HomeMy WebLinkAbout06-21-07
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
DECEDENrs NAME (LAST, FIRST. AND MIDDLE INITIAL)
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JANET
V.
DATE OF BIRTH (MM-DD-Year)
KEPNER
DATE OF DEATH (MM-DD-Year)
12/26/2006 02/02/1926
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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[X] 1. Original Retum
D 4. Limited Estate ,
0- 6. Decedent Died Testate (AttachcopyofWilij
D 9. Litigation Proceeds Received
o 2. Supplemental Retum
D 4a. Future Interest Compromise (dale of death alter 12.12-82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trust)
D 10. Spousal Poverty Credit (dale of death between 12-31-91 and 1-1-95)
OFFICiAl USE ONLY
FIBUMB~R 0 f W 0 d-
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COUNTY CODE YEAR NUMBER
SOCIAL SECURITY NUMBER
1 84- 2 0 - 4 056
THIS RETURN MUST BE FILED IN DUPUCATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 3. Remainder Retum (date of death prior to 12-13-82)
o 5. FederaJ Estate Tax Retum Required
_ 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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COMPLETE MAILING ADDRESS
60 WEST POMFRET STREET
0.00 X _ (15) 0.00
0.00 X .045 (16) 0.00
0.00 X .12 (17) 0.00
0.00 X .15 (18) 0.00
(19) 0.00
NAME
DOUGLAS G. MILLER ESQUIRE
FIRM NAME (If Applicable)
IRWIN & McKNIGHT
TELEPHONE NUMBER
717 249-2353
CARLISLE
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole.Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7.lnter.Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (line 8 minus Line 11)
13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(9)
(10)
14. Net Value Subiect to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPA YMENT
PA 17013
0.00
OFFICIAL USE ONLY
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25,734.76
23,734.29
6,994.20
(11)
(12)
(13)
30,728.49
-4,993.73
(14)
-4,993.73
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RJ;SIDENLQECEQI;NT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONALPROPERTV
-----
FILE NUMBER
ESTATE OF
KEP~ER___
JANET
V. __n _~~~==~~~____ ____ ___ _____ _ __==~~=_____
Include the proceeds of litigation and the date the proceeds were received by the estate.
_ __AIIf)ropt'I'ty~~n!l}'-oYln~d with right of survivorship must be disclosed on Schedule ~_________
1- ____nun
ITEM ~
~_~~;ft_ _~_~~_~ES~t=!I,=TI()N=.- ~=__.=
1. SOVEREIGN BANK - CHECKING ACCOUNT #2891035542
VALUE AT DATE
OF DEATH
652.1
2.
VEHICLE - MERCURY TRACER
3,500.0
TOTAL (Also enter on line 5, Recapitulation) _~_______ ~~gl~
(If more space is needed, insert additional sheets of the same size)
REV-1fi10 E>>-+ (6-98)
,. *
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
KEPNER JANET
FILE NUMBER
V.
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV.1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE Of TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST <IF APPLICABLE) VALUE
1. NELL'S 401 (K) 82.57 100. 82.57
2. 11 NORTHVIEW DRIVE, NORTH MIDDLETON TOWNSHIP, 21,500.00 100. 21,500.00
CARLISLE, PENNSYLVANIA
SOLD - SETTLEMENT SHEET ATTACHED
PERSONAL PROPERTY DONATED TO CHURCH-
NO VALUE
APPLIANCES TRANSFERRED WITH MOBILE HOME SALE
TOTAL (Also enter on line 7 Recapitulation) $ 21.582.57
(If more space is needed. insert additional sheets of the same size)
REY--151 ~X + (12-99)
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"
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
KEPNER
JANET
v.
Debts of decedent must be reported on Schedule I.
DESCRIPTION
~T
ITEM
NUMBER
L
AMOUNT
---- --------- -- --- ------
A. FUNERAL EXPENSES:
1. EWING BROTHERS FUNERAL HOME, INC. 7,083.
2. GEORGE'S FLOWERS 239.
3. FUNERAL LUNCHEON 106.
4. PASTOR 80.
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s}/EIN Number of Personal Representative(s}
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees IRWIN & McKNIGHT 1,800.
3. Family Exemption: (If decedents address is not the same as claimants, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Prepare~s Fees PATRICIA A. ROSENDALE, CPA 350.
7. REGISTER OF WILLS - FILING FEE 15.
8. DIANE GOLDER - REIMBURSEMENT OF CARPET DRYCLEANING 139.
9. DIANE GOLDER - REIMBURSEMENT OF HEATING BILL 374.
10. CLOSING COSTS FROM SALE OF MOBILE HOME 13,539.
11. NOTARY FEES 5.
9C
5C
81
DC
oc
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OC
95
9S
14
00
TOTAL (Alsoellteron~ine9. Heca~t~atiOl1)I: .
(If more space is needed, insert additional sheets of the same size)
.23,734.2Q
REV.'1512fx + (6-98)
, . \ $'
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SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
"
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
KEPNER
FILE NUMBER
JANET
v.
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1. PP&L - ELECTRIC
VALUE AT DATE
OF DEATH
217.99
2. NORTH MIDDLETON AUTHORITY - WATER/SEWER
448.28
3. YORK WASTE - TRASH
83.34
4. UNITED STATES TREASURY - REIMBURSEMENT OF SOCIAL SECURITY
1,002.00
5. ALLSTATE INSURANCE COMPANY - INSURANCE
40.35
6. CAPITAL ONE BANK - CREDIT CARD #5178052238958876
1,146.65
7. COM CAST CABLE - CABLE
134.28
8. 2005 COUNTY & TOWNSHIP PER CAPITAL TAX
NORTH MIDDLETON TOWNSHIP
28.50
9. BELVEDERE MEDICAL CORPORATION - MEDICAL
174.39
10. BLUE MOUNTAIN ANESTHESIA - MEDICAL
397.29
11. BRONSTEIN JEFFRIES, PA - MEDICAL
215.32
12. CARLISLE DIGESTIVE DISEASE ASSOCIATES, LTD. - MEDICAL
119.71
13. CARLISLE NEUROCARE - MEDICAL
80.85
14. CARLISLE HOSPITALlSTS - MEDICAL
392.77
15. CARLISLE REGIONAL MEDICAL CENTER - MEDICAL
1,091.66
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
6,994.20
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K~NER
"-
Decedent's Name
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
JANET
v.
Page 1
File Number
Schedule 1- Debts of Decedent, Mortgage Liabilities, & Liens
ITEM
NUMBER DESCRIPTION AMOUNT
16. CARLISLE UROLOGY - MEDICAL 19.12
17. CENTRAL PENN MGMT - MEDICAL 14.31
18. CRNA CARLISLE - MEDICAL 19.48
19. CUMBERLAND PATHOLOGY ASSOC. - MEDICAL 8.12
20. CV NEPHROLOGY ASSOC. INC. - MEDICAL 333.21
21. KINETIC IMAGING, INC. - MEDICAL 10.00
22. LANe HMA PHYS MGMT CENT PEN - MEDICAL 507.21
23. MOFFITT HEART AND VASCULAR GROUP - MEDICAL 114.32
24. PHILIP D. CAREY, MD - MEDICAL 100.79
25. YELLOW BREECHES FAMILY MEDICINE - MEDICAL 220.05
26. SOVEREIGN BANK - OVERDRAFT FEE 5.00
27. CUMBERLAND-GOODWILL FIRE RESCUE - AMBULANCE 69.21
SUBTOTAL SCHEDULE I 1,420.82
GRAND TOTAL SCHEDULE I $ 6,994.20
REV-1513 EX + (p_om
'1'..
... COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
.IANFT V
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS [include outri~ht spousal distributions, and transfers under
Sec. 9116 (a (1.2)]
1. SUSAN ROSARIO Lineal
40 G STREET 1/3 REMAINDER
CARLISLE, P A 17013
2. DIANE GOLDER Lineal
125 AMY DRIVE 1/3 REMAINDER
CARLISLE, PA 17013
3. SCOTT KEPNER Lineal
506 S. WATSON 1/3 REMAINDER
SEAGOVILLE, TX 75159
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
ll. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHAR IT ABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
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Sovereign Bank
Janet V. Kepner
184-20-4056
December 26, 2006
ESTATE OF
SOCIAL SECURITY #:
DATE OF DEATH:
Account #: 2891035542 Type: Checking
In the name of: Janet V Kepner or Diane J Golder
Date of Death Balance:
Int.(YTD) from 1/1/2006
Accrued interest to date of death:
Other Info: Account closed on 02/06/07.
Open date: 4/13/1994
to
$652.19
12/13/2006
$0.02
$0.24
Account#: 6817173094 Type: Loan
In the name of: Janet V Kepner
Date of Death Balance: Account closed prior to death
Int.(YTD) from to
Accrued interest to date of death:
Other Info: Account closed on 06/12/06.
Open date: 6/12/2002
Page 1 of 1
SETTLEMENT STATEMENT
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Sellers: LSt 0 \J C ~ , \-:\' I(~' 1
Buyers: H' f(e c1 en \ I , v-
SELLERS TRANSACTION
SALE PRICE :
) t=" (')0 C~('-\
LESS Commision . ) ..-' "- ,
LESS Payoff B I ') \ l\, (~f~l
I . - 'c'))-~ :),
LESS OtherC5-()b \O\{(-f~; -"()..- (, . )-1-
LESS Othe~)1 CD. To Ve<., 1 2 2'!:
LESS Othertlt rent Thn} b.\ \; \ I 4.) )_2_ 5(')
PLUS Proration of Lot Rent B-
PLUS Proration of Taxes ~)(} ..~/=)
/,_~USOther: / 0- (+) t;:.:O.')')
