00 07/13/01 101111 POOL BLD PRODUCT 1 21.00 07/13/01 101142 PROC PLTS,RANDOM/U 6 306.00 07/13/01 101143 IRRADIATE COMPONENT 1 43.00 07/13/01 101144 LEUKOREDUCE PLTS 1 63.00 07/13/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 07/13/01 111001 GLUCOSE BEDSIDE MaNIT 4 88.00 07/13/01 230892 MESNA INJ 7 677 . 18 07/13/01 245218 DOXORUBICIN HCL 50 MG 11 449.90 07/13/01 245479 METHOTREXATE 20MG 3 11.61 07/13/01 245492 SALINE 0.9% 500 ML 2 10.30 07/13/01 245579 SODIUM CHLORIDE 1 ML 1 2.10 07/13/01 245794 CYCLOPHOSPHAMIDE INJ 14 31.78 07/13/01 245911 ALLOPURINOL 300 MG 1 2.10 07/13/01 246127 DIPHENHYDRAMINE 25 MG 2 4.20 07/13/01 246176 FUROSEMIDE 10 MG/ML 2 4.20 07/13/01 246273 METHYLPRED. SOD. SUCC 2 13 .10 07/13/01 246563 DEXAMETHASONE 4 MG 1 3.60 07/13/01 246747 RANITIDINE 150 MG 2 4.20 07/13/01 246841 SODIUM BICARBONATE 50 4 8.40 07/13/01 246907 LORAZEPAM 0.5 MG 1 2.10 07/13/01 247831 ACETAMINOPHEN 325 MG 2 4.20 07/13/01 248793 DEXTROSE 5% 150ML 2 4.20 07/13/01 250524 SODIUM BICARBONATE 65 1 2.10 07/13/01 250530 VINCRISTINE 2MG/2ML 2 18.30 07/13/01 272176 ZOLIPIDEM 5MG TAB 4 19.80 07/13/01 273636 ONDANSETRON 24MG TABL 3 185.61 07/13/01 621042 I V SODIUM CHLORIDE 0 3 18.00 07/13/01 621244 I V SODIUM CHLORIDE 0 2 12.00 07/13/01 626080 I-V DILUENT NML SALIN 2 16.00 07/13/01 626081 I-V DILUENT NML SALIN 1 8.00 07/13/01 670330 IV INFUSION SET, UNIV 4 48.00 07/13/01 670334 IV INFUSION SET, UNIV 3 24.00 07/13/01 670335 SET IN-LINE FILTER W/ 3 51.00 07/14/01 10264 P PRIV MED/SURG RM 1 760.00 07/14/01 104028 IONIZED CALCIUM 1 66.00 07/14/01 104042 CREATININE, BLOOD 1 9.00 07/14/01 104047 MASS MB (MAGNUM) 2 68.00 07/14/01 104048 MYOGLOBIN 2 124.00 -------------------------------------------------------------------------------- - Continue - H'7 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 104049 104060 104065 104106 104129 104398 105656 111001 245911 246273 246280 246563 246747 246841 246907 247831 247842 250524 250926 272176 273636 307101 521211 621043 621244 626080 670330 670334 10264 104026 104042 104060 104065 104106 104129 104398 105656 245911 246273 246394 246747 Description TROPONIN GLUCOSE, BLOOD UREA NITROGEN (BUN), MAGNESIUM PHOSPHORUS, BLOOD ELECTROLYTES CBC W/PLT CNT, NO DIF GLUCOSE BEDSIDE MONIT ALLOPURINOL 300 MG METHYLPRED. SOD. SUCC MG-AL HYDROXIDE 180 M DEXAMETHASONE 4 MG RANITIDINE 150 MG SODIUM BICARBONATE 50 LORAZEPAM 0.5 MG ACETAMINOPHEN 325 MG CAL GLUCONATE 10ML SODIUM BICARBONATE 65 FILGRASTIM 480MCG ZOLIPIDEM 5MG TAB ONDANSETRON 24MG TABL CHEST 1 VIEW 12 LEAD ELECTROCARDIO I V SODIUM CHLORIDE 0 I V SODIUM CHLORIDE 0 I-V DILUENT NML SALIN IV INFUSION SET, UNIV IV INFUSION SET, UNIV P PRIV MED/SURG RM CALCIUM CREATININE, BLOOD GLUCOSE, BLOOD UREA NITROGEN (BUN), MAGNESIUM PHOSPHORUS, BLOOD ELECTROLYTES CBC W/PLT CNT, NO DIF ALLOPURINOL 300 MG METHYLPRED. SOD. SUCC PROCHLORPERAZINE 10 M RANITIDINE 150 MG PAGE: 6 Patient: PRICE BOBBY RAY Acct No: 1635548 Debits Credits I Units I 2 1 1 1 1 1 1 3 1 2 1 1 2 4 1 1 1 1 1 1 3 1 1 1 2 1 3 1 1 1 1 1 1 1 1 1 1 1 2 4 2 90.00 8.00 8.00 37.00 9.00 23.00 23.00 66.00 2.10 13.10 2.10 3.60 4.20 8.40 2.10 2.10 3.25 2.10 709.85 4.95 185.61 92.00 89.00 6.00 12.00 8.00 36.00 8.00 760.00 9.00 9.00 8.00 8.00 37.00 9.00 23.00 23.00 2.10 13 .10 4.52 4.20 -------------------------------------------------------------------------------- - Continue - fi-I? MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM Guarantor: PRICE BOBBY F~Y 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 07/15/01 07/15/01 07/15/01 07/15/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 08/01/01 08/15/01 08/16/01 09/16/01 11/04/01 10/31/02 10/31/02 249557 249819 250926 626080 101143 101144 101514 104028 104042 104065 104106 104129 104398 105656 245911 245958 246127 246394 246478 246747 247831 249557 249819 250926 670330 670335 920005 902003 920005 930017 930017 980090 980091 * - Not posted Description ACY'CLOVIR 200MG CIPROFLOXACIN 500MG FILGRASTIM 480MCG I-V DILUENT NML SALIN IRRADIATE COMPONENT LEUKOREDUCE PLTS PROC PLTS,APHER/U IONIZED CALCIUM CREATININE, BLOOD UREA NITROGEN (BUN), MAGNESIUM PHOSPHORUS, BLOOD ELECTROLYTES CBC W/PLT CNT, NO DIF ALLOPURINOL 300 MG HEPARIN SODIUM 100 UN DIPHENHYDRAMINE 25 MG PROCHLORPERAZINE 10 M SODIUM CHLORIDE 30 ML RANITIDINE 150 MG ACETAMINOPHEN 325 MG ACY'CLOVIR 200MG CIPROFLOXACIN 500MG FILGRASTIM 480MCG IV INFUSION SET, UNIV SET IN-LINE FILTER W/ MEDICARE DRG CONTRACT MEDICARE PAY HOSP MEDICARE DRG CONTRACT MEDICARE LATE CHG/CR MEDICARE LATE CHG/CR HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA fJ-1 PAGE: 7 Patient: PRICE BOBBY RAY Acct No: 1635548 I Units I 3 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 1 2 2 1 1 1 1 -1 -1 2 -1 -1 -1 1 Debits 6.30 23.60 709.85 8.00 43.00 63.00 698.00 66.00 9.00 8.00 37.00 9.00 23.00 23.00 2.10 2.10 4.20 2.26 4.20 2.10 4.20 4.20 11.80 709.85 12.00 17.00 914.63 792.00 Balance: Credits 2824.12- 22227.10- 1036.00- 40.00- 792.00- 792.00 I MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM Guarantor: PRICE BOBBY F~Y 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 PAGE: 1 Patient: PRICE BOBBY RAY Acct No: 1654762 I Units I 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 4 1 1 1 2 1 1 2 1 -1 -2 o o -1 -1 1 Date I Svc Code I ------------------------.-------------------------------------------------------- Credits Description CC OUTPATIENT VISIT E ABO BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN BLOOD PROCESSING PER LEUKOREDUCE RBCS IRRADIATE COMPONENT LEUKOREDUCE PLTS PROC PLTS,APHER/U CALCIUM MAGNESIUM PHOSPHORUS, BLOOD PLATELET COUNT CBC W/PLT CNT, NO DIF FILGRASTIM 480MCG TRANSF BLOOD/BLOOD CO IV INF TX 0-1 HR IV INF TX EA ADDL HR COLLECT BLD VIA PORT/ I V SODIUM CHLORIDE 0 I-V DILUENT NML SALIN IV INFUSION SET, UNIV SET IN-LINE FILTER W/ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ MEDICARE NON-COVERED HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA f} -j D Debits 24.00 16.00 28.00 15.00 108.00 81. 00 44.00 43.00 63.00 698.00 9.00 37.00 9.00 12.00 23.00 365.20 327.00 88.00 42.00 58.00 6.00 8.00 24.00 17.00 952.74- 520.79- 144.83- 75.12- 58.00- 393.72- 393.72 Balance: 393.72 I 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 07/17/01 08/10/01 08/10/01 10/29/01 10/29/01 10/31/01 10/31/02 10/31/02 8348 101003 101004 101005 101021 101102 101103 101143 101144 101514 104026 104106 104129 105054 105656 230750 292009 292010 292011 292028 621044 626081 670330 670335 902003 920015 902003 920015 920029 980090 980091 * - Not posted MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:51 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 07/18/01 08/14/01 08/14/01 10/31/02 10/31/02 8348 101143 101144 101514 104014 104016 104060 104096 104156 105054 105656 230164 230750 231444 292010 292011 292028 621042 626081 670330 670335 902003 920015 980090 980091 Description CC OUTPATIENT VISIT E IRRADIATE COMPONENT LEUKOREDUCE PLTS PROC PLTS,APHER/U ALKALINE PHOSPHATASE BILIRUBIN TOTAL GLUCOSE, BLOOD LDH SGPT (ALT) PLATELET COUNT CBC W/PLT CNT, NO DIF DIPHENHYDRAMINE CP25M FILGRASTIM 480MCG ACETAMINOPHEN 325MG T IV INF TX 0-1 HR IV INF TX EA ADDL HR COLLECT BLD VIA PORT/ I V SODIUM CHLORIDE 0 I-V DILUENT NML SALIN IV INFUSION SET, UNIV SET IN-LINE FILTER w/ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT w/o HOSPITAL BAD DEBT PLA PAGE: 1 Patient: PRICE BOBBY RAY Acct No: 1657864 I Units I 1 1 1 1 1 1 1 1 1 1 1 1 4 2 1 3 1 1 1 2 2 -1 -2 -1 1 Debits 24.00 43.00 63.00 698.00 9.00 9.00 8.00 11.00 10.00 12.00 23.00 4.25 365.20 4.24 88.00 126.00 29.00 6.00 8.00 24.00 34.00 244.56 * - Not posted ------------------------------------------------------------- Balance: f)-II Credits 822.41- 531.72- 244.56- 244.56 I MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 statement on: 11/27/02 at 08:51 AM PAGE: 1 Guarantor: PRICE BOBBY PAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1660990 Date I Svc Code I Description I Units I Debits Credits 07/19/01 8348 CC OUTPATIENT VISIT E 1 24.00 07/19/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 07/19/01 230750 FILGRASTIM 480MCG 4 365.20 07/19/01 231391 HEPARIN 1:100 10 ML 10 4.20 07/19/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 07/19/01 292010 IV INF TX 0-1 HR 1 88.00 07/19/01 292023 THERA/DrAG INJ SUB CUT 1 16.00 08/14/01 902003 MEDICARE PAY HOSP -1 763.36- 08/14/01 920015 MEDICARE CONT ADJ. 0/ -2 407.78 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 169.02- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 169.02 * - Not posted Balance: 169.02 I If-Iv MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:51 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1663834 Date I Svc Code I Description I Units I Debits Credits 07/20/01 8348 CC OUTPATIENT VISIT E 1 24.00 07/20/01 101111 POOL BLD PRODUCT 1 21.00 07/20/01 101142 PROC PLTS,RANDOM/U 6 306.00 07/20/01 101143 IRRADIATE COMPONENT 1 43.00 07/20/01 101144 LEUKOREDUCE PLTS 1 63.00 07/20/01 104014 ALKALINE PHOSPHATASE 1 9.00 07/20/01 104016 BILIRUBIN TOTAL 1 9.00 07/20/01 104096 LDH 1 11.00 07/20/01 104156 SGPT (ALT) 1 10.00 07/20/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 07/20/01 230750 FILGRASTIM 480MCG 4 365.20 07/20/01 231444 ACETAMINOPHEN 325MG T 2 4.24 07/20/01 231488 DIPHENHYDRAMINE CAP 2 1 4.25 07/20/01 231612 DIFLUCAN TAB 200MG 1 20.45 07/20/01 292028 COLLECT BLD VIA PORT/ 1 29.00 07/20/01 626081 I-V DILUENT NML SALIN 1 8.00 07/20/01 670330 IV INFUSION SET, UNIV 1 12.00 07/20/01 670335 SET IN-LINE FILTER W/ 1 17.00 08/14/01 902003 MEDICARE PAY HOSP -1 736.50- 08/14/01 920015 MEDICARE CONT ADJ. 0/ -2 89.24- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 153.40- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 153.40 ------------------------.-------------------------------------------------------- * - Not posted Balance: 153.40 I IJ - 13 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:52 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1666384 Date I Svc Code I Description I Unitsj Debits Credits 07/21/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 07/21/01 230012 DEXAMETHASONE TAB 4MG 10 5.70 07/21/01 230219 VINCRISTINE (VINCASAR) 1 22.30 07/21/01 230750 FILGRASTIM 480MCG 4 365.20 07/21/01 231391 HEPARIN 1:100 10 ML 10 4.20 07/21/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 07/21/01 231612 DIFLUCAN TAB 200MG 1 20.45 07/21/01 292003 CHEMO IV SINGLE PUSH 1 127.00 07/21/01 292010 IV INF TX 0-1 HR 1 88.00 07/21/01 292023 THERA/DIAG INJ SUB CUT 1 16.00 07/21/01 621042 I V SODIUM CHLORIDE 0 1 6.00 07/21/01 622024 IRRIGATION SOD CHL O. 1 6.00 07/21/01 670330 IV INFUSION SET, UNIV 1 12.00 08/14/01 902003 MEDICARE PAY HOSP -1 817.12- 08/14/01 920015 MEDICARE CONT ADJ. 0/ -2 295.40 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 178.33- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 178.33 * - Not posted Balance: 178.33 I fJ - PI MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:52 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1666782 Date I Svc Code I Description I Units I Debits Credits 07/22/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 07/22/01 230750 FILGRASTIM 480MCG 4 365.20 07/22/01 231391 HEPARIN 1:100 10 ML 10 4.20 07/22/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 07/22/01 231612 DIFLUCAN TAB 200MG 1 20.45 07/22/01 292010 IV INF TX 0-1 HR 1 88.00 07/22/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 08/15/01 902003 MEDICARE PAY HOSP -1 699.10- 08/15/01 920015 MEDICARE CONT ADJ. 0/ -2 331. 00 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 152.95- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 152.95 * - Not posted Balance: 152.95 I IT -/5 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:53 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1700327 Date I Svc Code I Description I Units I Debits Credits 08/07/01 8217 IV FLUIDS 2 18.00 08/07/01 8290 IV INF TX EA ADDL HR 2 84.00 08/07/01 8291 TRANSFUSION, BLOOD/CO 1 327.00 08/07/01 8297 VENIPUNCT TX/DX > AGE 1 29.00 08/07/01 8348 CC OUTPATIENT VISIT E 1 24.00 08/07/01 8509 PUMP TUBING UNIVERSAL 2 18.00 08/07/01 8510 FILTER, FENWAL 2 32.00 08/07/01 101003 ABO BLOOD GROUP 1 16.00 08/07/01 101004 ANTIBODY SCREEN 1 28.00 08/07/01 101005 RH TYPE 1 15.00 08/07/01 101021 COMPAT, IMMED SPIN 2 108.00 08/07/01 101102 BLOOD PROCESSING PER 2 162.00 08/07/01 101103 LEUKOREDUCE RBCS 2 88.00 08/07/01 101143 IRRADIATE COMPONENT 2 86.00 08/07/01 104014 ALKALINE PHOSPHATASE 1 9.00 08/07/01 104016 BILIRUBIN TOTAL 1 9.00 08/07/01 104042 CREATININE, BLOOD 1 9.00 08/07/01 104065 UREA NITROGEN (BUN) , 1 8.00 08/07/01 104096 LDH 1 11.00 08/07/01 104156 SGPT (ALT) 1 10.00 08/07/01 104398 ELECTROLYTES 1 23.00 08/07/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 09/04/01 902003 MEDICARE PAY HOSP -1 549.98- 09/04/01 920015 MEDICARE CONT ADJ. 0/ -2 262.94- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 329.08- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 329.08 -------------------------------------------------------------------------------- * - Not posted Balance: 329.08 I IJ /(; MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:54 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1723861 Date I Svc Code I Description I Units I Debits Credits 08/17/01 8346 CC OUTPATIENT VISIT E 1 23.00 08/17/01 101003 ABO BLOOD GROUP 1 16.00 08/17/01 101004 ANTIBODY SCREEN 1 28.00 08/17/01 101005 RH TYPE 1 15.00 08/17/01 101021 COMPAT, IMMED SPIN 1 54.00 08/17/01 101102 BLOOD PROCESSING PER 1 81.00 08/17/01 101103 LEUKOREDUCE RBCS 1 44.00 08/17/01 101143 IRRADIATE COMPONENT 1 43.00 08/17/01 230164 DIPHENHYDRAMINE CP25M 1 4.25 08/17/01 231444 ACETAMINOPHEN 325MG T 2 4.24 08/17/01 292010 IV INF TX 0-1 HR 1 88.00 08/17/01 292011 IV INF TX EA ADDL HR 1 42.00 08/17/01 292028 COLLECT BLD VIA PORT/ 1 29.00 08/17/01 626081 I-V DILUENT NML SALIN 1 8.00 08/17/01 670330 IV INFUSION SET, UNIV 1 12.00 08/17/01 670335 SET IN-LINE FILTER W/ 1 17.00 09/12/01 902003 MEDICARE PAY HOSP -1 241.61- 09/12/01 920015 MEDICARE CONT ADJ. 0/ -2 123.69- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 143.19- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 143.19 * - Not posted Balance: 143.19 I 1/-/7 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:54 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1742199 Date I Svc Code I Description I Units I Debits Credits 08/26/01 230394 FILGRASTIM 300MCG 1 229.20 08/26/01 292023 THERA/DrAG INJ SUBCUT 1 16.00 09/20/01 902003 MEDICARE PAY HOSP -1 190.60- 09/20/01 920015 MEDICARE CONT ADJ. 0/ 0 19.67- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 * - Not posted Balance: 34.93 I /lie MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:54 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1742414 -------------------------------------------------------------------------------- Date I Svc Code I Description I Unitsl Debits Credits -------------------------------------------------------------------------------- 08/27/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 08/27/01 230394 FILGRASTIM 300MCG 1 229.20 08/27/01 292023 THERA/DrAG INJ SUBCUT 1 16.00 08/27/01 292028 COLLECT BLD VIA PORT/ 1 29.00 09/20/01 902003 MEDICARE PAY HOSP -1 201.34- 09/20/01 920015 MEDICARE CONT ADJ. 0/ -2 65.93- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 ------------------------.-------------------------------------------------------- * - Not posted Balance: 34.93 I fJ-/9 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:54 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1745545 Date I Svc Code I Description I Units I Debits Credits 08/28/01 230394 FILGRASTIM 300MCG 1 229.20 08/28/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 09/21/01 902003 MEDICARE PAY HOSP -1 190.60- 09/21/01 920015 MEDICARE CONT ADJ. 0/ 0 19.67- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 * - Not posted Balance: 34.93 I jJ ;<D MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:54 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 09/24/01 09/24/01 02/05/02 02/05/02 02/15/02 10/31/02 10/31/02 8348 101003 101004 101005 101021 101102 101103 10 1111 101142 101143 101144 105054 105656 230164 230394 230625 231391 231444 231469 292009 292010 292011 292028 626081 661602 670330 670335 902003 920015 902003 920015 920029 980090 980091 Description CC OUTPATIENT VISIT E ABO BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN BLOOD PROCESSING PER LEUKOREDUCE RBCS POOL BLD PRODUCT PROC PLTS,RANDOM/U IRRADIATE COMPONENT LEUKOREDUCE PLTS PLATELET COUNT CBC W/PLT CNT, NO DIF DIPHENHYDRAMINE CP25M FILGRASTIM 300MCG CIPRO TAB 500MG HEPARIN 1:100 10 ML ACETAMINOPHEN 325MG T SODIUM CHLORIDE INJ 3 TRANSF BLOOD/BLOOD CO IV INF TX 0-1 HR IV INF TX EA ADDL HR COLLECT BLD VIA PORT/ I-V DILUENT NML SALIN CATH PREP TRAY CENT L IV INFUSION SET, UNIV SET IN-LINE FILTER W/ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ MEDICARE NON-COVERED HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA PAGE: 1 Patient: PRICE BOBBY RAY Acct No: 1748588 I Units I 1 1 1 1 2 2 2 1 6 3 1 1 1 1 1 1 10 2 30 1 1 1 2 3 1 3 3 -1 -2 o o -1 -1 1 Debits 24.00 16.00 28.00 15.00 108.00 162.00 88.00 21.00 306.00 129.00 63.00 12.00 23.00 4.25 229.20 7.85 4.20 4.24 4.20 327.00 88.00 42.00 58.00 24.00 12.00 36.00 51.00 56.33 383.66 * - Not posted ------------------------------------------------------------ Balance: 11-eJ, ( Credits 691.78- 745.57- 64.26- 58.00- 383.66- 383.66 I MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:55 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/30/01 08/31/01 10/09/01 10/09/01 02/11/02 02/11/02 02/18/02 10/31/02 10/31/02 8348 101003 101004 101005 101021 101102 101103 101143 105656 231391 231444 231469 231488 292009 292010 292011 292028 621042 621043 670330 670335 105656 902003 920015 902003 920015 920029 980090 980091 Description CC OUTPATIENT VISIT E ABO BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN BLOOD PROCESSING PER LEUKOREDUCE RBCS IRRADIATE COMPONENT CBC W/PLT CNT, NO DIF HEPARIN 1:100 10 ML ACETAMINOPHEN 325MG T SODIUM CHLORIDE INJ 3 DIPHENHYDRAMINE CAP 2 TRANSF BLOOD/BLOOD CO IV INF TX 0-1 HR IV INF TX EA ADDL HR COLLECT BLD VIA PORT/ I V SODIUM CHLORIDE 0 I V SODIUM CHLORIDE 0 IV INFUSION SET, UNIV SET IN-LINE FILTER W/ CBC W/PLT CNT, NO DIF MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ MEDICARE NON-COVERED HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA PAGE: 1 Patient: PRICE BOBBY RAY Acct No: 1751675 I Units I 1 1 1 1 2 2 2 2 1 10 2 30 1 1 1 1 1 2 1 2 1 1 -1 -2 o o -1 -1 1 Debits 24.00 16.00 28.00 15.00 108.00 162.00 88.00 86.00 23.00 4.20 4.24 4.20 4.25 327.00 88.00 42.00 29.00 12.00 6.00 24.00 17.00 23.00 56.33 323.25 * - Not posted ---------~--------------------------------------------------- Balance: IJ - cJ, d--. Credits 498.50- 276.21- 64.26- 29.00- 323.25- 323.25 ! MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:55 AM PAGE: 1 Guarantor: PRICE BOBBY P~Y 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1754727 Date I Svc Code I Description I Units I Debits Credits 08/31/01 8346 CC OUTPATIENT VISIT E 1 23.00 08/31/01 230394 FILGRASTIM 300MCG 1 229.20 08/31/01 292023 THERA/DIAG INJ SUB CUT 1 16.00 08/31/01 292028 COLLECT BLD VIA PORT/ 1 29.00 09/24/01 902003 MEDICARE PAY HOSP -1 190.60- 09/24/01 920015 MEDICARE CONT ADJ. 0/ -1 48.67- 11/28/01 902003 MEDICARE PAY HOSP 0 37.94- 11/28/01 920015 MEDICARE CONT ADJ. 0/ 0 24.43 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 44.42- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 44.42 * - Not posted Balance: 44.42 I f!~3 . MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:55 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1757513 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits 09/01/01 101143 IRRADIATE COMPONENT 1 43.00 09/01/01 101144 LEUKOREDUCE PLTS 1 63.00 09/01/01 101514 PROC PLTS,APHER/U 1 698.00 09/01/01 105054 PLATELET COUNT 1 12.00 09/01/01 230394 FILGRASTIM 300MCG 1 229.20 09/01/01 231391 HEPARIN 1:100 10 ML 10 4.20 09/01/01 231444 ACETAMINOPHEN 325MG T 2 4.24 09/01/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 09/01/01 231488 DIPHENHYDRAMINE CAP 2 1 4.25 09/01/01 292009 TRANSF BLOOD/BLOOD CO 1 327.00 09/01/01 292010 IV INF TX 0-1 HR 1 88.00 09/01/01 292011 IV INF TX EA ADDL HR 1 42.00 09/01/01 292028 COLLECT BLD VIA PORT/ 1 29.00 09/01/01 626081 I-V DILUENT NML SALIN 1 8.00 09/01/01 670330 IV INFUSION SET, UNIV 1 12.00 09/01/01 670335 SET IN-LINE FILTER W/ 1 17.00 09/25/01 902003 MEDICARE PAY HOSP -1 408.93- 09/25/01 920015 MEDICARE CONT ADJ. 0/ -3 918.48- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 257.68- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 257.68 * - Not posted Balance: 257.68 I /} -;;, f \ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:01 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1757708 -------------------------------------------------------------------------------- Date I Svc Code I Description I unitsl Debits Credits -------------------------------------------------------------------------------- 09/02/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 09/02/01 230394 FILGRASTIM 300MCG 1 229.20 09/02/01 231391 HEPARIN 1:100 10 ML 10 4.20 09/02/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 09/02/01 292010 IV INF TX 0-1 HR 1 88.00 09/02/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 09/26/01 902003 MEDICARE PAY HOSP -1 238.78- 09/26/01 920015 MEDICARE CONT ADJ. 0/ -2 49.79- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 76.03- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 76.03 ------------------------.-------------------------------------------------------- * - Not posted Balance: 76.03 I ffc:?:) MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:01 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1757879 Date I Svc Code I Description I Units I Debits Credits 09/03/01 102003 SENSI, DISK METHOD/PL 1 29.00 09/03/01 102116 CULTURE, CATHETER TIP 1 39.00 09/03/01 102189 ID DEFIN AEROB ISOL E 1 28.00 09/03/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 09/03/01 292010 IV INF TX 0-1 HR 1 88.00 09/03/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 09/27/01 902003 MEDICARE PAY HOSP -1 117.43- 09/27/01 920015 MEDICARE CONT ADJ. 0/ -1 60.18- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 50.39- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 50.39 _______________________M_________________________________________________________ * - Not posted Balance: 50.39 I /!-;<~ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:02 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1758058 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits 09/04/01 101143 IRRADIATE COMPONENT 1 43.00 09/04/01 101144 LEUKOREDUCE PLTS 1 63.00 09/04/01 101514 PROC PLTS,APHER/U 1 698.00 09/04/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 09/04/01 230394 FILGRASTIM 300MCG 1 229.20 09/04/01 231444 ACETAMINOPHEN 325MG T 2 4.24 09/04/01 231488 DIPHENHYDRAMINE CAP 2 1 4.25 09/04/01 292009 TRANSF BLOOD/BLOOD CO 1 327.00 09/04/01 292010 IV INF TX 0-1 HR 1 88.00 09/04/01 292011 IV INF TX EA ADDL HR 1 42.00 09/04/01 292028 COLLECT BLD VIA PORT/ 1 29.00 09/04/01 626081 I-V DILUENT NML SALIN 2 16.00 09/04/01 670330 IV INFUSION SET, UNIV 1 12.00 09/04/01 670335 SET IN-LINE FILTER W/ 1 17.00 10/01/01 902003 MEDICARE PAY HOSP -1 413.49- 10/01/01 920015 MEDICARE CONT ADJ. 0/ -3 929.52- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 257.68- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 257.68 --------------------------------------------------------------------------------- * - Not posted Balance: 257.68 I /Ie) J MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:02 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1761492 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 09/05/01 8347 CC OUTPATIENT VISIT E 1 09/05/01 105657 CBC/DIFF/PLT COUNT, A 1 09/05/01 230394 FILGRASTIM 300MCG 1 09/05/01 292028 COLLECT BLD VIA PORT/ 1 10/01/01 902003 MEDICARE PAY HOSP -1 10/01/01 920015 MEDICARE CONT ADJ. 0/ -2 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 30.00 28.00 229.20 29.00 202.89- 77.99- 35.32- 35.32 ------------------------------------------------------------------- * - Not posted Balance: 35.32 I -------------------------- //;;{6 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:03 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 09/06/01 10/01/01 10/01/01 10/31/02 10/31/02 292023 902003 920015 980090 980091 Description THERA/DIAG INJ SUBCUT MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA PAGE: Patient: PRICE BOBBY RAY Acct No: 1764861 I Units I 1 -1 1 -1 1 Debits 16.00 30.45 9.29 1 Credits 37.16- 9.29- * - Not posted -------------------------------------------------------------------------------- 9.29 I If -d, 9 Balance: MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:04 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1767847 Date I Svc Code I Description I Units I Debits Credits 09/07/01 8346 CC OUTPATIENT VISIT E 1 23.00 09/07/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 09/07/01 292028 COLLECT BLD VIA PORT/ 1 29.00 10/01/01 902003 MEDICARE PAY HOSP -1 48.68- 10/01/01 920015 MEDICARE CONT ADJ. 0/ -1 21.83- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 9.49- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 9.49 * - Not posted Balance: 9.49 I If-3D MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 12/10/02 at 09:39 AM PAGE: 1 Guarantor: PRICE BOBBY HAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1894427 Date I Svc Code I Description I Units I Debits Credits 09/14/01 8345 CC OUTPATIENT VISIT E 1 32.00 09/14/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 09/14/01 109804 BLOOD COLLECTION 1 12.00 10/08/01 902003 MEDICARE PAY HOSP -1 51.68- 10/08/01 920015 MEDICARE CONT ADJ. 0/ 0 10.83- 10/31/02 980090 HOSPITAL BAD DEBT w/o -1 9.49- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 9.49 * - Not posted Balance: 9.49 I fJ-3/ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:04 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1903057 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 09/19/01 337603 GATED HEART, PLANAR , 1 578.00 09/19/01 338050 TC 99M LABELED RBC/TE 1 79.00 10/15/01 902003 MEDICARE PAY HOSP -1 194.66- 10/15/01 920015 MEDICARE CONT ADJ. 0/ -1 263.82- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 198.52- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 198.52 -------------------------------------------------------------------------------- * - Not posted Balance: 198.52 I 11 ~ 32/ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:05 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1902657 Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 09/19/01 512706 FRC 1 96.00 09/19/01 512707 DLCO 1 89.00 09/19/01 512734 BRONCHODI LAT FLOW VOL 1 96.00 10/15/01 902003 MEDICARE PAY HOSP -1 99.17- 10/15/01 920015 MEDICARE CONT ADJ. 0/ -1 80.18- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 101.65- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 101.65 -------------------------------------------------------------------------------- * - Not posted Balance: 101. 65 I /1-33 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:05 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 11/13/01 11/13/01 10/31/02 10/31/02 8348 101143 101214 104026 104042 104065 104067 104106 104398 105657 230164 231391 231400 231444 231469 292009 292010 292011 292028 621042 621043 670330 902003 920015 980090 980091 Description CC OUTPATIENT VISIT E IRRADIATE COMPONENT PLT LR PHER EA U CALCIUM CREATININE, BLOOD UREA NITROGEN (BUN), URIC ACID, BLOOD MAGNESIUM ELECTROLYTES CBC/DIFF/PLT COUNT, A DIPHENHYDRAMINE CP25M HEPARIN 1:100 10 ML LIDOCAINE HCL 10MG.ML ACETAMINOPHEN 325MG T SODIUM CHLORIDE INJ 3 TRANSF BLOOD/BLOOD CO IV INF TX 0-1 HR IV INF TX EA ADDL HR COLLECT BLD VIA PORT/ I V SODIUM CHLORIDE 0 I V SODIUM CHLORIDE 0 IV INFUSION SET, UNIV MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA PAGE: 1 Patient: PRICE BOBBY RAY Acct No: 1968883 Debits Credits I Units I 1 1 1 1 1 1 1 1 1 1 1 10 20 2 30 1 1 1 1 1 1 2 -1 -2 -1 1 24.00 43.00 761.00 9.00 9.00 8.00 8.00 37.00 23.00 28.00 4.25 4.20 4.20 4.24 4.20 327.00 88.00 42.00 29.00 6.00 6.00 24.00 691.09- 475.71- 326.29- 326.29 * - Not posted -----------------~-------------------------------------------------------------- Balance: 326.29 I fI- -3 Lf MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:18 AM PAGE: 1 Guarantor: PRICE BOBBY &~y 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1971869 Date I Svc Code I Description I Units I Debits Credits 10/19/01 104131 POTASSIUM (K) , BLOOD 1 9.00 10/19/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 10/19/01 230750 FILGRASTIM 480MCG 4 383.16 10/19/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 10/19/01 292028 COLLECT BLD VIA PORT/ 1 29.00 11/13/01 902003 MEDICARE PAY HOSP -1 668.01- 11/13/01 920015 MEDICARE CONT ADJ. 0/ -1 314.70 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 111.85- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 111.85 * - Not posted Balance: 111.85 I f) -.].s- MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:19 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1974727 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 10/20/01 101111 POOL BLD PRODUCT 1 21.00 10/20/01 101143 IRRADIATE COMPONENT 1 43.00 10/20/01 101216 PLT LR EA U 6 378.00 10/20/01 104131 POTASSIUM (K) , BLOOD 1 9.00 10/20/01 105054 PLATELET COUNT 1 12.00 10/20/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 10/20/01 231391 HEPARIN 1:100 10 ML 10 4.20 10/20/01 231444 ACETAMINOPHEN 325MG T 2 4.24 10/20/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 10/20/01 231488 DIPHENHYDRAMINE CAP 2 1 4.25 10/20/01 292009 TRANSF BLOOD/BLOOD CO 1 327.00 10/20/01 292023 THERA/DIAG INJ SUB CUT 1 16.00 10/20/01 292028 COLLECT BLD VIA PORT/ 2 58.00 10/20/01 621042 I V SODIUM CHLORIDE 0 1 6.00 10/20/01 670330 IV INFUSION SET, UNIV 1 12.00 10/20/01 670335 SET IN-LINE FILTERW/ 1 17.00 10/21/01 230750 FILGRASTIM 480MCG 4 383.16 11/13/01 902003 MEDICARE PAY HOSP -1 1140.18- 11/13/01 920015 MEDICARE CONT ADJ. 0/ -2 200.24 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 382.11- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 382.11 * - Not posted Balance: 382.11 I /13;" MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:19 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1974990 Date I Svc Code I Description I Units I Debits Credits 10/21/01 230750 FILGRASTIM 480MCG 4 383.16 10/21/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 11/14/01 902003 MEDICARE PAY HOSP -1 650.92- 11/14/01 920015 MEDICARE CONT ADJ. 0/ 1 363.61 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 111.85- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 111.85 * - Not posted Balance: 111.85 I 11-37 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:19 AM PAGE: 1 Guarantor: PRICE BOBBY R~Y 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1975164 Date I Svc Code I Description I Units I Debits Credits 10/22/01 8347 CC OUTPATIENT VISIT E 1 30.00 10/22/01 101143 IRRADIATE COMPONENT 1 43.00 10/22/01 101214 PLT LR PHER EA U 1 761. 