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Home My WebLink About07-5717 SCHMIDT KRAMER PC BY: CHARLES E. SCHMIDT, JR., ESQUIRE I. D. #19198 209 State Street Harrisburg, PA 17101 (717) 232-6300 cschmid6pschmidtkramer.com Attorneys for Plaintiffs MICHAEL A. BLINN and IN THE COURT OF COMMON PLEAS SANDRA A. BLINN, CUMBERLAND, PENNSYLVANIA Plaintiffs, CIVIL ACTION-LAW V. : USAA CASUALTY INSURANCE NO. dr] - 571 rl 0 iv i I Term COMPANY, Defendant JURY TRIAL DEMANDED NOTICE 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 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. 0 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 LOCAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 (717) 249-3166 NOTICIA Le han demandado a usted en la corte. Si usted quiere defenderse de estas demandas expuestas en las paginas siguientes, usted tiene veinte (20) dias de plazo al partir de la fecha de la demanda y la notificacion. Usted debe presentar una apariencia escrita o en persona o por abogado y archivar en la corte en forma escrita sus defensas o sus objeciones a las demandas en contra de su persona. Sea avisado que si usted no se defiende, la corte tomara medidas y puede entrar una Orden contra usted sin previo aviso o notificacion y por cualquier queja o alivio que es pedido en la peticion de demanda. Usted puede perder dinero o sus propiedades o otros derechos importantes para usted. LLEVE ESTA DEMANDA A UN ABODAGO INMEDIATAMENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 (717) 249-3166 SCHMIDT KRAMER PC BY: CHARLES E. SCHMIDT, JR., ESQUIRE I.D. #19198 209 State Street Harrisburg, PA 17101 (717) 232-6300 c schmidt(c-i,)schmidtkramer. com Attorneys for Plaintiffs MICHAEL A. BLINN and SANDRA A. BLINN, Plaintiffs, v. USAA CASUALTY INSURANCE COMPANY, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND, PENNSYLVANIA CIVIL ACTION-LAW NO. D 7- ; 7l 7 C&J T.G? JURY TRIAL DEMANDED COMPLAINT AND NOW, come Plaintiffs, Michael A. Blinn and Sandra A. Blinn, by and through their attorneys, SCHMIDT KRAMER PC, and respectfully set forth as follows: 1. Plaintiffs, Michael A. Blinn and Sandra A. Blinn, are adult individuals, husband and wife, residing at 200 Hollywood Circle, Camp Hill, Cumberland County, Pennsylvania 17011. 2. Defendant, USAA Casualty Insurance Company (hereinafter "Defendant USAA"), is an insurer licensed to transact business in the Commonwealth of Pennsylvania, with its principal place of operations located at 9800 Fredericksburg Road, San Antonio, TX 78288. Operative Facts 3. Plaintiffs' claims arise out of an automobile accident, October 13, 2006. The Hampden Township Crash Report numbered HAM20061000449 shows the accident was caused by Srikanth Vadlakonda. (See Police Report attached as Exhibit A.) 4. At the time of the accident, Plaintiffs were insured on an auto insurance policy underwritten by Defendant USAA, numbered 00386 16 36C 71013, which was effective May 16, 2006 through November 16, 2006. 5. This automobile insurance policy provides $10,000 in first-party medical expense benefits in accordance with the requirements of the Pennsylvania Motor Vehicle Financial Responsibility Law, 75 Pa. C.S § 1701, et seq., as amended. (See Copy of Declarations attached as Exhibit B.) 6. As a result of the accident, Michael Blinn sustained injuries including: numbness in his right arm/hand, sensation/movement/pulse in his right upper extremity, right shoulder pain, stiff neck, and pain on the right side of his neck, with radiculopathy requiring surgery. 7. As a result of the accident, Sandra Blinn sustained injuries including: laceration to her nose, restricted and painful forward flexion, parasthesias of the right upper extremity, tingling and numbness into her hands, loss of normal cervical lordosis, and hyperextension-hyperflexion of the cervical and thoracic spine sprain/strain injury. 2 8. Following the accident, Plaintiffs gave timely notice to Defendant USAA of their injuries and their claim for first party medical benefits. 9. As a result of the accident, the Plaintiffs were obliged to receive and undergo medical attention and care and to incur various medical expenses. (See Medical Billings for Michael and Sandra Blinn attached as Exhibits C & D respectively.) 10. To date, Michael Blinn has incurred at least the following reasonable and necessary medical expenses, totaling $65,079.21: a. Arlington Group, Dr. Peppelman: $14,804.00 b. Central PA Rehabilitation Services: $3,554.51 c. Blue Mountain Family Practice: $65.00 d. Gerhart Chiropractic: $11997.00 e. Harrisburg Interventional: $2,200.00 f. Holy Spirit Hospital: $494.00 g. Quantum Imaging: $63.00 h. RS Medical: $735.00 i. Susquehanna Valley Pain Management: $1,275.00 j. Pinnacle Health Hospitals $39,308.70 11. To date, Sandra Blinn has incurred at least the following reasonable and necessary medical expenses, totaling $7,248.53: a. Arlington Group, Dr. Zeliger: $2,453.00 b. Central PA MRI Center: $965.00 c. Gerhart Chiropractic: $787.23 d. Holy Spirit Hospital: $1953.30 e. Quantum Imaging: $340.00 f. Silver Spring Ambulance: $435.00 g. Zabinski Chiropractic: $315.00 12. Plaintiffs are expected to continue to incur medical expenses for an indefinite period of time into the future in order to receive treatment for the injuries suffered in the above mentioned accident. 3 13. It is believed that all listed expenses have been submitted to the Plaintiffs' insurer, Defendant USAA. 14. It is believed that all of the medical bills specified above are fair and reasonable, and all treatment specified therein was medically necessary as a result of the injuries Plaintiffs sustained in the accident, October 13, 2006. 15. There are no conditions precedent to Defendant's performance. COUNT I BREACH OF CONTRACT MICHAEL BLINN v. DEFENDANT USAA 16. Paragraphs 1 through 15 are incorporated herein by reference as if set forth in full. 17. USAA policy numbered 0386 16 36C 71013 insured the Plaintiff, and was in full force and effect at the time of the auto accident causing the Plaintiff's injuries. 18. Plaintiff and/or his medical providers forwarded to Defendant USAA, reasonable proof of treatment and services. 19. Defendant USAA, pursuant to Section 1797(b)(1) of the Pennsylvania Motor Vehicle Financial Responsibility Law, as amended, contracted with a peer review organization, ostensibly for the purpose of confirming Michael Blinn's medical treatment, products, services or accommodations, performed or provided by Walter D. Peppelman, D.O., conform to the professional standards of performance and are medically necessary and reasonable. 4 20. The name and address of the peer review organization reviewing Dr. Peppelman's treatment is Disability Management Consultants, 920 West Sproul Road, Suite 202, Springfield, PA, 19064. 21. On or about July 26, 2007, Disability Management Consultants' Steven J. Valentino, D.O., issued a report which contained his conclusion that Michael Blinn no longer needed orthopedic care for injuries sustained in the accident of October 13, 2006, effective retroactively to November 20, 2006. (See Peer Review Letter attached as Exhibit E.) 22. Defendant USAA, has paid, or will pay to Disability Management Consultants cash or other valuable consideration as part of its inducement for them to reach its aforesaid conclusions. 23. Plaintiff believes and avers that the report is without foundation and is contrary to the opinions of the treating physician, Walter D. Peppelman, D.O. 24. Defendant USAA, notified Plaintiff, by its letter dated August 10, 2007, that it will not pay for Dr. Peppelman's services rendered after December 11, 2006, leaving Plaintiff responsible for, at least, $53,824.70 in medical bills due to visits after that date. (See USAA Correspondence attached as Exhibit F.) 25. Despite Plaintiff's request, Defendant USAA did not pay the first party benefits to which the Plaintiff was entitled under the policy of insurance, nor has the Defendant committed itself to pay such benefits, which is contrary to the terms and conditions of the policy of insurance and the Pennsylvania Motor Vehicle Financial Responsibility Act. 5 26. Defendant's denial of benefits is believed to be without reasonable foundation and is unreasonable. 27. As a result of Defendant's refusal to pay the balance of necessary and reasonable medical expenses due under the terms and conditions of the applicable policy of insurance and the Pennsylvania Motor Vehicle Financial Responsibility Law, Plaintiff has been required to hire an attorney to collect the medical bills herein due. 28. Plaintiff's attorney's normal and reasonable hourly rate for professional services of the type rendered and to be rendered in this case is $175.00, which Plaintiff, Michael A. Blinn, has agreed to pay. WHEREFORE, Plaintiff respectfully requests that this Honorable Court grant the following relief. (a) Award the Plaintiff all outstanding medical payments, plus interest at twelve percent (12%) per annum; and (b) Award attorney's fees and costs pursuant to 75 Pa. C.S. §§ 1716 and 1798(a), based on actual hours expended until the date of final judgment in this matter. COUNT II BREACH OF CONTRACT SANDRA BLINN v. DEFENDANT USAA 29. Paragraphs 1 through 28 are incorporated herein by reference as if set forth in full. 30. USAA policy numbered 0386 16 36C 71013 insured the Plaintiff, and was in full force and effect at the time of the auto accident causing the Plaintiffs' injuries. 6 31. Plaintiff and/or her medical providers forwarded to Defendant USAA, reasonable proof of treatment and services. 32. Defendant USAA, pursuant to Section 1797(b)(1) of the Pennsylvania Motor Vehicle Financial Responsibility Law, as amended, contracted with a peer review organization, ostensibly for the purpose of confirming Sandra Blinn's medical treatment, products, services or accommodations, performed or provided by Bernard I. Zeliger, D.O., conform to the professional standards of performance and are medically necessary and reasonable. 33. The name and address of the peer review organization reviewing Dr. Zeliger's treatment is Disability Management Consultants, 920 West Sproul Road, Suite 202, Springfield, PA, 19064. 34. On or about August 22, 2007, Disability Management Consultants' Steven J. Valentino, D.O., issued a report which contained his conclusion that Sandra Blinn no longer needed orthopedic care for injuries sustained in the accident of October 13, 2006, four to six weeks after the accident. (See Peer Review Letter attached as Exhibit G.) 35. Defendant USAA, has paid, or will pay to Disability Management Consultants cash or other valuable consideration as part of its inducement for them to reach its aforesaid conclusions. 36. Plaintiff believes and avers that the report is without foundation and is contrary to the opinions of the treating physician, Bernard I. Zeliger, D.O. 7 37. Defendant USAA, notified Sandra Blinn, by its letter dated September 7, 2007, that it will not pay for Dr. Zeliger's services rendered after December 13, 2006, leaving Plaintiff responsible for, at least, $1,036.00 in medical bills due to visits after that date. (See USAA Correspondence attached as Exhibit H.) 38. Despite Plaintiff's request, Defendant USAA did not pay the first party benefits to which the Plaintiff was entitled under the policy of insurance, nor has the Defendant committed itself to pay such benefits, which is contrary to the terms and conditions of the policy of insurance and the Pennsylvania Motor Vehicle Financial Responsibility Act. 39. Defendant's denial of benefits is believed to be without reasonable foundation and is unreasonable. 40. As a result of Defendant's refusal to pay the balance of necessary and reasonable medical expenses due under the terms and conditions of the applicable policy of insurance and the Pennsylvania Motor Vehicle Financial Responsibility Law, Plaintiff has been required to hire an attorney to collect the medical bills herein due. 41. Plaintiff's attorney's normal and reasonable hourly rate for professional services of the type rendered and to be rendered in this case is $175.00, which Plaintiff, Sandra A. Blinn, has agreed to pay. WHEREFORE, Plaintiff respectfully requests that this Honorable Court grant the following relief: (b) Award the Plaintiff all outstanding medical payments, plus interest at twelve percent (12%) per annum; and 8 (b) Award attorney's fees and costs pursuant to 75 Pa. C.S. §§ 1716 and 1798(a), based on actual hours expended until the date of final judgment in this matter. Respectfully submitted, SCHM ER P By: - ` Charles E. Schmidt, Jr., Esquire Attorney I.D. # 19198 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Plaintiff Date: -S?y T , ) q - a003? 9 VERIFICATION BASED UPON PERSONAL KNOWLEDGE AND INFORMATION SUPPLIED BY COUNSEL I, Michael A. Blinn, verify that I am the Plaintiff in this action and that the foregoing Complaint is based upon the information which has been gathered by my counsel in preparation of this lawsuit. The language of the Complaint is that of counsel and is not mine. I have read the Complaint, and to the extent that it is based upon information which I have given to my counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the contents of the Complaint are that of counsel, I have relied upon counsel in making this Verification. I understand that intentional false statements herein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsifications made to authorities. MICHAEL A. BLINN VERIFICATION BASED UPON PERSONAL KNOWLEDGE AND INFORMATION SUPPLIED BY COUNSEL I, Sandra A. Blinn, verify that I am the Plaintiff in this action and that the foregoing Complaint is based upon the information which has been gathered by my counsel in preparation of this lawsuit. The language of the Complaint is that of counsel and is not mine. I have read the Complaint, and to the extent that it is based upon information which I have given to my counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the contents of the Complaint are that of counsel, I have relied upon counsel in making this Verification. I understand that intentional false statements herein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsifications made to authorities. SANDRA A. BLINN ???y b k g z z O U f- U O a 0 c? 0 O s w O Q s w 6 a w ) U U w s Print CRS W0044863 Paae 1 of 9 POO K PASX REPOR! ING Fs??3? 1111111 Crash ?llwber Case Closed Reportable Crash fRage AA 500 1 Q Yes ONO Q Yes Q No f- 1 W0044863 !^ Incident Number ra ! Police Agency Patrol Zone HANf20061000449 a 21103 is i Agency Name 100 Precinct Investigation Date !fvIM-DD-YYYY) g Hampden Township 10 13 2006 L t Dispatch Time (mil) Arrival Time (mil) Investigator Badge Number 1802 1806 CPL JEFFREY A SNY'DER 19-11 20 I Reviewer Badge Number Approval Date (MM-DD-YYYY) SGT SHAUN A. FELTY 19-=' 10 20 ?Oi;6 County County Name Municipality Municipality Name pay of rft/eeh 21 Cumberland -? 