~ FaeM-SElbERS $ eJ \ 0 \ I L\- I
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DATE
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List #
Job #
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BUYERS TRANSACTION
SALE PRICE:
Title Fees:
forerrY,..5~')L Insurance _-- \ -
Closing Fees:
Proration of Lot Rent:
Proration of Taxes:
School ~_ County ~
,/""
Years
$ '2-\, ~), L~
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Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle, P A 17013-
(717)243-2421
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January ~7
Diane Golder
125 Amy Dr.
Carlisle, PA 17013
The Funeral Service for Janet V. Kepner
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
1. PROFESSIONAL SERVICES
Services of Funeral Director/Staff. . . . . . . $3695.00
FUNERAL HOME SERVICE CHARGES $3695.00
SELECTED MERCHANDISE:
200 NG Silver Baron Casket . . . . . . . . . . . . . . . . . .
#5 Regular Scaled OBC. . . . . . . . . . . . . . . . . . . .
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THAT YOU HAVE SELECTED . . . . . . . . . . . . .
Cash Advances
Opening Grave. . . . . . . . .
Certified Copies of the Death Certificate.
Hairdresser. . . . . . . .
Sentinel Obit. . . . . . . . . . .
2.5 Hours Rock Breaking/Removal. . . . . . . . .
TOTAL CASH ADVANCES AND SPECIAL CHARGES. .
Total
Total Cost .
. . . . . . . . .- . . . . . . . . . . . . . . . .
SUB-TOTAL
INITIAL PAYMENT I DISCOUNT I CREDITS
TOTAL AMOUNT DUE
The unpaid balance over 30 days is subjected to a 1.50 % service charge per month - 18.0000 % per annum.
Member of National Funeral Directors Association
$935.00
$995.00
$5625.00
$995.00
$72.00
$35.00
$106.90
$250.00
$1458.90
$7083.90
$7083.90
0.00
$7083.90
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'!I COm.....rcial Collector.. IDe.
CREDIT COLLECTION SERVICES
I"II~IIIIIIIIIII~ /11/1
Two Wells Avenue, Dept. 9135, Newton, MA 02459
Monday - Friday: 8~Midnight, ET
Saturday: 8AM - 4PM~lJnday: 2PM - 10PM, ET
Self Service: 24 hours-a-day, 7 days-a-week (Se Habla Espanol)
(800) 326-6400
.
ACA
**********AUTO**MIXED AADC 060
Date: 04/29/07
File Number: 06014772000
CANCEL DATE: 12/23/2006
0077807707-00000-037
JANET KEPNER
11 NORTHVIEW DR
CARLISLE PA 17013-9654
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4001112902140301 - 0049
'-. '.' ....:....'...
:.-':. ':':.".':.:' .
::'::'::'.':'.':.,: .
EASY PAY: You can pay by check, credit card and/or establish a payment plan on-line
via our website: www.ccspayment.com. Otherwise, call toll-free to either self-service
your file or receive live assistance from a CCS Service Representative.
MAILING INSTRUCTIONS: Include your file number below and send correspondence to:
ecs, P.O. Box 9135, Needham Heights, MA 02494. -Payment instructions below. This
office may process your payment as a one time electronic funds withdrawal using the
account information from our check.
.-----------------------------------------------
:.\:~~Fil.:.Nutriber+}~~ym~t~.;#~::~r.~~IV.t):){::.:.
::.:.:.:06..ti14172000/\\\~::..(.::: .:::..:: ...
: - :. '::. '.' ~'.":'. -.'. .':: .~..' .',' .... ':.: '.':
~::.:.:~iJ);gp~~:.Fj:.,qt~~
CCS offers check-by-phone accommodation
Instantly pay by check or credit card by calling toll-
free for se./f-service instructions or live personal
assistance. Visit WWW.ccspayment.com for the same
payment options.
VISA · MASTERCARD · AMERICAN EXPRESS
AMOUNT DUE AS OF: 04/29/07
$40.35
;;;
;;
;;;
-
-
- -
-
-
-
!!
-
-
- ~
iii ~
- -
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":':."':'-:':'."'."'-'
'-'.:.':.
.:.::::.::::::.:::...... .
Please write your file number (above) on your check. To expedite
credit, do not send payments(s) directly to our client.
c.c.S.
PAYMENT PROCESSING CENTER - 27
P.O. BOX 55126
BOSTON, MA 02205-5126
111.11111.11.1.11111111.1111.1111111111.1.1111111.1.11111.1111
82064-1
698000049014112000000040359
1111 IIIIJIUIIIII I
ASSOCIATED RECOVERY SYSTEMS
A DIVISION OF ARS NATIONAL SERVICES. INC.
P.O. BOX 469046
ESCONDIDO, CA 92046-9046
(888) 238-8232 FAX: (866) 422-0765
www.PayARS.com
Dc~rtmcnt # 5996
. . ~O. Box 1259
. ~.. Oaks, PA 19456
~
May 22, 2007
7259 - 4966
ACCOUNT IDENTIFICATION
Re: CAPITAL ONE BANK
Account: 5178052238958876
ARS Acct No: 12343113
Balance: $1146.65
JANET V KEPNER
11 NORTHVIEW DR
CARLISLE P A 17013-9654
Dear Sir/Madam:
Please be advised that the above-referenced account has been placed with Associated.Recovery Systems for collection.
To discuss payment, contact this office at (888) 238-8232, Monday through Friday, 6:30 a.m. - 8:00 p.m (Mountain
Time).
Unless you notify this office within 30 days after receiving this notice that you dispute the validity of thjs debt or any
portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days from receiving
this notice, this office will: obtain verification of the debt or obtain a copy of a judgment and mail you a copy of such
judgment or verification. If you request of this office in writing within 30 days after receiving this notice, this office will
provide you with the name and address of the original creditor. if different from the current creditor.
Sincerely,
ADAM ENGER
Account Representative
THIS COMMUNICATION IS FROl\'1 A DEBT COLLECTOR. THIS IS AN ATTEMPT TO COLLECT
A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
(SEE REVERSE SIDE FOR IMPORTANT INFORMATION)
------------------------------------------------------ I)ctach And Retunl Wit h Payulcnt -------------------------------------------------------------------------
100 - 12343113
Account: 5178052238958876
Print address/phone changes below
or call (888) 238-8232.
Amount Enclosed: $
HOME:(_)
WORK:(_)
Enclosing this coupon with your payment will
expedite credit to your account.
NOTICE OF ELECTRONIC CHECK
PROCESSING:
We r~serve the right to process checks electronically
by transmitting the routing, account, and check
Ilumber to the bank. By submitting a check, you
authorize us to initiate an electronic debit from your
account. A returned check may be collected
electronically if it is returned for insufficient funds.
Make your check or money order payable to:
ASSOCIATED RECOVERY SYSTEMS
PO BOX 469047
ESCONDIDO, CA 92046-9047
11.111111.11111111111.11111.1..1111111111111111
IIIIIIIIII~ 111111111110 111111111111111111111111111111111
100
7259 - 4966
November 15, 2006
EASTERN ACCOUNT SYSTEM
OF CONNECTICUT, INC.
New York License #1015456
P.O. Box 837
Newtown, CT 06470
(800) 750-6343
(914) 763-3351
.
, .. )P~O. Box 837
'~ ". Newtown, cr 06470
Change Service Requested
PERSONAL & CONFIDENTIAL
#BWNLPGJ
#0654 2700 0244 4303#
1...111.1.11111111.111111.1.1...11...1.1..11.11..111..111.1.11
Kepner, Janet 12902852
11 Northview Dr
Carlisle, P A 17013-9654
ACCOUNTIDEN~CATION
Creditor #: 375002- 1
Creditor: Comcast Harrisburg Service
Notice Date: November 15, 2006
EAS Account Number: 12902852
Service Balance Due: $ 134.28
Equipment Balance (if not returned): $
Total Balance Due: $ 134.28
* * * FINAL NOTICE * * *
Our records indicate that you owe $134.28 which is long past due.
Pay this account immediately. This is absolutely final.
III III IMPORTANT * *
To be sure of proper credit and to stop further procedure make your payment in full.
We are a debt collector. This is an attempt to collect a debt. Any information obtained from you or
anyone else will be used for that purpose.
--------------------------- ------------ --------------- Detach and Return with Payment ------------------------ -------------------- - ----____
Enter the requested information in the spaces provided below:
Change of Address:
For: Janet Kepner
Street Address:
City, State, Zip:
Telephone:
Creditor #: 375002- 1
Creditor: Comcast Harrisburg Service
Notice Date: November 15, 2006
EAS Account Number: 12902852
Service Balance Due: $ 134.28
Equipment Balance (if not returned): $
Total Balance Due: $ 134.28
Eastern Account System of Connecticut, Inc.
P.O. Box 837
Newtown, CT 06470-0837
1111.1.11.1.1..11..1111.1.111..1..1.1.1111...1..11111..1.1.1.1
Amount Enclosed: $
Please charge to my []Visa []MasterCard []American Express []Disco'V
Card Number
Expiration Date
Name of Cardholder
Signature
Enclosing this notice with your payment will expedite credit to yc
account.