00 10/22/01 104131 POTASSIUM (K) , BLOOD 1 9.00 10/22/01 105054 PLATELET COUNT 1 12.00 10/22/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 10/22/01 230012 DEXAMETHASONE TAB 4MG 10 5.70 10/22/01 230164 DIPHENHYDRAMINE CP25M 1 4.25 10/22/01 230219 VINCRISTINE (VINCASAR) 1 21.30 10/22/01 231444 ACETAMINOPHEN 325MG T 3 8.49 10/22/01 292003 CHEMO IV SINGLE PUSH 1 127.00 10/22/01 292009 TRANSF BLOOD/BLOOD CO 1 327.00 10/22/01 292028 COLLECT BLD VIA PORT/ 2 58.00 10/22/01 621042 I V SODIUM CHLORIDE 0 1 6.00 10/22/01 670330 IV INFUSION SET, UNIV 1 12.00 10/22/01 670335 SET IN-LINE FILTER W/ 1 17.00 11/20/01 902003 MEDICARE PAY HOSP -1 931.57- 11/20/01 920015 MEDICARE CONT ADJ. 0/ -2 85.59 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 618.76- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 618.76 * - Not posted Balance: 618.76 I //33 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:25 AM PAGE: 1 Guarantor: PRICE BOBBY F~Y 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1978513 Date I Svc Code I Description I Units I Debits Credits 10/23/01 230012 DEXAMETHASONE TAB 4MG 10 5.70 10/23/01 230750 FILGRASTIM 480MCG 4 383.16 10/23/01 292023 THERA/DIAG INJ SUB CUT 1 16.00 11/16/01 902003 MEDICARE PAY HOSP -1 650.92- 11/16/01 920015 MEDICARE CONT ADJ. 0/ 0 357.91 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 111.85- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 111.85 -------------------------------------------------------------------------------- * - Not posted Balance: 111.85 I Ill:; MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:25 AM Guarantor: PRICE BOBBY R.l;Y 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 11/19/01 11/19/01 10/31/02 10/31/02 8347 101003 101004 101005 101021 101111 101143 101212 101216 104131 105054 105656 230012 230750 231203 231444 231488 292009 292010 292011 292028 621042 626081 670330 670335 902003 920015 980090 980091 Description CC OUTPATIENT VISIT E ABO BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN POOL BLD PRODUCT IRRADIATE COMPONENT RED BLD CELL LR EA U PLT LR EA U POTASSIUM (K), BLOOD PLATELET COUNT CBC W/PLT CNT, NO DIF DEXAMETHASONE TAB 4MG FILGRASTIM 480MCG KLOR CON 10MEQ TABS ACETAMINOPHEN 325MG T DIPHENHYDRAMINE CAP 2 TRANSF BLOOD/BLOOD CO IV INF TX 0-1 HR IV INF TX EA ADDL HR COLLECT BLD VIA PORT/ I V SODIUM CHLORIDE 0 I-V DILUENT NML SALIN IV INFUSION SET, UNIV SET IN-LINE FILTER W/ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA PAGE: 1 Patient: PRICE BOBBY RAY Acct No: 1981791 I Unitsl 1 1 1 1 2 1 3 2 6 1 1 1 10 4 4 2 1 1 1 2 2 1 1 2 2 -1 -2 -1 1 Debits 30.00 16.00 28.00 15.00 108.00 21.00 129.00 290.00 378.00 9.00 12.00 23.00 16.70 383.16 4.24 4.24 4.25 327.00 88.00 84.00 58.00 6.00 8.00 24.00 34.00 7.76 ---------------------------------------------------------------- 584.67 * - Not posted Balance: 11-1;0 Credits 1523.68- 584.67- 584.67 I MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:25 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1998127 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 10/31/01 8347 CC OUTPATIENT VISIT E 1 30.00 10/31/01 104106 MAGNESIUM 1 37.00 10/31/01 104131 POTASSIUM (K) , BLOOD 1 9.00 10/31/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 10/31/01 230750 FILGRASTIM 480MCG 4 383.16 10/31/01 230956 DEXTROSE 5% INJ 290 2.90 10/31/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 10/31/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 10/31/01 292010 IV INF TX 0-1 HR 1 88.00 10/31/01 292011 IV INF TX EA ADDL HR 1 42.00 10/31/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 10/31/01 292028 COLLECT BLD VIA PORT/ 1 29.00 10/31/01 621042 I V SODIUM CHLORIDE 0 2 12.00 10/31/01 670330 IV INFUSION SET, UNIV 1 12.00 10/31/01 670334 IV INFUSION SET, UNIV 1 8.00 11/26/01 902003 MEDICARE PAY HOSP -1 774.82- 11/26/01 920015 MEDICARE CONT ADJ. 0/ -2 241.74 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 183.18- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 183.18 -------------------------------------------------------------------------------- * - Not posted Balance: 183.18 I /I-/;/ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:25 AM PAGE: 1 Guarantor: PRICE BOBBY PAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2001334 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 11/01/01 8348 CC OUTPATIENT VISIT E 1 24.00 11/01/01 230956 DEXTROSE 5% INJ 290 2.90 11/01/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 11/01/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 11/01/01 292010 IV INF TX 0-1 HR 1 88.00 11/01/01 621043 I V SODIUM CHLORIDE 0 1 6.00 11/26/01 902003 MEDICARE PAY HOSP -1 39.23- 11/26/01 920015 MEDICARE CONT ADJ. 0/ -2 35.77- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 65.10- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 65.10 -------------------------------------------------------------------------------- * - Not posted Balance: 65.10 I Ir!fv MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:26 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOtLING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2004509 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits 11/02/01 8348 CC OUTPATIENT VISIT E 1 24.00 11/02/01 101003 ABO BLOOD GROUP 1 16.00 11/02/01 101004 ANTIBODY SCREEN 1 28.00 11/02/01 101005 RH TYPE 1 15.00 11/02/01 101021 COMPAT, IMMED SPIN 4 216.00 11/02/01 101143 IRRADIATE COMPONENT 4 172.00 11/02/01 101212 RED BLD CELL LR EA U 4 580.00 11/02/01 104042 CREATININE, BLOOD 1 9.00 11/02/01 104065 UREA NITROGEN (BUN) , 1 8.00 11/02/01 104398 ELECTROLYTES 1 23.00 11/02/01 104591 VANCOMYCIN LEVEL 2 134.00 11/02/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 11/02/01 230956 DEXTROSE 5% INJ 290 2.90 11/02/01 231444 ACETAMINOPHEN 325MG T 2 4.24 11/02/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 11/02/01 231488 DIPHENHYDRAMINE CAP 2 1 4.25 11/02/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 11/02/01 292009 TRANSF BLOOD/BLOOD CO 1 327.00 11/02/01 292010 IV INF TX 0-1 HR 1 88.00 11/02/01 292011 IV INF TX EA ADDL HR 1 42.00 11/02/01 292028 COLLECT BLD VIA PORT/ 1 29.00 11/02/01 621042 I V SODIUM CHLORIDE 0 2 12.00 11/02/01 670330 IV INFUSION SET, UNIV 2 24.00 11/02/01 670335 SET IN-LINE FILTER W/ 2 34.00 11/26/01 902003 MEDICARE PAY HOSP -1 911.39- 11/26/01 920015 MEDICARE CONT ADJ. 0/ -2 480.07- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 448.13- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 448.13 ------------------------~-------------------------------------------------------- * - Not posted Balance: 448.13 I fI-13 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:26 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2007553 Date I Svc Code I Description I Units! Debits Credits 11/03/01 230956 DEXTROSE 5% INJ 290 2.90 11/03/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 11/03/01 292010 IV INF TX 0-1 HR 1 88.00 11/03/01 621042 I V SODIUM CHLORIDE 0 1 6.00 11/03/01 670330 IV INFUSION SET, UNIV 1 12.00 11/03/01 670334 IV INFUSION SET, UNIV 1 8.00 11/28/01 902003 MEDICARE PAY HOSP -1 39.23- 11/28/01 920015 MEDICARE CONT ADJ. 0/ -2 51. 57- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 41.10- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 41.10 * - Not posted Balance: 41.10 I 11- fj I( MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:26 AM PAGE: 1 Guarantor: PRICE BOBBY .RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2007760 Date I Svc Code I Description I Units I Debits Credits 11/04/01 104131 POTASSIUM (K), BLOOD 1 9.00 11/04/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 11/04/01 230956 DEXTROSE 5% INJ 290 2.90 11/04/01 231444 ACETAMINOPHEN 325MG T 2 4.24 11/04/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 11/04/01 231488 DIPHENHYDRAMINE CAP 2 1 4.25 11/04/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 11/04/01 292009 TRANSF BLOOD/BLOOD CO 1 327.00 11/04/01 292010 IV INF TX 0-1 HR 1 88.00 11/04/01 292011 IV INF TX EA ADDL HR 2 84.00 11/04/01 621042 I V SODIUM CHLORIDE 0 2 12.00 11/04/01 670330 IV INFUSION SET, UNIV 1 12.00 11/04/01 670335 SET IN-LINE FILTER W/ 1 17.00 11/28/01 902003 MEDICARE PAY HOSP -1 259.46- 11/28/01 920015 MEDICARE CONT ADJ. 0/ -3 147.72- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 200.41- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 200.41 * - Not posted Balance: 200.41 I f!~ lj-~ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:26 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2008018 Date I Svc Code I Description I Units I Debits Credits 11/05/01 8217 IV FLUIDS 1 9.00 11/05/01 8287 CHEMO INF UP TO 1 HR 1 152.00 11/05/01 8509 PUMP TUBING UNIVERSAL 1 9.00 11/05/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 11/05/01 230956 DEXTROSE 5% INJ 250 5.00 11/05/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 12/18/01 902003 MEDICARE PAY HOSP -1 9984.17- 12/18/01 920015 MEDICARE CONT ADJ. 0/ -1 9954.17 10/31/02 980090 HOSPITAL BAD DEBT w/o -1 188.00- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 188.00 * - Not posted Balance: 188.00 I It -I( b MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:26 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2009166 -------------------------------------------------------------------------------- Date I Svc Code I Description I Unitsl Debits Credits -----------------------.--------------------------------------------------------- 11/06/01 8214 SET ADMINISTRATION 1 6.00 11/06/01 8217 IV FLUIDS 1 9.00 11/06/01 8289 IV INF TX 0-1 HR 1 88.00 11/06/01 230956 DEXTROSE 5% INJ 250 5.00 11/06/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 12/03/01 902003 MEDICARE PAY HOSP -1 39.23- 12/03/01 920015 MEDICARE CONT ADJ. 0/ -2 42.67- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 41.10- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 41.10 ------------------------,-------------------------------------------------------- * - Not posted Balance: 41.10 I lI-f7 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:26 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2013092 Date I Svc Code I Description I Units I Debits Credits 11/07/01 8214 SET ADMINISTRATION 1 6.00 11/07/01 8217 IV FLUIDS 1 9.00 11/07/01 8289 IV INF TX 0-1 HR 1 88.00 11/07/01 8348 CC OUTPATIENT VISIT E 1 24.00 11/07/01 104014 ALKALINE PHOSPHATASE 1 9.00 11/07/01 104016 BILIRUBIN TOTAL 1 9.00 11/07/01 104042 CREATININE, BLOOD 1 9.00 11/07/01 104065 UREA NITROGEN (BUN) , 1 8.00 11/07/01 104096 LDH 1 11.00 11/07/01 104156 SGPT (ALT) 1 10.00 11/07/01 104398 ELECTROLYTES 1 23.00 11/07/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 11/07/01 230956 DEXTROSE 5% INJ 250 5.00 11/07/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 12/03/01 902003 MEDICARE PAY HOSP -1 61.97- 12/03/01 920015 MEDICARE CONT ADJ. 0/ -3 126.93- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 65.10- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 65.10 * - Not posted Balance: 65.10 I /J-Yt' MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:27 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 12/14/01 12/14/01 10/31/02 10/31/02 8279 8280 8502 101003 101004 101005 101021 101143 101212 105656 230394 230625 232592 902003 920015 980090 980091 * - Not posted Description THERA/DIAG INJ SUBCU/ THERA/DIAG INJECTION TRAY; CVP PREP ABO BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN IRRADIATE COMPONENT RED BLD CELL LR EA U CBC W/PLT CNT, NO DIF FILGRASTIM 300MCG CIPRO TAB 500MG ACYCLOVIR 400MG TABLE MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA II -J; J PAGE: 1 Patient: PRICE BOBBY RAY Acct No: 2046827 I Units I 1 2 1 1 1 1 1 1 1 1 1 1 1 -1 -2 -1 1 Debits 16.00 98.00 5.00 16.00 28.00 15.00 54.00 43.00 145.00 23.00 240.45 7.85 4.25 121.88 Balance: Credits 437.06- 136.61- 121.88- 121.88 I MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:28 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONBHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2050124 Date I Svc Code I Description I Units I Debits Credits 11/21/01 8217 IV FLUIDS 2 18.00 11/21/01 8279 THERA/DIAG INJ SUBCU/ 1 16.00 11/21/01 8280 THERA/DIAG INJECTION 1 49.00 11/21/01 8509 PUMP TUBING UNIVERSAL 2 18.00 11/21/01 8510 FILTER, FENWAL 2 32.00 11/21/01 101143 IRRADIATE COMPONENT 1 43.00 11/21/01 101214 PLT LR PHER EA U 1 761. 00 11/21/01 105054 PLATELET COUNT 1 12.00 11/21/01 230394 FILGRASTIM 300MCG 1 240.45 11/21/01 230625 CIPRO TAB 500MG 1 7.85 11/21/01 232592 ACYCLOVIR 400MG TABLE 1 4.25 12/17/01 902003 MEDICARE PAY HOSP -1 606.32- 12/17/01 920015 MEDICARE CONT ADJ. 0/ -2 449.65- 10/31/02 980090 HOSPITAL BAD DEBT w/o -1 145.58- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 145.58 * - Not posted Balance: 145.58 , IlSD MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:28 AM PAGE: , Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY "Acct No: 2051378 Date I Svc Code I I Units I Debits -------------------------------------------------------------------------------- Credits Description 1 11/22/01 230394 FILGRASTIM 300MCG 1 240.45 11/22/01 231391 HEPARIN 1:100 10 ML 10 4.20 11/22/01 23146Q SODIUM CHLORIDE INJ 3 30 4.20 11/22/01 292023 THERA/DrAG INJ SUB CUT 1 16.00 12/17/01 902003 MEDICARE PAY HOSP -1 190.60- 12/17/01 920015 MEDICARE CONT ADJ. 0/ -1 39.32- 10/31/02 980090 HOSPITAL BAD DEBT w/o -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 * - Not posted Balance: /1-5/ 34.93 I MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:28 AM PAGE: 1 Guarantor: PRICE BOBBY I~Y 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2051795 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 11/23/01 8217 IV FLUIDS 1 9.00 11/23/01 8261 CHEMO, IV PUSH 1 127.00 11/23/01 8289 IV INF TX 0-1 HR 1 88.00 11/23/01 8290 IV INF TX EA ADDL HR 1 42.00 11/23/01 8291 TRANSFUSION, BLOOD/CO 1 327.00 11/23/01 8502 TRAY; CVP PREP 1 5.00 11/23/01 8503 TELFA DRESSING 1 5.00 11/23/01 8509 PUMP TUBING UNIVERSAL 1 9.00 11/23/01 8510 FILTER, FENWAL 1 16.00 11/23/01 101111 POOL BLD PRODUCT 1 21.00 11/23/01 101143 IRRADIATE COMPONENT 1 43.00 11/23/01 101216 PLT LR EA U 6 378.00 11/23/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 11/23/01 230164 DIPHENHYDRAMINE CP25M 1 4.25 11/23/01 230219 VINCRISTINE (VINCASAR) 1 21. 30 11/23/01 230394 FILGRASTIM 300MCG 1 240.45 11/23/01 230625 CIPRO TAB 500MG 1 7.85 11/23/01 231444 ACETAMINOPHEN 325MG T 2 4.24 11/23/01 232592 ACYCLOVIR 400MG TABLE 1 4.25 12/18/01 902003 MEDICARE PAY HOSP -1 840.31- 12/18/01 920015 MEDICARE CaNT ADJ. 0/ -2 109.46- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 425.57- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 425.57 -------------------------------------------------------------------------------- * - Not posted Balance: 425.57 I -------------------------- f/-Jj MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:28 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2053303 Date I Svc Code I Description I Units I Debits Credits 11/24/01 37035 THERAPEUTIC INJ IM/SQ 1 16.00 11/24/01 230394 FILGRASTIM 300MCG 1 240.45 12/19/01 902003 MEDICARE PAY HOSP -1 190.60- 12/19/01 920015 MEDICARE CONT ADJ. 0/ 0 30.92- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93 - 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 * - Not posted Balance: 34.93 I ffsJ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:28 AM PAGE: 1 Guarantor: PRICE BOBBY F~Y 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2053499 Date I Svc Code I Description I Units I Debits Credits 11/25/01 37035 THERAPEUTIC INJ IM/SQ 1 16.00 11/25/01 230394 FILGRASTIM 300MCG 1 240.45 12/19/01 902003 MEDICARE PAY HOSP -1 190.60- 12/19/01 920015 MEDICARE CONT ADJ. 0/ 0 30.92- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 -----------------------_.-------------------------------------------------------- * - Not posted Balance: 34.93 I /J-5 ~ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:28 AM PAGE: 1 Guarantor: PRICE BOBBY HAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2053812 Date I Svc Code I Description I Units I Debits Credits 11/26/01 8214 SET ADMINISTRATION 3 18.00 11/26/01 8217 IV FLUIDS 3 27.00 11/26/01 8290 IV INF TX EA ADDL HR 5 210.00 11/26/01 8510 FILTER, FENWAL 3 48.00 11/26/01 101003 ABO BLOOD GROUP 1 16.00 11/26/01 101004 ANTIBODY SCREEN 1 28.00 11/26/01 101005 RH TYPE 1 15.00 11/26/01 101021 COMPAT, IMMED SPIN 2 108.00 11/26/01 101143 IRRADIATE COMPONENT 3 129.00 11/26/01 101212 RED BLD CELL LR EA U 2 290.00 11/26/01 101214 PLT LR PHER EA U 1 761.00 11/26/01 104131 POTASSIUM (K) , BLOOD 1 9.00 11/26/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 11/26/01 230394 FILGRASTIM 300MCG 1 240.45 11/26/01 230625 CIPRO TAB 500MG 1 7.85 11/26/01 232592 ACYCLOVIR 400MG TABLE 1 4.25 11/27/01 8279 THERA/DIAG INJ SUBCU/ 1 16.00 11/27/01 8280 THERA/DIAG INJECTION 2 98.00 11/27/01 8289 IV INF TX 0-1 HR 1 88.00 11/27/01 8291 TRANSFUSION, BLOOD/CO 1 327.00 12/20/01 902003 MEDICARE PAY HOSP -1 1257.31- 12/20/01 920015 MEDICARE CONT ADJ. 0/ -2 669.34- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 536.90- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 536.90 * - Not posted Balance: 536.90 I fJ-S!J MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:29 AM Guarantor: PRICE BOBBY :RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code II 11/27/01 11/27/01 11/27/01 11/27/01 11/27/01 12/21/01 12/21/01 10/31/02 10/31/02 8279 8280 230394 230625 232592 902003 920015 980090 980091 Description THERA/DIAG INJ SUBCU/ THERA/DIAG INJECTION FILGRASTIM 300MCG CIPRO TAB 500MG ACYCLOVIR 400MG TABLE MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA PAGE: 1 Patient: PRICE BOBBY RAY Acct No: 2056607 Debits Credits I Units I 1 2 1 1 1 -1 -1 -1 1 16.00 98.00 240.45 7.85 4.25 264.93- 48.11- 53.51- 53.51 * - Not posted -------------------------------------------------------------------------------- Balance: 53.51 I If-Sip MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:29 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2059851 Date I Svc Code I Description I Units I Debits Credits 11/28/01 8214 SET ADMINISTRATION 1 6.00 11/28/01 8217 IV FLUIDS 1 9.00 11/28/01 8280 THERA/DIAG INJECTION 2 98.00 11/28/01 8289 IV INF TX 0-1 HR 1 88.00 11/28/01 8290 IV INF TX EA ADDL HR 1 42.00 11/28/01 8291 TRANSFUSION, BLOOD/CO 1 327.00 11/28/01 8510 FILTER, FENWAL 1 16.00 11/28/01 101143 IRRADIATE COMPONENT 1 43.00 11/28/01 101214 PLT LR PHER EA U 1 761.00 11/28/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 11/28/01 230164 DIPHENHYDRAMINE CP25M 1 4.25 11/28/01 230394 FILGRASTIM 300MCG 1 240.45 11/28/01 230625 CIPRO TAB 500MG 1 7.85 11/28/01 231444 ACETAMINOPHEN 325MG T 2 4.24 11/28/01 232592 ACYCLOVIR 400MG TABLE 1 4.25 12/26/01 902003 MEDICARE PAY HOSP -1 833.64- 12/26/01 920015 MEDICARE CONT ADJ. 0/ -3 519.96- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 325.44- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 325.44 * - Not posted Balance: 325.44 I /1-J-7 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:29 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2063460 Date I Svc Code I Description ! Units I Debits Credits 11/29/01 8279 THERA/DIAG INJ SUBCU/ 1 16.00 11/29/01 8502 TRAY; CVP PREP 1 5.00 11/29/01 8504 TEGADERM DRESSING 1 6.00 11/29/01 230394 FILGRASTIM 300MCG 1 240.45 11/29/01 230625 CIPRO TAB 500MG 1 7.85 11/29/01 232592 ACYCLOVIR 400MG TABLE 1 4.25 12/26/01 902003 MEDICARE PAY HOSP -1 190.60- 12/26/01 920015 MEDICARE CaNT ADJ. 0/ -1 54.02- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 * - Not posted Balance: 34.93 ! f}~st MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:29 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2067311 Date I Svc Code I Description I Units I Debits Credits 11/30/01 8214 SET ADMINISTRATION 1 6.00 11/30/01 8217 IV FLUIDS 1 9.00 11/30/01 8280 THERA/DIAG INJECTION 2 98.00 11/30/01 8289 IV INF TX 0-1 HR 1 88.00 11/30/01 8290 IV INF TX EA ADDL HR 1 42.00 11/30/01 8291 TRANSFUSION, BLOOD/CO 1 327.00 11/30/01 8510 FILTER, FENWAL 1 16.00 11/30/01 101143 IRRADIATE COMPONENT 1 43.00 11/30/01 101214 PLT LR PHER EA U 1 761. 00 11/30/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 11/30/01 230164 DIPHENHYDRAMINE CP25M 1 4.25 11/30/01 230394 FILGRASTIM 300MCG 1 240.45 11/30/01 230625 CIPRO TAB 500MG 1 7.85 11/30/01 231444 ACETAMINOPHEN 325MG T 2 4.24 11/30/01 232592 ACYCLOVIR 400MG TABLE 1 4.25 12/26/01 902003 MEDICARE PAY HOSP -1 831.85- 12/26/01 920015 MEDICARE CONT ADJ. 0/ -3 516.75- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 325.44- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 325.44 * - Not posted Balance: 325.44 I fh5; MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:29 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2069785 Date I Svc Code I Description I Units! Debits Credits 12/01/01 37035 THERAPEUTIC INJ IM/SQ 1 16.00 12/01/01 230394 FILGRASTIM 300MCG 1 240.45 12/27/01 902003 MEDICARE PAY HOSP -1 190.60- 12/27/01 920015 MEDICARE CONT ADJ. 0/ 0 30.92- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 * - Not posted Balance: 34.93 I 11-0 () MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:29 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2070029 Date I Svc Code I Description I Units! Debits Credits 12/02/01 37035 THERAPEUTIC INJ IM/SQ 1 16.00 12/02/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 12/02/01 230394 FILGRASTIM 300MCG 1 240.45 12/27/01 902003 MEDICARE PAY HaSP -1 199.55- 12/27/01 920015 MEDICARE CONT ADJ. 0/ -1 44.97- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93 - 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 * - Not posted Balance: 34.93 ! 11-0 / MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:30 AM PAGE: 1 Guarantor: PRICE BOBBY ~~Y 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2071571 Date I Svc Code I Description I Units I Debits Credits 12/03/01 8279 THERA/DrAG INJ SUBCU/ 1 16.00 12/03/01 230394 FILGRASTIM 300MCG 1 240.45 12/03/01 230625 CIPRO TAB 500MG 1 7.85 12/03/01 232592 ACYCLOVIR 400MG TABLE 1 4.25 12/27/01 902003 MEDICARE PAY HOSP -1 190.60- 12/27/01 920015 MEDICARE CONT ADJ. 0/ -1 43.02- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 * - Not posted Balance: 34.93 I 1/0 ;U MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:30 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 PAGE: 1 Patient: PRICE BOBBY RAY Acct No: 2073964 I Units I 3 1 1 5 1 1 1 3 3 1 1 1 2 3 2 1 1 1 1 1 1 1 1 1 1 1 1 2 -1 -2 -1 1 Date I Svc Code I --------------------------------------------------------------------------------- Credits Description IV FLUIDS THERA/DIAG INJ SUBCU/ IV INF TX 0-1 HR IV INF TX EA ADDL HR TRANSFUSION, BLOOD/CO TRAY; CVP PREP TEGADERM DRESSING PUMP TUBING UNIVERSAL FILTER, FENWAL ABO BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN IRRADIATE COMPONENT RED BLD CELL LR EA U PLT LR PHER EA U ALKALINE PHOSPHATASE BILIRUBIN TOTAL CALCIUM CREATININE, BLOOD UREA NITROGEN (BUN), LDH MAGNESIUM SGPT (ALT) ELECTROLYTES CBC/DIFF/PLT COUNT, A FILGRASTIM 300MCG K DUR TAB 20MEQ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA f1-~3 Debits --------------------------------------------------------------------------------- 27.00 16.00 88.00 210.00 327.00 5.00 6.00 27.00 48.00 16.00 28.00 15.00 108.00 129.00 290.00 761. 00 9.00 9.00 9.00 9.00 8.00 11.00 37.00 10.00 23.00 28.00 240.45 4.24 1199.89- 780.48- 518.32- 518.32 Balance: 518.32 I 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 12/04/01 01/16/02 01/16/02 10/31/02 10/31/02 8217 8279 8289 8290 8291 8502 8504 8509 8510 101003 101004 101005 101021 101143 101212 101214 104014 104016 104026 104042 104065 104096 104106 104156 104398 105657 230394 230629 902003 920015 980090 980091 * - Not posted MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 13tatement on: 11/27/02 at 09:30 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2078903 -----------------------.--------------------------------------------------------- Date I Svc Code I Description ! Units I Debits Credits ------------------------.-------------------------------------------------------- 12/05/01 8279 THERA/DrAG INJ SUBCU/ 1 16.00 12/05/01 230394 FILGRASTIM 300MCG 1 240.45 12/31/01 902003 MEDICARE PAY HOSP -1 190.60- 12/31/01 920015 MEDICARE CONT ADJ. 0/ 0 30.92- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 ------------------------.-------------------------------------------------------- * - Not posted Balance: 34.93 I 1t-0 f MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:32 AM PAGE: 1 Guarantor: PRICE BOBBY I<AY 353 OLD STONBHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2082486 Date I Svc Code I Description I Units I Debits Credits 12/06/01 8348 CC OUTPATIENT VISIT E 1 24.00 12/06/01 104014 ALKALINE PHOSPHATASE 1 9.00 12/06/01 104016 BILIRUBIN TOTAL 1 9.00 12/06/01 104096 LDH 1 11.00 12/06/01 104156 SGPT (ALT) 1 10.00 12/06/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 12/31/01 902003 MEDICARE PAY HOSP -1 84.69- 12/31/01 920015 MEDICARE CONT ADJ. 0/ 0 9.76 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 16.07- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 16.07 * - Not posted Balance: 16.07 I fJ - t!J~ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:32 AM PAGE: 1 Guarantor: PRICE BOBBY HAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2085229 Date I Svc Code II Description I unitsl Debits Credits 12/07/01 8214 SET ADMINISTRATION 1 6.00 12/07/01 8217 IV FLUIDS 1 9.00 12/07/01 8280 THERA/DIAG INJECTION 2 98.00 12/07/01 8289 IV INF TX 0-1 HR 1 88.00 12/07/01 8290 IV INF TX EA ADDL HR 1 42.00 12/07/01 8291 TRANSFUSION, BLOOD/CO 1 327.00 12/07/01 8510 FILTER, FENWAL 1 16.00 12/07/01 101143 IRRADIATE COMPONENT 1 43.00 12/07/01 101214 PLT LR PHER EA U 1 761. 00 12/07/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 12/31/01 902003 MEDICARE PAY HOSP -1 678.41- 12/31/01 920015 MEDICARE CONT ADJ. 0/ -3 434.79- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 299.80- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 299.80 * - Not posted Balance: 299.80 I IJ-~~ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:33 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 PAGE: Patient: PRICE BOBBY RAY Acct No: 2087609 Date I Svc Code ! Debits I Units! Description 1 Credits 12/10/01 8280 THERA/DIAG INJECTION 1 49.00 12/10/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 01/04/02 902003 MEDICARE PAY HOSP -1 46.11- 01/04/02 920015 MEDICARE CONT ADJ. 0/ -2 16.60- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 9.29- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 9.29 * - Not posted Balance: Ij-~ } 9.29 I MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:33 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2106402 ------------------------.-------------------------------------------------------- I Svc Code I I Units I Date Description Debits Credits ------------------------.