103 Iatnpden Township O sun CD Thu z Gash Date (MM-DD-YYYY) Crash Time (mil) No of Units People Injured Killed, "If > oo O Mon Q Fri w fil, 10 13 2006 l 1802 + 3 (6 1 (i ? (n 1 complete O 7ue Q Sat I I I` I L __J Form F 0 Wed U Unk Workzone (If Yes, Complete 0 Yes O No School Bus School Zone Farm M, Section 29) Related O Yes O No O Yes O No Notify PENNDOTO Yes Q No Related Maintenance a lntersec4ion T:yoe O 4 Way Intersection Q ' Y' Intersection a O Intersection Multi-Le9 O Off Ramp 0 Railroad Crossin "sat v Q Midblock 'T' Intersection O Traffic Circle/ Crossing ,Loitfon QO o ? Round About 0 On Ramp O Crossover O Other __ 'See ®vL1L Oa Route Number Segment (Optional) Travel Lanes Speed Limit House Number (if applicable) el }el } North ® 0011 05 40 0` O 0 Sou Street Name 4 a Q Ea tth 1 Street ___J Ending For Mid-block crashes only. Use 'g i CARLISLE pK - O west postal House Number r and make sure O` Principal Roadway Street came is it Route O Unknown; filled in if using this option Interstate Turnpike Turnpike O state County Local Road zigII O ([Not Turnpike) O (Cast/West) O Spur ..Highway Road O O Private Other/ or Street Road O Unknown i Route Number Segment (Optional) Travel Lanes Speed Limit a " O North 02 25 e ? Street Name •M O South °- g Street Ending e O East JEFFREY D O West - O O Unknown Sigosinv Q Interstate Q Turnpike O Turnpike State County Local Road Private Other/ m (Not Turnpike) (Eastlwest) Sur O O O Spur Highway Road or Street O Road O Unknown Rt Num Or Mile Post Or Segment Marker rd E lil -C - ????JJJ --- _ O O North Feet v Please Ling Street Name N m e O South St Ending :3 O E t s 6 ?J 3 m Enter Information icr 50T11 as CD West O West Or Miles V% e g Landdmarks if Using N Intersecting Rt Num Or Mile Post Or Segment Marker g t ia This Option A = o O North D E Distance From Crash I ; . E Or Intersecting Street Name l ° Q South Scene to Landmark 1 _ a St Ending 5 O East (for Crash between J ? O West Landmark 1 and Landmark 2) 131 Degrees Minutes Seconds Degrees Minutes Seconds ' I Latitude: 40 14 e 31 000 Longitude: - 76 59 :F? 7000 Traf=fic Control Device -- -- - O Yield Sign 0 Police Officer or CD uncPio_ irta --= 8 ® O Not Applicable tO Traffic Signal o Active RR Crossinq Flagman O h Device Functionin Emergency } Controls O r ype TC No Controls 0 Improperly g ©PreempUve O Flashing Traffic Signal Signal O Stop Sian Sig O Passive RR 0 Device Not 0 Device Functioning _ Crossing Controls O hnknovm Functioning Properly O Unknown t one [loser/ (If 'Not Applicable", skip rest of the Lane Closure section) lane [&ULM O North 0 East Q North and South Q AIt ®I ? Not Applicable O Partially Q Fully Q Unknown Airrchon O South N, 0 West n ? Trat?c West 0 East and West ( 5,E, W, 011 ou ed Yes 0 No o Est Trm d Unknown O_ C10 O< 30 Min. O 30-60 Vin. O 1-3 hrs Q 3-6 hrs Q 5-9 ^rs 0> 9 hours Q Urknown FORM 0 AA-500 (twos) - -- --- PENNDOT COPY CRS NN 0044363 Pate 2 of 9 P ? ®rIASM?? PCRTI?JG av9 II1l?ll?lll???1lI???II?'I?II Page: Crash Numoer r?r? _ AA 500 2 Police Use Oniy L2 _j Woo44s63 Moor Veh.de in 7y?? Q Transport O Hit & Run Vehicle Q illegally Parked O Legally Parked Q Non • Motorized I CommercialYehide a i nit Pedestrian on Skates, Disabled From Yes Q Pedestrian Q Q Phantom Vehicle O Q No Q Train 9 , in Wheelchair, etc O Previous Crash (/f 'Pedestrian' or 'Pedestrian on 5kates, in Wheelchair, etc', Complete Form M. Sectinn 2d) (if Yes, Comp/eteForm Q jl .W e al s r v, e 9 •o bl e Unit No first Name MI Date of Birth (MI-DD•YYYY) OI SRIKANTH 04 IS 1977 Delete? Last Name Tele hone Number Q VADLAKONDA 7603176414 Address / City / State Zi 3521 SEPTEMBER DR APT 5 CAMP HILL PA Driver AlcohobDruas Suspected Q No Q Illegal Drugs Q Medication O Alcohol Q Alcohol and Drugs O Unknown Alcohol Test Type Q Test Not Given Q Blood Alcohol Test Resuhs M. 17011 State Class PA L O Apparently Illegal Drug Normal Use O Fatigue O Meditation 0 Had Been Drinking O Sick Q Asleep O Unknown Q Breath Other Primary Vehicle Code Violation Charged? Q Urine O Unknown st Gin if DRIVING VEHICLE AT SAFES O Yes No Test Refused Unknown Driver Presence Results 1=Driver Operated 3=Driver Fled Scene O Test Given, IT Vehicle 4=Hit and Run Contaminated Results 2=No Driver _ 9=Unknown Owner/Driver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Muniopal 98=Other O1r Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name (If Pedestrian, skip this Section) Driver Q SRIKANTH VADLAKONDA Address 1 City / State / Zip Vehicle Make -Make Codc 3521 SEPTEMBER DR APT 5 CAMP HILL PA 17011 Honda ?? VIN Model Year Vehicle Model (see overlay) I HGCB7678PA067682 1993 UEX License Plate Reg. State Est. Speed Vehicle Towed Towed By GLX4226 PA 025 Q Yes O % ROADSIDE AUTO R Insurance Insurance Company Policy No o° 0 '(es No Lln- O O known GEICU 4073-65-55-91 E 12 U Trailing Type 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Ta No Unit TrNo. of -1 a ri P 9 lag Year Tag 5¢ g I - Trailing 0 Unit 2=Towing Truck S=Camper B=Other d Units: 3=Towing Utility Trailer 6=Full Trailer 9=Unknown S I ra -cfion of a -Vehicle Position 03 -Movement 01 -See Overlay Vehicle Color Vehicle Type 05=Large Truck 20=Unicycle Bicycle 09 06=Yellow 07=Silver 01=Automobile O1 02=M l 05=SUV 07=V , , Tricycle 08=Gold otorcyc e an 21=Other Pedalcyde C1=Blue 09=Brown 03=Bus 10=Snowmobile 22=Horse & Bu c y 02=Red 10=Orange 04=Smal1 Tr',;ck (If "02", Complete form 11 =Farm Equip 12=Construction Equip 23=Horse & Ri 9r 24=Train 03=White 04=Green 11=Purple 12=Other M, Section 26) 13=ATV 25=Trolley 05=8!ack 99=Unknown (if "20" or "21", Compete er Spec Veh 19=O 98=Other form M, Section 27) nk Type Spec Veh 99=Unkno,,vn initial Impact Point j 00=Non-Co!li5!on 01.12=Clock Points 13=Top Special usage 00 12=Commercial Passenger 00-Net Applicable Carrier 01 =Fire Veh 13=Taxi 02=Ambulance 21=Tractor Trailer 03=Police 22=Twin Trailer 03=Other Emergency 23=Triple Traiier Vehicle 31=Modified Veh 11=Pupil Transport 99=Unknown uamage rnnrcator Gradient 3=Downhill Road Alignmenf 14=Undercarriage =None 2=Functional 4=Bottom of Hill 1=Straight 15=Towed Unit I=PAincr 3=Disabling M 1=level S=To of Hill 1 99=Unknown Ifl 9=Unkno:.vn 2=Uphill 9=Unknown 2=Curved - - 9=Unknown roRM 0 AA-500 (tang) PENNDOT COPY Prin', CRS W0044863 i (CZGt:UA0 W 1%L7 9 OF P Js?SS^I°_a>e?r 9 a r? Page; AA 5CO 2 Paiice Jz niy 1 I u;nn:tr12 <, Page 3 of 9 Crash Nuoer 7 o ? g v-1VV L Motor Vehicle in ' ! Tvne Transport Q Hit& Run Vehicle O Illegally Parked O Legally Parked 0 tdcn - Mcterized 10l ? •- Commercial7ehide ? i Unit Pedestrian on Skates, Disabled crorr I Q Yes Q No I 0 Pedestrian Q 0 0 Train O Ph i Wh l h • i n ee c antom Vehicle air, etc Previous Crash ' ' pf Pedestrian or Pedestrian on Skates, in Wheelchair, etc*, Complete Form M, Section 28) (/t Yes, CompleaForm Q' I Unit No First Name MI Date of Birth (MNI-DD-'(YYY) 02 SANDRA 03 08 1966 Delete? Last Name Tale hone Number 0 BLINK 7177379343 Address / City / State L ai 1 200 HOLLYWOOD CIR CAMP HILL PA s 17011 i f Driver License Number State Class o c 21270383 PA 6 .21 AlcohoUDrugs Suspected Driver or Pedestran PhysiCai Coalition 1 Q No Q Illegal Drugs O Medication O Apparently Illegal Drug O fati N u i l O g orma e O Medicat on Use 0 Alcohol 0 Alcohol and Drugs 0 Unknown O Had Been d Drinking O Sick O Asleep 0 Unknown 0 I Alcohol Test Type 9 0 Test Not Given Q Breath O Other Primary Vehicle Code Violation W Charged? °u 0 Blood 0 Urine Q Unknown if O Yes No 9 T t Gi es ven > Alcohol Test Results 0 Test Refused 0 Results Unknown Driver Presence 1=Driver Operated 3=Driver Fled Scene Test Given, a Vehicle O 0 Contaminated Results 4=Hit and Run 2=NO Diver 9=Unknown Owner/Driver 00=Not Applicable 02=Private Vehicle Not 04=5tate Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh 01 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=Oth er Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown l Same as Owner First Name Owner Last Name or Business blame (It Pedestrian, skip this Section) Driver p MICHAEL A BLINN Address / City / State / Zip Vehicle Make "Make Code 200 HOLLYWOOD CIR CAMP HILL PA 17011 Dod e 07 VIN Model Year Vehicle Model (see overlay) , 2B8GP44312R594978 2002 ' CAR License Plate Reg. State Est. Speed Vehicle Towed Towed By EPF9568 PA 000 Q Yes 0 No ROADSIDE AUTO R Insurance Insurance Company Policy No o' p Yes 0 No 0 "n- USAA CASUAL ? Y INS CO , known 00380 16 36-C 710 1 1 -, E J e Trailing Type 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St unit No. of Unit a 2=Towing Truck S=CamRer B r Trailing 0 =Cthe ?f Units: 3=Towing Utility Trailer 6=Full Trailer 9=Unknown E s' y Direction of rave E Vehicle Position *Move ment 03 03 "See Special Usa e LLJ ov g Vehicle Color Vehicle Type 05=Large Truck 20=Unicycle, Bicycle, 06=Yellow 00 12=Commercial 01=Automobile 06=SUV Tricycle 08 07=Silver 01 02=Ngotorc de 07=Van 21 =Other Pedalryc!e Passenger 00=Net Applicable Carrier 08=Gold d 03=Bus 10=Srowmobile 22=Horse & Buggy 01 =Blue 09=Brown Oq=Small Truck 11=Farm Equip 23=Horse & Rid 01=Fire Veh 13=Taxi 02=Ambulance 21=Tractor Trailer er 02=Red 10=0range (!f "02", Cemplete form 12=ConsUuCion Equip 24=Train 03=Whit P 11 l O==Police 22=Twin Trailer e = urp e M, Section 26) 13=ATV 25=Tro'ley 04=Green 12=0ther 03=0ther Emergency 23=Trple Trai:er (If "20" or "27 ", Complete 12=Other Type Spec %/eh 98=0ther 05=Black 99=Unknown Form M, Section 27) 19=Unk. Type Spec Veh 99=Unknown Vehicle 31=Modified Ich 1 1=Pupil Transport 99=Unknown Initial Impact Point Damage Indicator CO=Non-Collision 14=Undercarriage ? O=None 2=Functional F6 C1 12=Clock Points 15=Towed U 1=Elinor 3=Disabli i Gradient 3=Downhill ftad Alignment 4=Bottom of Hill c 1=Level 1= traight t n ng 13=Top 9g=Urknown 9=Unknown 2=Uphill S=Top of Hill 2=Curved _ 9=Unkno,,,n 9=Unknown FORM N AA-500 (12102) PENNDOT COPY P art CRS W0044863 ?age 4 of 9 ? 9 S CR H PO fte ° ? .-- A R z 6vo I BIIi NIIII 'll1181 llll il ?age: Crash Nun?r AA 500 G n Police 'Jse Cnhl AA L I - WOOa485-7 ?I ¢ : e ? Motor Vehicle ?n - 7ype 0 Transport Q Hit & Run Vehic!e Q illegaiiy Parked Legally Parked 0 hlcn - hlo,erized f ' ?o ° I " g ehide j Unit Commercial Q Pedestrian O Pedestrian on Skates, Disabled From Q Yes 0 No ! Q in Wheelchair Train Phant etc O Pr V h , ev10US Crash om e ice ?l (If 'Pedestrian' or 'Pedestrian on Skates, in Wheelchair, etc', Complete Form M, Section 28) (/f Yes, ComplertForm C,1 I Unit No First Blame 03 BONITA Nil Date of Birth(PdM-DD-YYYY) Last N 13 1960 ame Delete? Tee hone Number Q WELLS Address / City /State 7177323086 ? 705 CARRIAGE LN MECHANICSBURG PA Zi Driver License Number 17050 o' _I C (7233380 State Class PA AlcohoDDrugs Suspected sr ? Driver or Pedestrian Physical Condition Q No 0 1!legal Drugs Q Medication 0 Apparently Illegal Drug Q Fati Normal O U ue ti M i V O Alcohol O Alcohol and Drugs 0 Unknown g ca on se ed 0 Had Been O Drinking O Sick 0 Asleep Q Unknown a Alcohol Test Type ®? Q Test Not Given Q Breath O Other Primary Vehicle Code Violation _u CD Blood 0 Urine Q Unknown if a Test Given Charged? O Yes No I > Alcohol Test Results Q Test Refused Unknown O Results Driver Presence 1=Driver Operated 3=Driver Fled Scene ? • Q Test Given, Contaminated Results ? Vehicle 4=Hit and Run 2=No Craver 9=Unknown i Owner JDriver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police V h 01 01=Private Vehicle Owned/ Owned/Leased by Driver L e 09=Federal Gov Veh 05=PENNDOT Vehicle 08=Other Municipal 98 ,- eased by Driver 03=Rented Vehicle =0ther 06=0ther State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last (Name or Business Name (If Pedestrian, skip this Section) Driver 0 BONITA A & MITC WELLS f Address / City / State / Zip 705 CARRIAGE LN MECHANICSBURG PA 17050 Vehicle Ford Make *Make Cod( VEIN Model Year vehicle Model (see overlay) 1 F)ViDU77K44UA53395 2004 EpR License Plate YPE 1203 Reg. State Est. Speed Vehicle Towed Towed By 000 0 Yes Q No ?- Insurance Insurance Compan PA y Policy No o ` Q Yes c) INo kn a kno own AMERICAN FIRE & CASUAL iiVA 036?2j3c 12 v+o S g f Trarlrno T Q Unit No. of ? -? `- Trailing 0 Unit Units 1=Towing Pass. Vch 4=Mobile/Modular Home 7=Semi-Trailer -, 2=Towing Truck 5=Camper 8=0ther 3=Towing Utility Trailer 640 Trailer 9=Unknown Ta No 9 Tag Year Tag St (-? IL-_ :b Direction of "Vehicle Position 03 rave 'Movement O a *See 5pecial Usa e Overlay g Vehicle Color 6 Yellow Vehide Type OS.-Lai g- Truck 9° 0=Unit de, Di de, y ry 00 7 12=Commercial 0g 07=5ilver 01=Automobile 04 02=Motorc cle 06=5UV 07=Van Tricycle 00=Not A l bl Passenger 08=Gold y 21=Other Pedalcyde pp ca e Carrier 01=6!ue 09=Drc:vn 02 =R d 03=Bus 04=Small Truck 10=Snowmobile 11=Farm Equip 22=Horse & Buggy 23 =Horse & Pider 01=FIre Veh 02=Ambulance 13=Taxi 21=Tractor Trailer e 10=Orange 03 = White 11=Purple (If '02', Complete Form M Section 26) 12=Construction Equip 13 AT 24=Train 03=PoP(e 08 22=Twin Trailer 04=Green 12=Other , = V 25=Trolley =0ther Emergenc y 23=Triple Traiier 05=8lack 99=Unknown (If '20" or "21", Complete 18=0ther Type Spec Veh 98=Other Vehicle 31 =Modified Veh Form M, Section 27) 19=Unk. Type Spec Veh 99=Unknown 11=Pupil Transport 99=Unknown Initial Impact Point Damage Indicator Gradient 06 00=Non-Collision 14=Undercarriage 01-12=Clock Points 15=Towed Uni, O=None 2=Funct!onal 1=P.linor 3=Oisab!in IT] 1 1=Level 3=Downhill 4=Bottom of hill lloacfAlignmer)t 1=Straight 13=Top 99=Unknown 9=Unknown g 2=Uphilll 5=Top of Hill 1 2=Curled -_ 9=Unknown 9--Unknown FORM w M-5oo (12102) _ PENNDOT COPY -- -- Prim CRS W0044363 COMMONWEALTH OF PEEMNSYLVAMA AA POLICE 0ASH RL(POR'71?,t?C F?OR?1 Page ^? 5120 3 ?clice Jse Orry A 1=01river _1 . D 00=Not A Passenger/Occu ant 2=Passenger p 01=Driver - All Vehicles 7=Pedestrian 02=Front Seat Middle Pos+tion 8=Other 03=Front Seat Right Side 9=Unknown 04=Second Row - Left Side Cr Motorcycle Passenger 05=Second Row - Middle Position Sex. 06=Second Row - Right Side B F =Female 07=Third Row Cr Greater 0 M=Male Left Side U =Unknown 08=Third Row Or Greater - i E Middle Position b 09=Third Row Or Greater - ®I Right Side o bury Severity: 10=Sleeper Section of Truckcab e I G O=Not Injured 11=1n Other Enclosed ©i 1=Killed Passenger Or Cargo Area 2=Major Injury 12=In Open Area 3--Moderate (Back Of Pickup, Etc.) Injury 13=Trailing Unit 4=Minor Injury 14=Riding On Vehicle Extericr 8=Injury, Unk 1S=Bus Passenger Severity 98=Other 9=Unknown if 99=Unknown injury GG=None Used / Nct appIic_?bie 01 =Shoulder Belt Used 02=1 ao Belt Used 03=Lap And Shoulder Belt Used 04=Child Safer/ Seat Used 05=Motorcycle Helmet Used 06=Bic7cle Helmet Used 10=Sa•ety Belt used'mproperly 11=Child Safety Seat Used Improperly 12=Helmet Used Improperly 90=Restraint used, Type Unknown 99=Unknown Salo??quioment fivo: F 00=N Used / Not Applicable 01 =Front Air Bag Deployed (For This Seat) 02=Side Air Bag Deployed (For This Seat) 03=Other Type Air Bag Deployed 04=Multiple Air Bags Deployed 05=Motorcycle Eye Protection 06=6icycl;st Wearing Elbow/Knee/Pads 10=Air Bag Not Deployed, Switch On 11=Air Bag Not Deployed, Switch off 12=Air Bag Not Deployed, Unk Switch Setting 13=Air Bag Removed (Prior To Crash) 19=Unknown If Air Bag Deployed 99=Unknown Pale or 9 I"IW6fIIIVm'WR ..,,,..0. 7 WJ044363 G O=Not Applicable 1=Nct Ejected 2=Total)y Ejected 3=Parially Ejected 9=Unknown H C, _-n/ n Park: O=Nct Elected / Not Applicable 1=Through Side Doer Opening 2=Through Side Window 3=Through Windshield 4=Through Back Door 5=Through Back Door Tailgate 0fening 6=Through Roof Opening (Sunroof/ Convertible Top Down) 7=7hrough Roof Opening (Conveaible Top up) 9=Unknown Ex i ation: O=Not Applicable 1=Not Extricated 2=Extricated By Mechanical Means 3=Freed By Non - Mechanical Means 8=Other 9=Unknown EMS Agency: AMB 71, CO 30 -? Medical Facility: HOLY SPIRIT HOSPITAL Unit No Person No Date of Birth (MM-OD=YYYY) A B C D E F G H i Delete? OIKI (D O1 08 l5 - 1977 1 F10 O1 0? 00 1-l0 I Name / Address / Phone ? Same as VADLAKONDA, SRIKANTH 3521 SEPTEMBER DR APT 5 CAMP HILL P EMS Transport Operator CD Yes CD No Unit No Person No Delete? Date of Birth (MM DD-YYYY) A 8 C D E F G H i OZ O 1 p 03 - 03 - 1 1966 D P] U 01 03 10 l? 0? 1? Name / Address / Phone E]'-me as IBLINN, SANDRA A 200 HOLLYWOOD CIR CAMP HILL PA 17011 717 EMS Transport Operator Yes (:D No Unit No Person No Date of Birth (M Delete? M-DD-YWY) A B C D E F Og 00 - 0 - ? ? K] G H I OS 04 1964 11? NI 0 03 03 10 I? 0? I? Name / Address / Phone Same as MICHAEL A BLIN-N 200 HOLLYWOOD CIR CAMP HILL PA 17011 717 ELVIS Transport Operator 0 Yes 0 No Unit No FPerson No Date of Birth (MM DD YYYY) rA? B C D F G 1nDelete] J tJ I 0- 0' - 2? - 1998 V11 0 ? 04 0? 00 1 ? LJ L 0 1 Name / Address / Phone Same as CHRISTOPHER J BLINK 200 HOLLYWOOD CIR CAMP HILL PA 17011 EMS Transport Operator 0 Yes U No Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I ? ? ? 02 04 0 06 - 22 - 1991 [2 lei 0 06 03 00 1 0 1 Name / Address / Phone 1:1 OpeSamerattoor DAVID N BLIIvN 200 HOLLYWOOD CIR CAMP HILL PA 17011 71773 EMS Transport - „ ? res vivo Unit No Person No Delete? Date of Birth ;NIJJ-DD-YYYY) A B C D E F G H I 0> 0I Q 1960 In [F ] [0 ] 01 03 10 l? pa Name / Address / Phone 0 same as WELLS, BONITA ANN 705 CARRIAGE LN MECHANICSBURG PA 17050 EMS Transport Operator O Yes CD No roar 0 na-sop pvozl PENNDOT DOPY Prir.` CRS IW0044863 COMMONWEALTH OF PEEMYSSYLVANIA OM A .ta r? PCLIC-7 'CZASA REOR 71VIS FORM Ar 500 4 PG:ce Dnry Crash Descriotion 1a c 0 .q E I? I' E 11 Relation to Roadway o` c rl ts! r yj minat Illuion v` s l Weather Conditions c ;I Ej Vj Road Surface Conditions 'age 6 of 9 Page O=Ncn-Collision 2=Head On 1=Rear End 3=Pear to Rear (Backing) 1H1111111111111111111 '""0044863 Crash Murrier i 4=Angle 5=Sides1'1ipe 8=Hit Pedolri an 5=Sidoswioe (Opposite Direction) (Same Direction) 7=Hit Fixed Object 9=0ther/Umcwn a 1=0n Travel Lanes 3=Median S=Outside Trafficway 7=Gore !Ramp Intersection) 2=Shoulder 4=Roadside 6=1n Parking Lane 9=Unknown 1=Daylight 3=Dark-Street S=Dawn `---'- - B=Other 1 2=Dark - No Street Li ht Lights 4 6=Dark known U g s =Dusk Roadwa Li htin in 1? 