FINALCBL 000633A 1 511 000008319065427 S-CRE
MAKE CHECKS PAYABLE TO:
BEL,V1=DERE MEDICAL CORPORATION
85~WALNUT BOTTOM RD
, . ~~RLlSLE, PA 1;V<J13-3698
~ '(717) 243-312cr
March 19; 2007
~
Statement
Payment Due 30 Days From Statement Date
Account #
78328
Bi\IlG?
If P .
b Ch k
JANET KEPNER
ESTATE OF JANET KEPNER
11 NORTHVIEW DRIVE
CARLISLE, PA 17013
}(lIIr Ker to Betta Hm!tlI
avmo IV ec Check #
IF PAYING BY CREDIT CARD, FILL OUT BELOW
o MasterCard o VISA
o Discover
CARD NUMBER
EXP.DATE
SIGNATURE
~ P~~~~chp~h~~~hrn onroveffie~~e.
. - 1- . II -. . · '. -. I · "
Practice: BELVEDERE MEDICAL CORPORATION 850 WALNUT BOTTOM RD CARLISLE, PA 17013.3698
Responsible Party: 78328 . JANET KEPNER
Patient 78328. JANET KEPNER
Visit 610017
11/06/2006
12/11/2006
11/06/2006
12/11/2006
Monday, November 06,2006 INPATIENT HOSPITAL JAMES HARDESTY
Line Item 99222 - INITIAL HOSPITAL CARE 789.00
Ins: HIGHMARK MEDICARE SERVICES Pmt
Line Item 47562 - LAP CHOLESTECTOMY 574.10
Ins: HIGHMARK MEDICARE SERVICES Pmt
$227.00
-$205.11
$2,987.00
-$2.860.06
Visit 616784
11/23/2006
01/22/2007
Thursday, November 23.2006 INPATIENT HOSPITAL JAMES HARDESTY
Line Item 49420 - INSERT ABDOMINAL DRAIN 868.02
Ins: HIGHMARK MEDICARESER\lICESPmt
$592.00
-$566.44
$25.56
60.90 Days
$0.00
90-120 Days
$148.83
Over 120 Days
Aging: Current
30-60 Days
$0.00
$0.00
Accounl
Balance
Pending
Insurano':)
$174.39
THERE WILL BE A $25.00 CHARGE, IF A CHECK IS RETURNED FOR INSUFFICIENT FUNDS.
PAYMENT IS DUE APRIL 19, 2007.
**PAST DUE** CALL 243.9463
$0.00
Patient
Amount Due
$174.39
Bi\IlG?
tbur Key to Better Health
BELVEDERE MEDICAL CORPORATION
850 Walnut Bottom Road
Carlisle. PA 17013-3698
(717) 243-3120 FED ID NO. 23-1869105
Page: 1
~.b~ Box 329
.. ;temple, PA 19560
. ~ ~'-
~ ~ 2300000351 6707 J
RET SERV~QUESTED
IF PAYING BY VISA, MASTERCARD OR DISCOVER, FILL OUT BELOW
o 0 D.,
VISA MASTERCARD DISCOVER'
CARD NUMBER AMOUNT
PHONE
EXP. DATE
SIGNATURE
3 DIGIT SECURITY
CODE FROM BACK
OF CARD
568690-0
JANET V KEPNER
11 NORTHVIEW DRIVE
CARLISLE PA 17013-9654
1...111...1111111..111.11.1.11..11"11.1..1..1,"11...11..1.11
1'11111.111.1.1..11..1111.11'"11111111.11.11111.1.1
Berks Credit & Collections, Inc.
P.O. Box 329
Temple, PA 19560-0329
c
TOTAL.. $397.29
)
~ Dewll Hcre ~
. Detach Here.
May 7, 2007
RE .. BLUE MOUNTAIN ANESTHESIA
Account No. ~ 28505
Principal ~ $397.29
Total ~ $397.29
Dear JANET V KEPNER,
You have been previously notified regarding this delinquent account that has been placed with our office
for collection.
You are receiving this notice because you have not satisfied your outstanding delinquent balance. Your
payment or any questions you have should be directed to this office to assure proper credit to your
account.
In the event you would like to pay by phone please contact our collection representative at the phone
number listed below. F or your convenience, you can now pay by credit card online. Just go to
www.ezpaynow.com.
Berks Credit & Collections, Inc.
POBox 329
Temple, PA 19560
Sincerely,
Accounts Superyisor
610-916-7260
Out of the area, call 1-800-448-8709
All returned checks are subject to a minimum charge of $20.00.
This is an attempt to collect a debt by a debt collector, and any information obtained is used for
that purpose.
BCCOII
BCCOl1.VI
456707
..
..
Account
37614
Statement Date
May 5, 2007
Due Date
May 25, 2007
Total Due
215.32
Amount Enclosed $
1111111111111"'11111..11.1..1.1
Janet V. Kepner
11 Northview Drive
Carlisle, PA 17013
1111111,111,111111,1111111..1.11
Bronstein Jeffries, P A
4830 Londonderry Road
Harrisburg, PA 17109
r
o Please check box and indicate any change in address on reverse side.
..... ---......... ........ .......... ... .... ...... ....... ..... .... ...... ........ ....... .... ... ...... .... -... ........... ....... ...... ......... ......... ........... ... ............. ..... .... ...........
Detach at perforation and return above portion with payment.
.,
Service Date
Service Provider
Description
Payments I
Adjustments
215.32
r
t"
Bl {
.,
.---
(JIM
-
IF YOU HAVE RECENTLY MADE A PAYMENT, PLEASE DISREGARD THIS STATEMENT. BALANCES UNPAID AFTER
30 DAYS MAY BE ASSESSED A $10 BILL CHARGE. QUESTIONS REGARDING YOUR BILL, PLEASE CALL 657-2599.
Statement Date 1-30 Days
31-60 Days
61-90 Days
91-120 Days 121-150 Days Over 150 Days
May 5, 2007 0.00 0.00 126.34 88.98 0.00 0.00
Bronstein Jeffries. P A · 4830 Londonderry Road · Harrisburg, P A /7/09 · (7/7) 657-2599
Account Number: 37614 1.15.3.0 NOOOO -BEAZ20070505-00000635-00000697-0
Page 1 of 1
~
CARLISLE DIGESTIVE DISEASE
ASSOCIATES, LTD.
241 Alexander Spring Road
CarJible, P A 17015
J'ri-245-2228
Patient Statement
Wednesday, February 07, 2007
.;
~
$119.71 . .
Payment Type:
o Cash
DVisa
o
o
Check
Mastercard
Estate Of: Janet V Kepner
11 Northview Drive
Carlisle, PA 17013
Account #
Expiration Date _/_/_
Signature
Date _/
Reflects transactions posted through 21712007 for 9630
[ l't.- [.J-"'-.,-~I ~t I.. C~ ~ Kit r '-'~-' U'--It'" !., )l,f1r ...~:; P.. t r i
(Detach and remit with payment,
Estate Of: Janet V Kepner(9630)/Theodore Berk MD/086328
Location: Carlisle Regional Medical Center
11/23/2006 Ercp-lnsert.Of Stent In Duct $1,415.00 1.00 $1,415.00 $0.00
01/08/2007 Medicare Adjustment from Medicare 1078863- ($1,020.03) $0.00
01/08/2007 Payment from Medicare 1078863. ($315.98) $0.00
01/08/2007 Transfer from Insurance 1078863 ($78.99) $78.'99
Coinsurance
$0.00 $78.99
Estate Of: Janet V Kepner(9630)/Gregory Lewis MD/087117
Location: Carlisle Regional Medical Center
11/22/2006 Consult-lnitiaI/Compre/Mod Sev $220.00 1.00 $220.00 $0.00
01/03/2007 Medicare Adjustment from Medicare 1078738. ($82.48) $0.00
01/03/2007 Payment from Medicare 1078738 ($110.02) $0.00
01/03/2007 Transfer from Insurance 1078738. ($27.50) $27.50
Coinsurance
$0.00 $27.50
Estate Of: Janet V Kepner(9630)/Theodore Berk MD/087118
Location: Carlisle Regional Medical Center
11/24/2006 Subsequent-Focused Visit $90.00 1.00 $90.00 $0.00
01/03/2007 Medicare Adjustment from Medicare 1078738 ($56.97) $0.00
01/03/2007 Payment from Medicare 1078738 ($26.42) $0.00
01/03/2007 Transfer from Insurance 1078738. ($6.61 ) $6.61
Coinsurance
$0.00 $6.61
Estate Of: Janet V Kepner(9630)/Theodore Berk MD/087119
Location: Carlisle Regional Medical Center
11/25/2006 Subsequent-Focused Visit $90.00 1.00 $90.00 $0.00
01/03/2007 Medicare Adjustment from Medicare 1078738- ($56.97) $0.00
01/03/2007 Payment from Medicare 1078738. ($26.42) $0.00
01/03/2007 Transfer from Insurance 1078738- ($6.61 ) $6.61
Coinsurance
Just afriendly reminder $0.00 $6.61
that your account is overdue.
We would appreciate your payment
today!
$0.00
I I . I . · I . . ~mF.l.:IIl...,.~....''''.,.,.~:m.'''...".:
$0.00 $119.71 $0.00 $0.00 $0.00 L $119.71.l $o.oo---L $119.72.j
Carlisle Digestive Disease Associates * 241 Alexander Spring Road * Carlisle, PA 17015 * (717) 245-2228
. . . .
STATEMENT
, "
....)
, ..
This is a sta~ent for professional services
rendered~ your physician. You may receive a
separate bill from the hospital for its services.