-------------------------------------------------- 12/17/01 12/17/01 12/17/01 12/17/01 12/17/01 12/17/01 12/17/01 12/17/01 01/17/02 01/17/02 10/31/02 10/31/02 THERA/DIAG INJECTION CALCIUM CREATININE, BLOOD UREA NITROGEN (BUN), MAGNESIUM PHOSPHORUS, BLOOD POTASSIUM (K), BLOOD CBC/DIFF/PLT COUNT, A MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA 8280 104026 104042 104065 104106 104129 104131 105657 902003 920015 980090 980091 2 1 1 1 1 1 1 1 -1 -2 -1 1 98.00 9.00 9.00 8.00 37.00 9.00 9.00 28.00 105.14- 83.28- 18.58- 18.58 -------------------------------------------------------------------------------- * - Not posted Balance: 18.58 I II-/:;6 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:33 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2182223 Date I Svc Code I Description I Units I Debits Credits 01/19/02 01/19/02 10/31/02 10/31/02 10993 10995 980090 980091 NON EMERG TRANSPORT<; NON EMER TRNS>=21MI/M HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA 1 20 -1 1 71.00 40.00 111.00- 111.00 * - Not posted Balance: 111.00 I fi~b! >ENNSTATE BOBBY RAY PRICE 1 0115 353 OLD STONEHOUS RD IiiJ The Milton S. Hershey Medical Center SOUTH STATEMENT The College of Medicme BOiliNG SPRIN PA 17007 DATE: 10/31/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 ~ IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENTI GUARANTOR CODE CODE ADJUSTMENT BALANCE >>> PATIENT: BOB8Y RAY PRICE 1102021 1074254 PERFORMED BY: DIYISION OF HEM/ONe PLACE OF SVC: OP PHYSICI AN 10/19/00 99245 202.80 OFFICE CONSULTATION 165.00 07106/01 MEDICARE PAYMENT 131.42- 07/06/01 MEDICARE CONTRACTUAL ADJ 0.72- 07106/01 BALANCE AFTER INSI 32.86 1498374 PERFORMED BY: DIY OF OIAG RADIOLOGY PLACE OF SYC: OP HOSPITAL 05104/01 7417026 202.80 C T ABOOMEN 324.00 06121101 MEDICARE PAYMENT 59.04- 06/21101 MEDICARE CONTRACTUAL ADJ 250.20- 05129/01 CHECK PAY PHYS, THAN( YOU 12.67- 2.09 05104/01 7219326 202.80 CT PELVIS ENHANCED 236.00 06121101 MEDICARE PAYMENT 49.00- 06/21101 MEDICARE CONTRACTUAL ADJ 174.75- 06/21/01 BALANCE AFTER INSI 12.25 1499454 PERFORMED BY: DIYISION OF HEM/ONe PLACE OF SVC: OP PHYSICIAN 05104/01 99214 202.80 CIC OUTPATIENT VIS EST 56.00 06/19/01 MEDICARE PAYMENT 44.69- 06/19/01 MEDICARE CONTRACTUAL ADJ 0.14- 06/19/01 BALANCE AFTER INSI 11.17 1635548 PERFORMED BY: OIYISION OF HEM/ONe PLACE OF SVC: INPATIENT 07108101 99223.GC 208.00 INITIAL HOSPITAL CARE 306.00 09/05/01 MEDICARE PAYMENT 124.26- 09/05101 MEDICARE CONTRACTUAL ADJ 150.68- 09/05/01 BALANCE AFTER INSI 31.06 PERFORMED BY: DIY OF DIAG RADIOLOGY 07/09/01 7126026 202.80 CT THORAX ENHANCED 318.00 09/05101 MEDICARE PAYMENT 52.28- 09/05/01 MEDICARE CONTRACTUAL ADJ 252.65- 09/05/01 BALANCE AFTER INS- 13.07 07/09/01 7417026 202.80 C T ABDOMEN 340.00 09/05101 MEDICARE PAYMENT 59.04- 09/05/01 MEDICARE CONTRACTUAL ADJ 266.20- 09/05101 BALANCE AFTER INSI 14.76 07/09/01 7219326 202.80 CT PELVIS ENHANCED 248.00 09/05/01 MEDICARE PAYMENT 49.00- 09/05101 MEDICARE CONTRACTUAL ADJ 186.75- 09/05/01 BALANCE AFTER INS- 12.25 PERFORMED BY: DIY OF ANATOMIC PATHOLOGY TISSUE EXAM LEYE L 4 PAGE >ENNSTATE BOBBY RAY PRICE 20115 353 OLD STONEHOUS RD IIiJ The Mill; S. Hershey Medical Center SOUTH STATEMENT The Coil e of MediCIne BOILING SPRIN PA 17007 DATE: 10/31/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 ~ IF ANY QUESTIONS. PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENTI GUARANTOR CODE CODE ADJUSTMENT BALANCE 09105/01 MEDICARE PAYMENT 34.23- 09105/01 MEDICARE CONTRACTUAL ADJ 124. Zl- 09105/01 BALANCE AFTER INSll 8.56 07109101 8831226 204.00 SPECIAL STAINS-MICRO 46.00 09105/01 MEDICARE PAYMENT 22.75- 09105/01 MEDICARE CONTRACTUAL ADJ 17.56- 09105101 BALANCE AFTER INSll 5.69 07/09/01 8831326 204.00 SPECIAL STAINS-HISTO 45.00 09105/01 MEDICARE PAYMENT 10.61- 09105/01 MEDICARE CONTRACTUAL ADJ 31. 74- 09105/01 BALANCE AFTER INS- Z,65 PERFORMED BY: DIYISION OF HEH/DNC 07/09101 99233. GC 208.00 DAILY HOSPITAL CARE 196.00 09105/01 MEDICARE PAYMENT 63.01- 09105/01 MEDICARE CONTRACTUAL ADJ 117.24- 09105101 BALANCE AFTER INSll 15.75 07109101 85097 208.00 BONE MARRON ASP INTERPRET 100.00 10/16/01 MEDICARE PAYMENT 41.34- 10116/01 MEDICARE CONTRACTUAL ADJ 48.32- 10/16/01 BALANCE AFTER INSll 10.34 PERFORMED BY: DIY YASCULAR INSTITUTE 07/10/01 36489.GC Y58.81 PLCI'tIT /CENT UN OYER 2YRS 487.00 08127101 MEDICARE PAYMENT 61. 99- 08127101 MEDICARE CONTRACTUAL ADJ 409.51- 08127101 BALANCE AFTER INSll 15.50 07110/01 7694226. GC Y58.81 ULTRA GUIDINEEDLE BID INT 141. 00 08127/01 MEDICARE PAYMENT 28.54- 08127101 MEDICARE CONTRACTUAL ADJ 105.32- 08127/01 BALANCE AFTER INSll 7.14 07/10/01 76000.59 Y58.81 FLUOROS ROUT OITHAN 71034 79.00 08127101 MEDICARE PAYMENT 7.07- 08127/01 MEDICARE CONTRACTUAL ADJ 70.16- 08127101 BALANCE AFTER INSll 1.77 PERFORMED BY: DIY CLINICAL PATHOLOGY 07/10/01 8818026 202.80 14 FLOH CYTllHETRY 154.00 10/30/01 MEDICARE PAYMENT 123.20- 30.80 PERFORMED BY: DIYISION OF HEM/ONe 07110/01 99232.GC 208.00 DAILY HOSPITAL CARE 133.00 09105/01 MEDICARE PAYMENT 44.40- 09105/01 MEDICARE CONTRACTUAL ADJ 77.50- 09105/01 BALANCE AFTER INSll 11.10 PERFORMED BY: DIY OF ANATOMIC PATHOLOGY 07/11/01 8810826 YI0.79 CYTO CDNCEN HlSMEARS 63.00 09105/01 MEDICARE PAYMENT 24.50- 09105/01 MEDICARE CONTRACTUAL ADJ 32.38- 09105/01 BALANCE AFTER INS_ 6.12 PERFORMED BY: DIYISION OF HEM/ONe 99232.GC Y58.1 DAILY HOSPITAL CARE 133.00 MEDICARE PAYMENT 44.40- MEDICARE CONTRACTUAL ADJ 77 . 50- BALANCE AFTER INS- o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK PAGE )ENNSTATE BOBBY RAY PRICE 30115 353 OLD STONEHOUS RD Iiil The Milton S. Hershey Medical Center SOUTH STATEMENT The College of MediCIne BOiliNG SPRIN PA 17007 DATE: 10/31/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 ~ IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENTI GUARANTOR CODE CODE ADJUSTMENT BALANCE 07112101 99232.GC 208.00 DAILY HOSPITAL CARE 133.00 09105/01 MEDICARE PAYMENT 44.40- 09/05/01 MEDICARE CONTRACTUAL AOJ 77.50- 09/05/01 BALANCE AFTER INS* 11.10 07113/01 99232.GC 208.00 DAILY HOSPITAL CARE 133.00 09/05/01 MEDICARE PAYMENT 44.40- 09/05/01 MEDICARE CONTRACTUAL AOJ 77 .50- 09105/01 BALANCE AFTER INS* 11.10 PERFORMED BY: DIV OF DIAG RADIOLOGY 07/14/01 7101026 V58.81 CHEST 1 VIEW 56.00 08130/01 MEDICARE PAYMENT 7.66- 08130/01 MEDICARE CONTRACTUAL ADJ 46.43- 08130/01 BALANCE AFTER INS* 1.91 PERFORMED BY: DIVISION OF HEM/ONe 07114/01 99232.GC 208.00 DAILY HOSPITAL CARE 133.00 09/05/01 MEDICARE PAYMENT 44.40- 09/05101 MEDICARE CONTRACTUAL ADJ 77.50- 09/05101 BALANCE AFTER INS* 11.10 PERFORMED BY: DIV OF CARDIOLOGY 07114/01 93010 427.89 ECG ELECTROCARD INTERP 52.00 09/10101 MEDICARE PAYMENT 8.21- 09/10/01 MEDICARE CONTRACTUAL ADJ 41. 74- 09110/01 BALANCE AFTER INS* 2.05 PERFORMED BY: DIVISION OF HEM/ONe 07115/01 99233. GC 427.89 DAILY HOSPITAL CARE 196.00 09/05/01 MEDICARE PAYMENT 63.01- 09/05/01 MEDICARE CONTRACTUAL ADJ 117.24- 09/05/01 BALANCE AFTER INS* 15.75 1654762 PERFORMED BY: DIVISION OF HEHIONC PLACE OF SVC: OP HOSPITAL 07/17101 99214 202.80 C/C OUTPATIENT VIS EST 56.00 01/08102 MEDICARE PAYMENT 37.98- 01108102 MEDICARE CONTRACTUAL ADJ 8.52- 01108102 BALANCE AFTER INS* 9.50 1657864 PERFORMED BY: DIVISION OF HEHIONC PLACE OF SVC: OP HOSPITAL 07/18101 99214 202.80 C/C OUTPATIENT VIS EST 56.00 01108102 MEDICARE PAYMENT 37.98- 01108/02 MEDICARE CONTRACTUAL ADJ 8.52- 01/08102 BALANCE AFTER INS* 9.50 1660990 PERFORMED BY: DIVISION OF HEM/ONe PLACE OF SVC: OP HOSPITAL 99214 202.80 C/C OUTPATIENT VIS EST 56.00 MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK __ _______n__'__' --.-. ,--_. .-~---.-. )ENNSTATE BOBBY RAY PRICE 4.'15 , 353 OLD STONEHOUS RD Iii The MiI~ S. Hershey Medical Center SOUTH STATEMENT The Colle e of Medicme BOILING SPRIN PA 17007 DATE: 10/31/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 14 IF ANY QUESTIONS, pleAsE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG QTV DESCRIPTION INS CHARGE PAYMENTI GUARANTOR CODE CODE ADJUSTMENT BALANCE 01108102 BALANCE AfTER INS- 9.50 1663834 PERfORMED BY: DIVISION Of HEM/ONe PLACE Of SVC: OP HOSPITAL 07120/01 99214 202.80 C/C OUTPATIENT VIS EST 56.00 01108102 MEDICARE PAYMENT 37.98- 01108102 MEDICARE CONTRACTUAL ADJ 8.52- 01/08102 BALANCE AfTER INS- 9.50 1666939 PERfORMED BY: DIVISION OF HEM/DNC PLACE Of SVC: OP HOSPITAL 07123/01 99214 202.80 CIC OUTPATIENT VIS EST 56.00 01108102 MEDICARE PAYMENT 37.98- 01108102 MEDICARE CONTRACTUAL AOJ 8.52- 01108102 BALANCE AFTER INSiI 9.50 1670244 PERfORMED BY: DIVISION OF HEM/DNC PLACE Of SVC: OP HOSPITAL 07/24/01 99214 202.80 CIC OUTPATIENT VIS EST 56.00 01108102 MEDICARE PAYMENT 37.98- 01108102 MEDICARE CONTRACTUAL ADJ 8.52- 01/08102 BALANCE AfTER INSiI 9.50 1673298 PERfORMED BY: DIVISION Of HEM/DNC PLACE Of SVC: OP HOSPITAL I 07125/01 99214 202.80 CIC OUTPATIENT VIS EST KTR 56.00 I 01/08102 HEDICARE PAYMENT 0.00 0,00 1676389 PERfORMED BY: DIVISION Of HEM/DNC PLACE OF SVC: OP HOSPITAL 07126/01 99213 284.8 CIC OUTPATIENT VIS EST 35.00 01108102 MEDICARE PAYMENT 23.35- 01108102 MEDICARE CONTRACTUAL ADJ 5.81- 01108102 BALANCE AFTER INS- 5.84 1679075 PERfORMED BY: DIVISION OF HEM/ONe PLACE Of SVC: INPATIENT 07/27/01 99221 288.0 INITIAL HOSPITAL CARE 185.00 10/16/01 MEDICARE PAYMENT 55.19- 10/16/01 MEDICARE CONTRACTUAL ADJ 116.01- 10/16/01 BALANCE AFTER INS- 13.80 PERFORMED BY: DIV OF DUG RADIOLOGY 07/27/01 7102026 780.6 CHEST 2 VIENS fRONT/LAT 78.00 09126/01 MEDICARE PAYMENT 09126/01 MEDICARE CONTRACTUAL ADJ CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK )ENNSTATE BOBBY RAY PRICE 50115 353 OLD STONEHOUS RD fiJ The Milton S. Hershey Medical Center SOUTH STATEMENT The College of MediclOe BOILING SPRIN PA 17007 DATE: 10131/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09125102 ~ IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENTI GUARANTOR CODE CODE ADJUSTMENT BALANCE 09126/01 8ALANCE AFTER I~ 2.36 PERFORMED 8Y: DIYISION OF HEM/ONe 07128/01 99232.GC 288.0 DAILY HOSPITAL CARE 133.00 10/19/01 MEDICARE PAYMENT 44.40- 10/19/01 MEDICARE CONTRACTUAL ADJ 77 .50- 10/19/01 8ALANCE AFTER I~ 11.10 07129/01 99232.GC 288.0 DAILY HOSPITAL CARE 133 . 00 10/19/01 MEDICARE PAYMENT 44.40- 10/19/01 MEDICARE CONTRACTUAL AOJ 77.50- 12/04/01 MEDICARE PAYMENT 44.40- 10/19/01 REFUND TO MEOICARE 44.40 11.10 07130/01 99232.GC 288.0 OAILY HOSPITAL CARE 133.00 10/16/01 MEDICARE PAYMENT 44.40- 10/16/01 MEDICARE CONTRACTUAL ADJ 77.50- 10/16/01 8ALANCE AFTER I~ 11.10 07/31/01 99238.GC 288.0 HOSP DISC OAY MGT <30 MIN 115.00 10/16/01 MEDICARE PAYMENT 53.27- 10/16/01 MEDICARE CONTRACTUAL ADJ 48.41- 10/16/01 8ALANCE AFTER I~ 13.32 1700327 PERFORMED 8Y: OIYISION OF HEMIDNC PLACE OF SYC: OP PHYSICIAN 08107101 99214 202.80 C/C OUTPATIENT VIS EST 56.00 10/WOl MEDICARE PAYMENT 44.69- 10/WOl MEDICARE CONTRACTUAL ADJ 0.14- 10/2S/01 8ALANCE AFTER INSII 11.17 1723551 PERFORMED 8Y: DIY OF DIAS RADIOLOGY PLACE OF SYC: INPATIENT 08121/01 7101026 Y58.81 CHEST 1 YIEH 56.00 12/18/01 MEDICARE PAYMENT 7.66- 12/18/01 MEDICARE CONTRACTUAL ADJ 46.43- 12/18/01 8ALANCE AFTER I~ 1.91 PERFORMED 8Y: DIYISION OF HEM/ONe 08121101 99223.GC Y58.1 INITIAL HOSPITAL CARE 306.00 10/16/01 MEOICARE PAYMENT 124.26- 10/16/01 MEDICARE CONTRACTUAL ADJ 150.68- 10/16/01 8ALANCE AFTER I~ 31.06 08122/01 99232. GC Y58.1 DAILY HOSPITAL CARE 133.00 10/16/01 MEDICARE PAYMENT 44.40- 10/16/01 MEDICARE CONTRACTUAL ADJ 77 .50- 10/16/01 8ALANCE AFTER I~ 11.10 PERFORMED 8Y: DIY OF ANATOMIC PATHOLOGY 08122/01 8830526 284.9 TISSUE EXAM LEYE L 4 167.00 02/20/02 MEDICARE PAYMENT 34.23- 02/20/02 MEDICARE CONTRACTUAL ADJ 124.21- 02/20/02 8ALANCE AFTER I~ 8.56 08122/01 8831226 284.9 SPECIAL STAINS-MICRO 46.00 02/20/02 MEDICARE PAYMENT CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK PAGE )ENNSTATE BOBBY RAY PRICE 60115 353 OLD STONEHOUS RD IIiJ The Miltoil S. Hershey Medical Center SOUTH STATEMENT The College of MediCIne BOILING SPRIN PA 17007 DATE: 10/31/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 ~ IF ANY QUESTIONS. PLEASE CONTACT: M,SHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG Q1Y DESCRIPTION INS CHARGE PAYMENTI GUARANTOR CODE CODE ADJUSTMENT BALANCE 02/20/02 MEDICARE CONTRACTUAL ADJ 17.56- 02/20/02 BALANCE AFTER INSI 5.69 08122/01 8831326 284.9 SPECIAL STAINS-HISTO "'5.00 02/20/02 MEDICARE PAYMENT 10.61- 02/20/02 MEDICARE CONTRACTUAL ADJ 31. 7"'- 02/20/02 BALANCE AFTER INSI 2.65 PERFORMED BY: DIVISION OF HEMIONC 08122/01 85097 202.80 BONE MARROH ASP INTERPRET 100.00 10/30/01 MEDICARE PAYMENT ...1.3...- 10/30/01 MEDICARE CONTRACTUAL ADJ 48.32- 10/30/01 BALANCE AFTER INSI 10.3'" 08123/01 99232.GC V58.1 DAILY HOSPITAL CARE 133.00 10/16/01 MEDICARE PAYMENT 44....0- 10/16/01 MEDICARE CONTRACTUAL ADJ 77 .50- 10/16/01 BALANCE AFTER INSI 11.10 0812"'/01 99233 . GC V58.1 DAILY HOSPITAL CARE 196.00 10/16/01 MEDICARE PAYMENT 63.01- 10/16/01 MEDICARE CONTRACTUAL ADJ 117.2"'- 10/16/01 BALANCE AFTER INSI 15.75 08125/01 99238.GC V58.1 HOSP DISC DAY MGT <30 MIN 115.00 10/16/01 MEDICARE PAYMENT 53.27- 10/16/01 MEDICARE CONTRACTUAL ADJ 48....1- 10/16/01 BALANCE AFTER INSI 13.32 1723861 PERFORMED BY: DIVISION OF HEMIONC PLACE OF SVC: OP HOSPITAL 08117101 99212 285.9 CIC OUTPATIENT VIS EST 2....00 01/08102 MEDICARE PAYMENT 16.06- 01/08102 MEDICARE CONTRACTUAL ADJ 3.93- 01/08102 BALANCE AFTER INSI ....01 1748588 PERFORMED BY: DIVISION OF HEM/ONe PLACE OF SVC: OP HOSPITAL 08129/01 9921... 202.80 C/C OUTPATIENT VIS EST 56.00 01/08102 MEDICARE PAYMENT 37.98- 01/08102 MEDICARE CONTRACTUAL ADJ 8.52- 01/08102 BALANCE AFTER INSI 9.50 1751675 PERFORMED BY: DIVISION OF HEM/ONe PLACE OF SVC: OP HOSPITAL 08130/01 9921... 202.8D C/C OUTPATIENT VIS EST 56.00 01/08102 MEDICARE PAYMENT 37.98- 01/D8I02 MEDICARE CONTRACTUAL ADJ 8.52- 01/08/02 BALANCE AFTER INSll 9.50 1754727 D CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK )ENNSTATE BOBBY RAY PRICE 70115 353 OLD STONEHOUS RD _ The Milton S. Hershey Medical Center SOUTH STATEMENT The College of Medicme BOILING SPRIN PA 17007 DATE: 10/31/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 ~ IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG QTV DESCRIPTION INS CHARGE PAYMENT' GUARANTOR CODE CODE ADJUSTMENT BALANCE PERFORMED BY: DIVISION OF HEM/ONC PLACE OF SYC: OP HOSPITAL 08131101 99Z1Z Z84.8 CIC OUTPATIENT VIS EST Z4.00 01l08lOZ MEDICARE PAYI1ENT 16.06- 01lD8IOZ I1EDICARE CONTRACTUAL ADJ 3.93- 01l08l0Z BALANCE AFTER INS* 4.01 176149Z PERFORMED BY: DIVISION OF HEI1IDNC PLACE OF SYC: DP HOSPITAL 09/05/01 99Z13 Z84.8 C/C OUTPATIENT VIS EST 35.00 01lO8lOZ I1EDICARE PAYI1ENT Z3.35- 01l08lOZ MEDICARE CONTRACTUAL ADJ 5.81- 01l08l0Z BALANCE AFTER INS* 5.84 1767847 PERFORMED BY: DIVISION OF HEI1IDNC PLACE OF SYC: OP HOSPITAL 09/07101 99Z1Z Z87.5 C/C OUTPATIENT VIS EST Z4.OO Ol/08l0Z I1EDICARE PAYMENT 16.06- Ol/08lOZ I1EoICARE CONTRACTUAL ADJ 3.93- 01l08l0Z BALANCE AFTER INS* 4.01 18944Z7 PERFORMED BY: DIVISION OF HEM/ONC PLACE OF SYC: OP PHYSICI AN 09/14/01 99Z11 ZOZ.80 C/C OUTPATIENT VIS EST 10.00 10130/01 MEDICARE PAYI1ENT 7.35- 10130/01 I1EDICARE CONTRACTUAL ADJ 0.81- 10/3D/ol BALANCE AFTER INS* 1.84 19OZ657 PERFORMED BY: DIV OF PULI1DNARY MEDICINE PLACE OF SYC: OP PHYSICIAN 09/19/01 9406OZ6 Z04.00 BRONCHODILATOR SPIRDI1ETRY 83.00 11106/01 MEDICARE PAYI1ENT 14.44- 11/06/01 I1EDICARE CONTRACTUAL ADJ 64.95- 11106/01 BALANCE AFTER INS* 3.61 09/19/01 94Z4OZ6 ZD4.00 FUNCTIONAL RESIDUAL CAP 55.00 11/06/01 I1EDICARE PAYMENT 11.50- 11/06/01 I1EDICARE CONTRACTUAL ADJ 40.6Z- 11/06/01 BALANCE AFTER INS* Z.88 09/19/01 947Z0Z6 ZD4.0O CARBON I1DNDX DIFF CAP 54.00 11106/01 I1EDICARE PAYMENT 11.50- 11/06/01 I1EDICARE CONTRACTUAL ADJ 39.6Z- 11106/01 BALANCE AFTER INSlI Z.88 1903057 PERFORMED BY: DIV OF NUCLEAR I1EDICINE PLACE OF SYC: OP HOSPITAL CARD BLD POOL II1AG S1STUD PAGE )ENNSTATE BOBBY RAY PRICE 80115 353 OLD STONEHOUS RD _ The Milton S. Hershey Medical Center SOUTH STATEMENT The College of Medicme BOILING SPRIN PA 17007 DATE: 10/31/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 ~ IF ANY QUESTIONS. PLEASE CONTACT: M:SHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG QT'f DESCRIPTION INS CHARGE PAYMENTI GUARANTOR CODE CODE ADJUSTMENT BALANCE 11106/01 MEDICARE PAYMENT 41. 91- 11106/01 MEDICARE CONTRACTUAL ADJ 168.61- 11106/01 BALANCE AFTER I~ 10.48 1929208 PERFORMED BY, DIVISION OF HEH/DNC PLACE OF SYC, OP PHYSICIAN 10/01/01 99214 202.80 CIC OUTPATIENT VIS EST 56.00 11/20/01 MEDICARE PAYMENT 44.69- 11/20/01 MEDICARE CONTRACTUAL ADJ 0.14- 11120/01 BALANCE AFTER I~ 11.17 1956007 PERFORMED BY, DIVISION OF HEM/ONe PLACE OF SYC, INPATIENT 10/13/01 99222.GC V58.1 INITIAL HOSPTIAL CARE 250. 00 12/04/01 MEDICARE PAYMENT 90.70- 12104/01 MEDICARE CONTRACTUAL ADJ 136.63- 12104/01 BALANCE AFTER I~ 22.67 10114/01 99231. GC V58.1 DAILY HOSPITAL CARE 98.00 12104/01 MEDICARE PAYMENT 27.78- 12104/01 MEDICARE CONTRACTUAL ADJ 63.28- 12/04/01 BALANCE AFTER I~ 6.94 PERFORMED BY, DIV OF CARDIOLOGY 10/14/01 93010 427.89 ECG ELECTROCARD INTERP 52.00 12118101 MEDICARE PAYMENT 8.21- 12118101 MEDICARE CONTRACTUAL ADJ 41. 74- 12118101 BALANCE AFTER I~ 2.05 PERFORMED BY, DIVISION OF HEH/DNC 10/15101 99233 V58.1 DAILY HOSPITAL CARE 196.00 12/04/01 MEDICARE PAYMENT 63.01- 12104/01 MEDICARE CONTRACTUAL ADJ 117.24- 12104/01 BALANCE AFTER I~ 15.75 10/16/01 99232.GC V58.1 DAILY HOSPITAL CARE 133.00 12/04/01 MEDICARE PAYMENT 44.40- 12104/01 MEDICARE CONTRACTUAL ADJ 77 .50- 12/04/01 BALANCE AFTER I~ 11.10 10/17101 99238.GC V58.1 HOSP DISC DAY HGT <30 MIN 115.00 12104/01 MEDICARE PAYMENT 53.27- 12104/01 MEDICARE CONTRACTUAL ADJ 48.41- 12/04/01 BALANCE AFTER INS- 13.32 1968883 PERFORMED BY, DIVISION OF HEH/DNC PLACE OF SYC: OP HOSPITAL 10/18101 99214 284.8 C/C llVTPATIENT VIS EST 56.00 01/08102 MEDICARE PAYMENT 37.98- 01/08102 MEDICARE CONTRACTUAL ADJ 8.52- 01/08102 BALANCE AFTER I~ 9.50 D CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK 'ENNSTATE BOBBY RAY PRICE 90115 353 OLD STONEHOUS RD 'iJ The Milton S. Hershey Medical Center SOUTH STATEMENT The College of Medicme BOILING SPRIN PA 17007 DATE: 10/31/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 ~ IF ANY QUESTIONS, PlEASE CONTACT: M:SHMC PATIENT FINANCIAL SERVICES FED TAX 10 # 251857035 DATE PROCEDURE DIAG QT'f DESCRIPTION INS CHARGE PAYMENTI GUARANTOR CODE CODE ADJUSTMENT BALANCE PERFORMED BY: DIVISION OF HEMIONC PLACE OF SYC: OP HOSPITAL 10/22/01 99213 284.8 CIC OUTPATIENT VIS EST 35.00 01/08/02 MEDICARE PAYMENT 23.35- 01/08/02 MEDICARE CONTRACTUAL ADJ 5.81- 01108/02 BALANCE AFTER INSI 5.84 1981791 PERFORMED BY: DIVISION OF HEMIONC PLACE OF SYC: OP HOSPITAL 10/24/01 99213 284.8 C/C OUTPATIENT VIS EST 35.00 01108/02 MEDICARE PAYMENT 23.35- 01/08/02 MEDICARE CONTRACTUAL ADJ 5.81- 01108/02 BALANCE AFTER INSI 5.84 1984961 PERFORMED BY: DIVISION OF HEMIONC PLACE OF SYC: DP HOSPITAL 10/25101 99213 284.8 C/C OUTPATIENT VIS EST 35.00 01116102 MEDICARE PAYMENT 23.35- 01116/02 MEDICARE CONTRACTUAL ADJ 5.81- 01116/02 BALANCE AFTER INSI 5.84 1991125 PERFORMED BY: DIV OF DIAS RADIOLOGY PLACE OF SYC: INPATIENT 10/28/01 7102026 780.6 CHEST 2 VIENS FRONT/LAT 78.00 12118/01 MEDICARE PAYMENT 9.4'1- 12118/01 MEDICARE CONTRACTUAL ADJ 66.20- 12118/01 BALANCE AFTER INSll 2.36 PERFORMED BY: DIVISION OF HEHlONC 10/28/01 99223 . GC 288.0 INITIAL HOSPITAL CARE 306.00 12118/01 MEDICARE PAYMENT 124.26- 12118/01 MEDICARE CONTRACTUAL ADJ 150.68- 12118/01 BALANCE AFTER INSI 31. 06 10/29/01 99232.GC 288.0 DAILY HOSPITAL CARE 133.00 12118/01 MEDICARE PAYMENT 4'1.40- 12118/01 MEDICARE CONTRACTUAL AOJ 77.50- 12118/01 BALANCE AFTER INSll 11.10 1998127 PERFORMED BY: DIVISION OF HEMIONC PLACE OF SYC: OP HOSPITAL 10/31/01 99213 996.62 C/C OUTPATIENT VIS EST 35.00 01/16/02 MEDICARE PAYMENT 23.35- 01/16/02 MEDICARE CONTRACTUAL ADJ 5.81- 01116/02 BALANCE AFTER INSll 5.84 2001334 PAGE )ENNSTATE BOBBY RAY PRICE 100115 353 OLD STONEHOUS RD IiJ The Milton S. Hershey Medical Center SOUTH STATEMENT The College of Medicme BOILING SPRIN PA 17007 DATE: 10/31/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 ot IF ANY QUESTIONS. PLEASE CONTACT: M:!lHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG QT't DESCRIPTION INS CHARGE PAYMENTI GUARANTOR CODE CODE ADJUSTMENT BALANCE PERFORMED BY: DIVISION OF HEM/ONe PLACE OF SYC: OP HOSPITAL 11/01/01 ,,21f1 202.80 CIC OUTPATIENT VIS EST 56.00 01/16/02 MEDICARE PAYMENT 37.98- 01/16/02 MEDICARE CONTRACTUAL ADJ 8.52- 01/16/02 BALANCE AFTER INSI 9.50 2004509 PERFORMED BY: DIVISION OF HEHIONC PLACE OF SYC: OP HOSPITAL 11/02/01 99214 202.80 CIC OUTPATIENT VIS EST 56.00 01/16/02 MEDICARE PAYMENT 37.98- 01/16/02 MEDICARE CONTRACTUAL AOJ 8.52- 01/16/02 BALANCE AFTER INSI 9.50 2013092 PERFORMED BY: DIVISION OF HEM/ONe PLACE OF SYC: OP PHYSICIAN 11/07101 99214 202.80 C/C OUTPATIENT VIS EST 56.00 12/26/01 MEDICARE PAYMENT 44.69- 12126/01 MEDICARE CONTRACTUAL AOJ 0.14- 12126/01 BALANCE AFTER INSI 11.17 2029321 PERFORMED BY: DIVISION OF HEM/ONe PLACE OF SYC: INPATIENT 11/14/01 99222.GC V58.1 INITIAL HDSPTIAL CARE 250.00 01/02/02 MEDICARE PAYMENT 90.70- 01/02/02 MEDICARE CONTRACTUAL ADJ 136.63- 01/02/02 BALANCE AFTER INSI 22.67 11/15/01 99232.GC V58.1 DAILY HOSPITAL CARE 133.00 01/02/02 MEDICARE PAYMENT 44.40- 01/02/02 MEDICARE CONTRACTUAL ADJ 77 .50- 01/02/02 BALANCE AFTER INSI 11.10 PERFORMED BY: DIV OF PULMONARY MEDICINE 11/15/01 9472026 V72.82 CARBON HDNDX DIFF CAP 5lt.00 01/02/02 MEDICARE PAYMENT 11.50- 01/02/02 MEDICARE CONTRACTUAL ADJ 39.62- 01/02/02 BALANCE AFTER INSI 2.88 PERFORMED BY: DIV VASCULAR INSTITUTE 11/15/01 36533.LT V58.81 PASPORT 1325.00 01/14/02 MEDICARE PAYMENT 279.77- 01/14/02 MEDICARE CONTRACTUAL ADJ 975.29- 01/14/02 BALANCE AFTER INSlI 69.lJ<t 11/15/01 7694226.LT V58.81 ULTRA GUID/NEEDLE BID INT 141.00 01/14/02 MEDICARE PAYMENT 28.5lt- 01/14/02 MEDICARE CONTRACTUAL ADJ 105.32- 01/14/02 BALANCE AFTER INSI 7.14 11/15/01 7600326.59 V58.81 NEEDLE BIOPSY OR ASPIRAT 110.00 01/14/02 MEDICARE PAYMENT 22.69- 01/14/02 MEDICARE CONTRACTUAL ADJ 81. 64- CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK )ENNSTATE BOBBY RAY PRICE 353 OLD STONEHOUS RD " The Milton S. Hershey Medical Center SOUTH STATEMENT The College of Medietne BOiliNG SPRIN PA 17007 DATE: 10/31/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 ~ IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG Qn DESCRIPTION INS CHARGE PAYMENTI GUARANTOR CODE CODE ADJUSTMENT BALANCE 01/14/02 BALANCE AFTER INSIl 5.67 PERFORMED BY: DIYISION OF HEM/DNC 11/16/01 99232.GC Y58.1 DAILY HOSPITAL CARE 133.00 01/02/02 MEDICARE PAYMENT 44.40- 01102/02 MEDICARE CONTRACTUAL ADJ 77.50- 01102/02 BALANCE AFTER INSIl 11.10 11117101 99233 . GC Y58.1 DAILY HOSPITAL CARE 196.00 01/02/02 MEDICARE PAYMENT 63.01- 01102/02 MEDICARE CONTRACTUAL ADJ 117.24- 01102/02 BALANCE AFTER INSIl 15.75 2082486 PERFORMED BY: DIYISION OF HEHIONC PLACE OF SYC: OP PHYSICIAN lZ106101 99214 204.91 CIC OUTP ArIENT VIS EST 56.00 01122/02 MEDICARE PAYMENT 44.69- 01122/02 MEDICARE CONTRACTUAL ADJ 0.14- 01122/02 BALANCE AFTER INSll 11.17 2091184 PERFORMED BY: DIY OF DIAG RADIOLOGY PLACE OF SYC: OP HOSPITAL 12111/01 7055326 202.80 MRI BRAIN UNEN ENH 486.00 02/12/02 MEDICARE PAYMENT 99.78- 02/12/02 MEDICARE CONTRACTUAL ADJ 361.27- 02/12/02 BALANCE AFTER INSIl 24.95 2099075 PERFORMED BY: DIY OF NUCLEAR MEDICINE PLACE OF SYC: OP HOSPITAL 12/13/01 7847226 429.9 CARD BLD POOL IMAG S1STUD 221.00 02/04/02 MEDICARE PAYMENT 41. 91- 02104/02 MEDICARE CONTRACTUAL ADJ 168.61- 02/04/02 BALANCE AFTER INSIl 10.48 2101021 PERFORMED BY: DIY OF ANATOMIC PATHOLOGY PLACE OF SYC: INP ATIENT 12114/01 8810826 YI0.79 CYrO CDNCEN NlSHEARS 63.00 02104/02 MEDICARE PAYMENT 24.50- 02104/02 MEDICARE CONTRACTUAL ADJ 32.38- 02104/02 BALANCE AFTER INSIl 6.12 PERFORMED BY: DIY PSYCH CONSULTS ADULT 12114/01 99252.GC 296.80 INITIAL INPT CONSULTATION 140.00 02104/02 MEDICARE PAYMENT 59.62- 02104/02 MEDICARE CONTRACTUAL ADJ 65.48- 02/04/02 BALANCE AFTER INSIl 14.90 PERFORMED BY: DIY OF DIAG RADIOLOGY 12/14/01 7101026 786.05 CHEST 1 YIE" 56.00 02104/02 MEDICARE PAYMENT A -8 () 7.66- 02104/02 MEDICARE CONTRACTUAL ADJ 46.43- )ENNSTATE PAGE BOBBY RAY PRICE 120115 353 OLD STONEHOUS RD IIiJ The Milton S. Hershey MediicaI Center SOUTH STATEMENT The College of Medicme BOILING SPRIN PA 17007 DATE: 10/31/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 ~ IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG QTV DESCRIPTION INS CHARGE PAYMENTI GUARANTOR CODE CODE ADJUSTMENT BALANCE 02104/02 BALANCE AFTER INS* 1. 91 PERFORMED BY: OIVISION OF HEHVONC 12114/01 99223.GC 293.0 INITIAL HOSPITAL CARE 306.00 02104/02 11E0ICARE PAYMENT 124.26- 02104/02 MEDICARE CONTRACTUAL ADJ 150.68- 02104/02 BALANCE AFTER INS- 31. 06 12115101 99233.GC 293.0 DAILY HOSPITAL CARE 196.00 02104/02 MEDICARE PAYMENT 63.01- 02104/02 MEDICARE CONTRACTUAL AOJ 117.24- 02104/02 BALANCE AFTER INS- 15.75 2124695 PERFORMED BY: DIVISION OF HEHVONC PLACE OF SVC: INPATIENT 12127101 99223.GC V58.1 INITIAL HOSPITAL CARE 306.00 02120/02 MEDICARE PAYMENT 124.26- 02120/02 MEDICARE CONTRACTUAL ADJ 150.68- 02120/02 BALANCE AFTER INS* 31.06 12128101 99232.GC V58.1 DAILY HOSPITAL CARE 133.00 02120/02 MEDICARE PAYI1ENT 44.40- 02120/02 MEDICARE CONTRACTUAL ADJ 77 .50- 02120/02 BALANCE AFTER INS* 11.10 12129/01 99232.GC V58.1 DAILY HOSPITAL CARE 133.00 02120/02 MEDICARE PAYMENT 44.40- 02120/02 MEDICARE CONTRACTUAL AOJ 77 .50- 02120/02 BALANCE AFTER INS- 11.10 12130/01 99231.GC V58.1 DAILY HOSPITAL CARE 98.00 02120/02 MEDICARE PAYMENT 27.78- 02120/02 MEDICARE CONTRACTUAL ADJ 63.28- 02120/02 BALANCE AFTER INS* 6.94 2132674 PERFORMED BY: DIVISION OF HEHVONC PLACE OF SVC: OP HOSPITAL 01/02102 99214 202.80 CIC OUTP ATIENT VIS EST 56.00 03/05/02 MEDICARE PAYMENT 36.92- 03/05/02 MEDICARE CONTRACTUAL AOJ 9.85- 03/05/02 BALANCE AFTER INS* 9.23 2135821 PERFORMED BY: DIVISION OF HEHVONC PLACE OF SVC: INPATIENT 01/03/02 99214 202.80 CIC OUTPATIENT VIS EST 56.00 03/05/02 MEDICARE PAYI1ENT 0.00 05/21/02 MEDICARE PAYMENT 36.92- 05121/02 MEDICARE CONTRACTUAL AOJ 9.85- 05/21/02 BALANCE AFTER INS* 9.23 PERFORMED BY: DIV OF DIAG RADIOLOGY 01/04/02 7101026 780.6 CHEST 1 VIEH 56.00 03/05/02 APPLIED TO DEDUCTIBLE 03/05/02 MEDICARE CONTRACTUAL ADJ D CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK )ENNSTATE BOBBY RAY PRICE 353 OLD STONEHOUS RD IiJ The Milton S. Hershey Medical Center SOUTH STATEMENT The College of Medicme BOILING SPRIN PA 17007 DATE: 10/31/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 ~ IF ANY QUESTIONS. PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX 10 # 251857035 DATE PROCEDURE DIAG QT'f DESCRIPTION INS CHARGE PAYMENTI GUARANTOR CODE CODE ADJUSTMENT BALANCE 03/05/02 BALANCE AFTER I~ 8.74 01104/02 7048626 473.9 CT MAXILLOFACIAL UNENH 274.00 03/05/02 MEDICARE PAYMENT 44.54- 03/05102 MEDICARE CONTRACTUAL ADJ 218.33- 03/05/02 BALANCE AFTER INS" 11.13 PERFORMED BY: DIYISION OF HEM/ONe 01/04/02 99222 288.0 INITIAL HOSPTIAL CARE 250.00 03/05/02 MEDICARE PAYMENT 83.80- 03/05/02 MEDICARE CONTRACTUAL ADJ 145.25- 03/05/02 BALANCE AFTER I~ 20.95 01/05/02 99232 288.0 DAILY HOSPITAL CARE 133.00 03/05/02 MEDICARE PAYMENT 41.52- 03/05/02 MEDICARE CONTRACTUAL ADJ 81.10- 03/05/02 BALANCE AFTER INS" 10.38 01106102 99232.SC 288.0 DAILY HOSPITAL CARE 133.00 03/05/02 MEDICARE PAYMENT 41.52- 03/05/02 MEDICARE CONTRACTUAL AOJ 81.10- 03/05/02 BALANCE AFTER INS" 10.38 PERFORMED BY: DIY OF DIAS RADIOLOGY 01/06/02 7102026 780.6 CHEST 2 YIENS FRONT/LAT 78.00 03/05/02 MEDICARE PAYMENT 8.62- 03/05/02 MEDICARE CONTRACTUAL ADJ 67.15- 03/05/02 BALANCE AFTER INS" 2.23 PERFORMED BY: DIYISION OF HEM/ONe 01106102 99232.SC 288.0 DAILY HOSPITAL CARE 133.00 03/12102 MEDICARE PAYMENT 41.52- 03/12102 MEDICARE CONTRACTUAL ADJ 81.10- 03/12102 BALANCE AFTER I~ 10.38 01107102 99233 . SC 288.0 DAILY HOSPITAL CARE 196.00 03/05/02 MEDICARE PAYMENT 59.17- 03/05/02 MEDICARE CONTRACTUAL ADJ 122.04- 03/05/02 BALANCE AFTER INS" 14.79 01108102 99233 . SC 288.0 DAILY HOSPITAL CARE 196.00 03/05/02 MEDICARE PAYMENT 59.17- 03/05/02 MEDICARE CONTRACTUAL ADJ 122.04- 03/05/02 BALANCE AFTER I~ 14.79 01/09/02 99233.SC 288.0 DAILY HOSPITAL CARE 196.00 03/05/02 MEDICARE PAYMENT 59.l7- 03/05/02 MEDICARE CONTRACTUAL ADJ 122.04- 03/05/02 BALANCE AFTER I~ 14.79 PERFORMED BY: DIY OF DIAS RADIOLOGY 01/09/02 7102026 208.00 CHEST 2 YIENS FRONT/LAT 78.00 03/05/02 APPLIED TO DEDUCTIBLE 0.00 03/05/02 MEDICARE CONTRACTUAL ADJ 67.15- 03/05/02 BALANCE AFTER I~ 10.85 PERFORMED BY: DIYISION OF HEMIONC 01/10/02 99233. SC 288.0 DAILY HOSPITAL CARE 196.00 03/05/02 MEDICARE PAYMENT 59.17- 03/05/02 MEDICARE CONTRACTUAL ADJ 122.04- 03/05/02 BALANCE AFTER INS" 14.79 01/11102 DAILY HOSPITAL CARE >ENN5TATE BOBBY RAY PRICE 353 OLD STONEHOUS RD IiiJ The Milton S. Hershey Melliical Center SOUTH The College of Medicme BOiliNG SPRIN PA 17007 ACCOUNT # 1102021 ~ IF ANY QUESTIONS. PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES DATE PROCEDURE DIAG QTY DESCRIPTION CODE CODE 03/05/02 MEDICARE PAYMENT 03/05/02 MEDICARE CONTRACTUAL ADJ 03/05/02 BALANCE AFTER INS* 01/12/02 99233.GC 288.0 DAILY HOSPITAL CARE 03/05/02 MEDICARE PAYMENT 03/05/02 MEDICARE CONTRACTUAL ADJ 03/DS/02 BALANCE AFTER INSll PERFORMED BY: DIY OF DIAG RADIOLOGY 01112/02 7102026 780.6 CHEST 2 YIENS FRONT/LAT 03/05/02 MEDICARE PAYMENT 03/05/02 MEDICARE CONTRACTUAL ADJ 03/05/02 BALANCE AFTER INS* PERFORMED BY: DIYISION OF HEM/ONe 01113/02 99233.GC 288.0 DAILY HOSPITAL CARE 03/05/02 MEDICARE PAYMENT 03/0.5102 MEDICARE CONTRACTUAL ADJ 03/0.5102 BALANCE AFTER INS* 01114/02 99233. GC 288.0 DAILY HOSPITAL CARE 03/0.5102 MEDICARE PAYMENT 03/0.5102 MEOICARE CONTRACTUAL ADJ 03/0.5102 BALANCE AFTER INS* 0111.5102 99233.GC 288.0 DAILY HOSPITAL CARE 03/0.5102 IlEDICARE PAYMENT 03/0.5102 IlEDICARE CONTRACTUAL ADJ 03/05/02 BALANCE AFTER INS* 01/17/02 99233.GC 288.0 DAILY HOSPITAL CARE 03/12102 IlEDICARE PAYMENT 03/12102 MEDICARE CONTRACTUAL ADJ 03/12102 BALANCE AFTER INS* 01119102 99238.GC 288.0 HOSP DISC DAY I'IGT <30 MIN 03/12102 MEDICARE PAYMENT 03/12102 MEDICARE CONTRACTUAL ADJ 03/12102 BALANCE AFTER INSll 2141SSB PERFORMED BY: DIY OF CARDIOLOGY PLACE OF SYC: OP PHYSICIAN 01104/02 99245 414.01 OFFICE CONSULTATION 04/22/02 MEDICARE PAYMENT BALANCE: 8088Y RAY PRICE tl494.06 , INlICATES NEN FINANCIAL ACTIYITY SINCE LAST BILL. PAGE 140115 STATEMENT DATE: 10/31/02 LAST STATEMENT DATE: 09/25/02 FED TAX 10 # 251857035 INS CHARGE PAYMENTI GUARANTOR ADJUSTMENT BALANCE 59.17- 122.04- 14.79 196.00 59.17- 122.04- 14.79 78.00 8.68- 67.15- 2.17 196.00 59.17- 122.04- 14.79 196.00 59.17- 122.04- 14.79 196.00 59.17- 122.04- 14.79 196.00 59.17- 122.04- 14.79 115.00 Sl.28- 50.90- 12.82 171.00 72.54- 98.46 IF YOU HAYE ANY QUESTIONS ABOUT THE AI10UNT YOUR INSURANCE COMPANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTHER QUESTIONS REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMENT HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL. PLEASE FND TO CNRIGHT, CUST SERY A-K, AS8 SUITE 1140, X3623 o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK )ENNC"...,.r:' BOBBY RAY PRICE J 11'\1 L . 