1=No Adverse Conditions 3=Sleet (Hail) 5=Fog 7=Sleet & Fog 9=Unknown _ 2=Rain _ 4=Snow 6=Rain & Fog B=Other O=Dry 2=OOand, iUud, Dirt, 4=31ush 6=Ice Patches 8=Other 1=Wet 3=Snow Covered 5=Ice 7='haler -Standing or ovina Unit No t 02 F! 0 O1 2? ? O Please Put Q Evens in 3 ? ----? J 5equential c Order ? O ?i E. w Harm Event L/R Most7 Utility Pole Plumber W ? Unit No El 0 c? 02 2 03 0 Please Event Put Events in 3 ? ? Sequenval Order ? ? ? 0 First Unit No Harm Event Most Unit No Harm Event al armful Wa -rm ful vef <s 01 02 Eve o nt in 02 11 t t reh t h Do not repeat this .nromaiion on multple Papes fnvironmental / Roadway Potential Factors (FA) 1 00 2 3 00=None 11=Slippery Road Conditions (Ice/Snow) 01 =Windy Conditions 12=Substance On Roadway 02=Sudden Weather Conditions 13=Potholes 03=Other Weather Conditions 14=Broken Or Cracked Pavement 04=Deer In Roadway 15='rCD Obs;n.cted 05=Ob3tacle On Roadway 16=50ft Shoulder Or Shoulder Drop Off C6=Other Animal In Roadway 28=Other Roadway Factor 07=Glare 29=Other Environmental Factor 08=Work Zone Related 99=Unknown Possible Vehicle Failures (V) 12=Wipers 00=None 06=Exhaust 13=Driver Seating/Control 01=Tires 07=Headlights 14=Body, Doors, Hood, Etc 02=Brake System 08=Signal Lights 15=T aF'er Hitch 03=Steering System 09=Other Lights 16=Wheels 04=Suspension 10=Horn 17=Airbacs 05=Power Train 11=Mirrors 1 B=Trailer Overloaded Unit Plo O 1 1 00 2 19=Unsecure/Shifted Trailer Load Z0=improper Towing Unit 02 1 00 2 140 21=Obstructed Windshield 99=Unknown ' Indicated Prime Factor Do noI repeal this intormaticn on 19II mult?Pie pages. f/R V D P 0 00 0 FOnM ! AA-Soo (12io2) Unit No Factor Code O1 11 If E/R is the Prime Factor Type, leave Unit No blank Harmful Event_s_(Harm Event 01=Hit Unit I 02=Hit Unit 2 03=Hit Unit 3 04=Hit Unit 4 05=Hit Unit 5 06=Hit Other Traffic unit 07=Hit Deer 08=Hit Other Animal 09=Collision With Other Non Fixed Object 11=Struck By Unit 1 12=Struck By Unit 2 13=Struck By Unit 3 14=5 ruck By Unit 4 15=Struck By Unit 5 16=Struck By Other Traffic Unit 21=Hit Tree Or Shrubbery 22=H it Embankment 23 Hit Utility Pole 24=Hit Traffic Sign 25=Hit Guard Rail 26=Hit Guard Rail End 27=Hit Curb 28=Hit Concrete Or Longitudinal Barrier 29=Hit Ditch 00=No Contributirg Action 01=Driver Was DistrW..ed 02=Driving Using Hand Held Phone 03=Driving Using Hands Free phone 04=Making Illegal U-Turn 05=Improper/Careless Turning 06=Turning From Wrong Lane 07=Proceeding W/O Clearance After Stop 08=Running S!op Sign 09=Running Red Light 10=Failure To Respond To Other Traffic.-,.nt:ol Device 11=Tailgatingg 12=Sudden Slowing/Stop mg 13=I11egally Stopped On Road 14=Careless Passing Or Lane Change 15-Passing In No Passing Zone 16=Driving The Wrong Way On 1-Way Street 30=Hit Fence Or Wall 31=Hit Building 32=Hit Culvert 33=Hit Bndge Pier Or Abutmert 34=Hit Parapet End 35=Hit Bridge Rail 36=Hit Boulder Or Obstacle On Roadway 37=Hit impact Altenuator 38=Hit Fire Hydrant 39=Hit Roadway Equipment 40=Hit Mail Box 41=Hit Traffic Island 42=Hit Snow Bank 43=Hit Temporary Construction Barrier 48=Hit Other Fixed Object 49=Hit Unknown Fixed Object 50=Overturn/Roll over 51 =Struck By Thrown Or Falling Object 52=Pot Holes Or Other Pavement Irregularities 53=!acknife 54=Fire in Vehicle 58=Other Non-Colfsicn 99=Unknown Harmful Event 17=Careless Or Illegal Backing On Roadway 18=Driving On The Wrong Side Of Road 19=Making improper Entrance To Highway 20=Making Improper Exit Frcrn Highway 21=Careless Parking/Unparking 22=Over/Under Comoensation At Cure 23=Speeding 24=Driving Too Fast For Conditions 25=Failure Tr Maintai:1 Proper Speed 26=Driver Fleeing Police (Pol Chase) 27=Driver inexperienced 28=Failure To Use Specialized Equip 92=Affected By Physical Condition 98=10ther Improper Criving Actions 99=Unknown Unit No IT, 1 z = 3 .4 1 1 LLL????JJI Unit I I ?---? -? No 0? 1 00 z ? Pedestrian Ac-ion (P? 03=%A "1k;_ 00=Nose 04=Pushing Vehicle C1=Erterng Or Crossing At 05=Approa6ing Or Leaving Vehicle Specs` ,d Location 06=Workinq On Vehicle 02W/alkirng, Runnirg, jogging, 07-Standing Or Playing 98=Other 99=Unkrown Unit No O 1 00 Unit No 02 00 PEiNINI)OT CC,'?'d Print CRS W C04486.3 CCMA4C;TJVE:AL7H OF FL'uNNSYLVAMIA PCL;CF CRASM REPORT ING FDRM 17 AA 500 4 rol,ce USe onry Crash Description a I O vl Tunla; r? Relation to Roadwav a 1sl N ;!? Illumination Iv`ryt? c weather Conditions aE Road Surface Conditions Q? u Harm Event L/R IUios4 1 12 F1 0 e7of9 Page II1111NIIIIIIII111111?1?i1 CrashAAlurnceT { I I i O=Non-Collision 2=Head On 4=Angle 6=Sideswipe 8=Hit Peden an 1=Rear End 3--Rearm Rear B k 5=Sideswipe (Opposite Direction) ( lrg) ac (Same Direction) 7=Hit Fixed Object 9=Cther/UMOwn 1=On Travel Lanes 3=Median 5=Outside Trafficway 7=Gore (Ramp intersection) 2=Shoulder 4=Roadside 6=1n Parking Lane 9=Unknown 1=Daylight 3=Dark - Street 5=Dawn 8=01her 2=Dark - No Lights 6=Dark • Unknown Street Lights 4=Dusk Roadway Lighting 1=No Adverse 3=Sleet (Hail) 5-Fog 7=Sleet £ Fog 9=Unknown 2=Rain _ 4=Snow 6=Rain b Fog 8=Other O=Dry 2=50and, Mud, Dirt, 4=Slush 6=1ce Patches 8 --Other 1=Wet 3=snow Covered S=Ice 7=W tr - Standing nr mmnn 03 2 O ?0 Please iPut n 3 Events in -1 0 o i .M I 16 Sequential Order 4 ? ? O t-- II E c r I I 1 Harm Event L/R Most? Utility Pole Number 0 jN l Unit No ?2 ? `- 0 I ?lease Put Events in 3 ? 0 Sequential Order ? ? ? 0 First Event l Event rnrn Unit No ? 1 Harm Event Most Unit No Harm Event f ?2 Event in 11 n F7 t e ash i t e rash Do not repeal ;his intormawn on mdtiple pages c 0 c Dirt c a c v° Environmental /Roadway 1 Potential Factors (EM) 00 2 3 00=None 11=Slippery Road Conditions (Icei5now) 01=Windy Conditions 12=Substance On Roadway 02=Sudden Weather Conditions 13=Potholes 03=01her Weather Conditions 14=Broken Or Cracked Pavement 04=Deer In Roadway 1 S=TCD Obstructed 05=Obstacle On Roadway 16=Soft Shoulder Or Shoulder Drop Off 06=0ther Animat In Roadway 28=Other Roadway Factor 07=Glare 29=01her Environmental Factor 08=Work Zone Related 99=Unknown No 1 ?2? Possible Vehicle Failures (V) 12=Wipers 00=None 06=Exhaust 13=Driver Seating/Control O1=Tires 07=Headlights 14=Body, Doors, Hood, Etc 02=Brake System 08=Signal Lights 1 S=Trailer Hitch 03=Steering System 09=Other Lights 16=Wheels 04=Suspension 10=Horn 17=Airbags 05=Power Train 11 =Mirrors 18=Trailer Overloaded Unit 1 No 00 2 [77 19=Unsecure;Shifted Trailer Load 20=Improper Tov;ing 21=Obstructed Windshield Unit 99=Unknown Indicated Prime Factor Unit No Factor Code not repeal this information on mu Juple pages. O 1 1 ) EIR V D P Q Q Q CD If EIR is the Prime Facto, Type, leave Unit No Wank FORM 0 AA-500 (12102) Harmful Events (Harm Even) 01=Hit Unit 1 02=Hit Unit 2 03=Hit Unit 3 04=Hit Unit 4 05=Nit Unit 5 06=Hit Other Traffic Unit 07=Hit Deer 08=Hit Other Animal 09=Collision With Other Non Fixed Object 11=Struck By Unit 1 12=Struck By Unit 2 13=5truck By Unit 3 14=Struck By Unit 4 15=Struck By Unit 5 ' 6=Struck By Other Traffic unit 21=Hit Tree Or Shrubbery 22=Hit Embankment 23=Hit Utility Pole 24=Hit Traffic Sign 25=Hit Guard Rail 26=Hit Guard Rail End 27=Hit Curb 28=Hit Concrete Or Longitudinal Barrier 29=Hit Ditch 00=No Contributing Action 01=Driver Was Distracted 02=Dri11119 Using Hand Held Phone 03=Driving Using Hands Free Phone 04=Making Illegal U-Turn 05=Improper/Careless Turning 06=Turning From Wrong Lane 07=Proceeding W/O Clearance After Stop 08=Running Stop Sign 09=Running Red Light 10=Failure To Respond To Cther Traffic Conrrc! Device 11=Tailgatingg 12=Sudden Slcwing/S•opoing 13=Illegally Stopped On Read 14=Careless Passing Or Lane Change 15=Passing In No Passing Zone 16=Driving The Wrong W'ay On 1-Way Street 30=Hit Fence Or Wall 31=Hit Building 32=Hit Culvert 33=Hit Bridge Pier Or Abutment 34=Hit Parapet End 35=Hit Bridge Rail 36=Hit Boulder Or Obstacle On Roadway 37=Hit Impact Attenuator 38=Hit Fire Hydrant 39=Hit Roadway Equipment 40=Hit Mail Box 41=Hit Traffic Island 42=Hit Snow Bank 43=Hit Temporary Construction Barrier 48=Hit Other Fixed Object 49=Hit Unknown Fixed Object 50=Cvertur,VRoll Over 51 =Struck By Thrown Or Falling Object 52=Pot Holes Or Other Pavement Irregularities 53=)acknife S4=Fire In Vehicle 58=Other Non-Collision 99=Unknown Harmful Event 17=Careless Or Illegal Backing On Roadway 18=Driving On The Wrong Side Of Road 19=Making Improper Entrance To Highway 20=Making Improper Exit From Highway 21 =Careless Parking/tinparking 22=Over/Under Compensation At Curve 23=Speeding 24=Driving Too Fast For Conditions 25=Failure To %laintain Proper Speed 26=Driver Fleeing Police (Pol Chase) 27=Driver Inexperienced 28=Failure To Use Specialized Ecvip 92=Affected 8y Physical Cordition 98=Other Improper Driving Actions 99=Unknown No1t 03 1 00 2 3 . 4 Noll 2 ? 3 Pedestrian Action (i°) - I 00=None „y 04=Pushing Vehicle 01=Entering Or Crossing At 05=APpr0achn9 Or Leaving Vehicle SpeciEeo Location 0b=b'Jorking On Vehicle 02=Walking, Runr.irg, logging, 07=Standing Or Playing 98=ether 99=Unknown Unit No O3 OO Unit No = PEN:tiD0T C0?V Pr_nt CRS W0044863 8 011 9 E ...... .... .. .......... 20 m : .. Witness Name Address Phone 21 2 Narrative and additional witnesses: Accident Investigation Notification Issued? Q' Property Damage 0 V1, V2 & V3 WERE ALL EASTBOUND IN THE LEFT LANE OF THE 5800 BLK OF THE CARLISLE PIKE. V3 STOPPED IN FRONT OF V2 & V2 STOPPED IN FRONT OF V1. V1 WAS UNABLE TO STOP AND REAR-ENDED V2 CAUSING V2 TO REAR-END V3. V1 & V2 WERE TOWED BY/TO ROADSIDE AUTO RESCUE. OPER V2 WAS TRANSPORTED BY AMBULANCE 71 TO HOLY SPIRIT HOSPITAL. OPER V1 DID NOT HAVE AN EXPLANATION FOR THE CRASH. HE STATED THAT HE WAS ATTENTIVE, HE WASN'T SPEEDING OR TAILGAITING AND THAT VVS BRAKES W ERE COMPLETELY OPERATIONAL. c N w d C N 3 FORMA AA-500 (1=) PENNDOT COPY h print CRS wW0044863 'ace 9 of 9 Crash Number: W0044863 incident Number: HAM20061000449 Unit 1- -Unit 1-7Wt2- -?Jnit3- - 0 0 5800 blk Carlisle Pike - US 11 chuff City 6800 Carlisle Pike 'age 1 of Synopsis Quality Assurance Synopsis Report Crash Synopsis created 11/14/2006 for Crash Number W0044863 Web Group CA. Police Agency Data: The crash report was recorded by police agency 21103-Hampden Township, patrol zone - 100, under incident number HAM2001000449. The dispatch date was 10/13/2006, the dispatch time was 1802 hours, the investigation date was 10/13/2006, the arrival time wo 1806 hours. The investigator was CPL JEFFREY A SNYDER, badge number 19-11. The report was approved by SGT SHAUN A. FELTY, badge number 19-2 on 10/20/2006. Crash Data: This rear-end crash occurred in Cumberland county, in the municipality of Hampden Township, on Friday, 10113/2006 at 1802 hours. The illumination at the time of the crash was daylight. The 3-unit crash involved 6 people with 1 injury. There were no fatalities. This isa reportable crash. Highway maintenance was not notified. The crash was not school bus related. The crash was not school zone related. There was no PennDOT property damaged. The crash did not occur in a work zone. The roadway surface was dry. Weather conditions included No adverse conditions. A notification of an accident investigation was issued. Other environmental / roadway potential factors included None.The indicated prime factor for this crash was a driver's action (Tailgating) for unit 01. The first harp. ful event for this crash was that unit 'I Hit unit 02 and the most harmful event for this crash was that unit 2 was struck by unit 1. Type Location: This was a four way intersection crash, which occurred at no special location. Principal Roadway: Cumberland County, route 0011, the orientation of the roadway was East, there were 05 travel lane(s), the speed limit was 40 Mph, with State highway route signing. Intersecting Road: Cumberland County, JEFFREY Road, the orientation of the roadway was South, there were 02 travel lane(s), the speed limit was 25 Mph, with Local road or street route signing. GPS: The police-entered Latitude was 40 14:31.000 and the police-entered Longitude was 76 59:21.000 TCD: Traffic Control Device: a traffic signal, functioning properly. Work zone: Type of Work Zone: not a work zone. Lane Closure: Partially closed. Lane closure direction East. Traffic detoured no. Estimated hours closed 30 - 60 minutes. UNIT INFORMATION: 1 Unit Number 1 was a motor vehicle in transport. The unit was owned by SRIKANTH VADLAKONDA. Address: 3521 SEPTEMBER DR APT 5, CAMP HILL, PA 17011. This 1993 Honda identified by VIN: 1 HGC87678PA067682 was registered in PA with License GLX4226. Travel speed: 025. Unit insured: vehicle has insurance, Insurance Company: GEICO, Policy number: 4073-65-55-91. The Unit was towed by ROADSIDE AUTO RESCUE. This was not a commercial vehicle. This Unit was an automobile, Vehicle color: Brown, Special Usage: Not applicable. The initial impact point was at 12 o'clock, Damage Indicator: Functional (mod. - may be undriveable), Vehicle role: Striking, Vehicle position: in the left lane. Direction of travel: East, Movement: Going straight, Gradient: on a level roadway, Alignment: Straight. Driver Information: The driver of this unit was SRiKANTH VADL.AKONDA. Address: 3521 SEPTEMBER DR APT 5 CAMP HILL PA 17011. Telephone: 760-317- 6444, Height: 5 Ft 10 In. Drivers License #: 29030835, State: PA. DOB: 08/15/1977, Age: 29, Sex: Male. Seating position: driver's seat. Primary safety equipment: lap and shoulder belt were used. Secondary safety equipment: None used / Not applicable. Injury severity: Net injured. Ejection: Not ejected. Extrication: Not extricated. EMS Transport: No. Alcohol/Drugs Suspected: none suspected, Alc:)hol Test Type: Test not given, Alcohol Test Results: Result = 0.00. Driver's action(s), 1 Tailgating. The individuai's condition was apparently normal. Vehicle code DRIVING VEHICLE AT SAFE SPEED was violated. Citation was written. UNIT INFORMATION: 2 Unit Number 2 was a motor vehicle in transport. The unit was owned by MICHAEL A BLINN, Address: 200 HOLLYWOOD CIR, CAMP HILL, ? a!;e 0f PA 1701 1. This 2002 Dodge identified by VIN: 268GP44312R594978 was registered in ?A with License EPF9568. Trave! spee Stooped. Unit insured: vehicle has insurance, Insurance Company: USAA CASUALTY INS CO, Pciicy number OC386 16 36C 7101 3. Ti, Unit was towed by RCADSIDE AUTO RESCUE. This was not a commercial vehicle. This Unit was an automobile, Vehicle color: Gold; Szrial Usage: Nct applicabla. The initial impact point was at 6 o'clock, Damage indicator: Furctional i'mod. - may be undriveable), Vehicle rcleE?oth striking and struck, Vehicle position: in the left lane. Direction of travel: East, Movement: Stopped n traffic lane, Gradient. on a level roaway, Alignment: Straight. Driver Information: The driver of this unit was SANDRA A BLINN. Address: 200 HOLLYWOOD CIR CAMP HILL PA 17011. Telephone: 717-737.9v3, Height: 5 Ft 5 In. Drivers License #: 21270383, State: PA. DOB: 03/08/1966, Age: 40, Sex: Female. Seating position: driver's seat. Primal safety equipment: lap and shoulder belt were used. Secondary safety equipment: Air bag not deployed, switch on. Injury severity: Mindinjury. Ejection: Not ejected. Extrication: Not extricated. EMS Transport: Yes. Alcohol/Drugs Suspected: none suspected, Alcohol Testiype: Test not given, Alcohol Test Results: Result = 0.00. Driver's action(s), 1 No contributing action. The individual's condition was apparentlyiormal. Passenger Information: A passenger (1): MICHAEL A BLINN, Address: 200 HOLLYWOOD CIR CAMP HILL PA 17011, Telephone: 717-737-9343. DOB:05104/1964, Age: 42, Sex: Male. Seating position: Front seat right side. Primary safety equipment: lap and shoulder belt were used. Secondary safety equipment: Air bag not deployed, switch on. Injury severity: Not injured. Ejection: Not ejected. Extrication: Not extricated. EMS Transport: No. Passenger Information: A passenger (2): CHRISTOPHER.! BLINN, Address: 200 HOLLYWOOD CIR CAMP HILL PA 17011. Telephone: 717-737-9343.D0B: 06/22/1998, Age: 08, Sex: Male. Seating position: Second row - left side or motorcycle passenger. Primary safety equipment: lapand shoulder belt were used. Secondary safety equipment: None used / Not applicable. Injury severity: Not injured. Ejection: Not ejected. Extrication: