HomeMy WebLinkAbout06-12-07
Commomwea1th of Pennsylvania
County ofCumberIand
STATE OF fen 05Y/UQ () /0.. )
In Re: Co se..-#;)./ of,-lo7 I In the CUfYL ~dANo(p.;(r!;y HohdeCO()~
'istote. of :{y-etl~1"9neR- } C ouv+AOL/Sf;LS),CA It~
c;ar/isJe..-1 f!A. 170J3
STATEMENT OF CLAIM
1. Select Medical CorporatiowBureau of Account Management hereby presents for
tl!ing against the above estate this statement of claim in the amount of$?t>/-IJ S. ~1.
2. The basis for the claim is ~elect Medical Corporation Account # I ( ~:? ~ for date
of service crllLfJo6 -10/3/05.
3. The tax identification number of the claimant is 23-2892355.
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4. The name and address of the claimant is: Select Medical Corporation 3607 Rose!j!QJJt
Avenue Suite 502 Camp Hill P A 17011.": r~i
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5. This claim i!...!!.2! contingent.
6. This claim i!...!!.2! secured.
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Betore me the subscriber personally appeared Angel Brown. who is being duly sworn
according to law, doth depose and say that the above facts are true and correct to the best
of her knowledge and belief.
i.,h
ExecutedthiS~daYOf-ff.1m 0./ .20-1t1-
~~ ~~7/7-z...)L/-36Zl5
Angel Bro. . Bureau of Account Management Claimant
State of Pennsylvania. County of Cumberland
IN:"WITNESS WHEREOF. I haye set my hand and notarial seal this
7j),
day of
iJ' 1. JY/ ()
,20 H
..
m~~
SYLYANIA
. SEAL
Heather M Thorn. Notary PubUc
Camp Hill. Cumberland County
My COIIUIIiuion oxpiNs Apr. 08. 2008
~\
My Conunision Expires: {lph. J t ~IDY
10
1SSH..CAMPHILL
503__NORTH2lST
_.. ..cAMP-.l!ILL-.----
2...SSH...CAMPHTLL
. .STREE.T__~__..EO_....BOX.....6.42369.__
lTTSRURGR~.._~....._.PA
38ZIGNER IRENE M
4414 ROYAL OAK
CAMP HILL
PHONE (717)
ROAD
PA 17011
763-4449
b
C
d
42 REV. CD. 43 DESCRIPTION
44 HCPCS / RATE / HIPPS CODe
48 NO~ERED CHARGES 49
ROOM & .EOARD.... .
PHARMACY. aDEltAL
PHARMACY IV SOLUTIONS
'omft:..p~.". .
.MED/ SUR SUPpLIES GENERA.
iJLOOD.ADMINISTRATION
923.00
11
12
13
,.
17
,.
19
~i=';i'~~H~';;..'.' ..
~ 'o,':X
c
ff~llNT CONTROl NUMBER
$515MPL0't1ilt NAMl!
4?7 ~;I
V4t:; ;I
68
NPI
UB-POST DATE\P VEsoJ(fsjQo67
NlJB<:f~""'~ UC3610506
....
T FIRST lI--- ... . ... .~_
E CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF
* REPRINT *
"~I
bOSS O.3B~0 AT 0.308
111111.1.1'1.1,1.111111'111.1.11111'111111.111111..1.11.1'1.11
SELECT CAnp HILL
PO BOX "~i!3"'l
PITTSBURGH. PA 15i!"~-i!3b'l
2-l
,...."'Q'llestions concerning ~Iaim payment, denial, appeals; ~
contact customer se Ice at: (800) 410-7778 CUI
I MAIL HANDLERS ENEFIT PLAN
Ii PROVIDER NAME: ELECT CAMP HILL
I TAX 10 NUMBER: 51885943
i GROUP NUMBER: 5010 009
I CLAIM:
I MEMBER:
MEMBER 10: 1682 3548 I
PATIENT: IREN . (SPO) I
ACCOUNT #, . d *-E/ I
DATE: 11/102006 - fA" D 6-/ !
CHECK #: I1410 I
CHECK AMOUNT: 9,769,35 :
AS
eXPLANA ION OF BENEFITS
LESS r.':'.'PU~:,.'''1 LESS I""'~ " i
17,537,00 957 ")i:;;~lJ ~EDUCTI&E CO-PAY 1,~AYMe~1
X 10,639,06(977)( ~~i~;~' G~,~ )(.$.78$:~1
':"28::~l)~~~ NETPA~:::~~jl-
1"".'1":1$"'"
MAIL HANDLERS BENEFIT PLAN
PO, BOX 8~()2
LONDON. KY ~0742
;,.'
io
..,-
G
Fonnlrding Sen'ice Requested
. ,
3-DIGIT 1S2
476 - CAMP HILL
../
"::' ;.';", ','I PROC t':::.'" SERVICE DATES .Q~~oc;lol
',~.t~'" CODE '" ",.-.:.":~,,
'" ,~~", ',' ~~", DISCOUNT
=11'~~i: '~;\+p9I1 ?:::~i;=1
Jr,I~~~s'!:, :~:::!I:,f'9'1M>ST~~~ ":;;i';:,i~~~;~
;.. ',:::.:::::;~::' . ::t~t:;:~:;:-: ,. .., ::: :-:-:'::.:::::~-,::/:..:~:<<
... ..... ::"::::_:::-i;':':-:-..:
,".: .',:':. ,,:~. ":. :.:;:.:,. ,',c.,." ,';
: :_~): .~:?~.::.; . ,
11238 P132 MHBP Y3 345
~.. e:!(p,l~nl!!~i9J"! COVERAGE EXCLUDES EDUCATIONAL, VOCATIONAL OR TRAINING SE ICES OR SUPPLIES.
~ BENEFITS DENIED BECAUSE THE PLAN PROVIDES BENEFITS ONLY FO~ COVERED SERVICES AND SUPPLIES THAT ARE
MEDICALLY NECESSARY AS DEFINED BY YOUR PLAN, i
9n DISCOUNTED RATE WAS ARRANGED BY THE PROVIDER LISTED AND MIJL TIPLAN, PATIENT IS NOT RESPONSIBLE FOR
DISCOUNT. CALL 800-546-3887 WITH QUESTIONS,
.----
COMMENTS: PATIENTlDl476001123803
DEDUCT/COPAY:
THE PATIENT IS RESPONSIBLE FOR THIS AMOUNT, HOWEVER, SOME d>R ALL
OF THE AMOUNT SHOWN MAY HAVE BEEN PAID AT THE TIME OF SERViCE,
FIIIlST HIAL TH ACCEPTS MEDICAL & DENTAL CLAIMS ELECT"ONICALL y, CLAIMS FOR ALL FIRST HEALTH APDRCSSES CAN BE SUBMITTED USING PAYER 10 11&2413
... fir.' ....Ilh D1rKt I. now p.vI 0' the Coventry H.aIthCar. Network. on
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