353 OLD STONEHOUS RD B The Miltoh S. Hershey Medical Center SOIlTH . The Colle~ of Medicme BOiliNG SPRIN PA 17007 ACCOUNT # 1102021 ~ IF ANY QUESTIONS, P~EASE CONTACT: M,SHMC PATIENT FINANCIAL SERVICES DATE PROCEDURE DIAG QT't DESCRIPTION INS CODE CODE THAt<< YOU I'OR USIt~ HSHHe PHYSICIANS GROUP FOR YOUR PHYSICIAN SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE CONTACT US AT 717-531-5069 OR 800-254-2619, BETMEEN 8:00AM AND 5:30PM MONDAY THROUGH HEDNESDAY OR BETNEEN 8:00AM AND 4:30PM THURSOAY AND FRIDAY. PAGE 150115 STATEMENT DATE: 10131102 LAST STATEMENT DATE: 09125102 FED TAX ID # 251857035 CHARGE PAYMENTI GUARANTOR ADJUSTMENT BALANCE BALANCE Sl.ttIARY ,RESPONSIBLE PARTY HTR PALMETTO GBA RAILROAD HeR *1* GUARANTOR RESPONSIBILITY POLICY I A246806110lf TOTAL t 56.00 t 1494.06 ___________________________Jl_~~q~J[~~rt!_~~~J_~_Q~I_4~li1l~p_ft~ry_~~_'_QrIJ!~!_q~IJ_Q~_p"_J_r~IJ[~_~~r_!!u:~_!9_~~_!_4!~~!{r_Jl_______________________________ STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT: 10131102 $ 1494.06 $ 1494.06 BF6 1102021 MSHMC PHYSICIANS GROUP BILLING SERVICES POBOX 854 HERSHEY PA 17033.0854 00001102021 UP 0000000000149406103102 "011 To; MSHMC PHYSICIANS GROUP POBOX 828611 PHILA PA 19182-8611 BOBBV RAY PRICE 353 OLD STONEHOUS RD SOUTH BOILING SPRIN PA 17007 _M/C _VISA 11111111111111111 CARD NUMBER EXP DATE E!il ~i@WI&WSIJ:~UlITil1l411Hi1D1Il~. 11 02021 ~Wf'~~~W FleE USE ONL Y "CHECK ONE FOR CREDIT CARD PAYMENT, PLEASE FILL IN INFORMATION BELOW C, F6BO vp, DMND CARDHOLDER NAME (PRINT) (l-ti -- MSHMC PHYSICIANS GROUP CREDIT CARD SIGNATURE ------.-.,. ..-,.--...-... I, the undersigned, do hereby acknowledge and accept financial responsibility for the payment of all charges FOr services rendered to &'\ot.'I hC'u. ~lC r- I, the undersigned, do I1er~by acknowledge and understand tlltlVall chargae-f,ot covered by Insurance will be payable In full prfor to or upon date of and time of dIscharge. I, the undersIgned, authorize the hospital to make a credit Investigation if necessary. I hereby assign and authorize payment directly to The Milton S. Hershey Medical Center Hospital, Pennsylvania State University. Should the account become delinquent, and should it become necessary for the account to be referred to an attorney or collec- tion agency for collection or suit, the undersigned shall pay the reasonable attorney's fees or eoJleetion expense. Signed'1- xf /-/ /f',?< d- /91 ,( oJ(.; Date <0 ~ ~ " 1Y1. -, (\ '\ 0 ,\, \ "", . ,Witness \ 1 L.l.-C.A\.Q\.LO (j,) ',_\1 . I ._' } Date All persons will be accepted for admission without regard to race, color, creed, religion, national origin or sex. PA T1ENT RESPONSIBILITY AGREEMENT I, the undersigned, do hereby acknowiedge and accept fInancIal responsIbility for the payment of all charges For services rendered ~~L1:... ES ~~'f (? ~ I, the undersigned, do hereby acknowledge and understand that a/I charges not covered by insurance will be payable in full prior to or upon date of and time of discharge. I, the undersigned, authorize the hospital to make a credit investigation if necessary. I hereby assign and authorize payment directly to The Milton S. Hershey Medical Center Hospital, Pennsylvania State University. Should the account become delinquent, and should it become necessary for the account to be referred to an attorney or coJlee. tion agency for collection ~')1jJt, the N.slqned shall pay the reasonable attorney's fees or collection expense. Slgned/"~ ~ ";(!<--ff' Date 7rl7~()/ Witness /C::-e~ Date _ ;-,'::; 7 CJ f All persons will be accepted for admission without regard to race, color, creed, religion, national origin or sex. r- r\nL-IV I vn utJRrTL1{}'[lV PA T1ENT RESPONSIBILITY AGREEMENT I, the undersigned, do hereby acknowledge and accept financial responsibility for the payment 01 all charges For services rendered to I, the undersigned, do hereby acknowledge and understand that all charges .not covered by insurance will be payable in full prior to or upon date of and time of discharge. I, the undersigned, authorize the hospital to make a credit investigation if necessary. I hereby assign and authorize payment directly to The Milton S. Hershey Medical Center Hospital, Pennsylvanlil State University. Should the account become deiinquent, and should It become necessary for the account to be referred to an attorney or collee- von agency for.collec;!JJ' or suit, t';;'-:!j"ders:reJ s~all pay the reasonable attorney's fees or cOllect:n expe:se~ Signed f t./4./Y < .1":/Jc.CA. Date 0 d ( / Witness < <:::::;,~ ~~ Date f -d- ( - c... I All persons will be accepted for admission without regard to race, color, creed, religion, national origin or sex. ~ -\ ..,........., ......V. ........VII....f,I..I. f ,.._.l........'r'....'..' I, the undersigned, do hereby acknowledge and accept financial responsibility lor the payment 01 all charges :For se!)lices rendered to I, the undersigned, do hereby acknowledge and understand that all charges not covered by insurance will be payable in lull prior to or upon date 01 and time 01 discharge. I, the undersigned, authorize the hospital to make a credit investigation il necessary. I hereby assign and authorize payment directly to The Milton S. Hershey Medical Center Hospital, Pennsylvania State University. Should the account become delinquent, and should it become necessary for the account to be referred to an attorney or collec- tion agency r Golfeetion or suit, the undersigned shall pay the reasonable attorney's fees or collection expense. Signed ~ --;ft:~e Date /(). /10/ '" ,,,,~rt t~: b :"m"~m .,,,,,"' m"m" ,,~ ,- ~:: "'"m :~~: :~~:.~ PA T1ENT R PONSIBI TY AGREEMENT I, the undersigned. do hereby aCknmw edge an a ceQt f' ~nci I res7'J~ility fo:-the payment of all charges For selVices rendered to 11 r II (1..- I, the undersigned, do hereby acknowledge and understand t t all cha ges n t cove ed by insurance will be payable in full prior to or upon date 01 and tIme of dlscha,rge. I, the un~ersigned, aut~orize the hospital make a credit investigation if necessary. I hereby assIgn and authOrize payment dlfectly to The Milton S. Hershey Medical Center Hospital, Pennsylvania State University. . ShO~~:;;;ccount b. ecome delinquent, and should it become necessary for the account to be referred ,~p~ art. orney or collec- ::=J~~:!{Jj~~" ';'::; ""'" ,., .. ..~,'" .""'~:,:' 0, 7lJ>> 01 Witness :: 'P) ~1/ 2 h!Jf Date / /' II' 81 ~ ::t:o:s wtj acce ted for admission without regard to race, coior, creed, religion, national origin or sex. ,,,,,.....'v, Vfl uvnnLJ''''\' PA T1ENT RESPONSIBILITY AGREEMENT I, the undersigned. do hereby acknowiedge and accept financial responsibility for the payment of all charges For selVices rendered to m~)'t) maq (}) ~ I, the undersigned, do hereby acknowledge and unde---:'~;n~ t~a; aiiharges no~covered by insurance will be payable in full prior to or upon date 01 and time of discharge. I, the undersigned, authorize the hospital to make a credit investigation if necessary. i hereby assign and authorize payment directly to The Milton S. Hershey Medical Center Hospital, Pennsyivania State University. Should the account become delinquont, and should it become necessary for the account to be referred to an attorney or collec~ bon ag~Lor)fectlOn or SUIt, ,the u,,;/gned shalf pay the reasonable attorney's fees or collection expense. Slgne~~ /~Aee!1:::;~ Date /d-/V[J / WItness '.:9/lf0a I ~~ Date W/?lO/ All persons will be accepted tor admission without regard to race, color, creed, religion, national origin or sex. (!rJ- . ... .~... ..." ,.............,..,'01.....1"''11 PATIENT RESPONSIBILITY AGREEMENT I, the undersigned, do hereby acknowledge and accept linancial responsibility lor th~ 5~yment 01 all charges For services rendered to ;.. (J1.8o.f ~ '-t I'Ii1I' ~ I, the undersigned, do hereby acknowledge and understand that all charges not covered by insurance will be paytible in full prior to or upon date of and time of discharge. /, the undersigned, authorize the hospital to make a credit investigation if necessary. I hereby assign and authorize payment directly to The Milton S. Hershey Medical Center Hospital, Pennsylvania State University. Should the account become delinquent, and should it become necessary for the account to be referred to an attorney or collec- tion ag~_ for ~or::Jtion ~J9I~the undersigned shall pay the reasonable attorney's fees Or collection expense. SIgned -f" )!./ I 1jvteJ,. ,~ Date /2 /c -0.:- WItness, c;?:-~ 7~ Date /~~4> All persons wi/! be accepted for admission without regard to race, color, creed, religion, national origin or sex. PA T1ENT RESPONSIBILITY AGREEMENT I, the undersigned, do hereby acknowledge and accept financial responsibility for the payment of all charges For services rendered to V:>aM<;d .~.<.j Cf::J.-/~~ I, the undersigned, do hereby acknowledge and understand that all((i:f,arges not fhvered by insurance wi/! be payable in full prior to or upon date of and time of discharge. I, the undersigned, authorize the hospital to make a credit investigation if necessary. I hereby assign and authorize payment directly to The Milton S. Hershey Medical Center Hospital, Pennsylvania State University. Should the account become delinquent, and should. it become necessary for the account to be referred to an attorney or collec- tion agency for coli ction ?r}!:!J t!!.e undersigned shall pay the reasonable attorney's fees or collection expense. Signed ./~~ Date /, -</-. tJ:j ,.J Witness',L, Date /.4'o~ s will be accepted lor admission without regard to race, color, creed, religion, national origin or sex. 6-3 PRICE, BOBBY RAY (Dec'dJ> 111102021 $12,040.19 (Hasp) 1,494.06 (Phys) . . VERIFICATION LINDA SCHLADER hereby states that she is the Super- visor of Financial Counselors and Collection of Milton S. Hershey Medical Center, The Pennsylvania State University and verifies that the statements made in the foregoing pleading are true and correct to the best of her knowledge, information and belief. The undersigned understands that the statements therein are made subject to the penalties of 18 Pa. C.S. ~4904 relating to unsworn falsification to authorities. ~HLL~ DATE: ~113)03 (::)"'9. Pt - C1) \t- .Ui Vl - ~ () w '" _1 ..0 l::. it::: ~ ~ r - 0 ~ J:- o 1'-" r', ~;:~ -I: ;~. G.; r' , t,!) .,,', '::'. - )> i "'.~~ ,) 'CJ _.~i (JJ :::.. :8 ;'1 THE MIL TON S. HERSHEY MEDICAL CENTER, PLAINTIFF IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 03-3234 CIVIL TERM GINNY REID PRICE, DEFENDANT : JURY TRIAL DEMANDED NOTICE TO DEFEND You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Answer with Counter Complaint, and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 1-800-990-9108 Americans with Disabilities Act of 1990 The Court of Common Pleas of Cumberland County is required by law to comply with the Americans with Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the court, please contact our office. All arrangements must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled conference or hearing. 2 THE MILTON S. HERSHEY MEDICAL CENTER, PLAINTIFF IN THE COURT OF COMMON PLEAS CUMBERLANDCOUNT~ PENNSYL VANIA v. NO. 03-3234 CIVIL TERM GINNY REID PRICE, DEFENDANT : JURY TRIAL DEMANDED ANSWER TO COMPLAINT WITH COUNTERCLAIM AND NOW, this 14th day of August 2003, comes the defendant, GINNY REID PRICE, by her attorneys, Irwin, McKnight & Hughes, and makes the following Answer to Complaint of the plaintiff, The Milton S. Hershey Medical Center: 1. The averments offact contained in paragraph one (1) of the Complaint are admitted. 2. The averments offact contained in paragraph two (2) of the Complaint are admitted. 3. The averments offact contained in paragraph three (3) of the Complaint are specifically denied. On the contrary, it is denied that the Defendant was married to Bobby Ray Price on September 22, 2001, which date was after all or substantially all services rendered by the Plaintiff to Bobby Ray Price who died on February 2, 2002. 4. The averments offact contained in paragraph four (4) of the Complaint are admitted. 5. The averments of fact contained in paragraph five (5) of the Complaint are beyond the knowledge of the Plaintiff. They are, therefore, denied and proof thereof is demanded. 3 6. The averments offact contained in paragraph six (6) of the Complaint are beyond the knowledge of the Plaintiff. They are, therefore, denied and proof thereof is demanded. 7. The averments of fact contained in paragraph seven (7) of the Complaint are admitted. 8. The averments of fact contained in paragraph eight (8) of the Complaint are denied. On the contrary, the Plaintiff knows that the Defendant is financially insolvent and is unemployed. The Defendant is responsible for her own care and the care of her eight (8) year old child by a previous marriage. 9. The averments of fact contained in paragraph nine (9) of the Complaint are conclusions of law to which no answer is required. Since she was not married when the deceased became a patient, this act does not apply to this case. 10. The averments offact contained in paragraph ten (10) of the Complaint are denied. On the contrary, the Plaintiff has been paid by Medicare and knows that the Defendant is unable to pay and is not legally required to pay the balance claimed by the Plaintiff. II. The averments of fact contained in the first paragraph (II) of the Complaint are specifically denied. The Defendant has no legal responsibility to pay the amount sought by the Plaintiff. 12. The averments of fact contained in the first paragraph twelve (12) of the Complaint are specifically denied. On the contrary, the Defendant has no legal responsibility to pay the amount sought by the Plaintiff. 4 COUNTERCLAIM OF DEFENDANT GINNY REID-PRICE AND NOW, this 14th day of August 2003, comes the Defendant, Ginny Reid-Price, by her attorneys, Irwin, McKnight & Hughes, and makes the following Counterclaim against the Plaintiff, The Milton S. Hershey Medical Center: 13. The averments of fact contained in the Answers to paragraph one (1) through twelve of the Complaint are hereby incorporated by reference and are made a part of this Counterclaim. 14. Many of the charges claimed by the Plaintiff were incurred prior to the marriage ofthe Defendant to her deceased husband, Bobby Ray Price. 15. The amount claimed by the Plaintiff was never acknowledged or accepted by the Defendant, Ginny Reid-Price. 16. The Plaintiff has failed to pursue any claim against the Estate of Bobby Ray Price. 17. Following the death of Bobby Ray Price, the Plaintiff was given information by the Defendant, Ginny Reid-Price that she was unable to pay the bills claimed by the Plaintiff. The Plaintiff still filed this litigation to worry and harass the Plaintiff, Ginny Reid-Price. 18. The Plaintiff has received large sums from Medicare to pay these outstanding bills and does not need to seek future payment from the Defendant, Ginny Reid-Price. 5 19. The deceased, Bobby Ray Price, was a veteran entitled to full veteran medical benefits. If Bobby Ray Price had been transferred to a veteran health center there would be no amount due and owing. 20. The action brought by the Plaintiff against the Defendant is without basis and is vexatious harassment of the Defendant, Ginny Reid-Price. The action was brought without sufficient inquiry into the facts surrounding the treatment and death of Bobby Ray Price. The Plaintiff and its counsel may be subject to sanctions as pennitted by Pa.R.c.P. 1023.1. 21. The Defendant, Ginny Reid-Price seeks damages from the Plaintiff together with her reasonable legal fees and interest and penalties as pennitted by law. WHEREFORE, the Defendant requests that the Complaint filed by the Plaintiff be dismissed and that judgment be entered against the Plaintiff and in favor of the Defendant, Ginny Reid-Price in an amount in excess of Twenty Thousand and 00/100 ($20,000.00) Dollars with legal fees, costs, and interest as pennitted by law. Respectfully submitted, B IRWIN, Md<NIGHT & 7~ , tfsquire . 13 Date: August 14,2003 6 VERIFICATION The foregoing Answer is based upon information which has been gathered by counsel and myself in the preparation of this action. I have read the statements made in this document and they are true and correct to the best of my knowledge, information and belief. I understand that false statements herein made are subject to the penalties of 18 Pa. C.S.A. Section 4904, relating to unsworn falsification to authorities. rh, J2;/Yk t~ PRICE Date: iJ!t~oa"< THE MILTON S. HERSHEY MEDICAL CENTER, PLAINTIFF IN THE COURT OF COMMON PLEAS CUMBERLANDCOUNT~ PENNSYLVANIA v. NO. 03-3234 CIVIL TERM GINNY REID PRICE, DEFENDANT CERTIFICATE OF SERVICE I, Marcus A. McKnight, III, Esquire, hereby certifY that a copy of attached document was served upon the following by depositing a true and correct copy of the same in the United States mail, First Class, postage prepaid in Carlisle, Pennsylvania, on the date referenced below and addressed as follows: Lewis C. Traffer, Esq. TABAS & ROSEN 1845 Walnut St., 22"d FIr. Philadelphia, P A 19103 By: Marcus ~. Mc , III, Esquire 60 West Pomfret Street Carlisle,PA 17013 (717) 249-2353 Supreme Court LD. No. 25476 Date: August 14, 2003 7 SHERIFF'S RETURN - REGULAR CASE NO: 2003-03234 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND MILTON S HERSHEY MED CENTER VS PRICE GINNY REID ROBERT BITNER , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon PRICE GINNY REID the DEFENDANT , at 1600:00 HOURS, on the 11th day of July , 2003 at 353 OLD STONEHOUSE ROAD BOILING SPRINGS, PA 17007 by handing to GINNY PRICE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge So Answers: 18.00 4.83 .00 10.00 .00 32.83 .r~~"'<~ R. Thomas Kline 07/14/2003 TABAS & ROSEN Sworn and Subscribed to before By: --:;::) ~* \?')~j MUA, \ 9.~puty Sheriff h' (.~ me t 1S day of ().::/',..J- .;2vu, "1 fl., . C1 ~ ~ ~ r Prothonotary . A.D. TABAS & ROSEN, P.C. BY: LEWIS C. TRAUFFER Attorney I. D. 60267 1845 Walnut Street, 22nd Floor Philadelphia, PA 19103 (215) 569-5050 Attorney for Plaintiff v. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY D3 -3J-3c./- NO. 9~ 3l!H I THE MILTON S. HERSHEY MEDICAL CENTER GINNY REID PRICE CIVIL ACTION PLAINTIFF'S PRELIMINARY OBJECTIONS TO DEFENDANT'S COUNTERCLAIM NOW, comes the plaintiff, Milton S. Hershey Medical Center, by and through its attorneys Tabas & Rosen, P.C., and in support of its Preliminary Objections to Defendant's Counterclaim avers as follows: PRELIMINARY OBJECTION IN THE NATURE OF A MOTION TO STRIKE DEFENDANT'S ANSWER, NEW MATTER AND COUNTERCLAIM FOR FAILURE TO CONFORM TO LAW OR RULE OF COURT PURSUANT TO PA.R.C.P. 1026 (A) AND PA.R.C.P. 1028 (a)(2) 1. On July 8, 2003 plaintiff commenced the above action against defendant to recover medical bills for care and services provided to defendant's husband, Bobby Ray Price, deceased. A copy of the complaint is attached hereto as plaintiffs exhibit "A" and incorporated herein by reference. 2. On July 11, 2003 the above captioned complaint was served on Defendant by the Sheriffs Office of the Cumberland County, Pennsylvania. A copy of the return of service is attached hereto as plaintiffs exhibit "B" and incorporated herein by reference. 3. On August 14, 2003 Defendant filed her answer, new matter and counterclaim to plaintiffs complaint. A copy of the return of service is attached hereto as plaintiffs exhibit "C" and incorporated herein by reference. 4. Plaintiffs complaint contained a Notice to Plead requiring a response twenty (20) days from service pursuant to Pennsylvania Rules of Civil Procedure Rule 1026 (a). 5. Defendant filed her answer, new matter and counterclaim thirty-four (34) days after service of the complaint. 6. Defendant's counterclaim fails to conform to Pennsylvania Rule of Court and should therefore be stricken. WHEREFORE, for all the foregoing reasons, plaintiff respectfully requests the counterclaim of defendant Ginny Reid-Price be stricken for failure to conform to law or rule of court. PRELIMINARY OBJECTION IN THE NATURE OF A MOTION FOR MORE SPECIFIC PLEADING PURSUANT TO PA.R.C.P. 1028 (l!lill 7. The averments contained in paragraphs I through 6 of plaintiffs preliminary objections are incorporated as if set forth in their entirety herein. 8. Defendant's Counterclaim contains insufficient facts to set forth a claim for sanctions pursuant to Pa.R.C.P. 1023.1. 9. Defendant fails to state the theory of law upon which she bases her Counterclaim apart from alleging the complaint being filed to vex and harass the defendant. 10. Plaintiff asserts that as a result of the failure of defendant to identify the cause of action its bases her complaint, plaintiff cannot be reasonably expected to prepare an adequate answer to defendant's Counterclaim. 11. The counterclaim should therefore be dismissed for failure to state a claim with specificity upon which relief can be granted. WHEREFORE, plaintiff requests Defendant's Counterclaim be dismissed for failing to state a claim upon which relief may be granted, or in the alternative, be ordered to file a more specific pleading. 2 PRELIMINARY OBJECTION IN THE NATURE OF A MOTION TO STRIKE DEFENDANT'S COUNTERCLAIM FOR FAILURE TO CONFORM TO LAW OR RULE OF COURT PURSUANT TO PA.R.C.P. 1023.2 (A) AND PA.R.C.P. 1028 (a)(2) 12. The averments contained in paragraphs I through 11 of plaintiffs preliminary objections are incorporated as if set forth in their entirety herein. 13. In paragraph 20 of her counterclaim defendant alleged plaintiff hospital commenced this action without sufficient inquiry into the facts surrounding the treatment and death of Bobby Ray Price and may be subject to sanctions as permitted by Pa.R.C.P. 1023.1. 14. The averments of defendant's counterclaim allege defendant may seek damages pursuant to Pa.R.C.P. 1023.1. 15. Pursuant to Pa.R.C.P. 1023.2 (a) [a]n application for sanctions under this rule shall be made by motion, shall be made separate from other applications and shall describe the specific conduct alleged in Pa.R.C.P. 1023.1(c). 16. Defendant's allegations in support of sanctions are contained in her counterclaim rather than by motion, and by so doing fails to conform to law or rule of court. WHEREFORE, plaintiff respectfully requests defendant's counterclaim be stricken for failure to conform to law or rule of court pursuant to Pa.R.C.P. 1023.2(a) and 1028 (b). TABAS & ROSEN, P.C. ><,-?~ LEWIS C. TRAUFFER, ESQUIRE ATTORNEY FOR PLAINTIFF -------- ..I 3 , '. . TABAS & ROSEN, P.C. BY: LEWIS C. TRAUFFER LD. #602.67 22nd F1.,1845 Walnut Street Phi 1a. PA 19103 (215) 569-5050 P/aintljf(s) TEE MILTON S. HERSHEY MEDICAL CENTER P.O. Box 853 Hershey, PA 17033 I. f () 0 0 c:: w ., ~ '- "1:)(:7:"; n1rn (::: '-;j;Q Z::J:r r- -;>.- I , (jj~::. ',', r"-1 \.0 U 0 -$......, ,C") r~f-;'-, () < ~-' -0 T; ;l':(,.. :z: . ..,.., ..r:::.;-c::. '.-..' (') :i< '_.,1 ry C' m ~ ~~; .,.., ~. '" ':co. -< (D :0 -< ATTORNEY FOR Plaintiff vs Defendants(s) GINNY REID PRICE 353 Old Stonehouse Road Boiling Spring~, PA 17007 COURT OF COMMON PLEAS DIVISION CUMBERLAND COUNTY TERM. No. 0.3 _ ,3;)'3Y (!; c.;l:TV<...Vf\. NOTICE CIVIL ACTION COMPLAINT AVISO You have been sued in court. If you wish to defe~d against the claims set forth in the following pages, you must take .action within twenty (20) days after this complaint and notice are served. by entering a written appeal'ance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a jUdgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE. GO TO OR TELEPHONE THE OFFICE SET FORTH BELOWTO FINDOUTWHERE YOU CAN GET LEGAL HELP. Le han dcmandado a usted cilIa corte. Si usted quiere defendeThe de estas demandas cxpuestas en las paginas sigllientes. lISted Ilene veinte (20) dias de plazo al partirde]a fceha de la demanda y la notifieaeion. Haec falta asenlar una comparencia escrita 0 en persona aeon un abogado y entregara la corte en forma escrita sus defensas 0 sus objeciones a lasdemandas en contra de su persona. Sea avisado que si usted no se defiende.la eorte tomara medidas y puede continuar 101 demanda en contra suya sin previa aviso 0 nOlificacion. Ademas.la corte puede decidir a favor del demandante y requiere que usted cumpla con toda~; las provisioiles de esla demanda. Usted puede perder d(~ero 0 sus propiedades 0 atros derechos importantes para u.~ted. LLEVE ESTA DEMANDA A UN ABOGADO INMEDIATAMFNTE. SI NO TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO. VAYA EN PERSONA 0 LI.AME POR TEIEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA FSCRITA ABAJO PARA AVERIGUAR DON DE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 (717)249-3166 or (800)990-9108 . I , COMPLAINT - CIVIL ACTION THE MILTON S. HERSHEY MEDICAL CENTER VS. GINNY REID PRICE 10 Plaintiff is a non-profit corporation located at the address indicated in the caption hereof. 2. Defendant is an individual who resides at the address indicated in the caption hereof. 30 At all times material hereto, defendant was the spouse of Bobby Ray Price, Deceased. 4, As the result of a certain medical condition, defen- dant's spouse was admitted to the plaintiff hospital for medical care on October 19, 2000 thru January 19, 2002. 5. The amounts, quantities and nature of the medical care rendered, the date on which said medical care was rendered, and the charges therefore are set forth in Exhibit "A" which is incorporated herein as if set forth at length. 6. Said medical care was commensurate with the condition of defendant's spouse and was necessary for the health and welfare of defendant's spouse, 7. Defendant's spouse is deceased. 8. Defendant is financially able to pay for the medical care of the deceased spouse. 9. By virtue of the marital relationship, the Act of 1937, June 24, P.L. 2045, !l3, as amended, 62 Pa. Cons. Stat. Ann. !l1973 and Article 1, !l28 of the Pennsylvania Constitution and all other applicable statutes, laws and ordinances, defendant has a duty to support defendant's spouse. THIS DOCUMENT IS BEING USED IN CONNECTION WITH THE COLLECTION A DEBT; ANY INFORMATION OBTAINED MAY BE USED FOR THAT PURPOSE. 10, Defendant refuses to pay the balance due although plaintiff has made demand that defenant do so. 11, Defendant is liable for the medical care rendered to defendant's spouse, 12, As a result of the foregoing, there is due and owing from defendant to plaintiff the sum indicated in Exhibit "A", WHEREFORE, plaintiff demands judgment against defendant for the sum of $13,534.25 plus six percent (6%) interest per annum from the date of discharge to the date of :iudgment, record costs and non-record costs, TABAS & ROSEN, P.C. ~ ~ LEWIS Co ~ER, ESQUIRE THIS DOCUMENT IS BEING USED IN CONNECTION WITH THE COLLECTION OF A DEBT; ANY INFORMATION OBTAINED MAY BE USED FOR THAT PURPOSE. . . MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1292175 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 02/02/01 8347 CC OUTPATIENT VISIT E 1 30,00 02/02/01 310516 CT THORAX ENHANCED 1 1129,00 02/02/01 310521 CT ABD UNENH & ENH SA 1 1241.00 02/02/01 310567 CT PELVIS ENHANCED 1 885.00 02/02/01 310641 CT LOCM 300-399 MG 1 90.00 02/07/01 920029 MEDICARE NON-COVERED -1 90.00- 03/01/01 902003 MEDICARE PAY HOSP -1 156.39- 03/01/01 920015 MEDICARE CONT ADJ. 0/ -1 2554.23- 03/04/01 900011 PATIENT PAY CHECK -1 9065- 05/09/01 902003 MEDICARE PAY HOSP {) 38.22- 05/09/01 920015 MEDICARE CONT ADJ, 0/ 1 17,77 08/31/01 980090 HOSPITAL BAD DEBT w/o -1 544,28- 08/31/01 980091 HOSPITAL BAD DEBT PLA 1 544,28 10/10/02 980092 RETURN HOSPITAL BAD D -1 544,28- 10/10/02 980093 RETURN FROM B/D HOSP 1 544028 10/31/02 980090 HOSPITAL BAD DEBT w/o -1 544,28- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 544.28 --------------------------------------------------------------------------------- * - Not posted Balance: 544,28 I -------------------------- ~ - I . . MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1498374 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 05/04/01 8348 CC OUTPATIENT VISIT E 1 24.00 05/04/01 104033 CHOLESTEROL TOTAL 1 7000 05/04/01 104096 LDH 1 10,00 05/04/01 105656 CBC W/PLT CNT, NO DIF 1 22.00 05/04/01 109804 BLOOD COLLECTION 1 11.00 05/04/01 310516 CT THORAX ENHANCED 1 1129000 05/04/01 310521 CT ABD UNENH & ENH SA 1 1241.00 05/04/01 310567 CT PELVIS ENHANCED 1 885.00 05/04/01 310641 CT LOCM 300-399 MG 1 90000 05/07/01 920029 MEDICARE NON-COVERED -1 90,00- OS/28/01 902003 MEDICARE PAY HOSP -1 305,25- OS/28/01 920015 MEDICARE CONT ADJ. 0/ -1 2545.14- 09/10/01 902003 MEDICARE PAY HaSP 0 83,41- 09/10/01 920015 MEDICARE CONT ADJ. 0/ 0 25048 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 420068- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 420.68 --------------------------------------------------------------------------------- * - Not posted Balance: 420,68 I -------------------------- 4-;L MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 . . PAGE: 1 Patient: PRICE BOBBY RAY Acct No: 1635548 I Units I Debits Date -------------------------------------------------.