Not extricated. EMS Transport: No. Passenger Information: A passenger (3): DAVID N BLINN, Address: 200 HOLLYWOOD CIR CAMP HILL PA 17011. Telephone: 717-737-9343. DOB: 061,22/1991, Age: 15, Sex: Male. Seating position: Second row - right side. Primary safety equipment: lap and shoulder belt were used. Secondary safety equipment: None used / Not applicable. Injury severity: Not injured. Ejection: Not ejected. Extrication: Not extricated. EMS Transport: No. UNIT INFORMATION: 3 Unit Number 3 was a motor vehicle in transport. The unit was owned by BONITA A & MITCHELL WELLS. Address: 705 CARRIAGE LN, MECHANICSBURG, PA 17050. This 2004 Ford identified by VIN: 1 FMDU77K44UA53395 was registered in PA with License YPE1203. Travel speed: Stopped. Unit insured: vehicle has insurance, Insurance Company: AMERICAN FIRE & CASUALTY, Policy number: DVA 03652586 The Unit was not towed. This was not a commercial vehicle. This Unit was a small truck, Vehicle color: Gold, Special Usage: Not applicable. The initial impact point was at 6 o'clock, Damage Indicator: Minor (able to be driven), Vehicle role: Struck, Vehicle position: in the left lane. Direction of travel: East, Movement: Stopped in traffic lane, Gradient: on a level roadway, Alignment: Straight. Driver Information: The driver of this unit was BONITA A WELLS. Address: 705 CARRIAGE LN MECHANICSBURG PA 17050. Telephone: 717-732-3086, Height: 5• Ft 2 In. Drivers License #: 17233380, State: PA. DOB: 02/13/1960, Age: 46, Sex: Female. Seating position: drivers seat. Primary safety equipment: lap and shoulder belt were used. Secondary safety equipment: Air bag not deployed, switch on. Injury severity: Not injured. Ejection: Not ejected. Extrication: Not extricated. EMS Transport: No. Alcohol/Drugs Suspected: none suspected, Alcohol Test Type: Test not given, Alcohol Test Results: Result = 0.00. Driver's action(s), 1 No contributing action. The individual's condition was apparently normal. Close wincow rx L, 6 rl 13 USAA CASUALTY INSURANCE COMPANY W"A 1 I'1? {A Stock Insurance Company) USAF 9800 Fredericksburg Road - San Antonio, Texas 78288 PENNSYLVANIA AUTO POLICY RENEWAL DECLARATIONS arced Insured and Address ADDL INFO ON NEXT PAGE MAt PAGE 5 MCH-M-1 RENEWAL OF State 06 07 Veh POLICY NUMBER Terr 00386 16 36C 7101 3 POLICY PERIOD: (12:01 A.M. standard time) EFFECTIVE MAY 16 2006 TO NOV 16 2006 OPERATORS 01 MICHAEL A BLINN 03 SANDRA ANN BLINN MICHAEL A BLINN 200 HOLLYWOOD CIR CAMP HILL PA 17011-2627 ascri tion of Veh icle(s) VEH USE* woRK/sceooL H YEAR TRADE NAME MODEL BODY TYPE ?UJ MIlEA?E IDENTIFICATION NUMBER SYM aei Wee 6 02 DODGE GRCVN SPT WAG 4X2 4D 13000 2B8GP44312R594978 11 W 02 k 5 7 04 HONDA CRV LX UTILITY 10000 OHLRD78514CO12346 11 W 03 5 Vehicle(s) described herein is principally garaged at the above address unless otherwise stated. wrc=Work/Sthool• 9=9usfness• r=ra n•P= lessure EH 06 CAMP HILL PA 17011-2627 EH 07 CAMP HILL PA 17011-2627 Is go Icy prove as those coverages w ere a premium is shown below.-The Imps s own may be reduced by policy provisions and may not be cpmbined regardless of the um s of bar vehicles for which a remlum is listed unless s pecifically p authorized elsewhere .In this policy. --OVERAGES LIMITS OF LIABILITY VEH VEH VEH VEH ("ACV" MEANS ACTUAL CASH VALUE) 06 D=DED 6-MONTH PREMIUM 07 D=DED 6-MONTH PREMIUM D=DED PREMIUM D=DED PREMIUM ,RT A - LIABILITY AMOUNT $ MOUN S MOON $ AMOUNT $ BODILY INJURY EA PER $ 304,00 EA ACC $ 500,00 69.39 76.59 PROPERTY DAMAGE EA ACC $ 50,00 49.68 54.69 .RT B - FIRST PARTY. BENEFITS MEDICAL EXPENSE $ 10,000 WORK LOSS $ 5,000/$1,000 MO FUNERAL EXPENSE $1,500 19.31 28.67 RT C - UNINSURED MOTORISTS STACKED BODILY INJURY EA PER $ 300,00 EA ACC $ 500,00 25.13 25.13 RT C - UNDERINSURED MOTORISTS STACKED BODILY INJURY EA PER $ 300,00 EA ACC $ 500,00 60.37 60.37 TOTAL PRE IUM - SEE F0 LOWI G PAGE (S) SS PAYEE ' l I I H 06 CHASE MANHATTAN BANK, DALLAS TX H 07 USAA FEDERAL SAVINGS BANK, SAN ANTONIO TX DORSEMENTS: ADDED 05-16-06 - A10OPA(O2) MAIN IN EFFECT(REFER TO PREVIOUS POLICY)- A081(04) A089(04) A400CW(01) A142(01) 5100PA(01) FORMATION FORMS(NOT PART OF POLICY)- 39PA(01) 60PA(02) 663PACIC(03) 999PACIC(17) 0111 Pi 1 7 0122)0000 Q E E WITNESS WHEREOF, we have caused this policy to be signed by our President and Secretary at San Antonio, Texas, on this date A P R I L 9, 2006 G Pair,} USAA? 9800 Fredericksburg Road - San Antonio, Texas 78288 PENNSYLVANIA AUTO POLICY RENEWAL DECLARATIONS Named Insured and Address W11,11 USAA CASUALTY INSURANCE COMPANY (A Stock Insurance Company) MICHAEL A BLINN 200 HOLLYWOOD CIR CAMP HILL PA 17011-2627 PAGE 6 State 06 07 Veh POLICY NUMBER Teri 00386 16 36C,_ 7101 POLICY PERIOD: (12:01 A.M. standard time) EFFECTIVE MAY 16 2006 TO NOV 16 2006 Descri tion of Vehicles! VEH USE WORK/SCI Mpiles Dr VEH YEAR TRADE NAME MODEL BOGY TYPE eA6 cnaF IDENTIFICATION NUMBER SYM Wav W 07 04 HONDA CRV LX UTILITY 10000 JHLRD78514CO12346 11 J WJ 03 e etc e s described herein is prmct a y r a e a the above ? o ermse Sae r W/C=WorklSchool asBnsiness F=Farm P=Pleasur VEH 06 CAMP H ILL PA 170 27 11- 6 VEH 07 CAMP H ILL PA 17011-2627 This ppolicy provides ONLY those coverages where a premium is shown slow. he limits shown may be reduced_ by policy provisions and may not be combined regardless of the number of COVERAGES LIMITS OF LIABILITY ("ACV" MEANS ACTUAL CASH VALUE) p,?" 6-MONTH D=DED PREMIUM AMOUNT $ tit" 6-MONTH D=DED PREMIUM MOUN S w"' D=DED PREMIUM MOUN $ y" D=DED PREMUUb AMOUNT S A COMPREHENSIVE LOSS ACV LESS D 20 25.64 200 30.23 COLLISION LOSS ACV LESS D 50 90.76 500 113.76 INCREASED RENTAL REIMBURSEMENT 21.62 21.62 OTHER COVERAGES EXTRAORDINARY MEDICAL BENEFIT 12.40 17.72 VEHICLE TOTAL PREMIUM 374.30 428.78 6 MONTH PREMIUM $ 803.08 FULL TORT APPLIES THE FOLLOWING COVERAGE(S) DEFINED IN THIS POLICY ARE NOT PROVIDED FOR: VEH 06 - TOWING AND LABOR VEH 07 - TOWING AND LABOR THE LAWS OF THE COMMONWEALTH OF ENNSYLVANIA, AS ENACTED BY THE GENERAL ASSEMBLY, ONLY REQUIRE T AT Y U PURCH SE LIABILITY AND FIRST PARTY MEDICAL BENEFIT COVE AGES. ANY A DITI NAL C VERA ES OR COVERAGES IN EXCESS OF THE LIMITS REQUIRED BY LAW ARE PROVIDED ONLY AT YOUR REQUEST AS ENHANCEMENTS TO BASIC COVERAGES. THE PREMIUM FOR THE BASIC COVERAGE IS: BI 15/30 $ 77.75 PD 5000 $ 94.56 FIRST PARTY MEDICAL BENEFIT 5000 $ 33.29 n WIINES3 WHLHLUF, we nave caused this policy to be signed by our Nresrdent and Secretary at San Antonio, texas, on this date APRIL 9, 2006 PAGE 7 C I C 00386 16 j6 7101 SUPPLEMENTAL INFORMATION isle EFFECTIVE MAY 16 2006 TO NOV 16 2006 The following approximate premium discounts or credits have already been applied to reduce your policy premium costs. NOTE; Age or senior citizen status, if allowed by your state/location, was taken into consideration when your rates were set and your premiums have already been adjusted. VEHICLE 06 DAYTIME RUNNING LIGHTS DISCOUNT -$ 3,81 MULTI-CAR DISCOUNT -$ 54,28 PASSIVE RESTRAINT DISCOUNT -$ 9.19 VEHICLE INJURY RATING DISCOUNT -$ 14.75 VEHICLE 07 MULTI-CAR DISCOUNT -$ 56.92 PASSIVE RESTRAINT DISCOUNT -$ 12,29 ??,?,-? C PLEASE DO N 0 T STAPLE LVIVA l'N THIS A='EA ! PICA APPRC?EQ OMs-0938-Out USAA 27880 N MAIN ST DAP.IE, AL 36526 A S 4 U HEALTH INSURANCE CLAIM FORM PICA ; l T. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER Ia. INSU'RED'S I.D. NUMBER IFOR PROGRAM IN ITEM 1) ? ? ! ? HEALTH PLAN ?euc LUNG r1s dK:aid + (S ojsor's 551Q (VA SSN dr ID) SSN !C D1 i 003861636014008 p p ( / ( y , ( J Ned cere h ( a t 2. PATIENT'S NAME (Last Name, First Name, Middip Inilia'i 3 PATIE NT'S BIRTH LATE SEX 4. !NSURED'S NAME (Last Name, First Name, Middle IrJal) E T 1 9Y 6t 1 i BLINN, MICHAEL 1 64M 0 X I F BLINN, MICHAEL S. PATIENT'S ADDRESS (No., Street) S. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 200 HOLLYWOOD CIRCLE SenL-fj59oM ?-aa Oererl 1 1?.? 200 HOLLYWOOD CIRCLE CITY STATE S. PATIENT STATUS CITY STATE CAMP HILL PA S;n,,e? M -oF om„F CAMP HILL PA ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) j 17 011 (717 737 -9 3 4 3 Emplayod ? Sludenl a ?51u Ti e 17 011 17 73 7- 9343 9. OTHER INSURED'S NAME (Las; Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 17. INSURED'S POLICY GROUP OR FECA NUMBER DOI 101306 o a. OTHER INSURED'S POL a. EMPLOYMENT7 (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX I 1i YES NO F-1 7 MM I DD 1 YY i i M [:] F Z5 b. OTHER INSURED'S DAT b. AUTO ACCIDENT T PLACE (State) It. EMPLOYER'S NAME OR SCHOOL NAME N+ MM ; OD YY l YES NO COMMONWEALTH OF PA 6437 ' L- AM009 c. EMPLOYER'S NAME OR: c. OTHER ACCIDEFIT7 c. INSURANCE PLAN NAME OR PROGRAM NAME YES NO 1:1 USAA d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d, IS THERE ANOTHER HEALTH BENEFIT PLAN? ? YES M NO It yea, return to and complete Item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 1 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Informatlon payment of medical benefits to the undersigned physician or supplier for necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts services described below. assignment below. SIGNATURE ON FILE IGNATURE ON FILE DATE_ SIGNED SIGN o 3 14. DATE OF CURRENT: ILLNESS (First symptom) OR _4 15. IF PATIENT HAS MAO SAME OR SIMILAR ILLNESS. 18. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION .?((yypp,? 1 ,y INJURY (Accident) OR r 1 3 r U? 1? ' GIVE FIRST DATE MM i GO , YY fAM , OD r YY MM OD i Y Y F . , , PREGNANCY LMP1 i i ROM i i TO i i 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN Ia. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 3 DARDEN PAMELA :R P12389 MM , OD YY MM ; OD i YY FROM TO _ 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES ? YES ? NO 3 21. L:AGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS t, 2.3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION ) 723 1 CODE ORIGINAL PER, NO. 23. PRIOR AUTHORIZATION NUMBER IL 2.L-.- 4. I 24. A e C D E F G H I J K DATE(S) OF SERVICE From To Place of Type of PROCEDURES. SERVICES, OR SUPPLIES (Explain Unusual Clrcumstencos ) DIAGNOSIS E CHARGES DAYS OR EPSOT Family EMG COB C RESERVED FOR MM DO YY MM DD YY ¢ervice Service CPTHGPC9 MODIFIER CODE UNITS Plan LOCAL USE h 101,134-06 10Y13106 ;23 72050 1261 1 631 00 1 U - ( U ) 'J r i i i [Y I a ! - ) ? I v Y x I a 25. FEDERAL TAX I.D. NU!/,3ER SS!7 EIN 28. PATENT'S ACCOUNT NO, 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 23. AMOUNT PAIL 30. BALANCE DUE 2 517 9 2 8 0 6 }{ (For poN c aims, soa back) Ves ?NO 1 C A72360 A93 s 63 : 00 $ 0 ; 00 s 63 100 ?J i 31. SGNATURE OF P'riYSIQAN OR SUPPLIER - 32. NAME AND ADDRESS OF FACILIT(1VHERE SERVICES WERE INCr_U'DING DEGREES OR CREDENTIALS REN"uERED (II other !Nan home or uhice) I. calify that the stalernar,ls on Ire e HOLY SPIRIT HOSPITAL 33 PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE t 6?iH'UM IMAGING & THER ASSOC P app!y ply 10 to this bit; end are nade a Pail t the' thereo!.) 503 N 21ST STREET 2527 CRANBERRY HIGHWAY I GEORGE S D- ISEK, MD 12/04/06 (CAMP HILL PA 17011 WAREHAM MA 02571 `'179 2806 I S13h":D DATE I P INN I ORPh' z 0 a a 0 LL z O U.11 LL N Z_ O z a z w EL Q. (SPPRCVEO BY AS1A `0lJNCll ON MEDICgL SER'?ICF 8+95) PLEASE PRINT OR TYPE 1`0:4M RCF.4.1soe (1z-eo; FORK OWCP1507 rDflM RRB15nn WHCFA-1569-CS-90 (i0.r931 PLEASE 00 NOT STAPLE IN THIS AREA ?'? fU1V USAA ??-A r t.?' LC / w PO SQX 659966 ?L 2 SAN ANTONIO, 7A 78265 --? a LJV I PICA. HEALTH INSURANCE CLAIM FORM" ?I? i?l 4 PICA , , MECICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER ia. INSl1RED'S LD. NUMBER (FORMOGRAM IN ITEM I) (Aledre3rv IF) ? (Afadrea d K) 11 rSPO" S ssv) O (VA File 41) O rssv or HEALTH lo) PLAN O 9L.K!rSSNILING©(la) 286162 6 'Al S P me Flr6t Name, M dotter Initial) ?CY t A l) ?ltPi i l 3. PATIENTS BIRTH DATE SEX 4, INSUREC'S NAME (Laal Name, First Name. Middle laid , ? OS ?XD?196? ME F? °s q ? y j C DA 1E11& Lg? Y W&E C'Y9' LE 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) Self DSpouseLJ l IChildEl Other SA FM ?y C?,MP HILL STg-[? YA B. PATIENT STAT US CITY STATE Z O Single Married Other? uuu a 7 CO?E U 1 TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUCE AREA CODE) 717 ?37-9393 EmployedFI Se ? a 0 LL ludent nt Sttudentudent Stud LL, 9. OTHER INSURED'S NAME (Last Name, First Name. Middle Initial) 10. IS PATIENTS CONDITION RELATE TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER i UJ a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT7 (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH OYES 1;71 a NO SEX 05j 04 ;1964 Ma FO rn Z . OT b MMHER INS UREDYS DATE OF BIRTH SEX b. AUTO ACCIDENT? (a) b. EMPLOYER'S NAME OR SCHOOL NAME ?. Z M ? F YES a N H c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME z YES ? NO U3AA W F- Q d. INSURANCE PLAN NAME OR PROGRAM NAME lGd. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? 0- YES ENO if yes, return to and complete Item 9 aC. READ BACK OF FORM BEFORE COMPLETING 3 SIGNING THIS FORM. 12. PARENTS OR AUTHORIZED PE'RSON'S SIGNATURE I authorize the release d any medical or otter Information necrssary 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE 1 aueto,ize payment of medcal benefits to the undersigned physiaen or supplier for to proom this claim. I a'so request payment of government benefits either to myself or to the party who accepts assgnmonl services described below below, . SIGNATURE ON FILE 10 18 2006 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT- !LLNESS First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 1 U l.i `? 6 , INJURY (Accident) OR GIVE FIRST DATE MM OD YY MM DD YY MM DO YY PREGNANCY(LMP) I FROM 1 t TO I t 8 j:. ^ F`AEFOUi1pHVVAN CR OTHER SOURCE 17a. LDV?4 ffg §F REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM 00 YY MM DD YY FROM I I TO f t 19. RESERVED _R LOCAL USE 20. OUTSIDE LAB? S CHARGES ?YES R1 NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2.3 OR 4 TO ITEM 24E BY LINE) 22 MEDICAID RESUBMISSION 723 ' L ' CDDE ORIGINAL REF. NO. . T. 23. PRIOR AUTHORIZATION NUMBER r, 2. ).._ - 4. . 11 z O 24. A -Z. B C D E F 0 H I J K F- 0P1TE.FS1 OF SERVICE From To Place of T PROCEDURES SERVICES, OR SUPPLIES IT ``E,pplain tlnu it Circumstances DIAGNOSIS $ CHARGES DAYS OR EPSDT Femiy EMG COB RESERVED FOR Q MM DD rtiW MM DD W Service Service CPTItiCPCS MODIFIER UNFS Plan LOCAL USE cc 10 18 2'01116 10 •18 2006 11 01 99213 1 65 X00 LL 1 z w ?r I J CL a I I `' ? I I ! N K .. I 1 I 1? I I I f I ' 4 1•J I v z a. I IS. FEDERAL TAX I.D. NUTASEP SSN EIN 232933075 26. PATIENT'S ACCOUNT NO. $P048454 27. ACCEPT ASSJONMENT1 2 (FO. gat-tlmms See back) 8, TOTAL CHARGE 65 OD 29. AMOUNT PAID 0 00 3.0. BALANCE DUE 6 l? ?1 YES ONO S 1 $ S 5 00 31. SIGNATURE Of PHY5I1--t4N OF SUPPLIER INCLUDING DEGREE,. CREDENTIALS I! x 9,P riet nA t th l 3Z NAME AND ADDRESS OF FACILITY WHERE SEPVICES WERE 3 !RME 1GUNVA'T14 wFAMILY PRACTICE 3. PHYSICIAN'S. 5JPPLIER'S BILLING NAME. ADDRESS. ZIP COLE BM5'"'MU`rdrl'AIN FWILY PRACTICE Ir on , y ! s a ene nls verse e re a,Plyto r1i,& lr,Car,M"5.aPan:ha•wj 2151 LINGLESTOWN ROAD PO BOX 12942 BRIAN C OUIRN b11) SUITE 100 PHILADELPHIA, PA 19176 0942 PIRRRISBURG, PA 17110 7 17 545-4786 10 19 200 SIGNED DA-E P 232933075 INN 1 GR Pr e (APPROVED BY AMA COU.:CIL ON MEDICAL SERVICE 8iBin PLEASiE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-i5oo (12-9G). FORM RR6-1500. APPROVED OML3121SMSS FORM DWCP•ISOO, APPROVED DNB-0?20000i .rCHAMPUSi ?LEASE, DO NOT STAPLE ,N THIS AREA ?T,PICA APPROV`ED CMBOCB I i? I I u HEALTH 1NSi1RANr;: ri 111 :tr I I I. MEDICARE MECICAIO CHAMPUS CHAMPVA GROUP FECA OTHER 1a. INSUP,ED'S I.D. NUMBER IF n RAM IN ITEM 1) i (Medicare s) 12 (Medeaid r) (Sponsor's SSN) (VA R49 !) HEALTH ar DI/ 1N O B SANG 11D) 3861636 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4, INSURED'S NAME (Last Name First Name Blinn, Michael 'Sg 6/4/1964 , . \ Blinn Michael M F , 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSUREO'S ADDRESS (No., Street) 200 Hollywood Circle SeU FJ Spouseq Childg] OIhe,Lq ?J 200 Hollywood Circle I CITY STATE 8, PATIENT STATUS CITY STATE Cam Hill P PA Single® Married Other 3 it C? m Z 2 = ZIP CODE TELEPHONE (Include Area Code) a p PA ZIP CODE T"cLEPHONE (INCLUDE AREA CODE{ ? Q 17011 (717)p37-9343 Employed - Full-Time Pad-Tim. FEh Student St d { } It u ent 9. OTHER INSUREDS NAME (Last Name. First Name, Middle lni(ial) 10. IS PATIENT'S CONDITION RELATED T0: 11. I S RED'S POLICY GROUP OR FECA NUMBER U" Blinn, Michael 7_ 25 a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSUREDS DATE OF BIRTH LU ® YES ?NO yY SEX MM5/471 9A M F b. OTHER INSUREDS DATE OF BIRTH SEX MM DD YY i JJJ b. AUTO ACCIDENT? PLACE (Sato) 0. EMPLOYER'S NAME OR SCHOOL NAME Z Z , r t M YES NO PL 1 r? G Z c. EMPLOYER'S NAME OR SCHOOL NAME .? C.OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Q F- P, O. Box 779503 PA 17177.9503 YES ONO LISAA Insurance Z F d. INSURANCE PLAN NAME OR PROGRAM NAME Capital Blue Cros /CAIC ICo. RESERVED FOR I OCA-L USE d. IS ERE AND ER HEALTH BENEFIT PLAN? C a s Lvr YES S NO Jr yes, retum to and cormplote item 9 ad. LI READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM. t 2. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or olher Information necessar 13. INSURED -S OR AUTHORIZED PERSON'S SIGNATURE I authorixa y to process this claim. I also request payment of govemmeni benefits either to myself or to the party who accepts assignment payment of medical benefits Lo the undersigned physician or supplier for services described gl below. ow, SIGNED Signature on File 12/6/2006 AT Signature on File D E SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR y' INJURY (Acadenp OR /?? l 6 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM I DO I YY IG. DATES PATIENT UNABLE TO WORK in CURRENT OCCUPATION MM r DO YY MM 00 YY I L VU PREGNANCY(LMP) ; , , FROM TO i t 17, NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN i8. HOSPITALIZATION DATES RELATED TC CURRENT SERVICES Bernard Zeflger 834196 MM t DO I YY MM I DO I YY FROM I ! TO I I 19. RESERVED FOR LOCAL USE 20. OUTSID-LA B? $ CHARGES; r YES ? NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELAT E ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION 723 1 CODE ORIGINAL REF. NO. . 23. PRIOR AUTHORIZATION NUMBER t 847.0. 2 . 4. L-. - 24. A 8 C D E F G H I J K -y DATE(S) OF SERVIC Typo Place From ?o of of PROCEDURES, SERVICES, OR SUPPLIES DIAGNOSIS (E pta n Unusual C rcumslances) DAYS OR EPSOT F RESERVE D FOR p 7d1.1 DD YY MM OD YY SeMCe GPTMCPGS MODIFIER CODE $ CHARGES UNITS amily Plan EMG COB LOCAL USE Q 1.1 /29/200 11 97001 1 2 $79:90 1 ' , 1 o 11/29/200 11 97112 1 2 I $3076 1 , I 11/29/200 1 11 Fi 97110 1 2 f $29!68 1 f W I , I a- r t ? i ? f r) ! r I ; 1 ! ? t I , Iff I I `r ^ I I I i i i !? I II I Q I 1 ? ------------- ! r I , ? . I I , 1 ? 1 t " I I = 25 FERRAL TAX I D I NINEIER °St' EIN 1 i - n . e 26. PATIENTS ACCOUNT NO. 27. ACCEP i ASSIGNMENT? 28. TOTA{?..,y n? 29, AMOUNT PAID 30. 5AL f 23 2883302 X. 119246 o govt,dainu.Sooback) 5P 1 ?4? 24 ! 4Q.24 LI ? YES Ej NO S I S _ 31. SIGNATURE OF pHYS>C1A1( DR SUPPLIER 32. NAME A!{D ADDRESS OF FACILITY WHERE SERVICES WERE 33- JLF'}' _LLJ r• I 1lJCLUDINGOEGRfiESCRCNE0ENTIA:.S RENCEREPIlf + r n 1 "d r61 GNAME,ADDRESS,ZIP000[ ) ! orn, 1 the gPIS T, he e- I en!r?l ?7?"r??n2bi11t?Jon Services "ehtra1 PA Rehabilitation Services, Inc. ? (I g i eN I 3916 Trindle Road 75 Evelyn Driv I License Number: PT015093L Camp Hill, PA 17011 Millersburg, PA 17061 Signature on File 121,0610 6 i Si.^.,r:ED D:.TE I PIN$ GRPO (APPROVED BY Fk/.A-GUNCI'. ON rAZnicA?? snavlcE 6'36; PLEASE PRINT OR T}"PE APPFK)VED01.IB-Ce37>COWi FpRMCMStSW(12-90), FORM RRG •.:x.70. APPROJEDOrd3-1215-0055 rcwa Ch'rCP•150e, APPROVED ;JM''', 07Z6-0OGI (Cf1 JAr'US) ?LEASE DO NCT STAPLE iN THIS AFSA F_,r_r,PICA APPRCVQ CM13•097&0003 HEALTH INSURANCE CLAIM FORM P,r'A t: w Cr 0 F7--M 1 17, MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHE R '.a. !NSUREO'S I.D. NUMB ___R (FOA.°ROGRAM IN ITEM 1) 1 i t l (Medicare !)Q (AMBd i d , r (Sa0ns0r'3 SSN) HEALTH PLA BLK LUNG (VA FV8 1) 7-11 (SSN or 10) (SSN) (IC) LH-i '01 3861636 ?p 2. PATIENT'S NA.Mc (Last Name, Firs( Name, M'ddla Iniild) $linn Yich { 3. PATIENT'S BIRTH DATE SEX M 4. INSURED '5 NAME 1,"st Name, Fist Name, Midde Initial , ae t/49 64 M F Slinn, Michael 5. PATIENTS ADDRESS ,No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7, INSUREDS ADDRESS (NO.. Street) 230 Hollywood Circle SOI? Spouse Chit O1he4S 200 Hollywood Circle CITY STATE 8, PATIENT STATUS CITY STATE 2 Camp Hill PA SingJD1 Marria,W.1 t7J4 amp Hill PA p ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) 1 17011 (717)-,37-9343 Employes }/ ? Full•Timj? Port•Til }-7 cc I ?? Student Student t } i, 9. OTHER INSURE D'S NAME (Last Name. Fvst Name, Middl e initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSUREDS POLICY GROUP OR FECA NUMBER i, z Blinn, Michael _ 0 a. OTHER INSURE D'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'SDATE OO?F BIRTH SEX MtC Q PFP80046460300 I t 1 YES -L NO CJ ? C J/4f I yV'+ IM y F 7 (n b p ER S RE TE F BIRTH S i J LJ z . DO p U DA O SEX AH b. AUTO ACCIDENT? PLACE (Stara) b, EMPLOYER'S NAME OR SCHOOL NAME Q M F "YES ?NOP I Q c. EMPLOYER'S NAME OR SCHOOL NAME e. OTHER ACCIDENT? C. INSURANCE PLAN NAME OR PROGRAM NAME F- PO. Boy. 779503 PA 17177-9503 YES IV USAA Insurance LU E- d. INSURANCE PLAN NAME OR PROGRAM NAME Capital BlueCross/CAIC 10d. RESERVED FOR LOCAL USE d. I HERE A ER HEALTH BENEFIT PLAN? Q a YES NO H yes, return to and complete itom 9 .-d. READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM, 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical of ether Informallon necessary 13. INSUREDSS OR AUTHORIZED PERSON'S SIGNATURE I authorize f i to process this claim. I also request paymerv 01 goverrlmenl benefits either to myself of to the party who accapI3 assignment payment o med cal benefits to the undersigned physician or supplier for services described below boiow. Signature on File 12/2112006 . Signature on File SIGNED DATE SIGNED I 14. DATE OF CURRENT; ILLNESS (First symptom) OR 06 NIJURY (Acelaent) OR 119113Y2 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM 1 DO I YY 16. DATES PATIENT UNABLE TO WORK INCUR RENT OCCUPATION MM DO YY 0 PREGNANCY(LMP) 1 I MM I OD I YY I I FROM TO I I t7, NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Bernard Zeliger 17a. 1.0. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES DO YY B34196 MM , MM I 00 , YY I FROM I I TO 1 I 10. RESERVED FOR LOCAL USE 20. OUTSIDE LA137 S CHARGES YES ONO ZI. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, (RELATE ITEMS 1,2,3 OA 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION 723.1 CODE ORIGINAL REF. NO. 1. L;.. 3. L_.. 847,0 23. PRIOR AUTHORIZATION NUMBER 2. L_ . - 4. I_. . I 24. A B C D E F O H 1 J K z OATE(S) OF SERVICE Place Type PROCEDURES. SERVICES, OR SUPPLIES From To 01 of (Explain Unusual Circumstances) DIAGNOSIS A OR Family RESERVED FOR 0 MM DD YY MM DD Y'' Servi Sery ? MODIFIER D CODE SCHARGES EMG COB LOCAL USE UNITS Plan ?T1?72 (56 1 1 97112 1 2 30 76 I 1 , . 0 '12/11/2006 1 97110 I 1 2 $29 58 1 1 , . •12 12006 1 97140 59 1 2 $27 67 1 w ; I , . a T?i1"112006 -1 9701 1;2 _ _$T5_.64_ 1 ; ? I 1 I i ! ; i 0 `!:?/1112006 1 -1 00283-? 'f1798- 1 'I x111/2006 97G4 1,2 1.-74 1 2DFFR L TAX 1 D 13 ?18p3302 NUUSER SSN FIN 26. PAT! N-1 Ar,COUNT NO. 27. CCEPT ASSIGNMENT? (-- 19246 XFor govt. dams, eee bock) I 28. TOT 29. AMOUNT PAID 30. BA D $ 2 J .7 7 ? ?J YES D NO S 1 S ; S ; 7 31. SIGNATURE OF PHYS;CIAN OR SUPPLIER i 32. NAME AND ADDRESS OF FACILI iY W1iERE SERVICES WERE 33. PHYSICIAN .15UFr?EAr:?' 1LLI43 NAME, ADDRESS. ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERf?tltrglrPAiRe.* zti!:tgtlon Services GentUlI RA Rehabilitation Services, Inc Hll trl.Al:A L'.. k?L?Yrn?r^.nmL`u n i 6y tctnii bill aidar?mnao a pari inmoot,) 1 3916 Trindle Road License Number. PT015093L Camp Hill , PA 17011 Signature on File 12'21/061 75 Evelyn Ddv Millersburg, PA 17061 PIN# APP (APPROVED BY AMACOUNCI„ON MECVCAL SERVIC[6'Ea} PLEASE PRINT OR TYPE ,-iz'NCD oms-oc-aaoce FORM CMS-isx(12-oo), FORM!"3PZ-150a, APPPCVEDOM&1215?FC)AMON'P-1500, APrF4CVGDOrtg-C7WC=l(CtWAP-,;Sl PEASE CO NOT STAPLE iN THIS AREA I 1 PICA APPROVED OMS.0978-0008 HEALTH INSURANCE CLAIM FORM PICA ,1, !_ w cc a MEDICARE MEDICAQ CHAMPUS _q i • ' CHAMPVA GROUP FECA HEALTH PLAN BLK LUNG OTHER III, INSUREO'S I.D. NUMBER (FOAPROGRAM IN ITEM t) (Medicare s), f ; Mevicaid AI(sponsor I : SSN) ?Jj 19 (VA F4 I) (ssx or 10) 10] (ssrr) R T,, (0) 3361636 Z. PATIENT'S NAME (Last Name, FIr31 Namo, Miodie initioll Blinn, Michael 3. PATIENT'S BIRTH DATE SEX M 5/ ' `? Y 4. iNSURED'S NAME (Last Name, First Name, Miodl I?!tial) Mi h a'i r M F •f 4 96 nn, ael c S. PATIENT'S ADDRESS (No., Street) I S. PATIENT RELATIONSHIP TO INSURED ?. WSURED'S ADDRESS [No., Sueoll 200 HcllyWOOd Circle +} se1? spous? cnur? oNe? J 200 Hollywcod Circle 1 CITY STATE S. PATIENT STATUS CITY STATE Camp Hill PA 8X1901 Marrie- Othe(7 amp Hill PA ZIP CODE TELEPHONE (Include Area Code) 21P CODE _ TELEPHONE (INCLUDE AREA CODE) 1 T011 (717)137-9343 Emp!o?- f?.?1?_? lud e Full-Tim Pall-TI >=J StudenI iudanl? Sluden ' ( ' I 9. OTHER INSUREDS NAME (Last Name, First Name, MRsdle Initial) t0. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Blinn, Michael OTHER INSUR ' a. ED S POLICY OA GROUP NUMBER a. EMPLOYMENT? iCURAENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX PFP800464603DO [MI YES -/] NO r? n `Mt/4N-,,T MFV71 F ti71 U OTHER INSURED'S DATE OF BIRTH I I LJ LLLJJJ . SEX MM , DO YY b. AUTO ACCIDENT? PLACE (Stale) b. EMPLOYER'S NAME OR SCHOOL NAME I r M F R?j YES [MNOPA P ' ? J C. EM LOYER S NAME OR SCHOOL NAME C. OTHER ACCIDENT? c INSURANCE PLAN NAME OR PROGRAM NAME I P.O. Box 779503 PA 17177-9503 [P] YES WhNO USAA Insurance i l IN RANCE PLAN NAME OR PROGRAM NAME al Blue CrosslCAIC f 0d. RESERVED FOR LOCAL USE tl. I THERE AN ER HEALTH BENEFIT PLAN? Y t P YES _ NO Ir yea, return to and complete item 9 a-d. ` READ BACK OF FORM BE -ORE COMPLETING 6 SIGNING THIS FORM. IENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other !nlorrna!ion necessary 13, INSUREDS OR AUTHORIZED PERSON'S SIGNATURE I authorize f i process [his claim. I dso request paymeru of government benefits either to myself of to the parry who accepts assignment payment o med cal benefits to the undersigned physician of supp!ior toe services dascribed tsoFow wow. SIGNED Signature on File 12/21/2006 Signature on File y DATE SIGNED 14. GATE OF CURRENT: ILLNESS (Pest symptom) OR {?+ INJURY (0.¢idan) OR ?1?( 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM 1 OD 1 YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DO YY J PREGNANCY(LMP) 1 I , ! MM I DD I YY FROM t t TO I , 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 16. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES l3emard Zeliger 634196 MM , DD I YY MM , DD , YY FROM r TO ! [ 19. RESERVED FOR LOCAL USE 21). OUTSIDE LAB? $ CHARGES YES ONO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2.3 OR 4 TO ITEM 24E BYLINE) 22. MEDICAID RESUBMISSION 723 1 COCE ORIGINAL REF. NO. ? 23. PRIOR AUTHORIZATION NUMBER 2. L_ . a. 24. A B C D E DATE(S) OF SERVICE place Type PROCEDURES. SERVICES. OR SUPPLIES From To DI IS F 0 H 1 J K AYS Z 0 of MM DD YY MM DD YY (Explain Unusual Circumsances) DE CO MODIFIER PCS x RESERVED FOR f CHARGES OR Fam"y EMG COS LOCAL USE UNITS Pl F " 12/,812006 1 1 971 1 Z 2 an $30 76 1 2 . . 12/8/2006 t 1 111 I r I 97110 1 1,2 $29.58 1 - I I 1 , ; I 12/,8/2006 97140 59 1 2 $27 67 1 ' ' , I , . -I 27872-G06- I 1 97T12 ?2 $T5_64 r N 1'2/8/2006- Al G0283 -f,2 a F 2%8/2006 9701 1 a4 75. FECERAL TA.X I.D. NLWBER SS14 EIN 28. PATIENT'S ACC-_UNT NO, 27. A[:CEPT ASSIGNMENT? 28. TOT ?! +,? 29. AMOUNT PAID 30. BAL ,. r J 23-2833302 ! 119246 Fo: 90.11. claims, aeo back) 412 1'27.87 I YES O NO $ I S I 5 I I q 31 , SIGNATUR: OF PHYSICIAN OR SUPPLIER 32. NAME AND AOQRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN'7?S7ti?r'iEFi7yQB:LL!NG NAME, ADDRESS, ZIP COD IN CLUDINGDEGREESORCREDENTIALS RENDEf HIl?IrFA r"?AiYBWIi(!H(N e S i l R I 1713rr1 ahrIo ? f i?] Ap rg?(? ,{ q s nd?eruA YE1o? r ?:l '1 b t l BN 6ritld : CCS A Rehabilitation Services, inc ` 391 T , r v .) 6 rindle Road I 75 Evelyn Or iv License Number: PT015093L I Camp Hi!I , PA 17011 Millersburg, PA 17061 Signature on File 12/21105. (SIGNFO GATE I ! -- P(Nlt GRD.? ; .Il. (APPROVED BY AA4A000NCIL ON MEDICAL SERVICE &'89) PLEASE PA(H7 OA TYPE APPRJYEDOM9-N38_1W8 FORM CM,S-`500(12.90). Ff)tVA RRe-I50C, APP;701'EOOM&5215.OK5FORMOYJCP•I500, APPF VED OM8072(r,= (.h.SV.PUS) ?LEASE D+) NOT STAPLE ii) THIS AREA APPROVE) CNIB-)973-0008 .PICA TiGAL.I rl JI111 JUr ,RNgl r- LLAINI t•VtiI41 PICA FT-] 1, MEDICARE MEDICA:O CHAMPUS CHAMFVA GROUP FECA OTHE R to, INSUREDS -.D. `.UMBER (FORPROGRAM IN ITEM 1) [Medcare e ) (Mad(6aid 0 (Sponsors SSN) HEALTH PLAN BLK LUNG [D (VA )'do tJ (0 (SSN or to) ('i (SSN) ?jlr (ID) 3861636 12. PATIENT'S NAME (Last Name, First Name, MICdle Inlfla ll 3 PATIENT' S BIRTH DATE SEX C iNSUREO'S NAME (Last Name, Firs? Namo, Miodalniliai) Blinn, Michael D 0 5%4/1964 M F Blinn, Michael 1, PATIENTS ADORESS (No., Street) 6, PATIENT RELATIONSHIP TO INSURED 7. iNSURED'S ADDRESS (No., Street) 200 Hollywood Circle Sel? Spouu[Pi cnac[]? omeQj 200 Hollywood Circle CITY STATE B. PATIENT STATUS CITY STATE Camp Hill PA SinglcU Mamoc E] ane[D ?p ? pA ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) 17011 (717) ?37-9343 Employe - Full•Tim?jj Part•Tl; ? ( ` -' '-' ) j ? Student ? f Studenl _J 7g?1 1 e, OTHER INSUREDS NAME (Last Name, First Name, Mfodia Initial) 1D. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Blinn, Michael a. OTHER INSURED'S POLICY OR GROUP NUMBER o. cMPLOYMENT7 (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX PFPS0046460300 YES [??NO MI5/t I (9I M21 F b. OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PUCE (Salo) b. EMPLOYER'S NAME OR SCHOOL NAME MM , DD , YY I r I M r-1 F ES NOPAL J c. EMPLOYER'S NAME OR SCHOOL NAME F OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME P.O. .O. Box 779503 PA 17177-9503 jYES ? NO. USAA Insurance ? d. INSURANCE PLAN NAME OR PROGRAM NAME Capital Blue Cross/CAIG 10d. RESERVED FOR LOCAL USE d. I THERE ANQIHER HEALTH BENEFrT PLAN? YES NO It yes, return to "complete item 9 a4. READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM. 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical of other information necessary payment d medical benefits to the undorsipned physician or supplier for Io prooea thq da}tn. I also request payment of po,,ernmen t benefits either to myself or to the party who accepts assignment services described below, below. Signature on File 12121/2006 Signature on File SIGNED DATE SIGNED- 14. DATE OF CURRENT; ILLNESS (Frrst symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ?'}+1/ 1 '06 INJURY (Ac9dont) OR vv v GIVE FIRST DATE MM I DD I YY t MM I DD I YY MM , CD I YY PREGNANCY(LMP) ! FROM I t TO I I 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. 1.0. NUMBER OF REFERRING PHYSICIAN 16. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Bemard Zeli er 9 B34196 MM t 00 I ?? MM I oD , Yv FROM I I ? 70 i I 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES [] NO 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RE LATE ITEMS 1,43 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION 723.1 CODE ORIGINAL REF, NO. 23. PRIOR AUTHORIZATION NUMBER 87 - t 2, j 4. 24. A El C 0 E F G H I J K 2 From DATE(S) OF SERVICETo Place Type PROCEDURES, SERVICES, OR SUPPUES DIAGNOSIS DAYN RESERVED FOR MM DO YY MM OD YY of rv of rvi (Explain Unusual Circumstances) CPTIHCPCS MODIFIER CODE S CHARGES OR UNRS Family Plan EMG COB LOCAL USE P 12/,6/2006 1 97112 1,2 $30.76 1 a 12/6/2006 r 1 97110 1,2 $29.58 1 1 LL ILL 12! 6/2006 1 97140 59 I 1 2 $27 67 1 1 a , , . CL 1 6 2006 1 97012 1 2 15 64 1 r 1 I i I , . , LT - 2161200 11 G0283 2 1 rt-9 Q I 1 1 I 1 ; -1-2161-2006- t 9701-0 1;2 -1 uy u I I I ? r I I S I - I L I CL 25. FEDERAL TAX I.D. NUMBER S5114 EIN 26. PATIENTS ACCOUNT NO. 27. ?--CEPT ASSIGNMENT? 2 ror govt, dal ms, sae tack) 23 2883302 X I 119246 - 6. TOT?y } 12 MOUNT PAID 30. BA I '/y- 57 4 1 7 I ?L X YES NO r . S V $ i IV? 31. SIGNATUREc OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 3 3. PI{Y$ICIAN ?. C rDING NAME, AD-DRESS. ZIP CODE INCLUOIN3 DEGREESORCREDENTIALS RENDEF?6.'???? ?r? e a?liF2ti0h SCfViCCS ' G'SP:;RIPA Rehabilitation Services Inc I I IIC rt m^!•o?In n' , I 3916 Trindle Road 75 Evelyn Ddv License Number: PT015093L Camp Hill , PA 17011 MLlersbulg, PA 17061 I Signature on File 1J21,06' slnNEO DATE I P INI_ I GRP# j M 1 cc ill C3 Y (AaPROVED BY AMA COUNCIL ON MEDICAL SERVICE 6 14; PLEASE PRINT OR TYPE APPiK7VEC OM3-0FY3a-0 FO9M GJS-IWO (;rev;, r-oax RRo-i ae, - T - APPRCNEDON&1215-OM FORM OWrP-1500. APPRO?ED ON.B-O'2G Q7Ci ('JtAA1 Rlc} PLEASE i APPROViD OMB-09:380008 i 00 NOT - i_ STAPLE ! IN THIS w AREA ¢ ® Q iTPtcA HEALTH I v NSURANCE CLAIM FORM PICA -(-, j i t. MEDICARE MEDICAID CHAMPUS 1- (Medicare a) lWadraid a (S r' SSN y CHAMPVA GROUP FECA 18, AS D'S I.D. NUMBER (FGh?ROGRAM iW ITEM 1) I' HEALTH PLAN BLK LUNG OTHER I TT . 