Janet V Kepner
11 Northview Drive
Carlisle PA 17013
THIS IS A STATEfY1ENT OF SERVICES REnDERED BY
PHYSICIAf\I(S) WHO ARE f"lEfV1BERS OF
Carlisle NeuroCare
220 Wilson Street
Suite 210
Carlisle, PA 17013
717-249-8283
DATE OF SERVICE
DESCRIPTION OF SERVICE
AMOUNT
11/30/2006 Claim: 1686, Provider: Mohammad Ismail, MD
11/30/2006 Facility: Carlisle NeuroCare
11/30/2006 99254 INITIAL INPATIENT CONSULT 282.00
01/08/2007 Medicare Pennsylvania Payment 110.02
01/08/2007 Medicare Pennsylvania Adjustment 144.48
Your Balance Due On These Services ... 27.50
12/01/2006 Claim: 1695, Provider: Mohammad Ismail, MD
i2/01/2006 Facility: Carlisle NeuroCare
12/01/2006 95819 EEG MONITORING 207.00
12/27/2006 Medicare Pennsylvania Payment 46.79
12/27/2006 Medicare Pennsylvania Adjustment 148. 51
Your Balance Due On These Services ... 11.70
12/01/2006 Claim: 1696, Provider: Mohammad Ismail, MD
12/01/2006 Facility: Carlisle NeuroCare
12/01/2006 99234 OBSERV/HOSP SAME DATE 167.00
11:.'.I:I~..~'1."il I{.~'l'J~i.[. j PAYTIUS ( 80.85 ]
Janet V Kepner 9173
AMOUNT
MAKE CHECK Mohammad Ismail
PAYABLE TO:
lil:ltl9l"J.ll..il..~.:..__er,i':'~')I~[~'~'J:'.1._c:.mn
',,'..... /.>
-..':'.1 L\ anex
- ~ ASSET~AGEMENTLLC
APR 28 2007
Janet V Kepner
11 Northview Dr
Carlisle PA 17013-9654
1891 Santa Barbara Drive, #204
Lancaster, PA 17601
Telephone: 717-519-1770
Toll Free: 888-592-2144
Account For:
..
CARLISLE HOSPITALISTS
Client Account #:
343744
Balance Due:
$392.77
Your account(s) with CARLISLE HOSPITALISTS has been placed for collection.
List of accOlmts:
Name
KEPNER JANET V
KEPNER JANET V
KEPNER JANET V
KEPNER JANET V
KEPNER JANET V
KEPNER JANET V
KEPNER JANET V
KEPNER JANET V
KEPNER JANET V
KEPNER JANET V
KEPNER JANET V
KEPNER JANET V
343744
343744
343744
343744
343744
343744
343744
343744
343744
343744
343744
343744
Client Reference
CARLISLE HOSPITALISTS
CARLISLE HOSPITALISTS
CARLISLE HOSPITALISTS
CARLISLE HOSPITALISTS
CARLISLE HOSPITALISTS
CARLISLE HOSPITALISTS
CARLISLE HOSPITALISTS
CARLISLE HOSPITALISTS
CARLISLE HOSPITALISTS
CARLISLE HOSPITALISTS
CARLISLE HOSPITALISTS
CARLISLE HOSPITALISTS
Visit Date
11/08/06
11/23/06
11/23/06
11/24/06
11/25/06
11/26/06
11/26/06
11/27/06
11/28/06
11/29/06
11/30/06
12/01/06
Balance Due
1.76
27.50
25.17
40.28
40.28
40.28
25.17
40.28
40.28
15.37
10.81
10.81
Please contact this office at 717-519-1770 or 888-592-2144 to make suitable arrangements to pay this outstanding
balance.
This is an attempt to collect a debt and any infonnation obtained will be used for that purpose. Unless you notify this
office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereot: this
office will assume this debt is valid. If you notify this office in writing within 30 days after receiving this notice, this
office will obtain verification of the debt and mail you a copy of such verification. If you request from this office in
writing within 30 days after receiving this notice, we will provide you with the name and address of the original
creditor, if different from the current creditor. This communication is from a debt collector.
Please refer to our account number 2621740 when calling or writing about this account.
... Please detach below and retum in the enclosed envelope with your payment ...
lfyoQ wIsIt to pay by erecIit cant. pIaIe enter the requested inf'onnation in
spaces provided
IgIIIIOI_III_IIIII_lllgll
PO Box 7044
Lancaster PA 17604-7044
RETURN SERVICE REQUESTED
Date: APR 28 2007
Amount: $392.77
Account: 343744
002267-APEX1241 TY62492C46
=:ED ~ D IIiID II 0
~~----------------
E:lplnltion Date: AmotmtAuthorized: S
Slpature:
3 Digit Seew1ty Code (back of card) ___
BDIinc Addreu:
CPMC41 2621740 1241 LAN
Janet V Kepner
11 Northview Dr
Carlisle PA 17013-9654
1111111111111111.1.111111.111111111111.1..1..111.111..11..1.11
Send Payment To:
APEX Asset Management, LLC
PO Box 7044
Lancaster PA 17604-7044
111I11I11I1.111111111I1..1111111111I.1111.1111.1111.1111111111
. '.
..
l
,~
, CARuSLE
REGIONAL 45 Sprint Drive
ME Die ALe EN T E R Carlisle, PA 17013
~ADDRESS SERVICE R~~D
PATIENT ACCOUNT STATEMENT
007852 858HHA 000068R
IF PAYING BY CREDIT CARD, FILL OUT BELOW AND SEE REVERSE SIDE
CHECK CARD USING FOR PAYMENT
AlA 0 .0 :_0 t~o
~ MASTERCARD DISCOVER ! VISf I VISA I:'''"'''''''' AMERICAN EXPRESS
ACCOUNT NO. STATEMENT DATE BALANCE DUE
5010019
12/25/2006
$952.00
--
~ UPON RECEIPT
MAKE CHECKS PAYABLE TO:
KEPNER, JANET V
11 NORTHVlEW DR
g CARLISLE
....
PA 17013
CARLISLE REGIONAL MEDICAL CENTER
246 PARKER ST.
P.O. BOX 4100
CARLISLE PA 17013-4100
11111111111111.1..111.111.11.111.1.11111111.1111111111..1..1.1
1...111.11111......111111.111111111111.1..1111...11...11..1.11
o Please check if above address is incorrect and indicate change on reverse side.
PATIENT NAME
KEPNER, JANET V
TO INSURE PROPER CREDIT, DETACH AND RETURN THIS PORTION IN THE ENCLOSED ENVELOPE.
PATIENT ACCOUNT NO. DATE OF SERVICE
5010019 11/06/2006
DESCRIPTION
11/21/06
12/04/06
12/04/06
ADJUSTMENT
MEDICARE DISCOUNT
MEDICARE PAYMENT
PAYMENTS AND CHARGES RECEIVED AFTER THE STATEMENT DATE WILL BE REFLECTED ON THE NEXT STATEMENT.
MESSAGES
As of today, we have not received paymentin full on
your account. Immediate payment is required, please
contact our business office today.
FOR BilLING QUESTIONS, PLEASE CAll:
{717} 960-1680
, '.
- .
.,;
'4L
,
CARuSLE
REGIONAL 45 Sprint Drive
M ED I C ALe EN T E R Carlisle, PA 17013
~ADDRESS SERVICE REQUESTED
---~-------""""'''''-,,",''''''''l::~--'''._-~'.
-vunec: .!Nt""" VUlJ.n'.If---
IF PAYING BY CREDIT CARD, FILL OUT BELOW AND SEE REVERSE SIDE
CHECK CARD USING FOR PAYMENT
. 0 . 0 .1III!!J!IIIl 0
. - !>c., MASTERCARD DISCOVER ! ~ VISA
ACCOUNT NO. STATEMENT DATE BALANCE DUE
~~o
~:~Vf;j~ AMERICAN EXPRESS
...
~
UPON RECEIPT .1
9353310
12/18/2006
$139.66
MAKE CHECKS PA VABLE TO:
KEPNER, JANET V
11 NORTH VIEW DR
:;; CARLISLE
(II
PA 17013
CARLISLE REGIONAL MEDICAL CENTER
246 PARKER ST.
P.O. BOX 4100
CARLISLE PA 17013-4100
1...11111111111111.111111.1111.1.1..111111111111111111111111.1
111111111.111.111..111111.1.1.11111111.1..1..111.11.1111111.11
o Please check if above address is incorrect and indicate change on reverse side.
TO INSURE PROPER CREDIT, DETACH AND RETURN THIS PORTION IN THE ENCLOSED ENVELOPE.
PATIENT NAME
KEPNER, JANET V
11/21/06
11/21/06
MEDICARE DISCOUNT
MEDICAREPAVMENT
PATIENT ACCOUNT NO. DATE OF SERVICE TYPE OF SERVICE
9353310 11/02/2006 EMERGENCV/ROOM
DATE
PAYMENTS AND CHARGES RECEIVED AFTER THE STATEMENT DATE WILL BE REFLECTED ON THE NEXT STATEMENT.
MESSAGES
As of today, we have not received payment in fUll on
your account. . Immediate payment is required,' please
contact our business office today.
FOR BILLING QUESTIONS, PLEASE CALL:
(717) 960-1680
PAYMENT DUE BY ----.
. . ~
"~) 'Ii ~TQA~E~
1891 Santa Barbara Drive, #204
Lancaster, PA 17601
Telephone: 717-519-]"J70
Toll Free: 888-592-2144
MAR 23 2007
CARLISLE UROLOGY
Janet V Kepner
11 Northview Dr
Carlisle PA 17013-9654
489922
$19.12
Your account(s) with CARLISLE UROLOGY has been placed for collection.