------------------------------- Credits I Svc Code I Description --------------------------------------------------------------------------------- 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/08/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 10264 101003 101005 102183 102184 104013 104014 104016 104026 104042 104065 104067 104096 104106 104129 104156 104398 104585 105017 105052 105059 105657 106011 245490 246177 246478 246614 246841 250530 251719 273266 621034 626078 670330 670334 10264 79628 79629 105657 191023 191030 P PRIV MED/SURG RM ABO BLOOD GROUP RH TYPE CULTURE, URINE COL CO CULTURE, URINE PRESUM ALBUMIN ALKALINE PHOSPHATASE BILIRUBIN TOTAL CALCIUM CREATININE, BLOOD UREA NITROGEN (BUN), URIC ACID, BLOOD LDH MAGNESIUM PHOSPHORUS, BLOOD SGPT (ALT) ELECTROLYTES GENTAMICIN LEVEL PERIPHERAL SMEAR PARTIAL THROMBOPLAS T PROTHROMBIN TIME CBC/DIFF/PLT COUNT, A URINALYSIS-BASIC & MI SODIUM CHLORIDE 0.9% GENTAMICIN 5 ML SODIUM CHLORIDE 30 ML PREDNISONE 20 MG SODIUM BICARBONATE 50 VINCRISTINE 2MG/2ML ONDANSETRON 8MG TABS CEFEPIME 2GR VIAL I V DEXTROSE 5%-.45 S I V DILUENT DEX 5% 50 IV INFUSION SET, UNIV IV INFUSION SET, UNIV P PRIV MED/SURG RM TISSUE CULT NEOL BLD/ CYTOGENET BM KARYOTYP CBC/DIFF/PLT COUNT, A LVL4 SURGICAL PATHOLO DECALCIFICATION 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 I 1 1 1 1 760000 16,00 15,00 38.00 38.00 9000 9,00 9,00 9.00 9000 8.00 8.00 11000 37.00 9000 10000 23.00 67.00 8.00 28.00 18.00 28.00 34.00 5.30 2.25 2.10 2.16 8.40 18,30 123.76 127.60 18.00 8.00 7.00 8.00 760.00 204.00 478.00 28.00 56.00 17.00 ---------------------------------------------------~----------------------------- - Continue - f):3 2 2 1 1 24 4 2 2 2 3 1 1 1 1 1 1 1 1 1 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 PAGE: 2 Patient: PRICE BOBBY RAY Acct No: 1635548 Date --------------------------------------------------,------------------------------ Credits -------------------------------------------------------------------------------- 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/09/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 I Svc Code I 191073 191090 191091 245206 245490 245911 246394 246703 246747 246841 247831 273266 310516 310521 310567 310641 600908 600909 621014 621034 661606 10264 83193 101111 101142 101143 101144 101514 104028 104042 104065 104067 104106 104129 104398 105054 105657 245207 245490 245525 245579 Description IMMUNOPEROXIDASE @ GRP1 STAIN-MICRO GRP2 STAIN-HISTO LIDOCAINE 10MG/ML SODIUM CHLORIDE 009% ALLOPURINOL 300 MG PROCHLORPERAZINE 10 M LORAZEPAM 2 MG RANITIDINE 150 MG SODIUM BICARBONATE 50 ACETAMINOPHEN 325 MG CEFEPIME 2GR VIAL CT THORAX ENHANCED CT ABD UNENH & ENH SA CT PELVIS ENHANCED CT LOCM 300-399 MG NDL BIOP 116 4IN BONE NDL ASPlRAT ILLIN 156 I V DEXTROSE 5%-WATER I V DEXTROSE 5%-.45 S BIOPSY/ASPIR TRAY P PRIV MED/SURG RM CELL SURF MARKER EA POOL BLD PRODUCT PROC PLTS,RANDOM/U IRRADIATE COMPONENT LEUKOREDUCE PLTS PROC PLTS,APHER/U IONIZED CALCIUM CREATININE, BLOOD UREA NITROGEN (BUN), URIC ACID, BLOOD MAGNESIUM PHOSPHORUS, BLOOD ELECTROLYTES PLATELET COUNT CBC/DIFF/PLT COUNT, A LIDOCAINE 1 ML SODIUM CHLORIDE 0.9% HEPARIN SODIUM 1000 U SODIUM CHLORIDE 1 ML I Units I Debits 1 1 1 1 2 1 2 1 1 5 1 2 1 1 1 1 1 1 :3 1 1 1 14 1 40.00 12.00 13.00 2,10 5.30 2.10 2.26 3.65 2.10 10.50 2,10 127.60 1185.00 1303,00 929.00 95000 35,00 27,00 18,00 6.00 30.00 760.00 1036.00 21.00 306.00 86.00 126.00 698.00 66.00 18.00 16,00 8.00 37.00 9.00 46.00 12.00 28.00 2.10 5.30 3.40 2.15 6 :2 2 1 1 2 2 1 1 1 2 1 1 1 2 1 1 ---------------------~------------------------------------------ - Continue - /iJr/.! ----------------- , . MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM PAGE: 3 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1635548 --------------------------------------------------.------------------------------ I Svc Code I Date I Units I Description Debits Credits --------------------------------------------------.------------------------------ 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/10/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 245911 245958 246127 246273 246478 246841 247831 251251 272425 273266 306615 306778 307508 621014 621042 626080 626081 661645 670330 670334 670335 10264 101003 101004 101005 101021 101102 101103 101111 101142 101143 101144 104028 104042 104064 104065 104106 104129 104378 104398 105054 ALLOPURINOL 300 MG HEPARIN SODIUM 100 UN DIPHENHYDRAMINE 25 MG METHYLPRED, SOD. SUCC SODIUM CHLORIDE 30 ML SODIUM BICARBONATE 50 ACETAMINOPHEN 325 MG KDUR 20MEG UD MIDAZOLAM 1MG/ML 2ML CEFEPIME 2GR VIAL GUIDE WIRE(S) SEDATION IV/IM/INHALA CV CATH PLACE,PERC,<2 I V DEXTROSE 5%-WATER I V SODIUM CHLORIDE 0 I-V DILUENT NML SALIN I-V DILUENT NML SALIN TRAY LUMBAR PUNCTURE IV INFUSION SET, UNIV IV INFUSION SET, UNIV SET IN-LINE FILTER W/ P PRIV MED/SURG RM ABO BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN BLOOD PROCESSING PER LEUKOREDUCE RBCS POOL BLD PRODUCT PROC PLTS,RANDOM/U IRRADIATE COMPONENT LEUKOREDUCE PLTS IONIZED CALCIUM CREATININE, BLOOD GLUCOSE, FLUID UREA NITROGEN (BUN), MAGNESIUM PHOSPHORUS, BLOOD PROTEIN, MISC BODY FL ELECTROLYTES PLATELET COUNT 1 2 2 4 1 6 2 1 1 2 2 1 1 2 3 1 1 1 ,1 1 :3 1 1 1 1 ,l ~I ~l 1 6 5; 2.10 4.20 4020 26.20 2.10 12.60 4020 4,05 2.10 127.60 148.00 307000 302.00 12.00 18,00 8.00 8,00 18.00 28,00 8.00 51. 00 760.00 16.00 28,00 15.00 216,00 324.00 176.00 21. 00 306,00 215,00 63.00 132.00 18.00 17.00 16.00 74.00 18,00 18.00 46.00 12.00 1 2 2 1 2 2 2 1 2 1 ------------------------------------------------------------ -------------------- - Continue - ,&-5 . . MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM PAGE: 4 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1635548 -------------------------------------------------------------------------------- I Svc Code I Date I Units I Description Debits Credits -------------------------------------------------------------------------------- 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/11/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 07/12/01 105657 106036 111001 192070 245911 246127 246273 246563 246747 246841 247831 273636 621244 626080 626081 670330 670335 10264 104028 104042 104060 104065 104106 104129 104398 105656 111001 230892 245492 245794 245911 245958 246176 246273 246478 246563 246747 246841 246907 248793 250524 CBC/DIFF/PLT COUNT, A CELL COUNT & DIFF, BO GLUCOSE BEDSIDE MONIT SMEARS,CONCENTR, INTER ALLOPURINOL 300 MG DIPHENHYDRAMINE 25 MG METHYLPRED, SOD. SUCC DEXAMETHASONE 4 MG RANITIDINE 150 MG SODIUM BICARBONATE 50 ACETAMINOPHEN 325 MG ONDANSETRON 24MG TABL I V SODIUM CHLORIDE 0 I-V DILUENT NML SALIN I-V DILUENT NML SALIN IV INFUSION SET, UNIV SET IN-LINE FILTER W/ P PRIV MED/SURG RM IONIZED CALCIUM CREATININE, BLOOD GLUCOSE, BLOOD UREA NITROGEN (BUN), MAGNESIUM PHOSPHORUS, BLOOD ELECTROLYTES CBC W/PLT CNT, NO DIF GLUCOSE BEDSIDE MONIT MESNA INJ SALINE 0,9% 500 ML CYCLOPHOSPHAMIDE INJ ALLOPURINOL 300 MG HEPARIN SODIUM 100 UN FUROSEMIDE 10 MG/ML METHYLPRED. SOD. SUCC SODIUM CHLORIDE 30 ML DEXAMETHASONE 4 MG RANITIDINE 150 MG SODIUM BICARBONATE 50 LORAZEPAM 0.5 MG DEXTROSE 5% 150ML SODIUM BICARBONATE 65 1 1 2 1 1 2 1 1 1 5 .2 :3 :3 1 3 3 2 1 28.00 65,00 44.00 19,00 2,10 4.20 6.55 3060 2010 10050 4.20 185,61 18.00 8,00 24.00 36.00 34000 760000 132,00 18.00 8.00 16.00 74.00 18.00 46.00 23.00 88.00 1354.36 10.30 63.56 2.10 4.20 2.10 13 .10 4.20 3.60 4.20 16.80 2.10 8.40 2.10 ') <. ') <, 1 " L, L: 2 2 1 4 14 2 28 1 2 1 2 2 1 2 8 1 4 1 ~--------------------------------------------------------------- ---------------- - Col}tinue - 17-0 " . . MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIv~ HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM PAGE: 5 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1635548 -------------------------------------------------------------------------------- I Svc Code I Date I Units I Description Debits Credits -------------------------------------------------------------------------------- 07/12/01 07/12/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/13/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 273636 621244 10264 101111 101142 101143 101144 105656 111001 230892 245218 245479 245492 245579 245794 245911 246127 246176 246273 246563 246747 246841 246907 247831 248793 250524 250530 272176 273636 621042 621244 626080 626081 670330 670334 670335 10264 104028 104042 104047 104048 ONDANSETRON 24MG TABL I V SODIUM CHLORIDE 0 P PRIV MED/SURG RM POOL BLD PRODUCT PROC PLTS,RANDOM/U IRRADIATE COMPONENT LEUKOREDUCE PLTS CBC W/PLT CNT, NO DIF GLUCOSE BEDSIDE MONIT MESNA INJ DOXORUBICIN HCL 50 MG METHOTREXATE 20MG SALINE 0.9% 500 ML SODIUM CHLORIDE 1 ML CYCLOPHOSPHAMIDE INJ ALLOPURINOL 300 MG DIPHENHYDRAMINE 25 MG FUROSEMIDE 10 MG/ML METHYLPRED. SOD. SUCC DEXAMETHASONE 4 MG RANITIDINE 150 MG SODIUM BICARBONATE 50 LORAZEPAM 0.5 MG ACETAMINOPHEN 325 MG DEXTROSE 5% 150ML SODIUM BICARBONATE 65 VINCRISTINE 2MG/2ML ZOLIPIDEM 5MG TAB ONDANSETRON 24MG TABL I V SODIUM CHLORIDE 0 I V SODIUM CHLORIDE 0 I-V DILUENT NML SALIN I-V DILUENT NML SALIN IV INFUSION SET, UNIV IV INFUSION SET, UNIV SET IN-LINE FILTER W/ P PRIV MED/SURG RM IONIZED CALCIUM CREATININE, BLOOD MASS MB (MAGNUM) MYOGLOBIN 3 2 1 1 6 1 1 1 4 7 11 3 2 1 14 1 2 2 2 1 2 ,~ 1 :2 :2 1 ') .. 185061 12,00 760,00 21. 00 306.00 43.00 63000 23.00 88000 677.18 449090 11.61 10.30 2.10 31.78 2.10 4.20 4.20 13 .10 3.60 4020 8.40 2.10 4.20 4.20 2.10 18.30 19.80 185.61 18.00 12.00 16.00 8.00 48.00 24.00 51.00 760.00 66.00 9.00 68,00 124.00 4 3 " ~, ~: 2 1 4 3 3 1 1 1 2 2 --------------------- ----------------------------------------------------------- - Continue - 17-7 " MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM PAGE: 5 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1635548 -------------------------------------------------.------------------------------- I Svc Code I Date I Units I Description Debits Credits -------------------------------------------------.------------------------------- 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/14/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 07/15/01 104049 104060 104065 104106 104129 104398 105556 111001 245911 246273 246280 246563 246747 246841 246907 247831 247842 250524 250926 272176 273636 307101 521211 621043 621244 626080 670330 670334 10264 104026 104042 104060 104065 104106 104129 104398 105656 245911 246273 246394 246747 TROPONIN GLUCOSE, BLOOD UREA NITROGEN (BUN), MAGNESIUM PHOSPHORUS, BLOOD ELECTROLYTES CBC W/PLT CNT, NO DIF GLUCOSE BEDSIDE MONIT ALLOPURINOL 300 MG METHYLPREDo SODo SUCC MG-AL HYDROXIDE 180 M DEXAMETHASONE 4 MG RANITIDINE 150 MG SODIUM BICARBONATE 50 LORAZEPAM 0.5 MG ACETAMINOPHEN 325 MG CAL GLUCONATE 10ML SODIUM BICARBONATE 65 FILGRASTIM 480MCG ZOLIPIDEM 5MG TAB ONDANSETRON 24MG TABL CHEST 1 VIEW 12 LEAD ELECTROCARDIO I V SODIUM CHLORIDE 0 I V SODIUM CHLORIDE 0 I-V DILUENT NML SALIN IV INFUSION SET, UNIV IV INFUSION SET, UNIV P PRIV MED/SURG RM CALCIUM CREATININE, BLOOD GLUCOSE, BLOOD UREA NITROGEN (BUN), MAGNESIUM PHOSPHORUS, BLOOD ELECTROLYTES CBC W/PLT CNT, NO DIF ALLOPURINOL 300 MG METHYLPRED. SOD. SUCC PROCHLORPERAZINE 10 M RANITIDINE 150 MG 2 1 1 1 1 1 1 3 1 2 1 1 2 4 1 1 1 1 1 1 3 1 1 1 2 1 :I 1. 1. 1 1 1 1 1 1 1 1 1 2 4 2 90.00 8.00 8.00 37000 9,00 23,00 23.00 66,00 2.10 13.10 2.10 3060 4,20 8.40 2,10 2.10 3.25 2.10 709.85 4.95 185.61 92.00 89.00 6.00 12.00 8.00 36.00 8.00 760.00 9.00 9.00 8.00 8.00 37.00 9.00 23.00 23.00 2.10 13 .10 4.52 4.20 --------------------------------------------------------------- ----------------- - Continue - fr-P . ' " MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM PAGE: 7 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1635548 --------------------------------------------------------------------------------- I Svc Code I I Units I Date Description Debits Credits --------------------------------_________________u______________________________ 07/15/01 07/15/01 07/15/01 07/15/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 07/16/01 08/01/01 08/15/01 08/16/01 09/16/01 11/04/01 10/31/02 10/31/02 249557 249819 250926 626080 101143 101144 101514 104028 104042 104065 104106 104129 104398 105656 245911 245958 246127 246394 246478 246747 247831 249557 249819 250926 670330 670335 920005 902003 920005 930017 930017 980090 980091 ACY'CLOVIR 200MG CIPROFLOXACIN 500MG FILGRASTIM 480MCG I-V DILUENT NML SALIN IRRADIATE COMPONENT LEUKOREDUCE PLTS PROC PLTS,APHER/U IONIZED CALCIUM CREATININE, BLOOD UREA NITROGEN (BUN), MAGNESIUM PHOSPHORUS, BLOOD ELECTROLYTES CBC W/PLT CNT, NO DIF ALLOPURINOL 300 MG HEPARIN SODIUM 100 UN DIPHENHYDRAMINE 25 MG PROCHLORPERAZINE 10 M SODIUM CHLORIDE 30 ML RANITIDINE 150 MG ACETAMINOPHEN 325 MG ACY'CLOVIR 200MG CIPROFLOXACIN 500MG FILGRASTIM 480MCG IV INFUSION SET, UNIV SET IN-LINE FILTER W/ MEDICARE DRG CONTRACT MEDICARE PAY HOSP MEDICARE DRG CONTRACT MEDICARE LATE CHG/CR MEDICARE LATE CHG/CR HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA 3 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 1 2 2 1 1 1 1 -1 -1 :2 -1 -1 -1 1 6,30 23,60 709085 8000 43.00 63.00 698.00 66.00 9.00 8.00 37,00 9,00 23.00 23,00 2.10 2.10 4.20 2.26 4.20 2010 4.20 4.20 11.80 709.85 12.00 17.00 2824.12- 22227.10- 914.63 1036.00- 40.00- 792.00- 792.00 ---------------------------------------------------~-------------- * - Not posted Balance: 792.00 I -------------------------- ft-Cj . , MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:48 AM . PAGE.: l' Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1654762 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 07/17/01 8348 CC OUTPATIENT VISIT E 1 24.00 07/17/01 101003 ABO BLOOD GROUP 1 16000 07/17/01 101004 ANTIBODY SCREEN 1 28,00 07/17/01 101005 RH TYPE 1 15000 07/17/01 101021 COM PAT , IMMED SPIN 2 108,00 07/17/01 101102 BLOOD PROCESSING PER 1 81.00 07/17/01 101103 LEUKOREDUCE RBCS 1 44.00 07/17/01 101143 IRRADIATE COMPONENT 1 43.00 07/17/01 101144 LEUKOREDUCE PLTS 1 63.00 07/17/01 101514 PROC PLTS,APHER/U 1 698000 07/17/01 104026 CALCIUM 1 9,00 07/17/01 104106 MAGNESIUM 1 37,00 07/17/01 104129 PHOSPHORUS, BLOOD 1 9,00 07/17/01 105054 PLATELET COUNT 1 12,00 07/17/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 07/17/01 230750 FILGRASTIM 480MCG 4 365.20 07/17/01 292009 TRANSF BLOOD/BLOOD CO 1 327.00 07/17/01 292010 IV INF TX 0-1 HR 1 88.00 07/17/01 292011 IV INF TX EA ADDL HR 1 42,00 07/17/01 292028 COLLECT BLD VIA PORT/ 2 58.00 07/17/01 621044 I V SODIUM CHLORIDE 0 1 6000 07/17/01 626081 I-V DILUENT NML SALIN 1 8,00 07/17/01 670330 IV INFUSION SET, UNIV 2 24.00 07/17/01 670335 SET IN-LINE FILTER W/ 1 17,00 08/10/01 902003 MEDICARE PAY HOSP -1 952,74- 08/10/01 920015 MEDICARE CONT ADJ. 0/ -2 520.79- 10/29/01 902003 MEDICARE PAY HOSP 0 144.83- 10/29/01 920015 MEDICARE CONT ADJ. 0/ () 75,12- 10/31/01 920029 MEDICARE NON-COVERED -1 58.00- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 393.72- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 393.72 -------------------------------------------------------------------------------- * - Not posted Balance: 393.72 I -------------------------- If -10 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:51 AM . 0 PAGE~ l' Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1657864 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 07/18/01 8348 CC OUTPATIENT VISIT E 1 24,00 07/18/01 101143 IRRADIATE COMPONENT 1 43.00 07/18/01 101144 LEUKOREDUCE PLTS 1 63,00 07/18/01 101514 PROC PLTS,APHER/U 1 698.00 07/18/01 104014 ALKALINE PHOSPHATASE 1 9000 07/18/01 104016 BILIRUBIN TOTAL 1 9,00 07/18/01 104060 GLUCOSE, BLOOD 1 8.00 07/18/01 104096 LDH 1 11.00 07/18/01 104156 SGPT (ALT) 1 10.00 07/18/01 105054 PLATELET COUNT 1 12.00 07/18/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 07/18/01 230164 DIPHENHYDRAMINE CP25M 1 4025 07/18/01 230750 FILGRASTIM 480MCG .~ 365.20 07/18/01 231444 ACETAMINOPHEN 325MG T :2 4,24 07/18/01 292010 IV INF TX 0-1 HR 1 88.00 07/18/01 292011 IV INF TX EA ADDL HR :3 126,00 07/18/01 292028 COLLECT BLD VIA PORT/ 1 29.00 07/18/01 621042 I V SODIUM CHLORIDE 0 1 6.00 07/18/01 626081 I - V DILUENT NML SALIN 1 8,00 07/18/01 670330 IV INFUSION SET, UNIV ') 24.00 <, 07/18/01 670335 SET IN-LINE FILTER w/ " 34.00 <. 08/14/01 902003 MEDICARE PAY HOSP -1 822.41- 08/14/01 920015 MEDICARE CONT ADJ, 0/ -2 531. 72- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 244,56- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 244.56 -------------------------------------------------------------------------------- * - Not posted Balance: 244.56 I -------------------------- ft-/I MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:51 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1660990 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 07/19/01 8348 CC OUTPATIENT VISIT E 1 24.00 07/19/01 105656 CBC W/PLT CNT, NO DIF 1 23,00 07/19/01 230750 FILGRASTIM 480MCG 4 365.20 07/19/01 231391 HEPARIN 1:100 10 ML 10 4.20 07/19/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 07/19/01 292010 IV INF TX 0-1 HR 1 88.00 07/19/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 08/14/01 902003 MEDICARE PAY HOSP -.1 763.36- 08/14/01 920015 MEDICARE CONT ADJ, 0/ -.2 407.78 10/31/02 980090 HOSPITAL BAD DEBT w/o -.1 169.02- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 169.02 --------------------------------------------------.------------------------------ * - Not posted Balance: 169.02 I -------------------------- ff-/2/ ) MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:51 AM PAGEl: J: Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1663834 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 07/20/01 8348 CC OUTPATIENT VISIT E 1 24000 07/20/01 101111 POOL BLD PRODUCT 1 21.00 07/20/01 101142 PROC PLTS,RANDOM/U 6 306,00 07/20/01 101143 IRRADIATE COMPONENT 1 43,00 07/20/01 101144 LEUKOREDUCE PLTS 1 63,00 07/20/01 104014 ALKALINE PHOSPHATASE 1 9000 07/20/01 104016 BILIRUBIN TOTAL 1 9.00 07/20/01 104096 LDH 1 11.00 07/20/01 104156 SGPT (ALT) 1 10.00 07/20/01 105656 CBC W/PLT CNT, NO DIF 1 23,00 07/20/01 230750 FILGRASTIM 480MCG 4 365.20 07/20/01 231444 ACETAMINOPHEN 325MG T 2 4.24 07/20/01 231488 DIPHENHYDRAMINE CAP 2 1 4,25 07/20/01 231612 DIFLUCAN TAB 200MG 1 20.45 07/20/01 292028 COLLECT BLD VIA PORT/ 1 29.00 07/20/01 626081 I-V DILUENT NML SALIN 1 8,00 07/20/01 670330 IV INFUSION SET, UNIV 1 12.00 07/20/01 670335 SET IN-LINE FILTER W/ 1 17.00 08/14/01 902003 MEDICARE PAY HOSP -1 736,50- 08/14/01 920015 MEDICARE CONT ADJ, 0/ -2 89,24- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 153.40- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 153.40 -------------------------------------------------------------------------------- * - Not posted Balance; 153,40 I -------------------------- /J - /3 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:52 AM PAGE:' l' Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1666384 ----------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 07/21/01 105656 CBC W/PLT CNT, NO DIF 1 23000 07/21/01 230012 DEXAMETHASONE TAB 4MG 10 5.70 07/21/01 230219 VINCRISTINE (VINCASAR) 1 22,30 07/21/01 230750 FILGRASTIM 480MCG 4 365020 07/21/01 231391 HEPARIN 1:100 10 ML 10 4,20 07/21/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 07/21/01 231612 DIFLUCAN TAB 200MG 1 20.45 07/21/01 292003 CHEMO IV SINGLE PUSH :1 127.00 07/21/01 292010 IV INF TX 0-1 HR :1 88.00 07/21/01 292023 THERA/DrAG INJ SUBCUT :1 16.00 07/21/01 621042 I V SODIUM CHLORIDE 0 1 6,00 07/21/01 622024 IRRIGATION SOD CHL 0, 1 6.00 07/21/01 670330 IV INFUSION SET, UNIV 1 12000 08/14/01 902003 MEDICARE PAY HOSP -1 817 .12- 08/14/01 920015 MEDICARE CONT ADJ, 0/ -2 295.40 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 178.33- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1. 178.33 ---------------------------------------------------.----------------------------- * - Not posted Balance: 178.33 I -------------------------- f)-PI MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:52 AM PAGE,: 1. Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1666782 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credi ts -------------------------------------------------.------------------------------- 07/22/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 07/22/01 230750 FILGRASTIM 480MCG 4 365,20 07/22/01 231391 HEPARIN 1:100 10 ML 10 4.20 07/22/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 07/22/01 231612 DIFLUCAN TAB 200MG 1 20,45 07/22/01 292010 IV INF TX 0-1 HR 1 88.00 07/22/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 08/15/01 902003 MEDICARE PAY HOSP -1 699.10- 08/15/01 920015 MEDICARE CONT ADJo 0/ -.2 331. 00 10/31/02 980090 HOSPITAL BAD DEBT W/O -.1 152,95- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 152.95 -------------------------------------------------------------------------------- * - Not posted Balance: 152095 I -------------------------- If -1.5 j MS HERSHEY MEblCAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:53 AM PAGE': 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1700327 --------------------------------------------------------------------------~------ Date I Svc Code I Description I Units I Debits Credits --------------------------------------------------.------------------------------ 08/07/01 8217 IV FLUIDS 2 18,00 08/07/01 8290 IV INF TX EA ADDL HR 2 84,00 08/07/01 8291 TRANSFUSION, BLOOD/CO 1 327,00 08/07/01 8297 VENIPUNCT TX/DX > AGE 1 29.00 08/07/01 8348 CC OUTPATIENT VISIT E 1 24,00 08/07/01 8509 PUMP TUBING UNIVERSAL 2 18,00 08/07/01 8510 FILTER, FENWAL 2 32.00 08/07/01 101003 ABO BLOOD GROUP 1 16,00 08/07/01 101004 ANTIBODY SCREEN 1 28.00 08/07/01 101005 RH TYPE 1 15.00 08/07/01 101021 COMPAT, IMMED SPIN 2 108,00 08/07/01 101102 BLOOD PROCESSING PER 2 162.00 08/07/01 101103 LEUKOREDUCE RBCS .2 88.00 08/07/01 101143 IRRADIATE COMPONENT .2 86.00 08/07/01 104014 ALKALINE PHOSPHATASE :1 9.00 08/07/01 104016 BILIRUBIN TOTAL :1 9.00 08/07/01 104042 CREATININE, BLOOD 1 9,00 08/07/01 104065 UREA NITROGEN (BUN) , 1 8.00 08/07/01 104096 LDH 1 11.00 08/07/01 104156 SGPT (ALT) 1 10.00 08/07/01 104398 ELECTROLYTES 1 23000 08/07/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 09/04/01 902003 MEDICARE PAY HOSP -1 549.98- 09/04/01 920015 MEDICARE CONT ADJ, 0/ -2 262.94- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 329.08- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 329.08 -------------------------------------------------------------------------------- * - Not posted Balance: 329.08 I -------------------------- JJ /(0 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:54 AM PAGE:' 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1723861 -------------------------------------------------------------------------~------ Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 08/17/01 8346 CC OUTPATIENT VISIT E 1 23.00 08/17/01 101003 ABO BLOOD GROUP 1 16000 08/17/01 101004 ANTIBODY SCREEN 1 28.00 08/17/01 101005 RH TYPE 1 15.00 08/17/01 101021 COMPAT, IMMED SPIN 1 54000 08/17/01 101102 BLOOD PROCESSING PER :L 81. 00 08/17/01 101103 LEUKOREDUCE RBCS 1 44.00 08/17/01 101143 IRRADIATE COMPONENT 1 43000 08/17/01 230164 DIPHENHYDRAMINE CP25M 1 4.25 08/17/01 231444 ACETAMINOPHEN 325MG T " 4.24 .. 08/17/01 292010 IV INF TX 0-1 HR 1 88,00 08/17/01 292011 IV INF TX EA ADDL HR 1 42000 08/17/01 292028 COLLECT BLD VIA PORT/ 1 29,00 08/17/01 626081 I-V DILUENT NML SALIN 1 8,00 08/17/01 670330 IV INFUSION SET, UNIV 1 12000 08/17/01 670335 SET IN-LINE FILTER W/ 1 17.00 09/12/01 902003 MEDICARE PAY HOSP -1 241.61- 09/12/01 920015 MEDICARE CONT ADJ. 0/ -2 123.69- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 143,19- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 143.19 -----------------------------------------------------------------~-------------- * - Not posted Balance: 143,19 I -------------------------- f} '17 ') . . MS HERSHEY MBDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:54 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1742199 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 08/26/01 230394 FILGRASTIM 300MCG :1 229,20 08/26/01 292023 THERA/DIAG INJ SUBCUT 1 16,00 09/20/01 902003 MEDICARE PAY HOSP -1 190.60- 09/20/01 920015 MEDICARE CONT ADJ, 0/ () 19.67 - 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34,93 - 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34,93 ---------------------------------------------------.----------------------------- * - Not posted Balance: 34,93 I -------------------------- IJ-;e } MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:54 AM PAGE, 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1742414 --------------------------------------------------.------------------------------ Date I Svc Code I Description I Units I Debits Credits --------------------------------------------------,------------------------------ 08/27/01 105657 CBC/DIFF/PLT COUNT, A 1 28,00 08/27/01 230394 FILGRASTIM 300MCG 1 229,20 08/27/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 08/27/01 292028 COLLECT BLD VIA PORT/ 1 29.00 09/20/01 902003 MEDICARE PAY HOSP -1 201.34- 09/20/01 920015 MEDICARE CONT ADJ, 0/ -2 65093- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93 - 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 -------------------------------------------------------------------------------- * - Not posted Balance: 34.93 I -------------------------- /!-/9 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:54 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1745545 ------------------~------------------------------_._----------------------------- Date I Svc Code I Description I Unitsl Debits Credits -------------------------------------------------------------------------------- 08/28/01 230394 FILGRASTIM 300MCG 1 229.20 08/28/01 292023 THERA/DrAG INJ SUB CUT 1 16.00 09/21/01 902003 MEDICARE PAY HOSP -1 190,60- 09/21/01 920015 MEDICARE CONT ADJ. 0/ 0 19,67- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93 - 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 -------------------------------------------------------------------------------- * - Not posted Balance: 34.93 I -------------------------- /1.