1 ponso s ) (VA File a) (SSN or rD) ? (SSN) (10) 3861636 4J 2. PATIENT'S NAME (Last Name. Fast Nome, Middle Initial) Blinn Michael Z 3. PMATIIENT'B IRTH ATE SEX INSUREDS NAME (Last Name. First Name, Midc'e Inl;iel) , 514/1964 M R' F Blinn, Michael 5. PATIENT'S ADDRESS (No.. Slrestl 6, PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 230 Hollywood Circle sal SpousrE Chid OtheFF? ' 200 Hollywood Circle CITY STATE 8.PATIENTSTATUS CITY Camp Hill ,?-?y STATE PA Sing Q] Marrflx ? OthgM Z ZIP CODE TELEPHONE (IrKIuOe A ea Code) PA ZIP CODE TELEPHONE (INCLUDE AREA CODE) P Iq 11011 (717} ?37-9343 Em ll-Tim Part-Tin ploy i t s e ? ? Q t ont stuoent 9. OTHER INSURED'S NAME (Last Name, First Name. Middle Initial) 10.15 PATIEN T'S CONDITION RELATED TO; 7011 11. INSURED S POLICY GROUP OR FECA NUMBER p LL Blinn, Michael ? o. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) 3. INSUREDS DATE OF BIRTH 0 PFP8004 r? OYES (r1? iWO t MI ff96T SEX /4 M? F? b. OTHER ;NSURED'S DATE OF BIRTH SEX MM , OD t YY b. AUTO ACCIDENT? PLACE (Stale Cl tt??z ) o. EMPLOYER'S NAME OR SCHOOL NAME z M f I M F 6e lYES UlNoPA t ?t C] _ c EMPLOYERS NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Q P.O. Boa 779503 PA 17177-9503 01 YES NO USAA Insurance UJ d. INSURANCE PLAN NAME OR PROGRAM NAME Capital Blue Cross/CAIC Iod. RESERVED FOR LOCAL USE d. IC HERE An ER HEALTH BENEFIT PLAN? ? < a READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM YES ? NO It ysa, rettnn to and complete item 9 ad. 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I . authorize the release of any medical or other Information necessary 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize to process this claim, I also request payment of government benefits either to myself or to the party who accepts assignment , below. payment of medical benefits to the undertcigned physician or suppler for services described below. Signature on File SIGNED DATE 12/21/2006 Signature on File SIGNED y 14. Mil OF CURRENT: ILLNESS (First symptom) OR I U? 1 3? 206 INJURY (Accident) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION GIVE FIRST DATE N,f t I DD I Y. MM v PREGNANCY(LMP) i DD i YY MM I DD I VY FROM TO J 17• NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Eiernarcl Zeli er 17a. I.D. NUMBER OF REFERRING PHYSICIAN I 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES M g 634196 M I DO n YY MM I DD , YY FROM I I TO I t 10. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? S CHARGES YES ONO NATURE OF ILLNESS OR INJURY, (RELA TE ITEMS 1,2.3 OR 4 TO REM 24E BY LINE) 22.?? AID RESUBMISSION ORIGINAL REF, NO. E Z3. PRIOR AUTHORITION NUMBER 4. I_- . A a C D E FromOF SERVICE-TO Place f Typo PROCEDURES. SERVICES, Oq SUPPLIES DIAGNOSIS F G H I J K DAYS EPSP 7 O MM DO YY AIM DD YY Servic S' (Erplain Unuwai Circumstances CPT1HCPCs MODIFIER ) CODE RESERVED FOR S CHARGES UNIITTS FFany EMG COB LOCAL USE 12/,4/2006 1 97112 1 2 $30 76 1 1 , . 12/4/200fi I I 1 1 97110 l 1 2 $29 58 1 ° 1 2 1 , . (12/,4/2006 1 97140 59 1 2 $27 67 1 i?j t 12 47?OOS , , . T (11 1 97012 1,2 $15.fi 1 l t L 12/412006 -1 0283_ _ 172 11-98 o z I 5 `t 2/412006 t z L) 11-4 1 I I I I 6 , , 25. FEDERAL TAX :.D. NUMBER SSN E04 26 . PATIENT'S ACCOJN,- N0. 27. ACCEPT A3SIGNIAENT7 2 23-2883302 X 119246 (For Oov1. claims. sae back) 8, TOT r? u? 7,1. AMOUNT PA.D 30. SAI 1.37 ?L (.7 I YENO S ' 31. SIGNATUFE OF PHYSICIAN OR SUPPLIER 32. NW-- AND ADDRESS OF FACILITY ri'HER SERVICES WERE 33. PHYSICIAN ','giy?._ y ,LLII13 NAMt. ADDRESS. ZIP CJDE tNCL'JOtNGOEGREESORCREDENTIALS RENOEFtL,8LF?PzROtYabilif?tCnS ' I i Gi i j n3n?IrI?rr?rry ev ces t ?lPA Rehabilitation Servi es, Inc Lizenser Number; PT015093L 3916 Trindie Road 75 Evelyn Driv i Si nature ° FI-t Camp Hill , PA 17011 Millersburg, PA 17061 g o.. e 12121106 SIGNED DATE I (AC"RDVED BY AMACOUNCIL ON MEDICAL SERVICE ew) Pi.EASFPR/NTORTY. E APPROVFDCVS-Oa7aly,eFORM CMS-15Wti2-ern. FCRLARF6-ts oo, APPRpNEDOMB-1215-01055 FOFW gVCP-1500, APPR;7 EDOMrf-Ci20-=l (D4A).i P„ S! , .(Modicarv 0)[M. (Medreard J (Sponsors SSN) EALTH PLAN BLK LUNG G (VA File X) ( H(SSN or ID) Q (f) (10) 3861636 , ' 2. PATIENT'S NAME (Lass Name. First Name, M+ddte Inrtia9 unn, hlichae. 3. ENT'Sp IRTY GATE SEX F-- 5I4 1964 M ?] F (;,? 4. INSURED'S NAME (Last N1 a, FFsi N p Wait InitalL Blinn, ht;chael /`F?IJ1 1/? Y 5. PATIENT'S ADDRESS (NO., Street) 236 Hollywood Circle 6, PATIENT RELATIONSHIP TO INSURED SaI? SpouSdL Chad Othe PJ 7 J 7. INSURED'S ADDRESS (No., S:reeQ 200 Holl w d Ci l J CITY _j STATE 8. PATIENT STATUS y oo rc e CITY STATE I Camp Hill PA Sing) ? htar Othe? Hill J C ZIP CODE TELEPHONE (Include Area Colo) am PA ZIP CODE TELEPHONE (INCLUDE AREA CODE) F 17011 {(717) ?37-9343 Empty Full-Tim?-1 Part-Te S d t ( 9 OTHER INSURED'S NAME t N L Fi tu ent Studen ' J C . ame, ( as rst Name, Middle Inrtlal) 10. IS PATIENT S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER M Blinn, Michael z a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSUREDS DATE OF BIRTH c a PFP80046460300 YES ?NO MI SEX ( /,4'96Y MQ? F1?Tl V b. OTHER INSURE D'S DATE OF BIRTH SEX MM , . 00 , YY b. AUTO ACCIDENT? PLACE (Slate) I I lJ LJ b. EMPLOYER'S NAME OR SCHOOL NAME Z I I I M F ®?YES `CJNOPAI `CJ O Z c. EMPLOYER'S NAME OR SCHOOL NAME C. OTHER ACCIDENT? C. INSURANCE PLAN NAME OR PROGRAM NAME Q 1- F1.0. Box 779503 PA 17177-9503 QJYES ?NO USAA Insurance w d. !NSURANCE PLAN NAME OR PROGRAM NAME Capital Blue CTnsS1CAIC 100. RESERVED FOR LOCAL USE d. IERE AN?ViER HEALTH BENEFIT PLAN? ! j Y ~ a a READ BACK OF FORM BEFORE COMPLETING d SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of arty medical or other Information necessary YES NO It Pros, retum to and complete item 9 a-d. ' -tLJ J I 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize l to process this claim. I also request payment of government banerits either to Inyself Otto the party who accepts assignment payment of medical bonalaig to the undersigned physician or supplier for servicas described below bobw. , SIGNED Signature on File 12/21/2006 Signature on File DATE SIGNED t4, DATE OF CURRENT: ILLNESS (First symptom) OR ItU/1 12?d? `INJURYIACadent)OR t S. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE 'tM t OD I YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM , DD YY PREGNANCY(LMP) I I , MM I DO I YY FROM ! I TO I 17, NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Bernard Zeltgar 17a. I.D. NUMBER OF REFERRING PHYSICIAN 834196 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES OD YY MM 1 1 MM , DO , YY FROM I I TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE 1A87 $ CHARGES ED YES ONO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE IT 723.1 EMS 1,2.3 OR 4 TO ITEM 24E BY LINE) Z2. MEDICAID RESUBMISSION CODE I ORIGINAL REF. NO. 4 y 23. PRIOR AUTHORIZATION NUMBER 847.0 2. L 24. A B C D E F G H I J K Z DATE(S) OF SERVICE Plana Type PROCEDURES, SERVICES. OR SUPPLIES DAYS P D RESERVED FOR From TO DIAGNOSIS O (Explain Unusual Circumstances) CODE S CHARGES OR Farn Y EMG COB LOCAL USE 1P iUM DD YY MM DD YY of ervi r of vic CPTlHCPCS MODIFIER UNITS Plan 12/111 /2006 1 T-III 97112 1,2 $30.76 1 t 12/,1 /2006 1 1 97110 1,2 $29.58 1 I 2. L 1.27172606 12/,1/2006 1 97140 59 lw 1,2 $27.67 1 !a 3 I i I i I i a. r I 1 I I I ( ; , , fc 12/1/2006 1 G0283 i .2 I g I I I I I 5 12%112006 I 1 9701 1; 2 $ f 14 n I I I I r - I 1 I I Ia. 25. FEDERAL TAX I.D. NUMBER SSN EiN ' 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28, TOT 29. Ab!OUNT PAID 30. BA 1 ,? 23.2833302 119246 For go VI, dalms, 500 WCk) q '27537 ry ? I YES EJ NO $ $91$ i s21 j! 31. SiliP1ATIJRE OF PHYSICIAN OE SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. P4Y5ICIAN' '.S7U a LLING E. hDDR E5S. ZIP CODE 1.4=D1NG DEGREES OR CREDENTIALS RENDER ?tr')tPr?:R£'?1r11f(iYa58}1 Services 1361*94EPA Rehabilitation Services, Inc A n:a<i? (Ic ?0 r f? ?w, (O w •: Ad C w 6 d r?.r?,?OLI 3916 Trindle Road 75 Evelyn Driv License Number, PT015093L Camp Hill , PA 17011 Millersburg, PA 17061 Signature on File 12121/06 I sr;r:Ee DATE I I PINe I GRPt 1'r (APPROVED 8? AMA COUNCIL ON MEDICAL SERVICE 0.188; PLEASE PRINT OR TYPE AP'-'r'?Or"?'a°°a'`ORMCMs.15o0(12-so7, FORMRSB-1500• APPPOIED OMd-1215-Op?,?$ FORIA OVrCP-1500, APPRWEID W.r3C720-00ot (CHAMPL'S) PLEASE APPRO:fD? OMB-0938.00,008 STAPLE IN THIS w AREA ??r. S7 Cr 1, U (7-FIPICA HEALTH INSURANCE CLAIM FORM PICA 77-11'r 1.ME5CARE MEOICAfO CHAMPUS CHAMPVA GROUP FECA OTHER ta. INSURED'S I.D. NUMBER (FORPROGRAM IN ITEM 1J PL=ASE APPRC 6 ONB-0933-0006 CCU NOT STAPLE IN THIS UJ A?.E A a ® Q U T 'PICA HEALTH INSURAVCE CLAIIN FORM PICA Y 11. MEDICARE MEOICA0 CHAMPUS CHAMPVA GROUP FECA OTHE ?--? HEALTH PLAN BLK LUNG (Medicare q) (Medicaid q) r( (Sponsor's SSNJ (VA Fde i') ( (SSN or iD) SSN !D ? R !a.INSURED'S I.D. NUMBER (FOWROGRAM IN ITEM 1) , +-- I , ) ( ) ( 3661636 12. PATIENT'S NAME (Last Name. First Name. Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name. First Name, ii Initial) Blinn, Michael F MM5/4/1964 Blinn Michael M , 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 200 Hollywood Circle Etallv?l Spous= CH;1? o1heEL--h 200 Hollywood Circle CITY STATE 8. PATIENT STATUS CITY STATE Camp Hill PA singl Married O ne? am Hill PA ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INC.UDE AREA CODE) 17011 ((717) T37- 9343 Emplcye? sull-TI Ti a e dont s 9. OTHER INSUREDS NAME (Last Name, First Name, Middle India,) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Blinn, Michael a. OTHER INISURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSUREO'S DATE OF BIRTH SEX PFP8 0 04 64 60 30 0 IM YES ?NO MI5/4PP96T Mkt F ?f-rl It b. OTHER INSUREDS DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME I)JJ tJ MM DD YY I i M F W !YES D1NOPA u I c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c INSURANCE PLAN NAME OR PROGRAM NAME P.O. Box 779503 PA 17177-9503 ? YES ?NO USAA Insurance d. INSURANCE PLAN NAME OR PROGRAM NAME Capital Blue Cross/CAIC 1 Od. RESERVED FOR LOCAL USE d. i ERE AN 11 HEALTH BENEFIT PLANT YES NO M yoo, return to end cornprete aom 9 a4. U READ BACK OF FORM B EFORE COMPLETING E SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE? I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGN ATURE I authorize IHe release of any medical or other IntormaAon necessary payment of medical eenelrts to the undersioned physician or supplier for to process this clam. I also request payment of government benetas either to myself or to the parry who accepts =Vnmeni sarvlcas de=nbed below. below. Signature on File 1/8+2007 Signature on File i SIGNED CATS SIGNED 14. DATE OF CURRENT: ILLNESS (FUst symptom) OR 1S. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS 't'0/1 ?f20(?6 NJURY (Acodenth OR GIVE FIRST DATE MM DO YY 16. DATES PATIENT UNABLE TO WORK INCUR A ENT OCCUPATION MM DD YY MM DD YY PREGNANCY(LMP) . FROM TO i T NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPIT A L,ZA O N DATES RELATED TO C RENT S ERVICES R Bernard Zeliger B34196 M M, D O D D I U FROM To t3. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES Fj ND 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1.2,3 OR 4 TO ITEM 24E BY LINE) 22. WEDICAIC RESUBMISSION 723 1 CODE ORIGINAL REF. NO. 847.0 23. PRIOR AUTHORIZATION NUMBER 2. L__ .. 4. 24. A 8 C D E F G H I J K DATE(S) OF SERVICET From o Ptace Type PROCEDURES, SERVICES, OR SUPPLIES DIAGNOSIS DAY SD RESERVED FOR C MM DO YY MM DD YY al Se of Servic (Ezpla'n Unusual Curcumshances) CPT/HCPC MODIFIER CODE S CHARGES OR UNITS I miy jP)2n EMG COB LOCAL USE 1 1,2 59,16 12/18/2006 11 97112 1,2 $30.76 1 , D TZFf 2006 1 I 97140 59 1,2 27.67 1 n I `? I n 1 9701Z ,2 u 1-2/4-8A200& y60283`L- a a r•'1- 2-- ? 7 - , - } M i ` CL 25. FEE °'12 T1 Y t?I NUMBER SSN N LJ-26tiS31J2 l I LJ 26. PAT!" rr 4 COUNT NO. 27. ACCEPT ASSIGNMENT! i 92?4t; (For govt. claims, seo back) YES NO 26.TOT$jI 5?E 29. A+,40UNT PAID x 30 BAL'??L?? 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN U YC.IE WIL 'S LING NAME. ADDRESS, 21P CODE ItdCLUDI++G DcG IEES OR CREDENTIALS RENDEF?ritjrg)t AzREIT$t3111f>fth Se;-vices Oentrnl?A RehabilitatiDn Services Inc. ma^Ts'pCO..!!v?-PeIo1xTCr- r? M971, &,:pry to Iris ow and are made a par, Ncreol.) 3916 Trindle Road : 75 Evelyn Driv License Number: PT015093L Camp Hill , PA 17011 Millersburg, PA 17061 Signature on File 01/08107 I SIGNED DATE atNq I GRPO IAPPROVED BY AMA COUNCIL ON MEDICAL SERVICE s.'68) PLEASE PRINT OR TYPE APPEIwEn o?-6-c33a-oG+s FGRM CMS 1,50p(1280;. F6rL\t fiR&1500, APPR-VEDO1'&1215-0058FORMCN+CP 1500. APPRt7 = O+AB-0T2i?OOfit (CHWAP05; PLEASE CO NOT STAPLE IN THIS .AREA T -PICA APPROVED 0MB-09330003 HEALTH INSURANCE CLAIM FORM PICA M ut tti Q U I I I. MEDICARE MEDICAID GHAMPU5 CHAMFVA GrIUUY rcGA G7HE R Ia. INSUREDS I.D. NUMBER (rDRPR GRAM IN !TENT 1) ' ?'p'!I HEALTH PLAN BLK LUNG l f (Medlcaid P)i I (Sponsor's SSPJ,I (VA FAe A) i (SSN or ID) [M (SSMJ 90) (Medicare s)Il 3861636 --- 2. PATIENTS NAME (Last Name, Fw$l Name, Middle Initial) 3. PATIENTS BIRTH DATE SEX 4. INSURED's NAME (Last Name, First Name. Midds lnitap Blinn. Michael I 5r4OD YY M F Blinn, Michael 5. PATIENT'S ADDRESS (No., Strout) 6. PATIENT RELATIONSHIP TO INSURED 7. INSUREC'S ADDRESS (N3., Street) 200 Hollywood Circle SeILXJ? Spousr CN? oihe 1J 200 Hollywood Circle CITY S TATE 6. PATIENT STATUS CITY STATE Cam Hill P I PA Singlet Mat e? JVe j? am Hill PA C h ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) 17011 (717) T37-9343 Employ Full•Tunf? Part.Tl ( 1 Student Student l / C 9. OTHER INSURE D S NAME (last Name, First Name. Middle Inruall 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUM8EA -u. Blinn, Michael ? ! Q a. OTHER INSURED 'S POLICYOR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) s. INSURED'S DATE OF BIRTH SEX I W PFP80046460300 tt,IYES ?NO ?I M!5/.4FI96Y MWt F4-T1 LLLLJJJJ IIJJ u7 z b. OTHER INSUREDS DATE OF BIRTH SEX MM DD YY It. AUTO ACCIDENT? PLACE (Stale) r ? PA b. EMPLOYER'S NAME OR SCHOOL NAME _ O F M , Iv 1 ! YES [?NO 1 Z ?J Q a EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURA14CE PUN NAME OR PROGRAM NAME P.O. Box 779503 PA 17177-9503 YES ?NO USAA Insurance W ?- d. INSURANCE PLAN NAME OR PROGRAM NAME Capital Blue CrosSICAIC 10d. RESERVED FOR LOCAL USE d. I HERE A ER HEALTH BENEFIT PLAN? Tj I < YES NO X yes, return to and complete item 9 ad. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSUREO'S OR AUTHORIZED PERSON'S SIGNATURE I audlorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medial or other mfomatan necessary payment of medial benefits to the undersigned phypaan or suppLef for to process this claim. 1 also request payment of government bene!s either to myself or to the party who accepts assignment services described below, below, Signature on File 118/2007 Signature on File SIGNED DATE SIGNED 14 DATE OF CURRENT: ILLNESS (First symptom) OR I8. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 1 EV1 aY`!?0 S6 4 INJURY (Acidentl OR GIVE FIRST DATE MM DO YY MM DD YY MM DO YY PREGNANCY(LM?; FROM TO 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Bemard Zeliger 834196 MM Do YY MM DD YY PROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES 11 YES [:] NO 2t. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE- ITEMS 1,2.3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION 723 1 GOOF ORIGINAL REF. NO. 847.0 23, PRIOR AUTHORIZATION NUMBER 24, A B C D E F G H I J K ATE($) OF SERVICETo FroD Place Type PROCEDURES, SERVICES. OR SUPPLIES DIAGNOSIS DAYS EPSD RESERVED FOR V I M DO YY MM OD YY of rvi of Sere' (E,pla:n UwsuaI Circumstances) CPTMCPCS MODIFIER CODE S CHARGES OR UNITS Family Plan EMC COB LOCAL USE ~ < D7 $y f6 r t cc I 12/20/2006 1 1 971 12 1 2 ; $30.76 1 1 , ? -1272-072-OW 111- ? 140 59 ` 1,2 -5 ` -17 12120!'2 006 I 1 j 910 12 t rL 16 1.2/2N2006 ---C@2$3 z a 02/2-812*0 _4 1- --879-4-0 -1,2 -4-11.7 25. DAL TAX 10. NUMBER SSN LIN 26. PATIENT'S ACCOUNT NO. 27 ACCEPT ASSIGNMENT7 F a, s back U 119246 23 288330 X 28. TOT 1I5 6 19r0 29. AMOUNT PAID 30. (?A D ? r S ?J I ; m. I ( _ - 2 ? ? j YES S , S S 31. SIGNATURE OF PHYSICIAN OP SUPPLIER ; 32, NAME AND ADDRESS OF FACILITY WHEFE SERVICES WERE 77 33. PHYSICIANS?S eTL '. Bf ;.tNG NAME. ACDRcSS, ZIP CODE -t 8' INCWDINGDEGR'EE5C'RCREDENTIALS RENDEF jI ltJ?jrlxR?Bt1' T17(I?tk1f7 Services 0e',ntA41_QA RehaWitation Services, Inc. ?ma'r,e'Y-44,^G1h,rs F1'7r, r- rp 1? Tv'aT-,' app:ylo leis o?.f and areraCn a pan tnareo:.) 