List of accounts:
Name
KEPNER JANET V
48 99~2
Client Reference
CARLISLE UROLOGY
Visit Date Balance Due
11/11/06 19.12
Please contact this office at 717-519-1770 or 888-592-2144 to make suitable arrangements to pay this outstanding
balance.
This is an attempt to collect a debt and any information obtained will be used for that purpose. Unless you notify this
office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this
office will assume this debt is valid. If you notify this office in writing within 30 days after receiving this notice, this
office will obtain verification of the debt and mail you a copy of such verification. If you request from this office in
writing within 30 days after receiving this notice, we will provide you with the name and address of the original
creditor, if different from the current creditor. This communication is from a debt collector.
Please refer to our account number 2139612 when calling or writing about this account.
002456-APEX1241TY5E6E28
*** Please detach below and return in the enclosed envelope with your payment *.*
IIIB I1111I111 U 1I11111111I11II11I1111 111111111111111111
PO Box 7044
Lancaster PA 17604-7044
RETURN SERVICE REQUESTED
If you wish to pay by credit card, please enter the requested infonnation in
spaces provided
=r.E01E30.0 .0
Date: MAR 23 2007
Amount: $19.12
Account: 489922
Card#:________________
Expiration Date: Amount Authorized: $
Signature:
3 Digit Security Code (back of card) ___
BUUng Address:
CPC419 2139612 1241 LAN
Janet V Kepner
11 Northview Dr
Carlisle PA 17013-9654
111111111111111111111111111.111.111111.1111111.111111111111.11
Send Payment To:
APEX Asset Management, LLC
PO Box 7044
Lancaster PA 17604-7044
111.111.111.11..11111.1111111.111.11.111111111.1111.11111.1111
, '..
, ~ ~~DICAL REVENUE SERVICES
, P.O. BOX 1149
SEBRING FL 33871
Reference
13946
Total Amount Due
$14.31
Toll Free Number
(800) 315-6050
RETURN SERVICE REQUESTED
12/15/2006
.. CHECK CARD USING FOR PAYMENT
I i_~ D \~~~: D . 0
CARD NUMBER
AMOUNT I EXP DATE
SIGNATURE
~,:., ~'4 =-et:l=et~.:l'~"I:.' :I.=-'~~ 1...:1 ~~I. ..e
MED9AX.AITFSP000521.A12SQY.013147 013137
-
---
-
iiiiii
iiiiiiiiiii
!!!!!!!!!!!
JANET V KEPNER
11 NORTHVIEW DR
CARLISLE PA 17013
111111111111111111111111111111 a IIII
MEDICAL REVENUE SERVICES
PO BOX 1149
SEBRING FL 33871-1149
11111...11.1111.111.1'111111I11'1111.1..11.111.1..11.11111'111
D CHECK HERE IF ADDRESS OR INSURANCE INFORMATION IS
INCORRECT AND INDICATE CHANGE ON REVERSE SIDE
--,..- .H._' .On __ _ ...._.. . ._.,.. __ ".... __ . _ uu _ __ __..__Hhnu_u__._.,..
Page 1 of 1
.mmuu . ..umy'.~.~!~c;H.HERE". AND. RETURN TOP PORTI()~V\I~~.H.'l'()~~u~~v.~.~~!.
Medical Revenue Service is a collection agency, retained to represent the below named creditor. Since you have
failed to pay this obligation in full, we now must determine your ability to repay this debt. The information we may be
seeking, if available, to determine what further collection effort to take is:
Real Estate Ownership Business Ownership
Automobile Ownership Other Public Record Assets
Boat Ownership Verification of Employment
Aircraft Ownership Professional Licenses
Unless you notify this office within thirty (30) days after receiving this notice that you dispute the validity of this debt or
any portion thereof, this office will assume this debt is valid. If you notify this office in writing within thirty (30) days
from receiving this notice, this office will: obtain verification of the debt or obtain a copy of a judgement and mail you
a copy of such judgement or verification. If you request this office in writing within thirty (30) days after receiving this
notice, this office will provide you with the name and address of the original creditor, if different from the current
creditor.
Please make your check or money order payable to Medical Revenue Service. In order to assure proper credit to
your account, include the reference number with your payment. We also accept "check by telephone" for your
convenience. If you have any questions, you may contact an account representative at the above listed phone
number.
Pursuant to Section 807(11) FDCPA, this communication is from a debt collector and is an attempt to collect a debt.
Any further information obtained will be used for that purpose.
A. U. Clancy
Collection Department
AUC/tb
Account #
Client Name
Service
Date
Balance
Patient Name
13946
Central Penn MGMT
05/17/2006
14.31
Kepner, Janet V
TOTAL BALANCE: $14.31
PL1
, '..
..L~
....~.. a. ex
- ASSElb?AGEMENTLLC
1891 Santa Barbara Drive, #204
Lancaster, PA 17601
Telephone: 717-519-1770
Toll Free: 888-592-2144
MAY 08 2007
Account For:
CRNA CARLISLE
Client Account #:
496851
Balance Due:
$19.48
Janet V Kepner
11 Northview DR
Carlisle PA 17013-9654
Your account(s) with CRNA CARLISLE has been placed for collection.
Li~1 of accounts:
Name
KEPNER JANET V
496851
Clien~ Reference
CRNA CARLISLE
Visi~ Date Balance Due
11/07/06 19.48
Please contact this office at 717-519-1770 or 888-592-2144 to make suitable arrangements to pay this outstanding
balance.
This is an attempt to collect a debt and any infonnation obtained will be used for that purpose. Unless you notify this
office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this
office will assume this debt is valid. If you notify this office in writing within 30 days after receiving this notice, this
office will obtain verification of the debt and mail you a copy of such verification. If you request from this office in
writing within 30 days after receiving this notice, we will provide you with the name and address of the original
creditor, if different from the current creditor. This communication is from a debt collector.
Please refer to our account number 2687982 when calling or writing about this account.
012609-APEX1241 TY63472867
IDIIIII_IIIIIII_III_lgIU
PO Box 7044
Lancaster PA 17604-7044
RETURN SERVICE REQUESTED
- Please detach below and return in the enclosed envelope with your payment -
Iryou wish to pay by eredit ami, please enter the requested inlonnation in
spaten provided
Cleo EID iii 0 liD
Date: MAY 08 2007
Amount: $19.48
Account: 496851
~~----------------
EIpiration Date: Amount Authorized: S
Signature:
3 Digit Security Code (back of ami) ___
Billing Address:
CPC416 2687982 1241 LAN
Janet V Kepner
11 Northview DR
Carlisle PA 17013-9654
11111111111111111111111111111111111111111111111111111111111.11
Send Payment To:
APEX Asset Management, LLC
PO Box 7044
Lancaster PA 17604-7044
11..1111111.11..1111111..11.11111 m .1111.1111.1..1.11111.1111
. '..
.... .
!
'~..
~
Cumberland-Goodwilf Fire Rescu
GENERAL RECEIPTS
PO BOX 12910
PHilADELPHIA, PA 19101
Phone #: (800) 367-0512 Federal Tax 10: 23-2298422
,*'........LJ...I.~.,
/~ .'
" ...
~.
PATiENT NAME: JANET KEPNER
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF C !)'LL:
CALLER:
FROM:
TO:
INSURANCE; MEDICARE B
2040789530
CG0604424
JANET KEPNER
11 NORTHVIEW DR
CARLISLE, PA 17013
REASON(S)
FOR
TRANS PO FIT
INVOICE
7940
CG0604424
11/21/2006
NMCI
NONE
Police/Fire/911
11 NORTHVIEW DR
CARLISLE REGIONAL MEDICAL CTR
DIZZINESS - VERTIGO
WEAKNESS - MUSCLE
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
BLS EMERGENCY BASE RATE A0429 I 1.0 350.00 350.00
MILEAGE CHARGE A0425 8.0 7.00 56.00
I
Total Charges 406.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Medicare Assignment Adjustment 01/18/2007 59.95
Medicare Part B Payment 107921025 01/18/2007 276.84
Total Credits 336.79
PLEASE PAY THIS AMOUNT .... $69.21
PATIENT NAME: KEPNER, JANET
PATIENT NUMBER: 7940
CG0604424
02/02/2007
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
CALL NUMBER
BILLING DATE:
69.21
Medicare has paid their portion of your ambulance bill. The
balance is the Co-Payor Deductible that is your
responsibility.
Cumberland-Goodwill Fire Rescu GENERAL RECEIPTS PHILADELPHIA, PA 19101
" \>0 Box 8666
. ~ .~! Lancaster P A 17604-8666
~ .. ~ ADDRESS SERVICE REQUESTED
./
/
Ii
COLLECTION CENTER IND., INC.
(717) 569-5515. (800) 260-8264
December 12, 2006
AG No: 509962-1
Amount Due: $8.12
509962-1 - 4 - 001479
Janet V Kepner
11 Northview Dr
Carlisle PA 17013-9654
111111'111,,11111111'11"111111111111111111111111111111111'111
Collection Center Ind., Inc.
PO Box 8666
Lancaster PA 17604-8666
111111I111111111"111I'111111'111111111111,1111"11I1'11I'1111
.... Detach Up,... PII'dGa aad Rft1InI WIdI P.,....n ...