~D . . MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:54 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1748588 -------------------------------------------------------------------------------- I Svc Code I Date I Units I Description Debits Credi t s -------------------------------------------------------------------------------- 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 08/29/01 09/24/01 09/24/01 02/05/02 02/05/02 02/15/02 10/31/02 10/31/02 8348 101003 101004 101005 101021 101102 101103 101111 101142 101143 101144 105054 105656 230164 230394 230625 231391 231444 231469 292009 292010 292011 292028 626081 661602 670330 670335 902003 920015 902003 920015 920029 980090 980091 CC OUTPATIENT VISIT E ABa BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN BLOOD PROCESSING PER LEUKOREDUCE RBCS POOL BLD PRODUCT PROC PLTS,RANDOM/U IRRADIATE COMPONENT LEUKOREDUCE PLTS PLATELET COUNT CBC W/PLT CNT, NO DIF DIPHENHYDRAMINE CP25M FILGRASTIM 300MCG CIPRO TAB 500MG HEPARIN 1:100 10 ML ACETAMINOPHEN 325MG T SODIUM CHLORIDE INJ 3 TRANSF BLOOD/BLOOD CO IV INF TX 0-1 HR IV INF TX EA ADDL HR COLLECT BLDVIA PORT/ I-V DILUENT NML SALIN CATH PREP TRAY CENT L IV INFUSION SET, UNIV SET IN-LINE FILTER W/ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ MEDICARE NON-COVERED HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA 1 1 1 1 2 2 2 1 6 3 1 1 1 1 1 1 10 2 30 1 1 1 2 3 1 3 3 -1 -2 o o -1 -1 1 24.00 16000 28.00 15.00 108,00 162.00 88.00 21.00 306,00 129000 63.00 12,00 23.00 4.25 229,20 7.85 4,20 4.24 4.20 327.00 88.00 42,00 58.00 24,00 12.00 36.00 51,00 691,78- 745.57- 64.26- 56.33 58.00- 383.66- 383.66 ---------------------------------------------------------------- ---------------- * - Not posted Balance: 383.66 I -------------------------- ;r;;. ( MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:55 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 PAGEl 1. Patient: PRICE BOBBY RAY Acct No: 1751675 Date I Svc Code I Debits -------------------------------------------------------------------------------- Credits I Units I Description --------------------------------------------------------------------------------- 08/30/01 8348 CC OUTPATIENT VISIT E 1 24,00 08/30/01 101003 ABO BLOOD GROUP 1 16.00 08/30/01 101004 ANTIBODY SCREEN 1 28,00 08/30/01 101005 RH TYPE 1 15000 08/30/01 101021 COMPAT, IMMED SPIN 2 108,00 08/30/01 101102 BLOOD PROCESSING PER 2 162.00 08/30/01 101103 LEUKOREDUCE RBCS 2 88.00 08/30/01 101143 IRRADIATE COMPONENT 2 86,00 08/30/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 08/30/01 231391 HEPARIN 1:100 10 ML 10 4.20 08/30/01 231444 ACETAMINOPHEN 325MG T 2 4,24 08/30/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 08/30/01 231488 DIPHENHYDRAMINE CAP 2 1 4.25 08/30/01 292009 TRANSF BLOOD/BLOOD CO 1 327.00 08/30/01 292010 IV INF TX 0-1 HR 1 88.00 08/30/01 292011 IV INF TX EA ADDL HR 1 42.00 08/30/01 292028 COLLECT BLD VIA PORT/ 1 29.00 08/30/01 621042 I V SODIUM CHLORIDE 0 2 12.00 08/30/01 621043 I V SODIUM CHLORIDE 0 1 6.00 08/30/01 670330 IV INFUSION SET, UNIV 2 24,00 08/30/01 670335 SET IN-LINE FILTER W/ 1 17.00 08/31/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 10/09/01 902003 MEDICARE PAY HOSP -1 498,50- 10/09/01 920015 MEDICARE CONT ADJ. 0/ -2 276.21- 02/11/02 902003 MEDICARE PAY HOSP 0 64.26- 02/11/02 920015 MEDICARE CONT ADJ, 0/ 0 56.33 02/18/02 920029 MEDICARE NON-COVERED -1 29.00- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 323.25- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 323,25 * - Not posted Balance: ------------------------------------------------------------------------------ 323.25 I -------------------------- I} -}-..,A MS HERSHEY MEDICAL CENTER 500 UNIVERS!TY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:55 AM PAGE~ 1 ' Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1754727 --------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------~------------------------------------------------------------- 08/31/01 8346 CC OUTPATIENT VISIT E 1 23,00 08/31/01 230394 FILGRASTIM 300MCG 1 229020 08/31/01 292023 THERA/DrAG INJ SUB CUT 1 16.00 08/31/01 292028 COLLECT BLD VIA PORT/ 1 29,00 09/24/01 902003 MEDICARE PAY HOSP ..1 190.60- 09/24/01 920015 MEDICARE CONT ADJ. 0/ ..1 48.67- 11/28/01 902003 MEDICARE PAY HOSP 0 37,94- 11/28/01 920015 MEDICARE CONT ADJ, 0/ 0 24.43 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 44,42- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 44,42 --------------------------------------------------.------------------------------ * - Not posted Balance: 44.42 I -------------------------- fJ C::<3 ~l . , MS HERSHEY MEDICAL CENTER 500 UNlvERSI'I'Y DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 08:55 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1757513 -------------------------------------------------..------------------------------ Date I Svc Code I Description I Units I Debits Credits ------------------------------------_____________u______________________________ 09/01/01 101143 IRRADIATE COMPONENT 1 43000 09/01/01 101144 LEUKOREDUCE PLTS 1 63,00 09/01/01 101514 PROC PLTS,APHER/U 1 698.00 09/01/01 105054 PLATELET COUNT 1 12,00 09/01/01 230394 FILGRASTIM 300MCG 1 229,20 09/01/01 231391 HEPARIN 1:100 10 ML 10 4.20 09/01/01 231444 ACETAMINOPHEN 325MG T 2 4.24 09/01/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 09/01/01 231488 DIPHENHYDRAMINE CAP 2 1 4.25 09/01/01 292009 TRANSF BLOOD/BLOOD CO 1 327,00 09/01/01 292010 IV INF TX 0-1 HR 1 88,00 09/01/01 292011 IV INF TX EA ADDL HR 1 42000 09/01/01 292028 COLLECT BLD VIA PORT/ 1 29,00 09/01/01 626081 I-V DILUENT NML SALIN 1 8.00 09/01/01 670330 IV INFUSION SET, UNIV 1 12.00 09/01/01 670335 SET IN-LINE FILTER w/ 1 17,00 09/25/01 902003 MEDICARE PAY HOSP -1 408093- 09/25/01 920015 MEDICARE CONT ADJ. 0/ -3 918.48- 10/31/02 980090 HOSPITAL BAD DEBT w/o -1 257.68- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 257.68 -------------------------------------------------------------------------------- * - Not posted Balance: 257.68 I -------------------------- Ire? f \ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:01 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1757879 -------------------------------------------------------------------------------. Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------. 09/03/01 102003 SENSI, DISK METHOD/PL 1 29.00 09/03/01 102116 CULTURE, CATHETER TIP 1 39.00 09/03/01 102189 ID DEFIN AEROB ISOL E 1 28,00 09/03/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 09/03/01 292010 IV INF TX 0-1 HR 1 88.00 09/03/01 292023 THERA/DIAG INJ SUBCUT 1 16,00 09/27/01 902003 MEDICARE PAY HOSP -1 117.43- 09/27/01 920015 MEDICARE CONT ADJ. 0/ -1 60.18- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 50.39- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 50.39 --------------------------------------------------.------------------------------ * - Not posted Balance: 50.39 I -------------------------- /jc:<f:, .., .', MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:02 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1758058 ------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits ------------------------------------------------------------------------------- 09/04/01 101143 IRRADIATE COMPONENT 1 43.00 09/04/01 101144 LEUKOREDUCE PLTS 1 63.00 09/04/01 101514 PROC PLTS,APHER/U 1 698.00 09/04/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 09/04/01 230394 FILGRASTIM 300MCG 1 229.20 09/04/01 231444 ACETAMINOPHEN 325MG T 2 4.24 09/04/01 231488 DIPHENHYDRAMINE CAP 2 1 4.25 09/04/01 292009 TRANSF BLOOD/BLOOD CO 1 327.00 09/04/01 292010 IV INF TX 0-1 HR 1 88.00 09/04/01 292011 IV INF TX EA ADDL HR 1 42.00 09/04/01 292028 COLLECT BLD VIA PORT/ 1 29.00 09/04/01 626081 I-V DILUENT NML SALIN :2 16.00 09/04/01 670330 IV INFUSION SET, UNIV 1 12.00 09/04/01 670335 SET IN-LINE FILTER W/ 1 17.00 10/01/01 902003 MEDICARE PAY HOSP -1 413,49- 10/01/01 920015 MEDICARE CONT ADJ. 0/ -] 929.52- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 257.68- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 257.68 --------------------------------------------------.- ---------------------------- * - Not posted Balance: 257.68 I -------------------------- /fc)7 . MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE: HERSHEY, PA 17033 Statement on: 11/27/02 at 09:02 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1761492 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------. 09/05/01 8347 CC OUTPATIENT VISIT E 1 30.00 09/05/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 09/05/01 230394 FILGRASTIM 300MCG 1 229.20 09/05/01 292028 COLLECT BLD VIA PORT/ 1 29.00 10/01/01 902003 MEDICARE PAY HOSP -1 202.89- 10/01/01 920015 MEDICARE CONT ADJ, 0/ -2 77 0 99- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 35,32- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 35.32 --------------------------------------------------------------------------------- * - Not posted Balance: 35.32 I -------------------------- /I'd 6 '. MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:03 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1764861 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 09/06/01 10/01/01 10/01/01 10/31/02 10/31/02 292023 902003 920015 980090 980091 THERA/DIAG INJ SUBCUT MEDICARE PAY HOSP MEDI CARE CONT ADJ. 0/ HOSPITAL BAD DEBT w/o HOSPITAL BAD DEBT PLA 1 -1 1 -1 1 16.00 37.16- 30.45 9.29- 9.29 -------------------------------------------------------------------------------- * - Not posted Balance: 9.29 I -------------------------- I}-d 9 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:04 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1767847 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 09/07/01 8346 CC OUTPATIENT VISIT E 1 23,00 09/07/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 09/07/01 292028 COLLECT BLD VIA PORT/ 1 29,00 10/01/01 902003 MEDICARE PAY HOSP -1 48.68- 10/01/01 920015 MEDICARE CONT ADJ. 0/ -1 21. 83- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 9.49- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 9.49 -------------------------------------------------------------------------------- * - Not posted Balance: 9.49 I -------------------------- If-3D MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 12/10/02 at 09:39 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1894427 ----------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------.------------------------------ 09/14/01 8345 CC OUTPATIENT VISIT E 1 32.00 09/14/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 09/14/01 109804 BLOOD COLLECTION 1 12000 10/08/01 902003 MEDICARE PAY HOSP .-1 51.68- 10/08/01 920015 MEDICARE CONT ADJ. 0/ 0 10,83- 10/31/02 980090 HOSPITAL BAD DEBT W/O ,-1 9.49- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 9.49 --------------------------------------------------~----------------------------- * - Not posted Balance: 9.49 ------------------------- 1t~31 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:04 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1903057 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 09/19/01 337603 GATED HEART, PLANAR, 1 578,00 09/19/01 338050 TC 99M LABELED RBC/TE 1 79.00 10/15/01 902003 MEDICARE PAY HOSP -1 194.66- 10/15/01 920015 MEDICARE CONT ADJ. 0/ -1 263.82- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 198.52- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 198,52 --------------------------------------------------.------------------------------ * - Not posted Balance: 198.52 I -------------------------- 11 ^ 32/ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:05 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1902657 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 09/19/01 512706 FRC 1 96.00 09/19/01 512707 DLCO 1 89.00 09/19/01 512734 BRONCHODI LAT FLOW VOL 1 96.00 10/15/01 902003 MEDICARE PAY HOSP -1 99.17- 10/15/01 920015 MEDICARE CONT ADJ. 0/ -1 80.18- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 101,65- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 101.65 ---------------------------------------------------~----------------------------- * - Not posted Balance: 101. 65 I -------------------------- 11-33 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:05 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 PAGE: 1 Pa.tient: PRICE BOBBY RAY Acct No: 1968883 I Units I 1 1 1 1 1 1 1 1 1 1 1 10 20 2 30 J. J. 1 1 J. 1 2 -1 -2 -1 1 ---------------------------------------------------------- I Svc Code I 8348 101143 101214 104026 104042 104065 104067 104106 104398 105657 230164 231391 231400 231444 231469 292009 292010 292011 292028 621042 621043 670330 902003 920015 980090 980091 * - Not posted Description CC OUTPATIENT VISIT E IRRADIATE COMPONENT PLT LR PHER EA U CALCIUM CREATININE, BLOOD UREA NITROGEN (BUN), URIC ACID, BLOOD MAGNESIUM ELECTROLYTES CBC/DIFF/PLT COUNT, A DIPHENHYDRAMINE CP25M HEPARIN 1:100 10 ML LIDOCAINE HCL 10MG.ML ACETAMINOPHEN 325MG T SODIUM CHLORIDE INJ 3 TRANSF BLOOD/BLOOD CO IV INF TX 0-1 HR IV INF TX EA ADDL HR COLLECT BLD VIA PORT/ I V SODIUM CHLORIDE 0 I V SODIUM CHLORIDE 0 IV INFUSION SET, UNIV MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT w/o HOSPITAL BAD DEBT PLA ft . :31( Date -------------------------------------------------------------------------------- Credits Debits -------------------------------------------------------------------------~------ 24.00 43.00 761. 00 9.00 9,00 8,00 8.00 37.00 23.00 28.00 4.25 4.20 4.20 4.24 4.20 327.00 88,00 42.00 29.00 6.00 6,00 24.00 691.09- 475,71- 326.29- 326.29 ---------------------- Balance: 326.29 I 10/18/01 10/18/0J. 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/lS/01 10/18/01 10/1S/01 10/1S/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 10/18/01 11/13/01 11/13/01 10/31/02 10/31/02 -------------------------- MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:18 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1971869 -------------------------------------------------------------------------------. Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 10/19/01 104131 POTASSIUM (K) , BLOOD 1 9.00 10/19/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 10/19/01 230750 FILGRASTIM 480MCG .~ 383.16 10/19/01 292023 THERA/DrAG INJ SUBCUT 1 16.00 10/19/01 292028 COLLECT BLD VIA PORT/ 1 29,00 11/13/01 902003 MEDICARE PAY HOSP -1 668,01- 11/13/01 920015 MEDICARE CONT ADJ. 0/ -1 314.70 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 111.85- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 111.85 --------------------------------------------------------------------------------- * - Not posted Balance: 111.85 I -------------------------- fJ-]j MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:19 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Date I Svc Code I 10/20/01 10/20/01 10/20/01 10/20/01 10/20/01 10/20/01 10/20/01 10/20/01 10/20/01 10/20/01 10/20/01 10/20/01 10/20/01 10/20/01 10/20/01 10/20/01 10/21/01 11/13/01 11/13/01 10/31/02 10/31/02 101111 101143 101216 104131 105054 105656 231391 231444 231469 231488 292009 292023 292028 621042 670330 670335 230750 902003 920015 980090 980091 Description POOL BLD PRODUCT IRRADIATE COMPONENT PLT LR EA U POTASSIUM (K), BLOOD PLATELET COUNT CBC W/PLT CNT, NO DIF HEPARIN 1:100 10 ML ACETAMINOPHEN 325MG T SODIUM CHLORIDE INJ 3 DIPHENHYDRAMINE CAP 2 TRANSF BLOOD/BLOOD CO THERA/DIAG INJ SUB CUT COLLECT BLD VIA PORT/ I V SODIUM CHLORIDE 0 IV INFUSION SET, UNIV SET IN-LINE FILTER W/ FILGRASTIM 480MCG MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA PAGE: 1 Patient: PRICE BOBBY RAY Acct No: 1974727 I Units I 1 1 6 1 1 1 10 :2 30 :L :L :L " ., 1 1 1 4 -1 -2 -1 1 Debits 21.00 43.00 378.00 9.00 12.00 23.00 4.20 4.24 4020 4.25 327.00 16.00 58.00 6000 12.00 17.00 383.16 200.24 382,11 * - Not posted ------------------------------------------------------------ Balance: f/3,t, Credits 1140.18- 382.11- 382.11 I - MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:19 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1974990 -------------------------------------------------_.~----------------------------- Date I Svc Code I Description I Units I Debits Credits --------------'------------------------------------------------------------------ 10/21/01 230750 FILGRASTIM 480MCG 4 383.16 10/21/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 11/14/01 902003 MEDICARE PAY HOSP -1 650.92- 11/14/01 920015 MEDICARE CONT ADJ. 0/ 1 363.61 10/31/02 980090 HOSPITAL BAD DEBT W/O , 111.85- -.L 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 111,85 --------------------------------------------------~------------------------------ * - Not posted Balance: 111.85 I 1/-37 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:19 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1975164 --------------------------------------------------------------------------------- I Svc Code I I Units I Date Description Debits Credits --------------------------------------------------------------------------------- 10/22/01 10/22/01 10/22/01 10/22/01 10/22/01 10/22/01 10/22/01 10/22/01 10/22/01 10/22/01 10/22/01 10/22/01 10/22/01 10/22/01 10/22/01 10/22/01 11/20/01 11/20/01 10/31/02 10/31/02 8347 101143 101214 104131 105054 105656 230012 230164 230219 231444 292003 292009 292028 621042 670330 670335 902003 920015 980090 980091 CC OUTPATIENT VISIT E IRRADIATE COMPONENT PLT LR PHER EA U POTASSIUM (K), BLOOD PLATELET COUNT CBC W/PLT CNT, NO DIF DEXAMETHASONE TAB 4MG DIPHENHYDRAMINE CP25M VINCRISTINE (VINCASAR) ACETAMINOPHEN 325MG T CHEMO IV SINGLE PUSH TRANSF BLOOD/BLOOD CO COLLECT BLD VIA PORT/ I V SODIUM CHLORIDE 0 IV INFUSION SET, UNIV SET IN-LINE FILTER W/ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSpITAL BAD DEBT PLA 1 1 1 1 1 1 10 1 1 3 1 1 2 1 1 1 -1 -2 -1 1 30.00 43.00 761.00 9.00 12,00 23.00 5.70 4,25 21.30 8.49 127.00 327000 58,00 6.00 12.00 17.00 931. 57- 85.59 618.76- 618.76 -------------------------------------------------------------------- * - Not posted Balance: 618.76 I -------------------------- fJ33 - MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:25 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1978513 Date I Svc Code I Description I Units I Debits Credits --------------------------------------------------"------------------------------ 10/23/01 230012 DEXAMETHASONE TAB 4MG 10 5,70 10/23/01 230750 FILGRASTIM 480MCG 4 383.16 10/23/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 11/16/01 902003 MEDICARE PAY HOSP -1 650.92- 11/16/01 920015 MEDICARE CONT ADJ. 0/ 0 357,91 10/31/02 980090 HOSPITAL BAD DEBT wjO -1 111. 85- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 111. 85 * - Not posted Balance: 111. 85 I I? 35 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:25 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1981791 --------------------------------------------------.------------------------------ I Svc Code I I Units I Description Debits Credits Date 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 10/24/01 11/19/01 11/19/01 10/31/02 10/31/02 8347 101003 101004 101005 101021 101111 101143 101212 101216 104131 105054 105656 230012 230750 231203 231444 231488 292009 292010 292011 292028 621042 626081 670330 670335 902003 920015 980090 980091 CC OUTPATIENT VISIT E ABO BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN POOL BLD PRODUCT IRRADIATE COMPONENT RED BLD CELL LR EA U PLT LR EA U POTASSIUM (K), BLOOD PLATELET COUNT CBC W/PLT CNT, NO DIF DEXAMETHASONE TAB 4MG FILGRASTIM 480MCG KLOR CON 10MEQ TABS ACETAMINOPHEN 325MG T DIPHENHYDRAMINE CAP 2 TRANSF BLOOD/BLOOD CO IV INF TX 0-1 HR IV INF TX EA ADDL HR COLLECT BLD VIA PORT/ I V SODIUM CHLORIDE 0 I-V DILUENT NML SALIN IV INFUSION SET, UNIV SET IN-LINE FILTER W/ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA 1 1 1 1 30000 16.00 28,00 15.00 108.00 21.00 129.00 290.00 378.00 9.00 12.00 23.00 16.70 383.16 4.24 4.24 4.25 327.00 88.00 84.00 58.00 6.00 8.00 24,00 34.00 2 1 3 2 6 1 1 1. 10 4 4 " <. 1 1 1. " <. L: 1 1 2 2 -1 -2 -1 1 1523.68- 7.76 584,67- 584.67 ------------------------------------------------------------------ * - Not posted Balance: 584.67 I -------------------------- f! -I; 0 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:25 AM PAGE:. 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 1998127 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 10/31/01 8347 CC OUTPATIENT VISIT E 1 30.00 10/31/01 104106 MAGNESIUM 1 37,00 10/31/01 104131 POTASSIUM (K) , BLOOD 1 9.00 10/31/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 10/31/01 230750 FILGRASTIM 480MCG 4 383.16 10/31/01 230956 DEXTROSE 5% INJ 290 2.90 10/31/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 10/31/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 10/31/01 292010 IV INF TX 0-1 HR 1 88.00 10/31/01 292011 IV INF TX EA ADDL HR 1 42.00 10/31/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 10/31/01 292028 COLLECT BLD VIA PORT/ 1 29.00 10/31/01 621042 I V SODIUM CHLORIDE 0 2 12.00 10/31/01 670330 IV INFUSION SET, UNIV 1 12.00 10/31/01 670334 IV INFUSION SET, UNIV 1 8.00 11/26/01 902003 MEDICARE PAY HOSP -1 774.82- 11/26/01 920015 MEDICARE CONT ADJ. 0/ -2 241. 74 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 183018- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 183.18 -------------------------------------------------------------------------------- * - Not posted Balance: 183.18 I /I./;/ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:25 AM PAGE: 1 Guarantor: PRICE BOBBY RAY ~53 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2001334 ---------------------------------------------------.----------------------------- Date I Svc Code I Description I Units I Debits Credits ---------------------------------------------------.----------------------------- 11/01/01 8348 CC OUTPATIENT VISIT E 1 24.00 11/01/01 230956 DEXTROSE 5% INJ 290 2.90 11/01/01 231469 SODIUM CHLORIDE INJ 3 30 4020 11/01/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 11/01/01 292010 IV INF TX 0-1 HR 1 88.00 11/01/01 621043 I V SODIUM CHLORIDE 0 1 6,00 11/26/01 902003 MEDICARE PAY HOSP -1 39.23- 11/26/01 92 0015 MEDICARE CONT ADJ. 0/ -2 35.77- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 65.10- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 65.10 --------------------------------------------------------------------------------- * - Not posted Balance: 65.10 I f}-Ifv MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:26 AM PAGE: 1 Guarantor: PR1CE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2004509 -------------------------------------------------------------------------------- I Svc Code I I Units I Description Date Debits Credits --------------------------------------------------.------------------------------ 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/02/01 11/26/01 11/26/01 10/31/02 10/31/02 8348 101003 101004 101005 101021 101143 101212 104042 104065 104398 104591 105657 230956 231444 231469 231488 232459 292009 292010 292011 292028 621042 670330 670335 902003 920015 980090 980091 CC OUTPATIENT VISIT E ABO BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN IRRADIATE COMPONENT RED BLD CELL LR EA U CREATININE, BLOOD UREA NITROGEN (BUN), ELECTROLYTES VANCOMYCIN LEVEL CBC/DIFF/PLT COUNT, A DEXTROSE 5% INJ ACETAMINOPHEN 325MG T SODIUM CHLORIDE INJ 3 DIPHENHYDRAMINE CAP 2 VANCOMYCIN HCL INJ 10 TRANSF BLOOD/BLOOD CO IV INF TX 0-1 HR IV INF TX EA ADDL HR COLLECT BLD VIA PORT/ I V SODIUM CHLORIDE 0 IV INFUSION SET, UNIV SET IN-LINE FILTER W/ MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA 1 1 1 1 4 4 4 1 1 1 2 1 290 2 30 1 1500 1 1 1 1 2 2 2 -1 -2 -1 1 24.00 16,00 28.00 15000 216.00 172 0 00 580.00 9.00 8.00 23.00 134.00 28.00 2.90 4.24 4.20 4.25 15.00 327.00 88.00 42.00 29.00 12.00 24.00 34.00 911.39- 480.07- 448.13- 448.13 ------------------------------------------------------------- * - Not posted Balance: 448.13 I 11-13 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:26 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2007553 ---------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------. 11/03/01 230956 DEXTROSE 5% INJ 290 2.90 11/03/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 11/03/01 292010 IV INF TX 0-1 HR 1 88.00 11/03/01 621042 I V SODIUM CHLORIDE 0 1 6,00 11/03/01 670330 IV INFUSION SET, UNIV 1 12.00 11/03/01 670334 IV INFUSION SET, UNIV 1 8.00 11/28/01 902003 MEDICARE PAY HOSP -1 39.23- 11/28/01 920015 MEDICARE CONT ADJ. 0/ -2 51.57- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 41.10- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 41.10 -------------------------------------------------------------------------------- * - Not posted Balance: 41.10 I -------------------------- If-I! I.j MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:26 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2007760 ------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 11/04/01 104131 POTASSIUM (K), BLOOD 1 9.00 11/04/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 11/04/01 230956 DEXTROSE 5% INJ 290 2.90 11/04/01 231444 ACETAMINOPHEN 325MG T 2 4.24 11/04/01 231469 SODIUM CHLORIDE INJ 3 30 4.20 11/04/01 231488 DIPHENHYDRAMINE CAP 2 1 4.25 11/04/01 232459 VANCOMYCIN HCL INJ 10 1500 15,00 11/04/01 292009 TRANSF BLOOD/BLOOD CO 1 327.00 11/04/01 292010 IV INF TX 0-1 HR 1 88,00 11/04/01 292011 IV INF TX EA ADDL HR 2 84,00 11/04/01 621042 I V SODIUM CHLORIDE 0 2 12.00 11/04/01 670330 IV INFUSION SET, UNIV 1 12.00 11/04/01 670335 SET IN-LINE FILTER W/ 1 17.00 11/28/01 902003 MEDICARE PAY HOSP -1 259.46- 11/28/01 920015 MEDICARE CONT ADJ. 0/ -] 147,72- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 200.41- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 200.41 --------------------------------------------------------------------------------- * - Not posted Balance: 200.41 I -------------------------- ff~ 1;S- MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:26 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2008018 ------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 11/05/01 8217 IV FLUIDS 1 9.00 11/05/01 8287 CHEMO INF UP TO 1 HR 1 152.00 11/05/01 8509 PUMP TUBING UNIVERSAL 1 9.00 11/05/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 11/05/01 230956 DEXTROSE 5% INJ 250 5.00 11/05/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 12/18/01 902003 MEDICARE PAY HOSP -1 9984,17- 12/18/01 920015 MEDICARE CONT ADJ. 0/ -1 9954.17 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 188,00- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 188.00 -------------------------------------------------------------------------------- * - Not posted Balance: 188.00 I -------------------------- IT -Ij h " MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:26 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2009166 --------------------------------------------------------------------------------. Date I Svc Code I Description I Units I Debits Credits --------------------------------------------------.-----------------------------. 11/06/01 8214 SET ADMINISTRATION 1 6.00 11/06/01 8217 IV FLUIDS 1 9,00 11/06/01 8289 IV INF TX 0-1 HR 1 88.00 11/06/01 230956 DEXTROSE 5% INJ 250 5.00 11/06/01 232459 VANCOMYCIN HCL INJ 10 1500 15,00 12/03/01 902003 MEDICARE PAY HOSP -1 39.23- 12/03/01 920015 MEDICARE CONT ADJ. 0/ -2 42.67- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 41.10- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 41.10 -------------------------------------------------------------------------------- * - Not posted Balance: 41. 10 I -------------------------- IJ-/j J " MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:26 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOlLING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2013092 -------------------------------------------------------------------------------. Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 11/07/01 8214 SET ADMINISTRATION 1 6.00 11/07/01 8217 IV FLUIDS 1 9.00 11/07/01 8289 IV INF TX 0-1 HR 1 88.00 11/07/01 8348 CC OUTPATIENT VISIT E 1 24.00 11/07/01 104014 ALKALINE PHOSPHATASE 1 9.00 11/07/01 104016 BILIRUBIN TOTAL 1 9,00 11/07/01 104042 CREATININE, BLOOD 1 9.00 11/07/01 104065 UREA NITROGEN (BUN) , 1 8.00 11/07/01 104096 LDH 1 11.00 11/07/01 104156 SGPT (ALT) 1 10,00 11/07/01 104398 ELECTROLYTES 1 23.00 11/07/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 11/07/01 230956 DEXTROSE 5% INJ 250 5.00 11/07/01 232459 VANCOMYCIN HCL INJ 10 1500 15.00 12/03/01 902003 MEDICARE PAY HOSP -1 61. 97- 12/03/01 920015 MEDICARE CONT ADJ. 0/ -3 126.93- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 65.10- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 65.10 -------------------------------------------------------------------------------- * - Not posted Balance: 65.10 I -------------------------- /joy? MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:27 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOllTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2046827 --------------------------------------------------~-----------------------------. I Svc Code I Date I Units I Description Debits Credits --------------------------------------------------------------------------------. 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 11/20/01 12/14/01 12/14/01 10/31/02 10/31/02 THERA/DrAG INJ SUBCU/ THERA/DIAG INJECTION TRAY; CVP PREP ABO BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN IRRADIATE COMPONENT RED BLD CELL LR EA U CBC W/PLT CNT, NO DIF FILGRASTIM 300MCG CIPRO TAB 500MG ACYCLOVIR 400MG TABLE MEDICARE PAY HOSP MEDICARE CONT ADJ, 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA 8279 8280 8502 101003 101004 101005 101021 101143 101212 105656 230394 230625 232592 902003 920015 980090 980091 1 2 1 1 1 1 1 1 1 1 1 1 1 -1 -2 -1 1 16.00 98.00 5,00 16.00 28.00 15.00 54.00 43.00 145.00 23.00 240,45 7.85 4.25 437.06- 136.61- 121.88- 121.88 -------------------------------------------------------------------------------- * - Not posted Balance: 121. 88 I -------------------------- IJ-J;J MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:28 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2050124 -------------~------------------------------------------------------------------. Date I Svc Code I Description I Unitsl Debits Credits --------------------------------------------------.------------------------------ 11/21/01 8217 IV FLUIDS 2 18.00 11/21/01 8279 THERA/DIAG INJ SUBCU/ 1 16.00 11/21/01 8280 THERA/DIAG INJECTION 1 49.00 11/21/01 8509 PUMP TUBING UNIVERSAL 2 18.00 11/21/01 8510 FILTER, FENWAL 2 32.00 11/21/01 101143 IRRADIATE COMPONENT 1 43.00 11/21/01 101214 PLT LR PHER EA U 1 761.00 11/21/01 105054 PLATELET COUNT 1 12.00 11/21/01 230394 FILGRASTIM 300MCG 1 240.45 11/21/01 230625 CIPRO TAB 500MG 1 7.85 11/21/01 232592 ACYCLOVIR 400MG TABLE 1 4,25 12/17/01 902003 MEDICARE PAY HOSP -1 606,32- 12/17/01 920015 MEDICARE CONT ADJ. 0/ -2 449.65- 10/31/02 980090 HOSPITAL BAD DEBT w/o -1 145.58- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 145.58 -------------------------------------------------------------------------------- * - Not posted Balance: 145.58 I -------------------------- 1150 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 MS HERSHEY MEDICAL CENTER . 