3916 Trindle Road 75 Evelyn Driv License Number: ?TG150931_ Camp Hill , PA 17011 Wlersburg, PA 17061 Signature on File 01108!07, SIQNEO DATE vlNe GRPi ; (APPROVED 3t' AMA C?IUN'CIL ON MEDICAL SERVICE 8 38) PLEASE PRINT OR TYPE APPRDv'ED 0>.r B-oe780pc>0 F??,M CMSISW (t2-a01, FOq Tt Rga1500, AP?R:7JED OM&1215.0056 FORti1 DV?CP•ISD(), FS•PROVErJ OMB•07i'D•00p1 (CitAMP';; $) PLEASE ? APPROVE ora6-o9os oaoa DO 140T STAPLES w IN THIS _Ml AREA rr 4 V PICA HEALTH INSURANCE CLAIM FORM PICA ' MEDICARE ME ICArD CHAMPUS CHAMPVA GROUP FECA OTHER 1a. INSURED'S LD. NUMBER (FORPROGRAM IN ITEM HEALTH PLAN ELK LUNG l J (ATedxare rl r (Mid 1d Y}©j (Spcnsa'3 SSN) rill (VA Five rJ AT 11-1 (SSN or ID) I fSSN') L iTl (ID) -?J . Y' 'M 16116 2. PATIENT'S NAME (Lasl Name, First Name, Middle Initia l) G PATIENT'S BIRTH DATE SEX MM 4 INSL'AED'S NAME (:ds1 Name, Fast Name, Wcdalryuaq Blinn. Michael 5?4/1964 M 1. FE31 Blinn, Michael 5. PATIENTS ADDRESS (No.. S0e60 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., SL•eet) 200 Hollywood Circle Sal1 J Spouse Ch,d21 CnheL? 7rj 200 Hollywood Circle CIiY STATE B.PATIENT STATUS CITY STATE Camp Hill PA s p? Name Otne?j am Hill PA ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE] 17011 (717)x37-9343 im? Employee rn?}-1 Stude Slude St'Jdem Stud6nt r_J 171111 ` 9. OTHER INSURED S NAME (Last Name. First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: it. INSUREDS POLICY GROUP OR FECA NUMBER Blinn, Michael a. OTHER INSUREDS POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX PPPS0046460300 [M [M YES ?NO S µ1J4/ 6?F µr11 F? L? 11, OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) o. EMPLOYER'S NAME OR SCHOOL NAME MM , OD YY M F IrI tYES ?NOPA e. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT) c. INSURANCE PLAN NAME OR PROGRAM NAME P.O. Box 779503 PA 17177-9503 rFh YES NO USAA Insurance d. INSURANCE PLAN NAME OR PROGRAM NAME Capital Blue Cross/CAIC 10d. RESERVED FOR LOCAL USE d. t HERE ^' ER HEALTH BENEFIT PLAN? YES NO If yar, return to and compete nom 9 a4. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSUREDS OR AUTHORIZED PERSONS SIGNATURE 1 authon:e 12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned phys=n or supptler for to process this claim. I also request payment of gwemment benefits ether to mysa01 or to the party who accepts assignment services described below. below. Signature an File 1/8/2007 Signature on File SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR Is. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION INJURY TD/ 3P2006 1 OR (Aadd?U GIVE FIRST DATE MM DD YY MM DO YY MIA DO YY A REGNANCY( P P TO FROM 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 16. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Bernard Zeliger B34196 MM DD YY MM DO . YY FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB7 $ CHARGES 11 YES _? NO 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RE LATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION 723 CODE ORIGINAL REF. NO. 847.0 Z3. PRIOR AUTHORIZATION NUMBER 2. 1-. _ 4. L-._ 24, A E C D E F G K 2 Fr On1ATE(S) OF SERVICETo lace P of Tpe of PROCEDURES. SERVICES. OR SUPPLIES (Explain Unusual Clrcumsfances) DWGtOStS DAYS OR IE ERVED FOR C MM DO YY MM DD YY rv rvi CPTMCPCS MODIFIER CODE S CHARGES UNRS LC CAL USE fi272?1'?0 1 197110 1,2 59.16 2- M t r a C 12/21/2006 1 97112 1 2 $30.76 1 1 , 1 12/21/2006 1 97140 59 1,2 27.67 1 a 721211200 12 ,------ a U 1 ?f21 f290G --? ? ?G028-3 -2- I- fi 9 :98 O 2(2-1-/-2-006 I I n i? -970 -1 2 ;.- 1-1 74- 1 ; I z I a 25. FEC'r.RAL TAX I D NJMBER SSN EIN , 2F. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 23-2883302 119246 Fo govt, c(l?alrna, sae back) ?-? I 1 ,ij YES tV0 ( 28. TOT t56. E 29. AMOUNT PAID 30. BA L D $195 1 56. 355 S $ $ ? L J 131, SIGNATURE OF PHYSICIAN OR SUPPLIER J 172. NAME AN^ ADDRESS OF FACILITY WHERE SERVICES Via-RE 33 PHYSICIANS'Su rDz tLI,NG NAVE, ADDRESS, ZIP CODE 1 INCLUDING OEGREESCR CREDENTIALS RENDEF ?{h87 A=RQ1Tdt litdBOR Services (3MtfalL?4 Rehab;Itation Services, Inc. I maiiTvP fdicRi MS i;liTC rCe141S}? apply to ".'s w, an„ ara,^ade a per : 3916 Trindle Road 75 Evelyn Driv License Num?)er: PT015093L Camp Hi:!. PA 17011 Millersburg, PA 17061 Signature or. File 01;08107 f SIGNED DATE PINT GRPr I (APPROVED BY AMA ^DUNC!L ON MEDICAL SERVICE 8.188i PLEASE PRINT OR TYPE ?P` `D p`.<3-0835-0008 FORM CMS-15170 (t 2.9J1, rG+M RR&t5D0. AF'PRdvED Of/&1215-005,; FOR>.f UM?P-, 57C. AFPGY.NEO L)M3Q720-0'JO, (CNAlAPVSj PLEASE CO NCT STAPLE !N THIS AREA APPRCV0 CM3-028 000B 1 'PEA HEALTH INSURANCE CLAIM FORM PICA I i. rrcuiwanc rA_u4.Aiw ynAMrUJ l.NAW VA unuur r_t' pIFIE HEALTH PLAN BLK LING R 1a. INSUHtDS I.D. NUMBER (FORNOGRAM IN ITEM 1) (Medicare 01 (Malicaid 01[2 (Sponscr's SSN) (VA Fro R) U, (SSN or 10) CIF ! ; (SSN) "'6/71 (10) 3861636 , 2. PATIENT'S NAME (Last Name. First Name. MiWhi Initial) 3. PATIENTS BIRTH DATE SEX 4, iNSURED'S NAME (Last Name. Rest Hama. M-J01nlta4 Blinn, Michael MM514DO YY M F Blinn, Michael o PATIENT'S ADCRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSUREDS ADDRESS (No., Sl(6e1) 200 Hollywood Circle Se: Spouse Chlkn1 Ofhe 200 Hollywood Circle CITY STATE 8. PATIENT STATUS CITY STATE Camp Hill PA SYn0180 MarnediT Dthe[D ).IR II ZIP CODE TELEPHONE (Irx;lude Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) 17011 ((717) 137-9343 EmploytxUh Fu7•Tmt? Part•Tlnj? ' ' n 'J Studont Srudent t - 1 1 8. OTHER INSURED'S NAME (Last Name, First Name. Meddle ImUaq 10. IS PATIENTS CONCITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Blinn, Michael a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSUREDS DATE OF BIRTH SEX PFP8004WO300 V1 YES ?]NO S M'5/4Tf96T mFw t Fl?rl o. OTHER INSUREDS DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (Sate) b. EMPLOYER'S NAME OR SCHOOL NAMES J lJ I MM DD YY F M j?! ]YES ?NOPA E1 f c. EMPLOYER'S NAME 08 SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME f P.O. Box 779503 PA 17177-9503 YES ?NO USAA Insurance d. INSURANCE PLAN NAME OR PROGRAM NAME 4 Capital Blue Cross/CAIC 1Dd. RESERVED FOR LOCAL USE d. I HERE AN ER HEALTH BENEFIT PLANT ? YES NO M yoa, return !o and complete item 9 e-d. READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM. 12- PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of arty medical or other information necessary 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of medcal benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the parry who accepts as:-gnment serviCas descnbed below. below. Signature on File 1/8/2007 Signature on File SIGNED DATE SIGNED 14, OATS OFC•?URREErNT, 4 ILLNESS (First symptom) OR ) OR iden JURY (A ?,O/1 OO 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM DD YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY J` L V P C t FROM TO 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.O. NUMBER OF REFERRING PHYSICIAN 16. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Bernard Zeliger B34196 MM DD YY MM OD • YY FROM TO . 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES nYES NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1.2.3 08 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION 723.1 CODE ORIGINAL REF. 140. 1 1 .. 3. l__ . . 847.0 23. PRIOR AUTHORIZATION NUMBER 24. A B C D E F G H K 2 DATE(S) OF SERVIC From ?o PWce Type PROCEDURES. SERVICES, OR SUPPLIES DIAGNOSIS DAYS EPSD RESERVED FOR C MM DO YY MM DO YY of ervlc of ervice (Ezpla:n Unusual Circumstances) CPTIHCPCS MODIFIER CODE S CHARGES OR UNITS Family Plan LO CAL USE H C 12/28/2006 1 97110 1,2 $59.16 2 T 12/28/2006 1 97112 1 2 ! $30 76 1 I , . a 12/28/2006 1 97140 59 1,2 -' $27.67 I 1 Q 11-Z128720 - ` ' - $ ? Iz 1-2f28F200 a ! 12-/28/2-006 -1 4-9-70-1 1 $11-7 1- -- ?? 1 z -5. FEDERAL TAX I.D. NUMBER SSN FIN 26. PATIFNT'S AC•CO'J.NT NO. 27. ACCFPT ASSIGNMENT7 23-21383302 ? ?C Li 119246 fl-or go 1. dams. cea bacHi I r? 1'E$ -] NO ; 28. TOT r.4? 1 ??' $ 29. AMOUNT PAIL $ 30. BAL D I?. Q? S 3 t. SIGNATURE OF PHYS',01AN OR SUPPLIER 32. NAM'- AND ADDRESS OF FACILITY Yi HERE SERVICES WERE 33. PHYSICIAN IZE 1NLLNG NAME ZIP CODE ADDRESS INCLUDING DEGRcESOR CRECENTIALS RENOEFC?! i",Val'PA=Rbint l lRdt"h SerVIC.-.S . . 04ntlalt.Pfi Rehabililation Services Inc. man'i?' i?Rf?Sisi AT?e?l 33 I 3 npaQ tottns .?arklaro??4ea 1I),ureolj 916 Trindie Road , 75 Evelyn Driv License Number. FT015093;- Camp Hili , PA 17011 Millersburg, PA 1761 Signature on File 01108.107 SIGuC DATE PINtl ; I w U r I I! 1 X O ti d E !x n X_ 0 w to z Z Q (APPROVED BY AMA:CUNCIL ON MEDICAL SEP.VECE 8'83) PLEASE PRINT OR TYPE APPR''lIED 0A45C53&-Q0W FC4W CMS•1500(12 zi07 FORM RR&1500, APPROJEDOI.t&1215-OJSSF-0RMOY?CP-150C), AFPR IVEDOM&G724CXIJCkA.VP'L!E: PLEASE DO NOT STAPLE N THIS -AREA PICA APPROVED OMB-)038 0008 HEHALTH INSURANCE CLAIM FORM PICA 11. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHE R 13. INSURECS 11), NUMBER (FORFROGRAIA IN ITEM I) HEALTH PLAN BLK LUNG P (Mad?careYJ (Med+card Y)(i Tl (Sponsa's SSN) [Tl (VAFdo A') L?7 (SSNd 10) II?("I jSoN) ?j?j (I.rJ) J . u ' 3861636 ) u? ICI J U - 2. PATIENTS NAf IE (Las: Name, First Name, M,cd:e Initial) 3, PATIENT'S BIRTH DATE SEX 4. INSUREDS NA)AE (Last Name. First Name. M,odknllml) Blinn,, Michael Fes; M 5/4/1964 M; Blinn, M tl.aei 5. PATIENTS ADDRESS (rfo., Street) G. PATIENT RELATICNSHIP TO INSURED 7. INSUREDS ADDRESS (No., Street) 200 Hollywood Circle Set ` Spous.Eu ch u Olhe Q 200 Hollywood Circle Cl Ty STATE S. PATIENT STATUS CITY STATE Camp Hill PA Stng1? Marnea?j ome am Hill PA ZiP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) 17011 ((717)137.9343 Employe Part-Ti o ? e denl St t dent S 9. OTHER INSUREDS NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMSEil Blinn, Michael f a. OTHER INSUREDS POLICY OR GROUP NUMBER a. EMPLOYMENT (CURRENT OR PREVIOUS) a. INSUREDS DATE OF BIRTH SEX PFP80046460300 []l YES ?j ND Mf5/4N96)f M F j D. OTHER INSUREDS DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) lIIJ b. EMPLOYER'S NAME OR SCHOOL NAME I MM DO YY F M YES TJ ?1NOPA ?J I c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENTS c. INSURANCE PLAN NAME OR PROGRAM NAME P.O. Box 779503 PA 17177-9503 No El YES Iti LISAA Insurance d. INSURANCE PLAN NAME OR PROGRAM NAME Capital Blue Cross/CAIC 10a. RESERVED FOR LOCAL USE RE AN'O , HEALTH BENEFIT PLAN? ?Ell ES L NO If yea. return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING d SIGNING THIS FORM. ' ED'S OR AUTHORIZED PERSON'S SIGNATURE I Authorl2a I Z. PATIENT'S OR AUTHORIZED PERSON S SIGNATURE I authonle the release of any medical or other Information nec nt of medical benefits to the unoersgned physician or supp'.,or for to process then claim. I a!so request payment of government benefits either to myself or Io the party who accepts asgnme s oescnbed below. below. Signature on File 1/8/2007 Signature on File Z SIGNED DATE E ED f a. DATE OF CURRENT: ILLNESS (First symptom) OR ?'E/1 Sf2()d6 INJURY [Accident) OR 15 IF PATIENT HAS HAD S AME OR SIMILAR IL GIVE FIRST DATE MM DD YY PATIENT UNABLE 70 WORK IN CURRENT OCCUPATION MM DO YY MM DD YY PREGNANCY(LMP) . TO 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE B r ii d Z 17a. I.D. NUMBER OF REFERRING PHYSICIAN 834196 TALIZATION DATES RELATED TO CURRENT SERVICES MM DO YY e nar e ger MM DD YY FROM TO 19. RESERVED FOR LOCAL USE 29 OUTSIDE LAB? $ CHARGES YES 1:1 NO 2 t DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) --7 22. MEDICAID RESUBMISSION 723.1 JY_ CODE ORIGINAL REF. NO. ?.- 847.0 23. PRIOR AUTHORIZATION NUMBER 2. 24, A B C D E F G H I J K DATE(S) OF SERVICE Flom To Place Type PROCEDURES. SERVICES. OR SUPPLIES DIAGNOSIS DAYS P D RESERVED FOR C YY DD DD YY MM MY o! ServKX of (Explain Unusual Circumstances) Soni CPTM CS MODIFIER CODE $ CHARGES OR UNITS Famlty Plan EMG COB LOCAL USE r ~ Z/2W2UM ' 1 2 $5976- 2 I , 1 r2 C 12/29/2006 11 97112 1,2 $30.76 1 r I 1272-972Q X59 1,2 $277 u 1-2129P2006 -1 z 1,2 Q 0. 1-2-29/200 1- j ra I -$jfi 1 9$ ?`fi a a ?,2/29/-2-t10 25. FED2° A TA : NUMBER SSN 7 26. PAT11- A"COUNT NO. 27. ACCEPT ASSIGNMENT 2 i t U2 X { i yL4 _ (?For,oYl. dams, See bay} , 28. TOTV 12 q ? G,?5 29. Ah10UNT PAD V 30. aAL S?C? J NO u YES ? S S ? ? g 31. SIGNATURE CF PHYSICiANOR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE g 33. PHYSICIAN '? S ?• LII?;Er - ?LLING NAME, ADDRESS, ZIP CODE INCLUDING DEC RE Ei OR CREDENTIALS RFNDeF'?y$n(rg}tP ;(7 a}g(prtatiOn Services Centa4zP,A Rehabilitation Services, Inc. r 1aKC?1:Ni?R1RASPTPA.TCrC?1q MM" apply to this bill and are'-ade a pan ihorooi.) 3916 Trind'e Road 75 Eve!yrt Driv License Number: PT015093L Camp Hill , PA "7011 Millersburg, PA 1706, Signature on File 01108!07 SIGNED OAT'c PINT! { GRP# W LC d t? APPC (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE E'88) PLEASE PRINT OR TYPE V 0^Ma-OP}e-0008 FORM CMS-15X rORM R?3.150Q APF`40VED DIA3-1215-0005 FORM O.YCP-15,.17, APPiIC`,?EC OMS-07YJ-0p01 (CHAtAA S) PLEASE DO NOT STAPLE IN T HiS AREA f-i`, ?P1CA APPROVED OIAB `938-COC3 ???,D (l?4 3 CC ? uJ rt }HEALTH INSURANCE CLAIM FORM PICA 11, MEDICARE MEDICAID CHAMPUS CHAMPVA • GROUP FECA OTHE R :a. INSUREO'S 10. NUMBER (FORPACGRAM IN ITEM I) HEALTH PLAN BLK LUNG ? 7 (Modicara a) t'-? (Medicaid 1) (Sponsors SSN) Ij Tl (VA File r) (SSN ar !D) ? (SSN) 7 (!D) 3661636 U 1 2. PATIENT' NAME (Last Name. First Name. Middle Intia) 3. PATIENT'S BIRCH DATE SEX MM YY OD 4, INSUREDS NAME 1'.asl Name, First Name, Wo6'h Initial) Blinn, Michael 64 M F 4119 5! Blinn, N ichael i 5. PATIENT'S ADDRESS (NO., Street) 8. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Slroet) 200 Hollywood Circle sen spousol Child_ 6J ar? 200 Hollywood Circle CITY STATE B. PATIENT STATUS CITY STAT E z Camp Hill PA Single Married OhoEjJ am Hill PA ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE flrCLUDE AREA CODE) 4 17011 (717)y37-9343 Employed Full-Time Pan-Tim '` 1 ` ' / ¢ Student ? Student 1 17Q 1 0 9. OTHER INSUREO'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDI fICN RELATED TO: 11. INSURED'S POLICY GROUP OR. FECA NUMBER zZ Blinn, Michael o a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED 'S DATE OF BIRTH SEX w CC PFP8DO46460300 YES NO MMldi 96f M Sri F b. OTHER INSUREO'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. E MPLOYER'S NAME OR SCHOOL NAME _ p MM i 00 ; YY M F YES NO PA z S, c. EMPLOYER'S NAME OR SCHOOL NAME C. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME F' z P.O. Box 779503 PA 1 71 77-95 03 Q ? YES JNO USAA Insurance to ? d. INSURANCE PLAN NAME OR PROGRAM NAME C it /CHIC ( Bl C too, RESERVED FOR LOCAL USE d, [ERE ANG.TH HER HEALTH BENEFIT PLAN? a Q. ap a ue ross YES ] N O 11 yea, return to andcomplole Item 9a-d. L READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE Iauthorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of modiral benefits 10 the undersigned physician or supplier for to prb0013 INS 001M. 111 (OQuOd payment of government benefits either to myself or to the party who accepts assignmeN sorvices described below, below. Signature on File 1/22/2007 Signature on File SIGNED OATS SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 18. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION t 4 INJURY (Accidenl) OR GIVE FIRST DATE MIA I DO I YY ILL VV V 10111 t MM t DD i YY MM t oD 1 YY PREGNANCY(LMP) I FROM I TO I I 17, NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Semard Zeliger 634196 MM , DD , YY MM , DO , YY FROM 1 t TO I I 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? S CHARGES El YES [INO 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1.2.3 OR 4 TO ITEM 24E BYLINE) 22. MEDICAID RESUBMISSION 723. 1 CODE ORIGINAL REF, NO. 23. PRIOR AUTHORIZATION NUMBER 847.0 2. I__ . 4. I_. . 24, A 0 C 0 E F G H I J K z Fro ATE(S) OF SERVICETa Place Type PROCEDURES. SERVICES, OR SUPPLIES DIAGNOSIS DAYS EPSD RESERVED FOR MM DO YY MM DO YY of c M of Service (ErpJain Unusual Circumstances) CPTMCPCS MODIFIER CODE $ CHARGES OR UNITS Family Plan I EMG COB LOCAL USE t- Q 1T?12 1 7 1 11 97110 1 1,2 1 $59.16 2 d Q 1/2/2007 11 97112 1 2 I $30 76 1 z , . 