Client: CUMBERLAND PATIIOLOGY ASSOC
AG No: 509962-1
Client Ref#: 7585-01
Date ofSVC: 05/17/2006
Amount Due: $8.12
1.11 - CCIN2004TY52714F42
Dear Janet V Kepner,
Your account has been placed with our agency for collection. Our client has instructed us to commence with all the
collection means at our disposal. We are prepared to collect your account without inconvenience to you if at all
possible.
Your cooperation is necessary to resolve this most important matter. Because of your failure to remit, we are
scheduling this account to begin collection procedures.
To avoid further collection efforts, please make a prompt remittance and address all correspondence to Collection
Center Ind., Inc.
DO NOT DELA~ REMIT YOUR BALANCE IN FULL! Please call 800-260-8264 to discuss any questions you
may have.
Sincerely,
1)M4fd;e ~~
Donald R. Roberts
Collection Supervisor
Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this
debt or any portion thereof, this office will assume this debt is valid. If you notify this office in writing
within 30 days from receiving this notice, this office will: obtain verification of the debt or obtain a copy of
a judgment and mail you a coPY of such judgment or verification. If you request this office in writing within
30 days after receiving this notIce, this office will provide you with the name and address of the origtnal
creditor, if different from the current creditor. This is an attempt to collect a debt by a debt collector. Any
information obtained will be used for that purpose.
STATEMENT
. . .
..
~'/'~ HROLOGY ASSOC INC
6ct ~ WEST ST
RLISLE, PA 17013
Statement Date 01/29/07
Account Number 4840-1
Account 10 :84204056
Page Number 3 of 3
. BG MC A0
~
BILL TO:
JANET V. KEPNER
11 NORTHVIEW DR
CARLISLE PA 17013
Pa~lent: J~~ET v. KEPNER
INDICATE
AMOUNT PAID $
layments made after statement date will appear on your
ext statement.
PLEASE RETURN THE TOP PORTION WITH YOUR REMITTANCE
Reference DeSCription Amount Charged Payments 'Adjustments Insurance Pending Your Balanc
99231 HOSPITAL VISIT SUBSEQUENT l40.00 PAYMENT 13.2:
584.9
$13.21 PATIE NT'S RESPONSIBILITY
MCP MEDICARE PAYMENT -52.85
MCA MEDICARE ADJUSTMENT -73.94
99231 HOSPITAL VISIT SUBSEQUENT 70.00 PAYMENT 6. 6 i
584.9
$6.61 PATIEN T'S RESPONSIBILITY
MCP MEDICARE PAYMENT -26.42
MCA MEDICARE ADJUSTMENT -36.97
99232 HOSPITAL VISIT-SUBSEQUENT 90.00 0.00 Submi t te . 90 . 0(
584.9
PLEASE PAY 1
THIS AMOUNT
~ 333.2
-_._-_.._-~------ -
nv ~n* ~~_1~A~~~~
. ' .
l\.lIietic Imaging, Inc.
. . ~20 Union Deposit Road
" ~ Harrisburg P A rJ
CHECK CREDIT CARD USING FOR PA YMEm' AND FILL OUT BELOW.
O. o[Z] o ill O.
CARD NUMBER AMOUNT
NAME ON CARD (PLEASE PRINT) EXP. DATE
SIGNATURE
o4limo07 I ACCOUNT # PAY THIS AMOUNT
9353310 $7.79
Office Phone:
Patient Name:
717/652-6105
JANET V KEPNER
Amount Remitted:
3620 1 AT 0.308 *20 03620
1...111. 1111111111."1111.'.1,1111,111.1111111...1'11.11111.11
Janet V Kepner
11 Northview Drive
Carlisle P A 17013-9654
111.'11'11111""""""""'"
Kinetic Imaging, Inc.
4520 Union Deposit Road
Harrisburg P A 17111
.
TRISTAN3-013418S-0003620-o829417..Q01..Q00104-#003858
PlEASE RETURN TOP PORTION WITH PAYMENT
.
THIS IS YOUR FINAL NOTICE!
This is our final effort. Your account for will be turned over to the
collection agency and! or credit bureau within the next 15 days unless
we receive payment.
Respond to this collection notice today.
FINAL NOTICE
Kinetic Imaging, Inc.
4520 Union Deposit Road
Harrisburg P A 17111
Office Phone:
717/652-6105
Office Hours:
8:00 AM - 5:00 PM Monday - Friday
Patient Name:
Account #:
Amount Due:
JANET V KEPNER
9353310
$7.79
TRIST AN3-Q134186-o003620-o829417 -001-000104-#003858
\'l-RCP-SP
f'T,,, ._n~j:'''H,~_~1 1~r1~ :.~.u___,,__ __.._" .._.._.._l;."n;_~__ __._ r:..._..::: ..1\
. '.
Kittti~ Imaging, Inc.
, ' ~fon Deposit Road
""'Harrisburg P A 17111
CREDIT CARD USING FOR PA AND FIlL OuT BELOW.
~. o. D~ o.
CARD NUMBER
AMOUNT
NAME ON CARD (PLEASE PRINT}
EXP. DATE
SIGNATURE
STATEMENT DATE
04/0512007
ACCOUNT II
5010019
PAY THIS AMOUNT
$2.21
Office Phone:
Patient Name:
717/652-6105
JANET V KEPNER
Amount Remitted:
4299 1 AT 0.308 *22 04299
111111111111111'11."1111.1.1111111111.111111111.1111.11111.11
Janet V Kepner
11 Northview Drive
Carlisle P A 17013-9654
111.111'111...11...11...111.1..1
Kinetic Imaging, Inc.
4520 Union Deposit Road
Harrisburg P A 17111
.
TRIST AN2-0133329-0004299-0821954-001-OO0262-#004720
PLEASE RETURN TOP PORTION WITH PAYMENT
.
Dear Janet V Kepner:
This letter is in regard to your current balance due to Kinetic Imaging, Inc.. According to our records,
you have been provided with an itemized statement. If your insurance information was provided to our
office, it has been billed. We accept the following forms of payment:
1. Personal Check or Money Order
2. Cash
3. MasterCard, VISA, Discover and American Express.
Please return the top portion with your payment. If you have any questions about your account, feel free
to contact our Patient Service Department. Please remember, if we don't hear from you, we may be
forced to consider alternative actions.
Please contact us immediately to arrange payment. Thank you in advance for your cooperation.
Sincerely,
Accounts Receivable Department
Kinetic Imaging, Inc.
Office Phone:
Office Hours:
8:00 AM - 5:00 PM
Patient Name:
Account #:
Amount Due:
JANET V KEPNER
5010019
$2.21
717/652-6105
TRIST AN2-0133329-0004299-0821954-OO1-000262-#O04 720
-8CP.SP
1\/,.':' n1l:- L-,\i,';!' pI hd" i n\,'("n.:/) n:n'~l Iln~l /-"Y nll"~l('i/;n pn f~\.:n;lnnJI
021100 496851
IiW::. '-~PHYS M3vfr a.Nr PEN
~~R;
, , ;,PA 175ZXl619
"....
STATEMENT
PAYMENT OPTIONS
Check * Amt$
Imr.JfN SERV'7".a; m:J1ESIED
V1201J 0416
B5392M
FR30
BNS 004
2301 R
Please Include Security Code From Back Of Card
CHECK CARD USING FOR PAYMENT
. g1TERCARO I VISA I ~SA
CARD NUMBER EXP. DATE
CARDHOLDER NAME SECURITY CODe
SIGNA TURE AMOUN T
JANET V KEPNER
11 NORTHVIEW DR
CARLISLE, PA 17013-9654
111I11I11.111.1111I111111.1.111.1111.1.111111111.11.1111111.11
REMIT TO:
LANe HMA PHYS MGMT CENT PEN
PO BOX 619
EAST PETERSBUR, PA 17520-0619
'11I11I11.,.1.1.11,.,11.1111.11.111111.11I.'1111.11,.1111.1111
717 519-0753
03/29/07
496851
PLEASE RETURN THIS PORTION WITH PAYMENT
Patient Balance SHOW AMOUNT
36.28 PAID HERE $
Office Phone Number
Statement Date
Your Account Number
.---------------------------------------------------------------------------------------------------------------------
.
PROVIDER EXPLANATION OF ACTIVITY
NAME
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL Bill OR STATEMENT
PATIENT NAME
CHARGES
AND DEBITS
PAYMENTS
AND CREDITS
_:f.'llr.'lUIJ
10706 SEBELIN
011607
011607
CRN ANESTHESIA INV':1 KEPNER, JANET
AMOUNT TO BE PAID BY CO INS $19.48
MEDICARE PAYMENT
MEDICARE ADJUSTMENT
Insurance Balance: 0.00
576.30
-77.93
-478.89
Patient Balance:
19.48
12306 MCANULTY CR SPECIAL ANESTHESIA
Insurance Balance: 67.20
INV#:3
KEPNER, JANET 84.00
Patient Balance:
16.80
ltement
03/29/07
PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE:
496851
te:
Current
84.00
31-60 Days
0.00
61-90 Days
0.00
>90 Days
19.48
Total
Ins Pending
PATIENT BALANCE
PA Y THIS AMOUNT
103.48
67.20
36.28
-JD INQUIRIES I PAYMENTS TO:
LANC HMA PHYS MGMT CENT PEN
PO BOX 619
EAST PETERSBURG, PA 175200619
717 519-0753
Balance due not paid by ins.
Please mail payment now or
call to make payment
arrangements.
020597 489922
IRe 1M! EmS MMI' arNI' FFN
.ro B;:P(. ~
&\ST~' PA 1752XJ619
.
,.....