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:28 AM ' PAG,E: .1 ------------------------------------------------------------------------------ Patient: PRICE BOBBY RAY 'Acct No: 2051378 Date I Svc Code I Description I Units I Debits Credits ------------------------------------------------------------------------------ 11/22/01 230394 FILGRASTIM 300MCG 1 240,45 11/22/01 231391 HEPARIN 1:100 10 ML 10 4.20 11/22/01 23146,! SODIUM CHLORIDE INJ 3 30 4.20 11/22/01 292023 THERA/DIAG INJ SUBCUT 1 16.00 12/17/01 902003 MEDICARE PAY HOSP- - , -1 190.60- 12/17/01 920015 MEDICARE CONT ADJ. 0/ -1 39032- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93 - 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 ------------------------------------------------------------------------------- * - Not posted Balance: 34093 -------------------------- Ils/ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:28 AM . PAGE':" 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2051795 ------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits ------------------------------------------------------------------------------- 11/23/01 8217 IV FLUIDS 1 9.00 11/23/01 8261 CHEMO, IV PUSH 1 127.00 11/23/01 8289 IV INF TX 0-1 HR 1 88.00 11/23/01 8290 IV INF TX EA ADDL HR 1 42.00 11/23/01 8291 TRANSFUSION, BLOOD/CO 1 327.00 11/23/01 8502 TRAY; CVP PREP 1 5.00 11/23/01 8503 TELFA DRESSING 1 5.00 11/23/01 8509 PUMP TUBING UNIVERSAL 1 9.00 11/23/01 8510 FILTER, FENWAL 1 16.00 11/23/01 101111 POOL BLD PRODUCT 1 21.00 11/23/01 101143 IRRADIATE COMPONENT 1 43.00 11/23/01 101216 PLT LR EA U 6 378.00 11/23/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 11/23/01 230164 DIPHENHYDRAMINE CP25M 1 4.25 11/23/01 230219 VINCRISTINE (VINCASAR) 1 21.30 11/23/01 230394 FILGRASTIM 300MCG 1 240.45 11/23/01 230625 CIPRO TAB 500MG 1 7.85 11/23/01 231444 ACETAMINOPHEN 325MG T 2 4.24 11/23/01 232592 ACYCLOVIR 400MG TABLE 1 4.25 12/18/01 902003 MEDICARE PAY HOSP -1 840.31- 12/18/01 920015 MEDICARE CONT ADJ. 0/ -2 109.46- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 425.57- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 425.57 --------------------------------------------------~------------------------------ * - Not posted Balance: 425.57 I -------------------------- 11- j~ ;< Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:28 AM . . PAGJ!;: 1. ------------------------------------------------..------------------------------ Patient: PRICE BOBBY RAY Acct No: 2053303 Date I Svc Code I Description I Units I Debits Credits --------------------..-------------------------------------------------..-------- 11/24/01 37035 THERAPEUTIC INJ IM/SQ 1 16.00 11/24/01 230394 FILGRASTIM 300MCG 1 240.45 12/19/01 902003 MEDICARE PAY HOSP -1 190.60- 12/19/01 920015 MEDICARE CONT ADJ. 0/ 0 30.92- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 -------------------------------------------------------------------------------, * - Not posted Balance: 34.93 -------------------------- H S"J Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:28 AM PAGE: '1 ------------------------------------------------------------------------------ Patient: PRICE BOBBY RAY Acct No: 2053499 Date I Svc Code I Description I Unitsl Debits Credits ------------------------------------------------------------------------------ 11/25/01 37035 THERAPEUTIC INJ IM/SQ 1 16.00 11/25/01 230394 FILGRASTIM 300MCG 1 240.45 12/19/01 902003 MEDICARE PAY HOSP -1 190.60. 12/19/01 920015 MEDICARE CONT ADJ, 0/ 0 30.92- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34,93 ------------------------------------------------------------------------------- * - Not posted Balance: 34.93 ------------------------- f)~5 ~ " MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:28 AM )?AGE:. ' . 1 '. Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2053812 ----------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------.------------------------------ 11/26/01 8214 SET ADMINISTRATION 3 18.00 11/26/01 8217 IV FLUIDS 3 27.00 11/26/01 8290 IV INF TX EA ADDL HR 5 210000 11/26/01 8510 FILTER, FENWAL 3 48.00 11/26/01 101003 ABO BLOOD GROUP 1 16.00 11/26/01 101004 ANTIBODY SCREEN 1 28.00 11/26/01 101005 RH TYPE 1 15.00 11/26/01 101021 COMPAT, IMMED SPIN 2 108.00 11/26/01 101143 IRRADIATE COMPONENT 3 129.00 11/26/01 101212 RED BLD CELL LR EA U 2 290.00 11/26/01 101214 PLT LR PHER EA U 1 761. 00 11/26/01 104131 POTASSIUM (K) , BLOOD 1 9.00 11/26/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 11/26/01 230394 FILGRASTIM 300MCG 1 240.45 11/26/01 230625 CIPRO TAB 500MG 1 7.85 11/26/01 232592 ACYCLOVIR 400MG TABLE 1 4.25 11/27/01 8279 THERA/DIAG INJ SUBCU/ 1 16.00 11/27/01 8280 THERA/DIAG INJECTION 2 98.00 11/27/01 8289 IV INF TX 0-1 HR 1 88.00 11/27/01 8291 TRANSFUSION, BLOOD/CO 1 327.00 12/20/01 902003 MEDICARE PAY HOSP -1 1257.31- 12/20/01 920015 MEDICARE CONT ADJ. 0/ -2 669.34- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 536.90- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 536,90 --------------------------------------------------------------------------------- * - Not posted Balance: 536.90 I -------------------------- fl-S!J .' MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:29 AM .PAGE; . . 1 '. Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2056607 ------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits ---------------------------------------------------------------------------- 11/27/01 8279 THERA/DIAG INJ SUBCU/ 1 16,00 11/27/01 8280 THERA/DrAG INJECTION 2 98.00 11/27/01 230394 FILGRASTIM 300MCG 1 240.45 11/27/01 230625 CIPRO TAB 500MG 1 7.85 11/27/01 232592 ACYCLOVIR 400MG TABLE 1 4.25 12/21/01 902003 MEDICARE PAY HOSP -1 264.93- 12/21/01 920015 MEDICARE CONT ADJ. 0/ -1 48,11- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 53051- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 53.51 -------------------------------------------------------------------------------- * - Not posted Balance: 53.51 I -------------------------- If - 5?p MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:29 AM .PAGE; . . 1 , Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2059851 ------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------. 11/28/01 8214 SET ADMINISTRATION 1 6.00 11/28/01 8217 IV FLUIDS 1 9.00 11/28/01 8280 THERA/DIAG INJECTION 2 98.00 11/28/01 8289 IV INF TX 0-1 HR 1 88.00 11/28/01 8290 IV INF TX EA ADDL HR 1 42.00 11/28/01 8291 TRANSFUSION, BLOOD/CO 1 327.00 11/28/01 8510 FILTER, FENWAL 1 16.00 11/28/01 101143 IRRADIATE COMPONENT 1 43.00 11/28/01 101214 PLT LR PHER EA U 1 761.00 11/28/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 11/28/01 230164 DIPHENHYDRAMINE CP25M 1 4.25 11/28/01 230394 FILGRASTIM 300MCG 1 240.45 11/28/01 230625 CIPRO TAB 500MG 1 7.85 11/28/01 231444 ACETAMINOPHEN 325MG T 2 4.24 11/28/01 232592 ACYCLOVIR 400MG TABLE 1 4.25 12/26/01 902003 MEDICARE PAY HOSP -1 833.64- 12/26/01 920015 MEDICARE CONT ADJ. 0/ -3 519.96- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 325.44- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 325.44 -------------------------------------------------------------------------------- * - Not posted Balance: 325.44 I -------------------------- I1-J-7 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:29 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 PAGE: ., 1 . . '. Patient: PRICE BOBBY RAY Acct No: 2063460 Date I Svc Code I -------------------------------------------------.------------------------------. Credits Description I Units I Debits ------------------------------------------------------------------------------- 11/29/01 11/29/01 11/29/01 11/29/01 11/29/01 11/29/01 12/26/01 12/26/01 10/31/02 10/31/02 8279 8502 8504 230394 230625 232592 902003 920015 980090 980091 THERA/DIAG INJ SUBCU/ TRAY; CVP PREP TEGADERM DRESSING FILGRASTIM 300MCG CIPRO TAB 500MG ACYCLOVIR 400MG TABLE MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA 1 1 1 1 1 1 -.1 ..1 -.1 1 16.00 5.00 6.00 240.45 7.85 4.25 190.60- 54.02- 34.93- 34.93 * - Not posted --------------------------------------------------.------------------------------ 34.93 I Il~S6 Balance: -------------------------- MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:29 AM Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 PAGE:, .,1 , Patient: PRICE BOBBY RAY Acct No: 2067311 Date I Svc Code I -------------------------------------------------------------------------------, Credits -------------~-----------------------------------------------------------------. 11/30/01 11/30/01 11/30/01 11/30/01 11/30/01 11/30/01 11/30/01 11/30/01 11/30/01 11/30/01 11/30/01 11/30/01 11/30/01 11/30/01 11/30/01 12/26/01 12/26/01 10/31/02 10/31/02 8214 8217 8280 8289 8290 8291 8510 101143 101214 105656 230164 230394 230625 231444 232592 902003 920015 980090 980091 Description SET ADMINISTRATION IV FLUIDS THERA/DIAG INJECTION IV INF TX 0-1 HR IV INF TX EA ADDL HR TRANSFUSION, BLOOD/CO FILTER, FENWAL IRRADIATE COMPONENT PLT LR PHER EA U CBC W/PLT CNT, NO DIF DIPHENHYDRAMINE CP25M FILGRASTIM 300MCG CIPRO TAB 500MG ACETAMINOPHEN 325MG T ACYCLOVIR 400MG TABLE MEDICARE PAY HOSP MEDICARE CONT ADJ. 0/ HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA * - Not posted ---------------------------------- ------------------------------------ 325.44 I ITS; I Units I 1 1 2 1 1 1 1 1 1 1 1 :L 1 " <, 1 -1 -3 -1 1 Debits 6,00 9,00 98,00 88,00 42.00 327.00 16.00 43.00 761.00 23.00 4.25 240.45 7.85 4.24 4.25 325.44 831. 85- 516,75- 325.44- ---------- Balance: -------------------------- MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:29 AM PAGE: " 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2069785 ------------------------------------------------------------------------------- Date I Svc Code I Description , Units I Debits Credits ------------------------------------------------------------------------------- 12/01/01 37035 THERAPEUTIC INJ IM/SQ 1 16.00 12/01/01 230394 FILGRASTIM 300MCG 1 240.45 12/27/01 902003 MEDICARE PAY HOSP ..1 190.60- 12/27/01 920015 MEDICARE CONT ADJ. 0/ 0 30092- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34,93 -------------------------------------------------------------------------------- * - Not posted Balance: 34.93 -------------------------- 11-0 () MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRlv~ HERSHEY, PA 17033 Statement on: 11/27/02 at 09:29 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2070029 ------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits ------------------------------------------------------------------------------- 12/02/01 37035 THERAPEUTIC INJ IM/SQ 1 16,00 12/02/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 12/02/01 230394 FILGRASTIM 300MCG 1 240,45 12/27/01 902003 MEDICARE PAY HOSP --1 199.55-- 12/27/01 920015 MEDICARE CONT ADJ. 0/ ..1 44,97- 10/31/02 980090 HOSPITAL BAD DEBT W/O ..1 34.93 - 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 --------------------------------------------------.------------------------------ * - Not posted Balance: 34.93 I -------------------------- 11-0 / MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:30 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2073964 ------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------. 12/04/01 8217 IV FLUIDS 3 27.00 12/04/01 8279 THERA/DIAG INJ SUBCU/ 1 16.00 12/04/01 8289 IV INF TX 0-1 HR 1 88.00 12/04/01 8290 IV INF TX EA ADDL HR 5 210.00 12/04/01 8291 TRANSFUSION, BLOOD/CO 1 327.00 12/04/01 8502 TRAY; CVP PREP 1 5.00 12/04/01 8504 TEGADERM DRESSING 1 6.00 12/04/01 8509 PUMP TUBING UNIVERSAL 3 27.00 12/04/01 8510 FILTER, FENWAL 3 48.00 12/04/01 101003 ABO BLOOD GROUP 1 16.00 12/04/01 101004 ANTIBODY SCREEN 1 28.00 12/04/01 101005 RH TYPE 1 15.00 12/04/01 101021 COMPAT, IMMED SPIN 2 108000 12/04/01 101143 IRRADIATE COMPONENT 3 129.00 12/04/01 101212 RED BLD CELL LR EA U 2 290.00 12/04/01 101214 PLT LR PHER EA U 1 761. 00 12/04/01 104014 ALKALINE PHOSPHATASE 1 9,00 12/04/01 104016 BILIRUBIN TOTAL 1 9000 12/04/01 104026 CALCIUM 1 9.00 12/04/01 104042 CREATININE, BLOOD 1 9.00 12/04/01 104065 UREA NITROGEN (BUN) , 1 8.00 12/04/01 104096 LDH 1 11. 00 12/04/01 104106 MAGNESIUM 1 37.00 12/04/01 104156 SGPT (ALT) 1 10.00 12/04/01 104398 ELECTROLYTES 1 23.00 12/04/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 12/04/01 230394 FILGRASTIM 300MCG 1 240.45 12/04/01 230629 K DUR TAB 20MEQ 2 4.24 01/16/02 902003 MEDICARE PAY HOSP -1 1199.89- 01/16/02 920015 MEDICARE CONT ADJ. 0/ -2 780.48- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 518.32- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 518.32 -------------------------------------------------------------------------------- * - Not posted Balance: 518.32 I -------------------------- 11-03 MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:30 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2078903 --------------------------------------------------.----------------------------- Date I Svc Code I Description I Units I Debits Credits ------------------------------------------------------------------------------- 12/05/01 8279 THERA/DIAG INJ SUBCU / 1 16.00 12/05/01 230394 FILGRASTIM 300MCG 1 240.45 12/31/01 902003 MEDICARE PAY HOSP -1 190060- 12/31/01 920015 MEDICARE CONT ADJo 0/ 0 30.92- 10/31/02 980090 HOSPITAL BAD DEBT w/o -1 34.93- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 34.93 -------------------------------------------------------------------------------- * - Not posted Balance: 34.93 j -------------------------- /J--0 If MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRI\~ HERSHEY, PA 17033 Statement on: 11/27/02 at 09:32 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2082486 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------.------------------------------- 12/06/01 8348 CC OUTPATIENT VISIT E 1 24.00 12/06/01 104014 ALKALINE PHOSPHATASE 1 9.00 12/06/01 104016 BILIRUBIN TOTAL 1 9.00 12/06/01 104096 LDH 1 11.00 12/06/01 104156 SGPT (ALT) 1 10.00 12/06/01 105657 CBC/DIFF/PLT COUNT, A 1 28.00 12/31/01 902003 MEDICARE PAY HaSP -1 84.69- 12/31/01 920015 MEDICARE CONT ADJ. 0/ 0 9.76 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 16,07- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 16.07 -------------------------------------------------------------------------------- * - Not posted Balance: 16.07 I -------------------------- f)-~!J~ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:32 AM ~AGE : ., 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2085229 -------------------------------------------------~------------------------------. Date I Svc Code I Description I Units I Debits Credits --------------------------------------------------.------------------------------ 12/07/01 8214 SET ADMINISTRATION 1 6.00 12/07/01 8217 IV FLUIDS 1 9.00 12/07/01 8280 THERA/DIAG INJECTION 2 98,00 12/07/01 8289 IV INF TX 0-1 HR 1 88.00 12/07/01 8290 IV INF TX EA ADDL HR 1 42.00 12/07/01 8291 TRANSFUSION, BLOOD/CO 1 327.00 12/07/01 8510 FILTER, FENWAL 1 16.00 12/07/01 101143 IRRADIATE COMPONENT 1 43.00 12/07/01 101214 PLT LR PHER EA U 1 761. 00 12/07/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 12/31/01 902003 MEDICARE PAY HOSP -1 678041- 12/31/01 920015 MEDICARE CONT ADJ. 0/ -3 434.79- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 299.80- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 299.80 -------------------------------------------------------------------------------- * - Not posted Balance: 299,80 I -------------------------- Ir0~ MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:33 AM PAGE: 1 Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY AcctNo: 2087609 --------------------------------------------------.-----------------------------. Date I Svc Code I Description ./ Units I Debits Credits --------------------------------------------------.------------------------------ 12/10/01 8280 THERA/DIAG INJECTION 1 49,00 12/10/01 105656 CBC W/PLT CNT, NO DIF 1 23.00 01/04/02 902003 MEDICARE PAY HOSP -1 46.11- 01/04/02 920015 MEDICARE CONT ADJ, 0/ -2 16,60- 10/31/02 980090 HOSPITAL BAD DEBT W/O -1 9.29- 10/31/02 980091 HOSPITAL BAD DEBT PLA 1 9.29 -------------------------------------------------------------------------------- * - Not posted Balance: 9,29 I -------------------------- II/a? MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/27/02 at 09:33 AM PAGE: 1 . , Guarantor: PRICE BOBBY RAY 353 OLD STONEHOUS RD SOUTH BOILING SPRIN, PA 17007-0000 Patient: PRICE BOBBY RAY Acct No: 2182223 -------------------------------------------------------------------------------- Date I Svc Code I Description I Units I Debits Credits -------------------------------------------------------------------------------- 01/19/02 01/19/02 10/31/02 10/31/02 10993 10995 980090 980091 NON EMERG TRANSPORT<= NON EMER TRNS>=21MI/M HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA 1 20 -1 1 71.00 40.00 111.00- 111.00 -------------------------------------------------------------------------------- * - Not posted Balance: 111,00 I -------------------------- f}-b! >ENNSTATf !B1 The,Milton S, Hers\J:ey Medical Center , ., The College ot: MediCIne BOBBY RAY PRICE 353 OLD STONEHOUS RD SOUTH BOILING SPRIN PA 17007 ACCOUNT # 1102021 STATEMEN'I" ' , DATE: 10/31/02 : LAST STATEME/IT DATE: 09/25/02 FED TAX ID # 251857035 INS CHARGE PAYMENTI GUARANTO ADJUSTMENT BALANcE 1 < . .~ IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES DATE PROCEDURE DIAG QTV DESCRIPTION CODE CODE >>> PATIENT: 8OB8Y RAY PRICE 1102021 10/19/00 99245 07106/01 07/06/01 07106/01 05/04/01 7417026 06/21101 06/21101 OS/29/01 05/04/01 72193Z6 06/21101 06/21101 06/21101 05/04/01 99214 06/19/01 06/19/01 06/19/01 202.80 202.80 202.80 202.80 07/08101 99223.GC 208.00 09/05/01 09/05/01 09/05/01 07/09/01 7126026 202.80 09/05/01 09/05/01 09/05/01 07/09/01 7417026 202.80 09/05/01 09/05/01 09/05/01 07/09/01 7219326 202.80 09/05/01 09/05/01 09/05/01 1074254 PERFORMED BY: DIVISION OF HEM/DNC PLACE OF SVC: DP PHYSICIAN OFFICE CONSULTATION MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INSI 165,00 131.42- 0.72- 32,86 1498374 PERFORMED BY: DIV OF DIAS RADIOLOGY PLACE OF SVCI OP HOSPITAL C T ABOOHEN MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ CHECK PAY PHYS, THAN( YOU CT PELVIS ENHANCED MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INSI 1499454 PERFORMED BY: DIVISION OF HEM/ONe PLACE OF SVC: OP PHYSICIAN CIC OUTPATIENT VIS EST MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ 8ALANCE AFTER INS- 324,00 59.04- 250,20- 12.67- 2,09 236.00 49.00- 174.75- 12.25 56.00 44.69- 0.14- 11.17 1635548 PERFORMED BYI DIVISION OF HEMIONC PLACE OF SVC: INPATIENT INITIAL HOSPITAL CARE MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INSI PERFORMED BYI OIV OF OIAG RADIOLOGY CT THORAX ENHANCED MEDICARE PAYMENT MEDICARE CONTRACTUAL AOJ BALANCE AFTER INS- C T ABDOHEN MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INSI CT PELVIS ENHANCED MEDICARE PAYMENT MEDICARE CONTRACTUAL AOJ BALANCE AFTER INS- PERFORMED BY: OIV OF ANATCHIC PATHOLOGY TISSUE EXAM LEVEL 4 306,00 124.26- 150,68- 31. 06 318,00 52.28- 252,65- 13,07 340,00 59, 04- 266,20- 14.76 248,00 49,00- 186 , 75- lUS ClENNSTATE BOBBY RAY PRICE 353 OLD STONEHOUS RD Iii The Milton S. Hers~ Medical Center SOUTH STATEMENT' , . The College of Medicme BOILING SPRIN PA 17007 DATE: 11131102: LAST STATEMENT ACCOUNT # 1102021 DATE: 09125102 Ei IF ANY qUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857C35 DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENTI GUARJ,NTC CODE CODE ADJUSTMENT BALANCE 09/05101 MEDICARE PAYMENT 34.23- 09/05101 HEDICARE CONTRACTUAL ADJ 124.21- 0'/05/01 BALANCE AFTER INS- 8.5. 07/0'101 8831226 204.00 SPECIAL STAINS-MICRO 46.00 0'/05/01 MEDICARE PAYMENT 22.75- 09/05101 MEDICARE CONTRACTUAL ADJ 17.56- 0'105101 BALANCE AFTER INS! 5.6'; 07/0'101 8831326 204.00 SPECIAL STAINS-HISTO 45.00 09/05/01 MEDICARE PAYMENT 10.61- 09/05/01 MEDICARE CONTRACTUAL ADJ 31. 74- 09105101 BALANCE AFTER INS- 2,6!, PERFORHED BY: DIVISION OF HEHION: 07/09101 "233 . GC 208.00 DAILY HOSPITAL CARE 196.00 09105/01 MEDICARE PAYMENT 63.01- 0'/05101 MEDICARE CONTRACTUAL ADJ 117.24- 0'/05101 BALANCE AFTER INS! 15,7S 07/0'101 85097 208.00 BONE MARRllII ASP INTERPRET 100,00 10/16101 MEDICARE PAYHENT 41.34- 10116101 MEDICARE CONTRACTUAL ADJ 48,32- 10/16101 BALANCE AFTER INS- 10.34 PERFORMED BY: DIV VASCULAR INSTITUTE 07/10/01 36489.SC V58.81 PLCItlT /CENT UN OVER 2YRS 487.00 08127/01 MEDICARE PAYMENT 61. ,,- 08/27/01 MEDICARE CONTRACTUAL ADJ 409,51- 08/27/01 BALANCE AFTER INSlf 15,50 07/10/01 7694226.GC V58.81 ULTRA GUIDINEEDLE BID INT 141. 00 08/27/01 MEDICARE PAYHENT 28,54- 08127/01 MEDICARE CONTRACTUAL ADJ 105.32- 08127/01 BALANCE AFTER INS! 7,14 07/10/01 76000,5' V58,81 FLlJORDS ROUT OITHAN 71034 7'.00 08127/01 MEDICARE PAYMENT 7.07- 08127/01 MEOICARE CONTRACTUAL ADJ 70.16- 08127/01 BALANCE AFTER INS- 1. 77 PERFORMED BY: DIV CLINICAL PATHOLOGY 07/10/01 8818026 202,80 14 FLOH CYTOMETRY 154,00 10130/01 MEDICARE PAYMENT 123,20- 30.80 PERFORMED BY: DIVISION OF HEHlllNC 07/10/01 "232,GC 208,00 DAILY HOSPITAL CARE 133.00 09105/01 MEDICARE PAYMENT 44.40- 09105/01 MEDICARE CONTRACTUAL ADJ 77.50- 09105/01 BALANCE AFTER INS- 11.10 PERFORMED BY: DIV OF ANATOMIC PATHOLOGY 07/11/01 8810826 VI0,79 CYTO CONCEN WHARS 63.00 09105/01 MEDICARE PAYMENT 24.50- 09105/01 MEDICARE CONTRACTUAL ADJ 32.38- 09105/01 BALANCE AFTER INS! 6.12 PERFORMED BY: DIVISION OF HEHlllNC "232,GC V58.1 DAILY HOSPITAL CARE 133,00 MEDICARE PAYMENT 44,40- MEDICARE CONTRACTUAL ADJ 77,50- BALANCE AFTER INS- STATEMENTOF PHYSICIAN SI:RVlCE5 '., 'ENNSr6II;;' BOBBY RAY PRICE 3 It" 15 353 OLD STONEHOUS RD "Tbe =S. ~ey Medical Center SOUTH sTlITEMENT , .TheCoI of edicme BOILING SPRIN PA 17007 DATE: 10/81/02 LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 ~ IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID #. 251857035_ DATE PROCEDURE DIAG Qrv DESCRIPTION INS CHARGE PAYMENTI GUARANTOI CODE CODE ADJUSTMENT BALANCE 07/12101 99t3t.GC t08.00 DAILY HOSPITAL CARE 133.00 09/05/01 MEDICARE PAYMENT 44.40- 09/05/01 MEDICARE CONTRACTUAL AOJ 77.50- 09/05/01 BALANCE AFTER INSI 11.10 07113/01 99t3t.GC t08.00 DAILY HOSPITAL CARE 133,00 09/05/01 MEDICARE PAYMENT 44.40- 09/05/01 MEDICARE CONTRACTUAL AOJ 77.50- 09/05/01 BALANCE AFTER INSI 11.10 PERFORMED BY: OIV OF OIAS RADIOLOGY 07/14/01 71010t6 VS8.81 CHEST 1 VIE" 56.00 08130/01 MEDICARE PAYMENT 7.66- 08/30/01 MEDICARE CONTRACTUAL ADJ 46.43- Da/30/01 BALANCE AFTER INS!! 1. 91 PERFORMED BY: DIVISION OF HEHIONC 07114/01 99t3t.GC t08.00 DAILY HOSPITAL CARE 133.00 09/05/01 MEDICARE PAYMENT 44.40- 09/05/01 MEDICARE CONTRACTUAL AOJ 77.50- 09/05/01 BALANCE AFTER INS!! 11.10 PERFORMED BY: OIV OF CARDIOLOGY 07/14/01 93010 4t7.89 ECG ELECTROCARO INTERP 5t.00 09/10101 MEDICARE PAYMENT 8.U- 09/10/01 MEDICARE CONTRACTUAL ADJ 41. 74- 09/10/01 BALANCE AFTER INSI 2.05 PERFORMED BY: DIVISION OF HEHIDNC 07/15/01 99233.GC 427.89 DAILY HOSPITAL CARE 196.00 09/05/01 MEDICARE PAYMENT 63,01- 09/05/01 MEDICARE CONTRACTUAL AOJ 117,24- 09/05/01 BALANCE AFTER INS!! 15.75 16S476t PERFORMED BY: DIVISION OF HEHIDNC PLACE OF SVC: OP HOSPITAL 07/17/01 99214 202.80 C/C OUTPATIENT VIS EST 56.00 01108/02 MEOICARE PAYMENT 37.98- 01/08/02 MEDICARE CONTRACTUAL ADJ 8.52- 01108102 BALANCE AFTER INS!! 9.50 1657864 PERFORMED BY: DIVISION OF HEHIONC PLACE OF SVC: OP HOSPITAL 07118/01 99tl4 202.80 C/C OUTPATIENT VIS EST 56,00 01108102 MEDICARE PAYMENT 37.98- 01108/02 MEDICARE CONTRACTUAL AOJ 8,52- 01/08/02 BALANCE AFTER INS!! 9.50 1660990 PERFORMED BY: DIVISION OF HEM/ONe PLACE OF SVC: OP HOSPITAL 99t14 202,80 C/C OUTPATIENT VIS EST 56,00 MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ ENNSrATE' .' BOBBY RAY PRICE 4 of ";5 353 OLD STONEHOUS RD . " The Milton S. Hershey Medical Center SOUTH STATEMENT' , .TheCoI1egeofMedicme BOILING SPRIN PA 17007 DATE: 10/~1/02 LAST STATEMEIIT ACCOUNT # 1102021 DATE: 09/25/02 I IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 DATE PROCEDURE DIAG CITY DESCRIPTION INS CHARGE PAYMENTI GUARAN,'OF CODE CODE ADJUSTMENT BALANCE 01/08102 BALANCE AFTER I~ 9.50 166383Cf PERFORMED BY: DIVISION OF HEM/ONe PLACE OF SVC I OP HOSPITAL 07120/01 99214 202.80 C/C llUTP ATIENT VIS EST 56,00 01/08102 MEDICARE PAYMENT 37.98- 01/08102 MEDICARE CONTRACTUAL ADJ 8.52- 01/08102 BALANCE AmR INSll 9.50 1666939 PERFORMED BYI DIVISION OF HEKIONC PLACE OF SVC: OP HOSPITAL 07/23/01 9921Cf 202,80 C/C llUTP ATIENT VIS EST 56.00 01/08102 MEDICARE PAYMENT 37.98- 01/08102 MEDICARE CONTRACTUAL ADJ 8.52- 01/08102 BALANCE AFTER I~ 9.50 1670244 PERFORMED BY: DIVISION OF HEMIONC PLACE OF SVC: OP HOSPITAL 07/24/01 99214 202.80 C/C llUTP ATIENT VIS EST 56.00 01/08102 MEDICARE PAYMENT 37.98- 01/08102 MEDICARE CONTRACTUAL ADJ 8,52- 01/08102 BALANCE AFTER INS- 9,50 1673298 PERFORMED BY: DIVISION OF HEMIONC PLACE OF SVC: OP HOSPITAL .. 07/25/01 99214 202.80 C/C DllrPATIENT VIS EST HTR 56.00 .. 01/08102 MEDICARE PAYMENT 0.00 0.00 1676389 PERFORMED BY: DIVISION OF HEHIONC PLACE OF SVC: OP HOSPITAL 07126/01 99213 2M,8 C/C OUTPATIENT VIS EST 35,00 01/08102 MEDICARE PAYMENT 23.35- 01/08/02 MEDICARE CONTRACTUAL ADJ 5,81- 01108102 BALANCE AFTER INSlI 5.M 1679075 PERFORMED BY: DIVISION OF HEM/ONC PLACE OF SVC: INPATIENT 07/27/01 99221 288,0 INITIAL HOSPITAL CARE 185,00 10/16101 MEDICARE PAYMENT 55.19- 10/16/01 MEDICARE CONTRACTUAL ADJ 116,01- 10/16/01 BALANCE AFTER INSlI 13.80 PERFORMED BY: DIV OF DIAG RADIOLOGY 07/27/01 7102026 780.6 CHEST 2 VIEWS FRONT/LAT 78.00 09126/01 MEDICARE PAYMENT 09126/01 MEDICARE CONTRACTUAL ADJ o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK D CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK ~1"'It:Mt:N"V"'''"T::lI(,'AN S!:l'tvteeS :'ENNSTATE IS! The'Milton S. He~ Medical Center , ., The College of.Medicme BOBBY RAY PRICE 353 OLD STONEHOUS RD SOUTH BOILING SPRIN PA 17007 ACCOUNT # 1102021 STATEIIIEN'r DATE: 10'31102 : lAST STATEMENT DATE: 09125102 FED TAX ID # 251857035, INS CHARCE PAYMENTI GUARANTO ADJUSTMENT BALANCE H' IF ANT qUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES DATE PROCEDURE DIAC QTY DESCRIPTION CODE CODE PERFORMED BY: DIVISION OF HEM/ONe PLACE OF SYC: OP HOSPITAL CIC OUTPATIENT VIS EST MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER It/Sll 08131/01 01/08102 01/08102 01/08102 99tlt 09/05/01 99213 01/08102 01/08102 01/08102 09/07/01 99212 01/08102 01/08102 01/08102 09/14/01 99211 10130101 10/30/01 10/30/01 09/19/01 9406026 11/06/01 11/06/01 11/06/01 09/19/01 9424026 11/06/01 11/06/01 11/06/01 09/19/01 9472026 11/06101 11/06/01 11/06/01 284.8 284.8 287.5 202.80 204.00 204.00 204,00 24.00 16.06- 3.93- 4.01 1761492 PERFORMED BY' DIYISION OF HEMIONC, PLACE OF SYC: OP HOSPITAL CIC OUTPATIENT VIS EST MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER It/Sll 35.00 23.35- 5.81- 5.84 1767847 PERFORMED BY, DIVISION OF HEMIONC PLACE OF SYC: OP HOSPITAL CIC OUTP ATIENT VIS EST MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER It/Sll 24.00 16.06- 3.93- 4.01 1894427 PERFORMED BY: DIVISION OF HEMIONC PLACE OF SYC: OP PHYSICIAN CIC OUTPATIENT VIS EST MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER It/Sll 10.00 7.35- 0,81- 1.84 1902657 PERFORMED BY, DIY OF PULMONARY MEDICINE PLACE OF SYC: OP PHYSICIAN BRONCHODILATOR SPIROMETRY MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER It/Sll FUNCTIONAL RESIDUAL CAP MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INS- CARBON HONOX DIFF CAP MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER It/Sll 83.00 14.44- 64,95- 3,61 55.00 11,50- 40.62- 2,88 54.00 11.50- 39.62- 2,88 1903057 PERFORMED BY: DIY OF NUCLEAR MEDICINE PLACE OF SYC: OP HOSPITAL CARD BLD POOL IMAS SlSTUD CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK . ~"I'\ I r;;;lyli:Oi....iI-.Vr.rA'I-O.vll'.U,. -o-t:;nYI"~'" o PA9E , NNSTA.TE BOBBY RAY PRICE 9 o' -:5 353 OLD STONEHOUS RD _ The'Milton S, Hers~ Medical Center SOUTH STATEMENt The College ofMedicme BOILING SPRIN PA 17007 DATE: 10131/02 UU1T STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 IF ANY QUESTIONS. PlEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID iI. 251857035 .)ATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENTI GUARANTOF CODE CODE ADJUSTMENT BALANCE PERfORMED BY: DIVISION OF HEM/ONe PLACE OF SVC: OP HOSPITAL lO/22/01 99213 284.8 CIC OUTPATIENT VIS EST 35,00 11/08102 MEDICARE PAYMENT 23.35- 31/08102 MEDICARE CONTRACTUAL ADJ 5.81- 31/08102 BALANCE AFTER INSf 5.84 1981791 PERfORMED BY: DIVISION Of HEM/ONe PLACE OF SYC: OP HOSPITAL lO/24/01 99213 284.8 CIC OUTPATIENT VIS EST 35.00 11/08102 MEDICARE PAYMENT 23.35- 11/08102 MEDICARE CONTRACTUAL ADJ 5.81- 11/08102 BALANCE AFTER INSf 5.84 1lJ84961 PERfORMED BY: DIVISION OF HEHIONC PLACE Of SVC: OP HOSPITAL LO/25I0l 99213 284.8 C/C OUTPATIENT VIS EST 35,00 11/16102 MEDICARE PAYMENT 23.35- 11/16/02 MEDICARE CONTRACTUAL ADJ 5,81- 11/16/02 BALANCE AFTER INSM 5,84 1991125 PERfORMED 8Y: DIY Of DrAG RADIOLOGY PLACE OF SYC: INPATIENT lO/28/o1 7102026 780,6 CHEST 2 YIENS fRoNT/LAT 78,00 l2l181o1 MEDICARE PAYMENT 9.44- l2l181o1 MEDICARE CONTRACTUAL AoJ 66.20- .,2118101 BALANCE AfTER INSf 2.36 PERfORMED BY: DIYISION Of HEM/ONe ,0/28101 99223 . GC 288.0 INITIAL HOSPITAL CARE 306.00 l2l18/o1 MEDICARE PAYMENT 124,26- ,2118101 MEDICARE CONTRACTUAL ADJ 150.68- :2118101 BALANCE AfTER INSll 31.06 .0/29/01 99232.GC 288.0 DAILY HOSPITAL CARE 133.00 .2118101 MEDICARE PAYMENT 44,40- .2118/01 MEDICARE CONTRACTUAL ADJ 77 ,50- ,2118/01 BALANCE AfTER INSf 11.10 1998127 PERfORMED BY: DIYISION Of HEHIDNC PLACE Of SYC: OP HOSPITAL 0/31/01 99213 996.62 C/C OUTPATIENT VIS EST 35.00 :1/16/02 MEDICARE PAYMENT 23.35- 1/16/02 MEDICARE CONTRACTUAL ADJ 5,81- '1/16/02 BALANCE AfTER INSll 5,84 2001334 CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK - '_'-'--"~"~-'7'.---~P".'--- 'ENN~ BOBBY RAY PRICE , , 353 OLD STONEHOUS RD S:rATEMENT' , Iiil The Milton S. Hershey Medical Center SOUTH The College of Medicme BOILING SPRIN PA 17007 DATE: 10131102: ' , . .. LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 '4 IF ANY QUESTIONS, PlEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 PROCEDURE DIAG QTY DESCRIPTION INS PAYMENTI GUARANTa DATE CODE CODE CHARGE ADJUSTMENT BALANCE PERFORMED BY I DIVISION OF HEMIllNC PLACE OF SVC I OP HOSPITAL 11101101 99214 202.80 CIC OUTPATIENT VIS EST 56.00 01116/02 IlEDICARE PAYIlENT 37,98- 01116/02 MEDICARE CONTRACTUAL AOJ S,52- 01116/02 BALANCE AFTER INSll 9,50 2004509 PERFORMED BY I DIVISION OF HEM/ONC, PLACE OF SVC: OP HOSPITAL 11102101 99214 202.80 CIC OUTPATIENT VIS EST 56.00 01116/02 1lE0ICARE P AYIlENT 37,98- 01116/02 MEDICARE CONTRACTUAL ADJ 8.52- 01/16/02 BALANCE AFTER INSll 9,50 2013092 PERFORMED BY: DIVISION OF HEM/ONe PLACE OF SVC: OP PHYSICIAN 11/07/01 99214 202.80 CIC OUTPATIENT VIS EST 56.00 12126/01 MEDICARE PAYltENT 44.69- 12126/01 MEDICARE CONTRACTUAL ADJ 0,14- 12126/01 BALANCE AFTER INSll 11.17 2029321 PERFORMED BY: DIVISION OF HEHlONC PLACE OF SVC: INPATIENT 11114/01 99222.GC V58.1 INITIAL HOSPTIAL CARE 250,00 01/02102 MEDICARE PAYMENT 90,70- 01102102 MEDICARE CONTRACTUAL ADJ 136,63- U/02/02 BALANCE AFTER INSll 22,67 11115/01 99232. GC Y58.1 DAILY HOSPITAL CARE 133,00 11/02102 MEDICARE PAYIlENT 44.40- il1l02l02 MEDICARE CONTRACTUAL AOJ 77.50- 11102102 BALANCE AFTER INS- 11.10 PERFORMED BY: DIY OF PULMONARY MEDICINE 11115/01 9472026 Y72.82 CARBON MONOX DIFF CAP 54,00 11102102 JoEDICARE PAYMENT 11.50- 111102102 MEDICARE CONTRACTUAL AOJ 39,62- 01/02102 BALANCE AFTER INSll 2,88 PERFORMED BY: DIY YASCULAR INSTITUTE :.1/15/01 36533.LT Y58,Sl P ASPORT 1325,00 111/14/02 MEDICARE PAYMENT 279,77- 111/14/02 MEDICARE CONTRACTUAL ADJ 975.29- 1:11114/02 BALANCE AFTER INS_ 69.94 11115/01 76'14226, L T Y58,81 ULTRA GUIDINEEDLE BID INT 141. 00 11114/02 MEDICARE PAYMENT 28,54- (:1114/02 MEDICARE CONTRACTUAL AOJ 105,32- (l/14/02 BALANCE AFTER INSll 7,14 ] 1115/01 7600326,59 Y58,Sl NEEDLE BIOPSY OR ASPIRAT 110.00 01/14/02 MEDICARE PAYMENT 22.69- 01114/02 MEDICARE CONTRACTUAL AOJ 81. 64- "IAII:Mt:NT OFPI'IYSICIAN SERVICES . PAlJE . I'NNSrATE BOBBY RAY PRICE 11 "r', 353 OLD STONEHOUS RD . . The Milton S. Hers~ Medical Center SOUTH STATEM~ ' The Co1lege ot"Medicme BOILING SPRIN PA 17007 DATE: 1 131/02 ' LAST STATEMENT ACCOUNT # 1102021 DATE: 09/25/02 IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035 I)ATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENTI GUARANH) , CODE CODE ADJUSTMENT BALANCE 1I111410Z BALANCE AFTER INSIi 5.67 PERFORMED BY: DIVISION OF HEM/ONC :LI/16/01 99m.GC V58.1 DAILY HOSPITAL CARE 133.00 Ill/OZlOZ MEDICARE PAYMENT 44.40- 1I1102lOZ MEDICARE CONTRACTUAL ADJ 77.50- lIl/OZlOZ BALANCE AFTER INSIi 11.10 :.1117/01 99Z33.GC V58.1 DAILY HOSPITAL CARE 196.00 1I110Zl0Z MEDICARE PAYMENT 63.01- 1I11D2IOZ MEDICARE CONTRACTUAL ADJ 117.Z4- !il/02IOZ BALANCE AFTER INS- 15.75 Z08Z486 PERFORMED BY: DIVISION OF HEHIONC PLACE OF SYC: UP PHYSICIAN : Zl06l01 99Zl4 Z04.91 C/C Dl/TPATIENT VIS EST 56,00 ':1IZZlOZ MEDICARE PAYMENT 44.69- C 1I2Z10Z MEDICARE CONTRACTUAL ADJ 0.14- r; 1I2210Z BALANCE AFTER INSIi 11.17 2091184 PERFORMED BY: DIV OF DIAG RADIOLOGY PLACE OF SYC: UP HOSPITAL ~Z/ll/Ol 7055326 ZOZ.80 HRI BRAIN UNEN ENH 486.00 DZl1210Z MEDICARE PAYMENT 99.78- OZll210Z MEDICARE CONTRACTUAL ADJ 36l.Z7- UZl1Z10Z BALANCE AFTER INSIi 24,95 Z099075 PERFORMED BY: DIV OF NUCLEAR MEDICINE PLACE OF SYC: OP HOSPITAL iZl13/01 78472Z6 429.9 CARD BLD POOL IMAG S1STUD ZZ1. 00 l'U04/0Z MEDICARE PAYMENT 41. 91- I;U04/0Z MEDICARE CONTRACTUAL ADJ 168.61- IU0410Z BALANCE AFTER INSIi 10.48 ZlO1021 PERFORMED BY: DIV OF ANATOMIC PATHOLOGY PLACE OF SYC: INPATIENT 1!l14/01 88108Z6 V10,79 CYTO CONCEN H/SHE ARS 63.00 : Y04/0Z MEDICARE PAYMENT Z4.50- :Y04/0Z MEDICARE CONTRACTUAL AOJ 32.38- : ~/04/0Z BALANCE AFTER INSIi 6,12 PERFORMED BY: DIV PSYCH CONSULTS ADULT 1::/14/01 99Z5Z,GC Z96.80 INITIAL INPT CONSULTATION 140,00 1::/04/0Z MEDICARE PAYMENT 59.6Z- ,1::/04/0Z MEDICARE CONTRACTUAL ADJ 65,48- I::/04/0Z BALANCE AFTER INS- 14,90 PERFORMED BY: DIV OF OIAG RADIOLOGY ./14/01 71010Z6 786,05 CHEST 1 VIE" 56.00 I :/04/0Z MEDICARE PAYMENT A -8 [) 7,66- r :/04/0Z MEDICARE CONTRACTUAL AOJ 46.43- CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK '_,",,'I ""n;IYlE::f'f"r'VI""'Tn,."Of\;"'....OCftYIVt::~ ::NNSTATE em The Milton S, Hershey Medical Center , . ~he College ofoMedlcme BOBBY RAY PRICE 353 OLD STONEHOUS RD SOUTH BOILING SPRIN PA 17007 ACCOUNT # 1102021 . PAGE , 1401' , .. stATEMENt , DATE: 10131/02 ' LAST STATEMENT DATE: 09/25/02 FED TAX ID # 251857035 INS CHARGE PAYMENTI GUARANTOI ADJUSTMENT BALANCE 59.l7- 122,04- 14.79 196.00 59.l7- 122.04- 14,79 78.00 8.68- 67.15- 2,17 196,00 59.l7- 122.04- 14.79 196.00 59.17- 122.04- 14.79 196,00 59.l7- 122.04- 14.79 196,00 59.l7- 122.04- 14,79 115,00 51. 28- 50,90- 12.82 rL,lF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES DATE PROCEDURE DIAG QTY DESCRIPTION CODE CODE MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INSI DAILY HOSPITAL CARE MEDICARE PAYllENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INS- PERFORMED BY: DIV OF DIAG RADIOLOGY CHEST 2 VIENS FRONT/LAT MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INSI PERFORMED BY: DIVISION OF HEM/ONt DAILY HOSPITAL CARE MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INSlI DAILY HOSPITAL CARE MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INSI DAILY HOSPITAL CARE MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INS- DAILY HOSPITAL CARE MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INSlI HOSP DISC DAY MGT <3D HIN MEDICARE PAYMENT MEDICARE CONTRACTUAL ADJ BALANCE AFTER INSlI 03/05/02 n/D5I02 C3/05l02 01/1V02 03/D5I02 C3/05/02 B/05/02 99233.GC 288.0 01/12102 7102026 03/05/02 03/05/02 (13/05/02 n/13/02 23/05/02 13/05/02 )3/05/02 1l/14/02 13/05102 B/05/02 13/05102 11/15/02 13/05102 :13/05/02 13/05/02 11/17102 13/12/02 !3/1V02 13/12/02 11/19/02 '3/12/02 3/12/02 3/12/D2 780.6 99233.GC 288.0 99233.GC 288.0 99233,GC 288,0 99233. GC 288.0 99238,GC 288,D 1/04/02 99245 4/22/02 414.01 2141558 PERFORMED BY: DIV OF CARDIOLOGY PLACE OF SVC: OP PHYSICI AN OFFICE CONSULTATION MEDICARE PAYMENT BALANCE: BOBBY RAY PRICE t1494.06 171,00 72,54- 98,46 NDICATES NEN FINANCIAL ACTIVITY SINCE LAST BILL, IF YOU HAVE ANY QUESTIONS ABOUT THE AMOUNT YOUR INSURANCE CDMP ANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTHER QUESTIONS REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE, IF PAYMENT HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL. PLEASE FND TO CNRIGHT, CUST SERV A-K, ASB SUITE 1140, )(3623 o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK _ _-._ ...1........... J ur....n lOIVlAN::Jt:t1VK..r"1:S' 'ENNSTATE 15'1 The Milton S, Hershey Medical Center . The College of Medicme BOBBY RAY PRICE 353 OLD STONEHOUS RD SOUTH BOILING SPRIN PA 17007 ACCOUNT # 1102021 PABE' ~,5 0; "j , , STATEM~T ' DATE: 10/31/02 LAST STATEMENT DATE: 09/25/02 fL IF ANY QUESTIONS, PlEASE CoNTACT: MSHMC PATIENT FlJIIANCIAL SERVICES DATE PR~~g~RE g~~~ QTY DESCRIPTION INS THAt<<. YOU FOR USING HSHMC PHYSICIANS GROUP FOR YOUR PHYSICIAN SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING TillS 8ILL, PLEASE CONTACT US AT 717-531-5069 OR 800-254-2619, 8E1Wf.EN 8:00AM AND 5:30PM HlHlAY THROUGH NEDNESDAY DR 8ETNEEN 8:00AM AND 4:30PM THURSDAY AND FRIDAY. FED TAX ID # 251857035 PAYMENTI GUARANTC CHARGE ADJUSTMENT BALANCE ! ALANCE SUMMARY RESPONSI8LE PARTY MTR PALMETTO GaA RAILROAD MeR ~ GUARANTOR RESPONSI8ILITY POLICY I A24680611011 TOTAL t 56.00 t 1494,06 -------___m_____.____Ll",P..Q!!J:.~!!!.r.tP},,€~J_€.P..UA!;!:!.A.I!!.'_l!.m!_'!!t!1Jl,mlM.P"Q!!JLQ.lLQH_t~rA"'~.I!r_!".ILI:f_rQJ!.!!_PArM€!YL.l_____________h_______. STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMENl 10/31/02 $ 1494.06 $ 1494,06 BF6 1102021 MSHMC PHYSICIANS GROUP BILLING SERVICES POBOX 854 HERSHEY PA 1703300854 00001102021 UP 0000000000149406103102 ,1/ . ~J: MSHMC PHYSICIANS GROUP POBOX 828611 PHILA PA 19182-8611 BOBBY RAY PRICE 353 OLD STONEHOUS RD SOUTH BOILING SPRIN PA 17007 USE ONL Y v' CHECK ONE FOR CREDIT CARD PAYMENT, PLEASE FILL IN INFORMATION BELOW K _M/C _VISA 1102021 EXP DATE 11/21/02 F6BO DMND CARDHOLDER NAME (PRINT) _ ' ,", _ ' _,__,...._.~_._._<oII"'.,.._.;,..HT IVI Ule! J.R1ymenr OT all charges Forserv/cesrenderedto ~'r-,'tU.\~ ~'~ '~l( r- I, theundersigne(l, do hereby acknowledge and understand thaVall charg at covered by Insurance will be payable In full prior 10 or upon date of and time of discharge. I, the undersigned, authorize the hospital to make a credit investigation if neCessary. . ' I hereby assign and auihorize payment directly to The Milton S. Hershey Medical Center Hospital, Pennsylvania Stete Unlv6rsity. , Should the aceount bocome delinquent, and should it become necessary lor the account to be relerred to an attorney or collec- tion agency for collection or-suit, the undersigned shall pay the reasonable attorney's fees or collection expense. Signed'1- 44 f",,,). 8L'C'O-, Date ,,~~~\ Witness ~QQo l.9. )"j;'",,/) Date All persons will be accepted for admission without regard to race, color, creed, religion, national origin or sex. PA T/ENT RESPONSIBILITY AGREEMENT I, the undersigned, do hereby acknowiedge and accept financial responsibility lor the payment 01 all charges For services rendered ~c.::t~ ~ 'G6~y f' ~ I, the undersigned, do hereby acknowledge and understand that all charges not covered by insurance wiJ/ be payable in full prior to or upon date of and time of discharge. /, the undersigned, authorize the hospital to make a credit investigation if necessary. I hereby assign and authorize payment directly to The Milton S, Hershey Medicai Center Hospital, Pennsylvania State University, Should the account become delinquent, and should it become necessary for the account to be referred to an attorney or collec- lion agency for collection at it, th:N,Siqned shall pay the reasonabie attorney's fees or collection expense. Signed /<'. Date 7'ri7 - () / /~ Witness Date 7 -,;J 7 - cJ f All persons will be accepted for admission without regard to race, color, creed, religion, national origin or sex. r1'1rrr;:;rv I .un- ,;;:;t-l7J"i\rTO'{P;/V PA T1ENT RESPONSIBILITY AGREEMENT I, the undersigned, do hereby acknowledge and accept financial responsibility lor the payment of all charf/es For services rendered to I, the undersigned, do hereby acknowledge and understand that all charges not covered by insurance will be payable in lull prior to Qr upon date oi and time of discharge. I, the undersigned, authorize the hospital to make a credit investigation if necessary. I hereby assign and authorize payment directly to The Milton S, Hershey Medical Center Hospital, Pennsylvania State University, Should the account become delinquent, and should it become necessary tor the account to be referred to an attorney or collec- lion agency for eollectio or suit, the ndersig shall pay the reasonable attorney's fees or collection expense. Signed c..-... Date 0-'+( - 0-/ f-C)-I-<.../ Witness " =;:~ Date All persons will be accepted for admission without regard to race, cofor, creed, religion, national origin or sex. ~ -\ ._ ____,. ....-..-.-. .--r--.-.-....I ._.. ...-{'" ................ ............"....::;1...... For services rendered to I, the undersigned, do hereby acknowledge and understand that all charges not covered by insurance will bE> payable in iull prior to or upon date of and iime of Jischa,ge. I, the undersigned, authorize the hospital to make a credit investigation If necessary. " , J"here"!y -aSSlr;;n and a~thorize payment directly to The Milton S. Hershey Medical Center Hospital, Pennsylvania Slate UnIYerslty. " Should the account become delinquent, and should it become necessary ior the aCGount to be referred to an attorney or COllec. lion agency r collection or suit, the undersigned shall pay the reasonabie attorney's fees or collection expense, IV- /10/ /(J-/!-()/ Signed Date Date ccepted for admission without regard to race, color, creed, religion, national origin or sex. For services rendered to I, the undersigned, do hereby acknowledge and understand t t all cha ges n t cove ed by insurance will be payable in full prior to or upon date of and time of discharge. I, the undersigned, authorize the hospital make a credit investigation if necessary, I hereby assign and authorize payment directly to The Milton S. Hershey Medical Center Hospital, Pennsylvania State University. , Should the account become delinquent, and should it become necessary for the account to be referred to a attorney or collec- tion a encM or collection or ?jit, the un i~ned shall pay the reasonable attorney's fees or collection ex s/iV /r;-; Date U, Date ted for admission without regard to race, c%r, creed, religion, national origin or sex. , r1ru.:,,....., .....n \.;:fl,JI.,rll:.IlMr.,. PA T1ENT RESPONSIBILITY AGREEMENT I, the undersigned, do hereby acknowledge and accept financial responsibility for the payment of all charges For services rendered to ~ ~~ CY ~ I, the undersigned, do hereby acknowledge and understand that al harges no covered by Insurance Will be payable In full pflor to or upon date of and time of discharge. I, the undersigned, authorize the hospital to make a credit investigation if necessary. I hereby assign and authorize payment directly to The Milton S. Hershey Medical Center Hospilal, Pennsylvania State University. Should the account become delinquent, and should It become necessary ior the account to be referred to an afforney or cOllec. Don agM~for ollection or SUIt, ,the ,urt';igned shall pay the reasonable afforney's fees or coilection expense Slgne~~i'f~ Date Id-/00/ Witness, ~. ._~ Date l-.:J-/c101 All persons wi/l be accepted for admission without regard to race, color, creed, religion, national origin or sex. (!rd.- . .,_........,.. ......,..........",'.11.../11"'11'1 PA TIENT RESPONSIBILITY AGREEMENT I, the undersigned, do hereby ecknowledge and acc~pt financla' responsibility for th~ ~ayment 01 a/l charges For services rendered to If... (l" 8 0.{ ~ 'i /fh '/' <,;;;= I, the undersigned, do hereby acknowledge end understand that all charges not covered by insurance will be pay!i:ble in full prior to or upon date of end time of discharge. I, the undersigned, authorize the hospital to make a credit investigaiion if necessary. 1 hereby assign and authorize payment directly to The Milton S. Hershey Medical Center Hospital, Pennsyivania State University. Should the account become delinquent, and should it become necessary for the accounl to be reierred to an attorney or collec- lion ag..::r tor col tion or it, the undersigned shall pay the reasonable attorney's fees or collection expense. , "'",0 -P . ,~ / Z, /Z .f/-:> Witness Date /.c./~~l / / All persons will be accepted for admission without regard to race, color, creed, religion, national origin or sex, . ... ._. _. _._. _'_r<...._.~...-. PA T1ENT RESPONSIBILITY AGREEMENT I, the undersigned, do hereby acknowledge and accept financial responsibility for the payment of all charges For services rendered to cf3t1~ ' ~ t C/? I ~ .R .. ,.. I, the undersigned, do hereby acknowledge and understand that all arges not vered by insurance will be payable in full prior to or upon date of and time of discharge, I, the undersigned, authorize the hospital to make a credit investigation if necessary. 1 hereby assign and authorize payment directiy to The Milton S. Hershey Medicai Center Hospital, Pennsylvania State University. Should the account become delinquent, and shouldit become necessary ior the account to be referred to an attorney or collec. lion agency ior coli ction r s . the undersigned shall pay the reasonable attorne)"s fees or collection expense. Signed Date /.. -jI'111 / . .if .0;2, Witness Date s will be accepted for admission without regard to race, color, creed, religion, nationa' origin or sex. &3 CASE NO: 2003-03234 P ~HERIFF'S RETURN - REGULAR COMMONWEALTH OF PENNSYLVANIA: , COUNTY OF CUMBERLAND MILTON S HERSHEY MED CENTER VS PRICE GINNY REID ROBERT BITNER , Sheriff or Deputy Sheriff of Cumberland County,PennsYlvania, who being duly SWorn according to law, says, the within COMPLAINT & NOTICE was served Upon PRICE GINNY REID DEFENDANT GINNY PRICE BOILING SPRINGS, PA 17007 , at 1600:00 HOURS, on the 11th day of July the at 353 OLD STONEHOUSE ROAD ,~ by handing to a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge 18.00 4.83 .00 10.00 .00 32.83 So Answers: r-~.c<r~~~ R, Thomas Kline . Sworn and SUbscribed to before 07/14/2003 TABAS & ROSEN me this By: '-~~I:~\ ~h10A, eputy Sheriff day of A.D. Prothonotary THE MILTON S, HERSHEY MEDICAL CENTER, PLAINTIFF v. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GINNY REID PRICE, DEFENDANT NO, 03-3234 CIVIL TERM : JURy TRIAL DEMANDED NOTICE TO DEFEND You have been sued in court, If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Answer with Counter Complaint, and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOu DO NOT HAVE A LAWYER, OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP, Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 I~8mPi90:;9i(j8 TRUE COPY FROM RECORO In Testimony wncnlOf, I h<lie unlo ool my hall\l and the s8111 of said COil <11 Carlisle. PI. rhi ay 0 THE MIL TON S, HERSHEY MEDICAL CENTER, PLAINTIFF v. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA GINNY REID PRICE, DEFENDANT NO. 03-3234 CIVIL TERM : JURY TRIAL DEMANDED ANSWER TO COMPLAINT WITH COUNTERCLAIM AND NOW, this 14th day of August 2003, comes the defendant, GINNY REID PRICE, by her attorneys, Irwin, McKnight & Hughes, and makes the following Answer to Complaint of the plaintiff, The Milton S. Hershey Medical Center: 1. The avennents of fact contained in paragraph one (1) of the Complaint are admitted. 2. The averments of fact contained in paragraph two (2) of the Complaint are admitted. 3. The averments of fact contained in paragraph three (3) of the Complaint are specifically denied. On the contrary, it is denied that the Defendant was married to Bobby Ray Price on September 22, 200 I, which date was after all or sUbstantially all services rendered by the Plaintiff to Bobby Ray Price who died on February 2, 2002, 4. The avennents of fact contained in paragraph four (4) of the Complaint are admitted. 5. The avennents of fact contained in paragraph five (5) of the Complaint are beyond the knowledge of the Plaintiff They are, therefore, denied and proof thereof is demanded. 3 6. The avennents of fact contained in paragraph six (6) of the Complaint are beyond the knowledge of the Plaintiff. They are, therefore, denied and proof thereof is demanded. 7. The averments offact contained in paragraph seven (7) of the Complaint are admitted. 8. The avennents offact contained in paragraph eight (8) of the Complaint are denied. On the contrary, the Plaintiff knows that the Defendant is financially insolvent and is unemployed. The Defendant is responsible for her own care and the care of her eight (8) year old child by a previous marriage, 9. The averments of fact contained in paragraph nine (9) of the Complaint are conclusions of law to which no answer is required. Since she was not married when the deceased became a patient, this act does not apply to this case, 10. The averments of fact contained in paragraph ten (10) of the Complaint are denied. On the contrary, the Plaintiff has been paid by Medicare and knows that the Defendant is unable to pay and is not legally required to pay the balance claimed by the Plaintiff. II. The averments of fact contained in the first paragraph (II) of the Complaint are specifically denied. The Defendant has no legal responsibility to pay the amount sought by the Plaintiff. 12. The averments of fact contained in the first paragraph twelve (12) of the Complaint are specificaI1y denied. On the contrary, the Defendant has no legal responsibility to pay the amount sought by the Plaintiff. 4 COUNTERCLAIM OF DEFENDANT GINNY REID-PRICE AND NOW, this 14th day of August 2003, comes the Defendant, Ginny Reid-Price, by her attomeys, Irwin, McKnight & Hughes, and makes the following Counterclaim against the Plaintiff, The Milton S. Hershey Medical Center: 13. The avennents offact contained in the Answers to paragraph one (1) through twelve of the Complaint are hereby incorporated by reference and are made a part of this Counterclaim. 14. Many of the charges claimed by the Plaintiff were incurred prior to the marriage of the Defendant to her deceased husband, Bobby Ray Price. 15. The amount claimed by the Plaintiff was never acknowledged or accepted by the Defendant, Ginny Reid-Price. 16. The Plaintiffhas failed to pursue any claim against the Estate of Bobby Ray Price. 17. Following the death of Bobby Ray Price, the Plaintiff was given infonnation by the Defendant, Ginny Reid-Price that she was unable to pay the bills claimed by the Plaintiff. The Plaintiff still filed this litigation to worry and harass the Plaintiff, Ginny Reid-Price. does not need to seek future payment from the Defendant, Ginny Reid-Price. 18. The Plaintiff has received large sums from Medicare to pay these outstanding bills and 5 19. The deceased, Bobby Ray Price, was a veteran entitled to full veteran medical benefits. If Bobby Ray Price had been transferred to a veteran health center there would be no amount due and owing. 20. The action broUght by the Plaintiff against the Defendant is without basis and is vexatious harassment of the Defendant, Ginny Reid-Price. The action was brought without sufficient inquiry into the facts surrounding the treatment and death of Bobby Ray Price. The Plaintiff and its counsel may be subject to sanctions as permitted by Pa,R.C.p. 1023.1. 21. The Defendant, Ginny Reid-Price seeks damages from the Plaintiff together with her reasonable legal fees and interest and penalties as permitted by law. WHEREFORE, the Defendant requests that the Complaint filed by the Plaintiff be dismissed and that jUdgment be entered against the Plaintiff and in favor of the Defendant, Ginny Reid-Price in an amount in excess of Twenty Thousand and 00/100 ($20,000.00) Dollars with legal fees, costs, and interest as permitted by law, Respectfully submitted, IRWIN, M'KNIGHT & z~ J\1ar s A. McKnight, I , squire 6fJ West Pomfret Street ,Iisle,Pennsylvania 17 jj (71 49-2353 Supreme o. 25476 Attorney for the defendants Date: August 14,2003 6 VERIFICATION The foregoing Answer is based Upon information which has been gathered by counsel and myself in the preparation of this action. I have read the statements made in this document and they are true and correct to the best of my knowledge, information and belief. I understand that false statements herein made are subject to the penalties of 18 Pa. C.S.A. Section 4904, relating to unsworn falsification to authorities. ~~'>-- UJX2/ GINNy IttID PRICE Date: J!/;~oa <( THE MILTON So HERSHEY MEDICAL CENTER, PLAINTIFF v. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA GINNY REID PRICE, DEFENDANT NO, 03-3234 CIVIL TERM CERTIFICATE OF SERVICE I, Marcus A. McKnight,. III, Esquire, hereby certifY that a copy of attached document was served upon the following by depositing a true and correct copy of the same in the United States mail, First Class, postage prepaid in Carlisle, Pennsylvania, on the date referenced below and addressed as follows: Lewis C. Traffer, Esq. T ABAS & ROSEN 1845 Walnut St., 22,d Fir, Philadelphia, PA 19103 By: Marcus ~. McKm , III, Esquire 60 West Pomfret Street Carlisle, PA 17013 (717) 249-2353 Supreme Court LD. No, 25476 -.- - -- - Date: August 14,2003 7 CERTIFICATE OF SERVICE I, Lewis C. Trauffer, Esquire, certify that on November 12, 2003 a true and correct copy of plaintiffs Preliminary Objections to Defendant's Answer and New Matter to Counterclaim was served on the following individual(s) via United States mail, first class, postage pre-paid, and addressed as follows: Marcus A. McKnight, Esquire Irwin, McKnight & Hughes West Pomfret Professional Building 60 West Pomfret Street Carlisle, Pennsylvania 17103-3222 TABAS & ROSEN, P.C. :- ~-~ Lewis C. Trauffer, Esquire 1845 Walnut Street, 22nd FL Philadelphia, PA 19103 (215) 569-5050 '. --- 4 \'\ :<f ~ ?-- $ ... ~ ::. """ j:::) ;;i ~ 8 ~~ ~ D ~ ~ &' vs COURT OF COMMON PLEAS CUMBERLAND COUNTY Case No. 03-d-2Z74 .3J.~'( CIVIL ACTION THE MILTON S. HERSHEY MEDICAL CENTER GINNY REID PRICE Statement of Intention to Proceed To the Court: Plaintiff intends to proceed with the above captioned matter. Print Name LEWIS C. TRAUFFER Sign Name ~ ~- --- Date: I. Iii /t;, Attorney for Plaintiff Explanatory Comment The Supreme Court of Pennsylvania has promulgated new Rule of Civil Procedure 230.2 governing the termination of inactive cases and amended Rule of Judicial Administration 190 I. Two aspects of the recommendation merit comment. I. Rule of civil Procedure New Rule of Civil Procedure 230.2 has been promulgated to govern the termination of inactive cases within the scope of the Pennsylvania Rules of Civil Procedure. The termination of these cases for inactivity was previously governed by Rule of Judicial Administration 1901 and local rules promulgated pursuant to it. New Rule 230.2 is tailored to the needs of civil actions. It provides a complete procedure and a uniform statewide practice, preempting local rules. This rule was promulgated in response to the decision of the Supreme Court in Shop v. Eagle, 551 Pa. 360,710 A.2d 1104 (1998) in which the court held that "prejudice to the defendant as a result of delay in prosecution is required before a case may be dismissed pursuant to local rules implementing Rule of Judicial Administration 1901." Rule of Judicial Administration 1901(b) has been amended to accommodate the new rule of civil procedure. The general policy of the prompt disposition of matters set forth in subdivision (a) of that rule continues to be applicable. II Inactive Cases The purpose of Rule 230.2 is to eliminate inactive cases from the judicial system. The process is initiated by the court. After giving notice of intent to terminate an action for inactivity, the course of the procedure is with the parties. If the parties do not wish to pursue the case, ihey will take no action and "the Prothonotary shall enter an order as of course terminating the matter with prejudice for failure to prosecute." If a party wishes to pursue the matter, he or she will file a notice of intention to proceed and the action shall continue. a. Where the action has been terminated If the action is terminated when a party believes that it should not have been terminated, that party may proceed under Rule230(d) for relief from the order of termination. An example of such an occurrence might be the termination of a viable action when the aggrieved party did not receive the notice of intent to terminate and thus did not timely file the notice of intention to proceed. The timing of the filing of the petition to reinstate the action is important. If the petition is filed within thirty days of the entry of the order of termination on the docket, subdivision (d)(2) provides that the court must grant the petition and reinstate the action. If the petition is filed later than the thirty-day period, subdivision (d)(3) requires that the plaintiff must make a show in to the court that the petition was promptly filed and that there is a reasonable explanation or legitimate excuse both for the failure to file the notice of intention to proceed prior to the entry of the order of termination on the docket and for the failure to file the petition within the thirty-day period under subdivision (d)(2). B. Where the action has not been terminated An action which has not been terminated but which continues upon the filing of a notice of intention to proceed may have been the subject of inordinate delay. In such an instance, the aggrieved party may pursue the remedy of a common law non pros which exits independently of termination under Rule 230.2. (') C -". $.. -on.!. mrr' ...,.. -., :z-~. -1"') ~,. ~r"~ ~~:; '-"..{", .~~O :Pc :z :< I"-.) c:::> ~ Q"'\ C> n -f ~ ~:o j1.~ OJ.. --f~ '1:-ri :4- (5~ ~ ~ \.0 -0 3: r.,> N ----