S~TATEMENT
PAYMENT OPTIONS
Check *
Amt $
Iml.R1 EERIICE FEJ;J.E:mID
V1201!' 0419
B5372A
WE20
BNS 004
2049 L
Please Include SecurtiV Code From Baek Of Card
CHECK CARD fJUIG FOR PAVMENT
II ~STERCARO I VISA I ~A II ~COVER iii 'i'MERtCAN EXPRESS
CARD NUMBER EXP. DATE
CARDHOLDER NAME SECURITY CODe
SIGNATURE AMOUNT
REMIT TO:
LANe HMA PHYS lvGMr CENT PEN
PO BOX 619
EAST PETERSBUR, PA 17520-0619
111I111...1.1.1. ..1.11I. ..111...111111I111.11111I111.1..1.1..1
JANET V KEPNER
11 NORTHVIEW DRIVE
CARLISLE, PA 17013-9654
111I111.. .111... III II ..11.1.1.. .11.. .1.1..1. .1...1111I11..1.11
--------------------------------------------------------_.~------------------------------------------------------------
717 519-0753
12/18/06
489922
PLEASE RETURN THIS PORTION WITH PAYMEI\
Patient Balance SHOW AMOUNT
19.12 PAID HERE $
Office Phone Number
Statement Date
Your Account Number
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT
DA TE PROVIDER I REFERRING PROVIDER
EXPLANA TlON OF ACTIVITY
PATIENT NAME
CHARGES
AND DEBITS
INSURANCE
PENDING
PAYMENTS
AND CREDITS
BE.
.'.l -
. .
111106 MUNCASTER M HOSPITAL CONSULT LEVEL
Insurance Balance: 186.88
INVI:1
KEPNER,JANET 206.00
Patient Balance:
19.12
Statement
)ate:
Current
12/18/06
PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE:
489922
0.00
31-60 Days
206.00
61-90 Days
0.00
>90 Days
0.00
Total
Ins Pending
PATIENT BALANCL
PAY THIS AMOUNI
206.00
186.88
19.12
:iEND INQUIRIES I PAYMENTS TO:
LANe HMA PHYS M3M1' CENT PEN
PO BOX 619
EAST PETERSBURG, PA 175200619
717 519-0753
f\lnTt::. r'h.,r/"'loC:lC' .::.nrf .,........:\\Jf..y''''ntc- nr"l.t ';:)""'no~rinrt 1""'\." th;c- ct-:::.domant U/ill ':U"U"'\t.:"I-:'ar I"'In novt rT"tl"'\nth'("" .....t":1t.o""lrnont
005532 437721
UN; Iffl Ff1YS MlYfr CRIr PfiN
. !U9
~~, /.fA 175ZXJ619
,~ /
".... ./
S7~\"""'ErvlEl;'~T PAYMENT OPTIONS
Check # Amt $
AI:I:FESS SERv.TCE ~
V1297 0411
B5392M
TH04
BNS 002
0011 R
Please Inelude Seeurltv Code From Baek Of Card
CHECK CARD USING FOR PA YMENT
(II SlSTERCARO , VISA j ~SA
CARD NUMBER EXP.DATE
CARDHOLDER NAME SECURITY CODE
SIGNATURE AMOUNT
JANET V KEPNER
11 NORTHVIEW DR
CARLISLE, PA 17013-9654
111111111.111'11111111111.1.11111111.1.11111111111111.11111.11
RF:tvllT TO:
LANe HMA PHYS :M:;MT CENT PEN
PO BOX 619
EAST PETERSBUR, PA 17520-0619
111.11111.1.1.1.111.111.1111.11.1111111111.111...111.1,,1.1111
Office Phone Number
717 519-0753
Statement Date
01/03/07
Your Account Number I Page No.
437721 1
PLEASE RETURN THIS PORTION WITH PAYMEN
New Balance SHOW AMOUNT
59.04 PAID HERE $
----------------------------------------------.----------..-------------------------------------------------------------
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT
.y~~
PROVIDER
NAME
EXPLANATION OF ACTIVITY :
PATIENT NAME
CHARGES
AND DEBITS
PAYMENTS
AND CREDITS
-
"12106 MILLER M)
121506
121506
EMERGENCY VISIT INV#:2 KEPNER, JANET
AMOUNT TO BE PAXD BY CO INS $29.52
MEDICARE PAYMENT
MEDICARE ADJUSTMENT
Insurance Balance: 0.00
411.00
-118.08
- 263 . 40
Patient Balance:
29.52
11
10206 CLOONAN Me EMERGENCY VISIT INV#:3 KEPNER, JANET
AMOUNT TO BE PAXD BY CO INS $29.52
MEDICARE PAYMENT
MEDICARE ADJUSTMENT
Insurance Balance: 0.00
411.00
122806
122806
-118.08
-263.40
Patient Balance:
29.52
3.tement
te:
01/03/07
PLEASE INDICATE YOUR ACCOUNT !'IUMBER WHEN CALLING OUR OFFICE:
437721
Current
29.52
31-60 Days
29.52
61-90 Days
0.00
>90 Days
0.00
Total
59.04
Ins Pending
0.00
NEW BALANCE
PAY THIS AMOUNT
59.04
NO INQUIRIES f PAYMENTS TO:
LANC>BMAPHYS ..!!GMl' >CENT PEN
PO BOX 619
EAST PETERSBURG, PA 175200619
717.519....0753
007449 343744
IR:C Jf.'A Em!S' MMl' CJ!Nr PEN
EO R:I,C.1J9
EASr~, PA 1752!XJ619
'~> ...
~... ,
STATEMENT
PAn.1ENT OPTIONS
Check # Amt $
V1252 041
BS392M
WZ14
I:IM 003
2734 L
~..4IS. Include Securltv Code From Back Of Card
CH~CK CARD USING FOR PAYMENT
. SITERCARD ~ VISA 1 ~SA
CARD NUMBER EXP.DATE
CARDHOLDER NAME SECURITY CODE
SIGNATURE AMOUNT
RmRl tEIMlE f8irJ~
REMIT TO:
LANe liMA PHYS :MGMT CENT PEN
PO BOX 619
EAST PETERSBUR, PA 17520-0619
111I11111.1.1.1,"1.111...11'11I11"11I11I.111I1111I.1"1.1111
JANET V KEPNER
11 NORTHVIEW DR
CARLISLE, PA 17013-9654
111I11I11.111..11I.111111.1.1...1111.1.1111..111I1111I11111.11
Office Phone Number
717 519-0753
Statement Date
03/13/07
Your Account Number
343744
PLEASE RETURN THIS PORTION WITH PA YMENl
Patient Balance SHOW AMOUNT
CONTINUED PAID HERE $
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT
PATIENT NAME
-
,.- -?<(,
..
PROVIDER EXPLANATION OF ACTIVITY
NAME
PAVMENTS
AND CREDITS
20106 PREVIOUS BALANCE :
12306 COLLINS Me HOSPITAL CONSULT LEVEL INVI:8 KEPNER, JANET
.AMOUNT TO BE PAID BY CO INS $27.50
MEDICARE PAYMENT
MEDICARE ADJUSTMENT
Insurance Balance: 0 . 00
12306 COLLINS MD INSERTION CENTRAL CATS INVt: 9 KEPNER, JANET
AMOUNT TO BE PAID BY CO INS $25.17
MEDICARE PAYMENT
MEDICARE ADJUSTMENT
Insurance Balance: 0 . 00
12406 COLLINS MD CRITICAL CARE INVI ~11. KEPNER, JANET
.AMOUNT TO BE PAID BY CO INS $40.28
MEDICARE PAYMENT
MEDICARE ADJUSTMENT
Insurance Balance: 0.00
030507
030507
030507
030507
030507
030507
CHARGES
AND DEBITS
1~1
260.00
<N'::\J'~
-110.02
-122.48
Patient Balance:
/'/,,<,
"'h/
lA.,
27.50
408.00
-100.67
-282.16
Patient Balance:
25.17
440.00
-161.10
-238.62
Patient Balance:
.;",i:}
40.28
12506 NITECKI NO CRITICAL CARE INV':12 REPNER,JANET
AMOUNT TO BE PAID BY CO INS $40.28
MEDICARE PAYMENT
MEDICARE ADJUSTMENT
Insurance Balance: 0.00
030507
030507
440.00
-161.10
-238.62
Patient Balance:
40.28
12606 NITECKI MIl CRITICAL CARE INV':13 KEPNER, JANET
AMOUNT TO BE PAID BY CO INS $40.28
440.00
atement
3.te:
03/13/07
PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE:
343744
PATIENT BALANCE
PAY THIS AMOUNT
CONTINUED
:ND INQUIRIES/ PAYMENTS TO;
LANe SMA PBYS MGMT CENT PEN
PO BOX 619
EAST PETERSBURG, PA 175200619
717 519-0753
~: '!J!I~tllll ~U III/II
~.t \1iddlelown PA 17057-051 ~
RETURN SERVIY-"E REQLJESTl:LJ
/
/
PEERLE,~S CREDIT SERviCES, INC.
Phon~ (717) 702-2003
Fax (717)/02-2007
Oate
12/22,(16
Our . \cct #
2361 56-2E
\mt Owed
$11432
236156-2E-013 41418 12727
1...11 111.11111"1111..11.1.111.11...1.1111..' ...11...11..1.11
Janet V Kt:pner
II Northview Dr
Carlisle P A 17013-9654
PEERLESS CREDIT SERVICES, INC.
PO Box 518
MiJdktown PA 17057-0518
1...111,"111'1111.1.1...11111111.1,,"111..1....111..1.1...11
IF PAYING BY CREDIT CARD, COMPLETE ALL. SIGN AND RETURN.
CHECK CARD USING FOR PAYMENT ... 0 II 0
- VISA MASTERCARD
CARD NUMBER PLUS 3 DIGIT SECURITY CODE (on back ot card) EXP DATE
I
CARDHOLDER NAME CARDHOLDER SIGNATURE AMOUNT
$-
"-Detach Upper Portion and Return with Payment..-
Our Account #: 236156-2E
Total of all your Accounts with this office: $114.32
Creditor Account #
Moffitt Heart And Vascu 61032
Regarding
Amt Owed
114.32
Dear Janet V Kepner,
Unfortunately, this account was reported against your credit history with Trans Union and Equifax Credit Services
because it was not paid. If your account is paid, we will update your file to show you have cooperated.
Please send payment of your balance to this office today. If that is not possible. please call our office today to
arrange payment. A good credit rating is very valuable.
Thank you,
?H4-, ?IJ~
This letter is from a debt collector and is an attempt to collect a debt. Any information obtained will be used for
this purpose.
** Direct your questions to: Peerless Credit Services (717) 702-2003 **
** Payment should be made directly to our office. * *
** Please contact our office if you would like to pay by Me/Visa or Check by Phone. **
ISDI'I::EROI02.l
--t.
Checks by telephone,
please call for details.
(717) 702-2003
PeerlessCreditService.\', [1IC. .. PO Box 5/8 -Middletown PA 1-;057-05/8 -Phone (~/-) -:'02-}(){)3 -hlX(7j'1j -(}2-2()();
PHILI~~~. CAREy, MD
3~60 ~XANDER SPRING ROAD
C ISLE/ PA 17015
)t.
Place Of Service
/
/
/
STATEMENT FOR PROFESSIONAL SERVICES
CARLISLE REG MED CENTER I
PT-0002
Page No.
Return This Portion
With Your Payment
1
Billing Date
05/02/07
JANET V KEPNER
11 NORTHVIEW DR
CARLISLE PA 17013
Amount Du~ 0 0 . 7 9
Amount Enclosed
$
Bill To KEPNER JANET Chart No. 23042
o CHECK HERE and See Reverse For Chanae of Address and/or Insurance Information.
---~~~~~-
11/26/06
11/27/06
11/28/06
11/30/06
12/01/06
12/02/06
12/04/06
01/08/07
01/26/07
01/26/07
CURRENT
0.00
------------------------------------------------------------------------------------------ ------------------------
An
PROCEDURE CODE DESCRIPTION CHARGES CREDITS BALANCE
p a. tJ.:e-ilt :
Doctor:
99253
DX:
31622
DX:
99232
DX:
99232
DX:
99232
DX:
THRU
99231
DX:
:36 66 DA'iS
0.00
J KEPNER
PHILIP D CAREY
INITIAL INPATIENT CONSULT/ LOW C
486
DIAGNOSTIC BRONCHOSCOPY/ W/ OR W
486
SUBSEQUENT HOSPITAL CARE, MOD CO
486
SUBSEQUENT HOSPITAL CARE, MOD CO
486
SUBSEQUENT HOSPITAL CARE/ MOD CO
486
140 . 00
140.00
450.00
590,00
80.00
670.00
80.00
750.00
80.00
830.00
SUBSEQUENT HOSPITAL CARE, LOW CO
486
MEDICARE #
PMT MEDICARE c#
W/O MEDICARE c#
150.00
980.00
403.09-
476.12-
576.91
100.79
YOUR ACCOUNT IS PAST DUE. WE
WILL BE FORCED TO TAKE STEPS
TO COLLECT YOUR ACCOUNT
UNLESS PAYMENT IS RECEIVED.
66-30 DAL.!3
0.00
:;;0 ~6 DA"iS
100.79
Il~.s fl z.MDING
0.00
.LV.L.l;1,i~
.LU.J.AL
100.79
100.79
hart Number
illTo
ace of Service
lone
23042
"r
PLACE OF SERV. COOE:C
PHILIP D. CAREY/ MD
360 ALEXANDER SPRNG RD
CARLISLE PA 17015
11
12
21
22
23
24
31
32
81
1\.99
/
Office
Patient's Home
Inpatient Hospital
Outpatient Hospital
Emergency Room-Hospital
Ambulatory Surgical Center
Skilled Nursing Facility
Nursing Facility
Independent Laboratory
Other Unlisted Facility
CARLISLE REG MED
KOVACS
Referring Physician
717 243 7444
14\ ~21 BILL FORM #21 tt1enarne '21 laser \8/2(104) MIS't'S HEAL THCAAE SYSTEMS (800} 877 -56.;~ 16(2610) 38862-03.3
,___<,~:I.::.!\!' :JA'r=.
'.
Yellow Breeches Famll
1358 Lutztown Road
Boiling Springs PA 17007
KEPNJA-OO 01 05/01/07
IF PAVING BVC;~~.P.!_!__.~~~~.' P~~~~E S~~REVERSE SIDE
- .,. ~~.
FORWARDING.~ICE REQUESTED
...
..,..
-
'IfSoI
~,';'"
_~"_.,'.'''''_W "~"--~-'.-''''llC:""''__M''' ~~_.____'_'_._ ____.'.~_,',~...~,_____1-'--'.-
~ ,'~~! TI~; ~ ....,
.___~~icu;~ /> $
- .---....,,---,..~-~_.~ ~-----~~-'------
220.05
1 -:;.\; J._"
} 'S
'. .AIl PAYMENT 10: ' ,<::~ ~", <. ' ADDRESSEE:
Yellow Breeches Famil
1358 Lutztown Road
Boiling Springs PA 17007
11111111..1111111111.1,1.11.11,111111111.11,,111.111..1.1,1.11
Janet V Kepner
.... 11 Northview Drive
~ CARLISLE PA 17013-9654
1...111...111'11,"111111.1.1'111111I1.1..11111111111111'11.11
o Please cheCk box if above addressee is incorrect or insurance
information has changed. and indicate change(s) on reverse side.
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAY MEN
. Date Dr. ptnt Name Proc. Description DiagCd Chg/Credit Balance
01/10/06dik Janet V K 99213 level 2 (est) 401.1 56.00 49.89
04/04/06 Plan Payment:l072615 1.81-
04/04/06 Adi:Medicare Writeof 6.11-
04/04/06 Adi:Medicare Writeof 1.81
02/16/06dik Janet V K 99213 level 2 (est) 401.1 56.00 49.89
03/01/06 Plan Payment:l071516 0.00
03/01/06 Adi:Medicare Writeof 6.11-
applied to deductible
03/30/06dik Janet V K 99213 level 2 (est) 401.1 56.00 9.98
04/25/06 Plan Payment:l073167 39.91-
04/25/06 Adi:Medicare Writeof 6.11-
03/30/06dik Janet V K 36415 Phlebotomy 401.1 5.00 0.00
04/25/06 Plan Payment:1073167 3.00-
04/25/06 Adi:Medicare Writeof 2.00-
applied to coinsurance
08/24/06dik Janet V K 99213 level 2 (est) 401.1 56.00 9.98
09/12/06 Plan Payment:1076488 39.91-
09/12/06 Adi:Medicare Writeof 6.11-
10/23/06dik Janet V K 99213 level 2 (est) 401.1 60.00 9.98
11/15/06 Plan Payment:1077697 39.91-
11/15/06 Adi:Medicare Writeof 10.11-
ll/07/06dik Janet V K 99233 Hasp Sub-detailed 575.0 87.00 15.37
01/02/07 Plan Payment:l078737 61.46-
01/02/07 Adj:Medicere Writeof 10.17-
11/08/06djk Janet V K 99232 Hasp Sub-expanded 575.0 130.00 21.62
01/02/07 Plan Payment:l018737 86.46-
01/02/07 Adi:MedicareWriteof 21.92-
11/10/06dik Janet V K 99231 Hosp Sub-focused 515.0 210.00 39.64
01/02/01 Plan Payment:1078137 158.54-
01/02/01 Adi:Medicare Writeof 71.82-
11/16/06dik Janet V K 99238 Hasp Discharge Day 515.0 78.00 13.70
01/02/07 Plan Payment:1078731 54.80-
01/02/07 Adi:Medicare Writeof 9.50-
patient responsibility
PLEASE CALL BETH WITH ANY
BIllING QUESTIONS.
... ~ ~ -5 ~'".. ~
: MA'KE~~efte~cks PAYABLE TO: ' .;"
. ... f _ ~..<~ "'; _ ' .
Vellow Breeches Famil
I PROVIDER/ .
Pr::V,CTICE iJA\1E Yellow Breeches Fam11
I Gj,~.:rcC'!:;" . I'KCC!J~'.j_T KEPNJA-OO-'-~------;:-~sT 08/;9/06! INp~:~gE
~r<~H_,t:~._,_____ j NI!~lbt;" T __...._____L__.___..,....-. I
105/01/07i 0.00 I 0.00' O.OO! 90.33 I 129.72
L:~_~~:5L{~_~":::E___ _________._1-__~VER30 D~~.__1----_~y~~.~ DAYS ___...l._ OVEA90 DAYS lOVER \20 DAYS
TRANSACTIONS AFTER THE CLOSING DATE WILL APPEAR ON YOUR NEXT STATEMENT
i FOR BilLING
[ INOUiR1ES. C!~LL 717-258-3214
I PAYMErf;
I DUE DATE
I 220.05
I PLEA.;:=: PI>,'! THIS AMOUNT