1 2 2007 11 97140 59 12 l $27.67 1 n. I I a 17212007 11 97012 1;2 $'C564 1 112/2007 -1 G0283 -2 W-.98 1 ; z I t I a 11212007 11- 97010 l 1-2 $1? 74 1 N r I I I r I ? ' _ 1 1 1 I I 1 ; l a 25. FEDERAL T? I.D. NUMBER SSN EIN 23.2883302 X I0 25. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT) a tacit 2 'F e ) I 119246 16 YES Ej NO 8. TDT F9 $1?6t5 S I 29. AMOUNT PAID ( I S 30. BAL. 11 ?15?•95 I S i I 31. SIGNATURE OF PHYSICIAN OR SUPPLER 32. NAME AND ADDRESS OF FACILIT`i wRERE SERVICES'f+ERE 3 qp?ERM d 3. PHYSIC IA!; 'S 1 . S?7P'L:, Un'G NAME. ADDRESS. ZIP COLE i INCLUDI NG DEGREES OR CREDENTIALS RENDERU"Oh'trg}'P?C•'t?etT bTRatTcn SeMCt:S GEtYRIFPA Rehabilitation Services. Inc I j II ?? ?m ???m ?..j:?'tb s 4 !. c uu or- a N^d,l7? Srtp 1Y"? 1 3916 Trindle Road 75 Evelyn Driv I License NUrnbec P''015093L Camp Hill , PA 17011 Millersburg, PA 17061 Signature on File 01/22/07 I SIGN'"c0 CATE I P IN! I GRPX APP (APPgEOV`D E3Y AMtCD'Jh'GL ON MEDICAL SERVICE 6188) PLEASE PRINT OR TYPE WJVED OMv0A3a-OOfi FORM CAl4 t 500 (12-BG,. FLIRMRRS-1500, APPROVED OM&1215.OCS5 FORM OVlCP 1500, APPRC4'BO OMD 0720-ocol (CNNA?L;cI PLEASE ?Ilr va NOT STAPLE: :N THIS AREA ,(-PICA APPROVE) OMB-O9:8-0608 HEALTH INSURANCE CLAIM FORM PICA 1. T U I'- MEDICARE MECiCAID CHAMP'JS CHAMPVA GROUP FEECA OTHE R Ia.INSURE7'S!.O.NUMBER (FORfROGRAMIN ITEM Ii I('!? (Medicare r Ma6ca4 rJ (Spotoor3 SSN) (VAFde s HEALTH PLAN BLS LUNG J ( Q ) © /sSN a +D} I (SSN) Sit (ID) 2 3861636 PATIENT'S NAME (Last Name, First Name, Middle Initial) 3, PATIENT'S BIRTH DATE SEX a. INSURED S NAME (Last Name, First Name, Middlliniilal) Blinn, Mictiael MM51 ? 904 M _ F Blinn, Michael 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 200 Hollywood Circle sar'? SpouseM Chkp ahem 200 Hollywood Circle CfTY STATE a. PATIENT STATUS CITY STATE 1 Z Camp Hill PA Single MarriedFj DlhQQ Cam Hill PA 1F ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) Q 17011 (717) 737-9343 Employetl ? Full-Tlmea Pan-TtmE ` / a Student CJ Student j 0.1 1 '0 9. OTHER INSURED-5 NAME (last Name. First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z U. Blinn, Michael a w a. OTHER INSUREDS POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSUREDS DATE OF BIRTH SEX Er PFP80046460300 I NO Pi YES LL MI J/4Yi 96Y M u' F LLLL ???? I z b. OTHER INSURED 'S DATE OF BIRTH SEX - b. AUTO ACCIDENT? PLACE (Stalo) b. EMPLOYER'S NAME OR SCHOOL NAME ---- C3 MM DO I YY I I M F Ql YES ? NO PA Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME t- W P.O. Box 779503 PA 17177-9503 YES WhNo USAA Insurance I- d. INSURANCE PLAN NAME OR PROGRAM NAME Capita! Blue Cross/CAIC 1Otl. RESERVED FOR LOCAL USE a. *-ZHERE AN 1,iER HEALTH BENEFIT PLAN? YES NO !r ysr, return to andcomptato item 9a-d. READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM. 13. INSURED '9 OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'$ SIGNATURE I authorize the release of any medlcal or other Inlormadon necessary payment of medical Wrietlts to Me undersigned physu n at supplier for 10 process tMs claim. I also request payment of government benetll5 either 10 myself or to the party who accepts assignment services described below, below. Signature on File 1122/2007 Signature on File SIGNED DATE SIGNED 14. DATE F rURPENT; ILLNESS (First symptom) OR INJURY (Accident) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM I DO I YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I DD I YY MM I DO I YY I I PREGNANCY(LMP) I ! FROM I I TO I 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE yUM R OF REFERRING PHYSICIAN l7a 19 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Bernard Zeliger , C 4196 MM I DO ; YY MM OD YY FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES 11 NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2.3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION 723.1 CODE ORIGINAL REF. NO. 3 1 ? ? . - - 847.0 23. PRIOR AUTHORIZATION NUMBER I J 2.I__,_ 4. I 24. A B C D E F 0 H F DATE(S) OF SERVICETo Place Type PROCEDURES. SERVICES, OR SUPPLIES pIAGNOSIS DA EPSD ff RESERVED FOR O MM DD vY MM DD YY of SQrvic of S rvl (Explain Unusual Circumstances) CPT/HCPCS MODIFIER CODE S CHARGES OR UNITS Famil Plan COB LOCAL USE Q 1%SJ200 l 11 Q 97110 I 1;Z I $59-1'6 2 0 1/5/2007 11 97112 1 2 $30 76 1 z 17572007 11 4a 59 , 1 , 27- 67- -1 1 . a 1/5/2007 970-12 ;24 $71 1- N ' 1-/5t2Q47 GO283 1-2 I $11:98 1- o q 11/5/206-7- 11 7010 I 1,2 - -$1174- 1 } I I I I ( - I ? l ' I I I 1 I I ? CL 25. FEO° Ar NLIMBER SSN E? 2 -21 CS t?2 X 28. PATI' S l-COUNT NO, I rS??2- 6 1 ACC-PT ASS,GNM"NT7 2 27 01 goat. Calms. see?aak) 0. TOTr E 456.95 23. AMOUNT FAIR 30, BAL ?1 .?? YES U NO S '17 6 S S i j 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND AOCRESS OF FACILITY WHERE SERVICES WERE 2 I « 3 PHYSIC(AU'¢, SUPP IER'S BILU G NAME A DRESS. ZIP CODE - INCLUDING DEGREES OR CREDENTIALS RENDERCWtCaijP.A, RehabilitatiDn Services , go(11 Qt_ A !-ZChaCI(ilation ervice5, nC `.mand a,Dlteic iNSGTti ? r t+11E3? 3316 Trindle Road 75 Evel;m Driv thereof.) h p P ce se t?urntiect PTO aSU93l I Camp Hill , PA 17011 Mille bur PA 17061 9, Signature on File 01122/07 - i ! f -D DATE P SIGN, INT _ _GRPr APPrMED (APPROVED 9Y AMA ?DUNCIE. DN MEDICAL SERVICE &'60 PLEASE PRfNT OR TYPE OM9-0336 OCM FORM CMS1 500 112-PO), FORT.'. RR5.1500, e' APPROVED OMB-121 5OCSS FORM OVdCP-1500. APPRpVE D OMO O.2D0071 (CHAN.!''j., (Med,i:erei) (- (Med;c'rid 0) 711 (sponsor'sSSN) OTHER ia. INSUREDS I.D. NUMBcR (r"ORPRCGRAM IN ITEM . ) al (VAFu'9 A) NSSNorIC?N? e(SJNG (11 3861fi36 F? I? 2. PATIENT S NAME (Last Name, First Name, M:ddle Inmal) Blinn, Michael 3. PAA ENTp'S ei *TH DATE SEX S/ /?1 4. INSURED'S NAME (Last Name. First Name, M:dca irrlial) Bli Mi h l 4 J.4 M F r1 nn, c ae 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO WSUREO 7. INSUREDS ADDRESS (No.. Street) 200 Hollywood Circle Selfwh Spouse Child ahorg 200 Hollywood Circle CITY STATE 8.PATIENTSTATUS CITY STATE Camp Hill ] PA SingloJ ? Married Q 01he r ? Cam Hill PA C ZIP CODE TELEPHONE (Include Area Code) - ? dr 17011 Em ll lo F Tt P ZIP CODE TELEPHONE (INCLUDE AREA CODE) I ((717) T37-9343 p ye - m u art•Trm f? ? r ? ?1 Student, Sludeni ?j 01J G 9. OTHER INSURED'S NAME (Last Namu, Firrl Name, Middl e Initmt) 10. IS PATIENT'S CONDITION RELATED TO: I I, INSURED 'S POLICY GROUP OR FECA NUMBER u Blinn, Michael Z - ..OTHER INSUREDS POLICY OR GROUP NUMBER a. EMPLOYMENT7 (CURRENT OR FAEVIOUS) e. INSURED'S DATE CF BIRTH SET( c ¢ PFP80046460300 J ves JNo M"5/,4996 M F (? b. OTHER INSUAED'S DATE OF BIRTH SEX MM DD YY b. AUTO ACCIDENT? PLACE (State) 1 b. EMPLOYER'S NAME OR SCHOOL NAME z I , I M F ? YES 1,0 PAI J G] Q c. EMPLOYER'S NAME OR SCHOOL NAME - C. OTHER ACCIDENT? C. INSURANCE PLAN NAME OR PROGRAM NAME f P.O. Box 779503 PA 17177-9503 A Ell YES INO USAA Insurance w d INSURANCE PLAN NAME OR PROGRAM NAME Capital Blue CrOSS/CAIC ;Dd. RESERVED FOR LOCAL USE d, I?-?}4ERE ANrp=}{ER HEALTH BENEFIT PLAN? _ I (J L?J r= a t> U u ES Y NO rr yes, return to and complete vem 9 a d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or ofhor Informalion necessar 13. INSURED '5 OR AUTHORIZED PERSON'S SIGNATURE I authorize y to process Ihb claim, I also toques, payment of government benefits ollhor to mysolf or to the party who accepts assignment pnymenl of medical benefits to the undarsigned physician or supplier fo services described bobw r below. Signature on File 1/22•'2007 . Signature on File SIGNED DATE SIGNED ? 14. DATE OF CURRENT; ILLNESS (Firs/ symptom) OR 3'Q?6 INJURY (Accident) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST GATE MM I DD I YY IS. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM r DD I YY MM OD YY PREGNANCY(LIMP) I 1 FROM r TO I 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Bernard Zeliger 17a. lo. NUMBER OF REFERRING PHYSICIAN 834196 18, HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD Y , , Y MM : DD , YY FR i OM i TO 1 I 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES 11 YES E] NO 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 723 1 22. MEDICAID RESUBMISSION D . ORIGINAL REF. NO. 847.0 z3. PRIOR AUTHORIZATION NUMBER 2. 1_ .. 4. L? . . 24. A 13 C E GATE 5) OF SERVICE Place T PROCEDURERVICES. OR SUPPLIES From ( To ype DIAGNOSIS of of (Explasual Cirwmstancos) o F G H I K DAYS EPSD RESERVED FOR OR Z r M DD YY MM 00 YY Sorvic S 1 I20.07 1 CODE C11&CPCS MODIFIER - Family S CHARGES UNITS Plan EMG COB LOCAL USE l f ?7?1? I $&87-4 o 1/8/20P7 11 I 97112 r 1,2 ? $30.76 1 z 1?t8 07 11 I 97140 59 1 2 1 $27 67 1 D J : i 1 I I 1 . 8 0 r i20 7 1"1 970-1-2 1-2 1 f8/2oo7 r1 G0283 1 z $-11f 98 1- ; - z t I 1/8/2007 1 I 11 , ! I 97010 ` 1 2 ' $1-1-74 1- .1 25. FED°3 TAY I E2 NUMBER SSt: E'N 126, PA T.7 A (,OUNT NO. 27, ACCEPT ASSIGNMENT? 29. AMOUNT PAID ?30. BA L ? l j 2- aa33b2 D n ( 1 ?Z4? for govt, elmr s, see back) 29. TOT,$T86 53 '86:53 I 1 1 L) YES E NO S $ i y - •-1?-s2 7cs 31. SIGNPJ ;RE CF PHYSICIAN OR SUPPLIER 32 NAME ANC ADDRESS OF FACILITY WHERE SEF.VICES WERE 33. r'HYSSCIAN S. SU PI.IER"S BILLING NAME. ADDRESS, ZIP CODE I II:CLUDtNG DEGREESRCREDENTIALS RENDER (trg(;PA1AshBbi',iiatiOn Services (ienta'-PA Rehabilitation Services, Inc I mar>u6 W f ! 1SPTr.4TCrCsti'11d37' I a„ray to tn:s anand aremace a pen Inmool.) 3916 Trindte Road 75 Evelyn Driv I Lirr nse Number: PT015093L - i Camp H(A , PA 17011 Millersburg, PA 17061 I Signature cn File 01/22/0 SIGNED DATE PINK GPP# (APPROVED BY"A'r.(A COUNCIL ON IJEDICAL SERVICE B/88) PLEASE PRINT OR TYPE APPROVED OMB-(1638-DO08 FORM rmn-I Soo 117.90;, FORMAAts-I500, APPROVEDOM&1215-0055FORMOWGP-1500. APi>RC?EDC+,5f3-c7 -0cq?iCt;hlaa?Sl PLEASE APPR ;ED CMB-09380908 JO NGT STAPLE IN THIS to AREA ®® a, d HEALTH INSURANCE CLAIM FORP41 PICA r?1; 1, MEDICARE MEDICAID CHAMPUS CHAM?VA ` GROUP FECA PLEASE DC NOT STAPLE iN THIS AREA rT , jk APFr100 CM8-0938.0008 HEALTH INSURANCE CLAIh1 FORM PICA t ;sl tr d U F-I-n+ . I. MEDICARE MECICAID CHA:MPUS CHAMPVA • GROUP FECA OTHE R Ia. INSURED'S I.O. NUMBER iFCB?FiCGRAM IN REM 1) ) (po ) (AfedKnre ?) C`l) (Medicaid S nscr's SSN HEALTH PLAN BLK LUNG ' (VA File s) (Say or 101 --r (SSN) t f (D) 3861636 12. PATIENT'S NAME (Ust Name, First Name. Middle In3Wt) 3. PATIENT'S BIRTH DATE EX MM 4. INSURED'S NAME (Last Name. First Name, Moo fr-iat) Blinn, Michael ??-•,-- I 5/411964 S M V F IJ' Blinn, Michael S. PATIENTS ADDRESS (No_ Slroo;) 6, PATIENT RELATIONSHIP TO INSURED 7. INSUREED'S ADDRESS (No., Stroel) 200 Hcilywood Circle SelIK Spouse ChMn Othoe 700 Hollywood Circle OJY S A TE 8. PATIENT STATUS CITY STATE Camp Hill r A SingtoJ Married ?J Olhel "I Cam Hiil PA ZIP CODE TELEPHONE (tndude Area Code) ZIP CEDE TELEPHONE (INCLUDE AREA CODE) 17011 (717) '37-9343 EmployedFj Full-Timunj Pan-Tim ( ` ?J Sludent rJ Student 70IJ- 9. OTHER INSURED'S NAME (Lest Name, First Name, Middle Inrlal) 10. IS PATIENT'S CONDITION RELATED TO: 11, INSURED'S POLICY GROUP OR FECA NUM13E Blinn, Michael a. OTHER INSUREDS POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSUREDS DATE OF BIRTH SEX PFP80046460300 YES Lv?INO ??i 9 M ? F "'15/471964 1 b. OTHER INSURED '5 DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (Slate) b. EMPLOYER'S NAME OR SCHOOL NAME MM , 00 1 YY F I t I M YES NC PA ?/?) 9J I c. EMPLOYER'S NAME OR SCHOOL NAME C. OTHER ACCIDENT? c, INSURANCE PLAN NAME OR PROGRAM NAME I P.O. Sox 779503 PA 17177-9503 YES NO USAA Insurance S d. INSURANCE PLAN NAME OR PROGRAM NAME Capital Biue Cross/CHIC IDo. RESERVED FOR LOCAL USE d. eRE AN iER HEALTH BENEFIT PLAN? n L YES NO If yeas return to and template Item 9 a•d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benafris in the undersigned physic;on or supplier for to process this claim, I also romes1 payment of government benefits either to myself or to the party who accepts assignment services described below, botow. Signature on File 1/22/2007 Signature on File SIGNED DATE SIGNED I 74. DATE OF CURRENT: ILLNESS tFirst symptom) OR ??/ ?r2dQ'S INJURY (Accident) OR IS. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM I DD I W 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I DO I YY MM I DO I YY 1 A PREGNANCY(LMP) I I FROM l I TO I i 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Bemard Zeliger B34196 MM , DD I YY MM I DD I YY FROM I I TO I 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? S CHARGES El YES RNO 2 S. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) Z2. MEDICAID RESUBMISSION 723.1 CODE ORIGINAL REF. NO. 847.0 23. PRIOR AUTHORIZATION NUMBER ' L____., . - e. I_, _ 24. A 13 C D E F G H 1 J K Z Fir DATE(S) OF SERVICETO Pla o Type PROCEDURES, SERVICES, OR SUPPLIES DIAGNOSIS DAYS _PSO RESERVED FOR C MM DO YY MM DO YY of Lry of rv e (Explain Unusual Circumstances) CPTMCPCS MODIFIER CODE S CHARGES OA UNITS Family Plan EMG COB LOCAL USE H -3 1?1,172007 11 97V1 1 2 $88-74 , Cr C 1!1;1/2007 11 97112 1,2 I $3036 1 1 1 , IW 1T1 1 /2ZT07 11 g7?-?? ?J $2767 1? I 1 l i I I I a I 1 11? Y2007- t 1 I 9701 ,2 l $T5-.64 1 17 I 1-114/2407 I I 11 G0283 ?- -' ; 1; I -$11-98 1 z i I 1/--1'1/2007 I I I 1- I 574101- 1 -4;2 ` 1-1 7 - ,a N I I I I I , I Q t ,.5 FEDFRA T4X 1.pp N,UNvER SSN EIN 26. PA 3- e833L`2 (X? I TIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 2 119246 Xfporgo",claims.asst=x) _ 6. TOT, E 29. AMOUNT PAID 30. BA' y?i?g?.53 8 :J ? u YES [] NO S i s I a I 31 $I'aNATURE OF NAYSICIAN OR SUPPLIER 32 NAME AND ADDi =SS Oi= FACILITY WHERE SERVICES WERE ? ? I j - . . 3 INC:UONG DEGREESOR CREDENTIALS RENOERCbr{(Tal!P4fjehat)/lllltSdn Senvices 3. PHYSICL:N . SUFrL E ILLING NAt1E, ACDRESS, UP COCE GeRta?P.A Rehati;itabon SerR-;ceS, Inc j ?m&r"da't1 NWPT-A?1?--C6F"l ' 0.. Ely 10tnls bill and at made a earl ilereor.) 3915 Tdnd!e Road 75 Evelyn Criv License Number: PT015C93L ? Camp Hill , PA. 17011 g, PA 17061 Millersburg, I Signature on File 01!22/07 I ` SIGNFO DATE I PI Ns ( GRPi I+ APPRC`.'ED8YAfJ,ACOUNCIL Of:MEDICALSERVICE 6.881 PLERS6PH!NTCHTYPE AP PROVEDOM3a833 We FORM CMS-15M(12-ixp. FORMFIR&15x, - APPROVEDOM3i215.ODS5FORMOWCP•1500. APPROVED Dbt&072P0001(CHAMPJS; PLEAS 00 NOT STAPLC ,N THIa AREA (j ?PICA APPRO'hO 06130938-0008 HEALTH INSURANCE CLAIM FORM PICA 1 s w a U 71T-1 I, MEDICARE MEDICAID CHAMPUS CHAMPVA 'GROUP FECA OTHE R IIa.INSJRED'S1.0.NUMBER (FOR'ROGRAMIN ITEM I) I ` HEALTH PLAN BI-K LU4G [j Woofcare /) (Med:card s)[ (SPOrL,at's SSN) ( (vA Fda r) O (SSN arr0) U (SSN) R (10) 3861636 ' 2. PATIENT'S NAME (Last Namo. First Name, Middle Inalal) 3. PMMIENT'SS BIHTY DATE SEX 4, INSUREDS NAME (Lost Name, First Name, MidCil Ir1U01) Blinn, Michael 5%4P1964 M Blinn, Michael 5. PATIENT'S ADDRESS (No., Sheol) 6. PATIENT RELATIONSHIP TONSURED 7. INSUREO'S ADDRESS (No., Straoi) 200 Hollywood Circle setr? Spouse childP OtherLPJ 200 Hollywood Circle CITY STATE 9. PATIENT STATUS CITY STATE Z I Camp Hilt PA singleoJ Married ?? anee Cam Hill PA 0 H. ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) G 17011 t (717) T37-9343 Employed(?y 1 Fvll•TimeEj Pan•Tima, ` / O L_f Student _ Student TJ 7011 1 ' 9. OTHER INSURED'S NAME (Lail Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATEO TO: 11, INSUREDS POLICY GROUP OR FECA NUMBEA I Z Blinn, Michael Q E a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? ICURRENTOR PREVIOUS) a. INSUREM'S DATE OF BIRTH SEX w UJ PFP80046460300 YES ?NO '?/,4?1964 M? F z b. OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (Stale) b, EMPLOYER'S NAME OR SCHOOL NAME 0 WM , DD , YY M F rrte?,, fvIIYES IDI tl IINOP Q CJ c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? C. INSURANCE PLAN NAME OR PROGRAM NAME Z P.O. Box 779503 PA 17177-9503 B1 YES KNO USAA Insurance to d. INSURANCE PLAN NAME OR PROGRAM NAME Capital Blue Cross/CAIC 10d. RESERVED FOR LOCAL USE d. t?EERE AN ER HEALTH BENEFIT PLAN? YES NO t f., es, realm to and complete Item 9 a-0. HEAD BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM. Q. INSURED'S OR AUTHORIZED PERSONS SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary paymorl of medical bennflis to the undorslgnod physician or supplier for to process thla cia'm.1 also request payment of government bonelas either to myself of to the party who accepts asalgnmenl cervices described bolow. below. Signature on File 1/22/2007 Signature on File SIGNED DATE SIGNED r URRENT: ILLNESS (F rat symptom) OR OF 14. DATE C 15. IF PATIENT HAS HAD SAME DA sIMIIAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ? ryry 77 OR `?`GOO? ? INJURY ? GIVE FIRST DATE MM i DO I YY t 1 MM , DD i YY MM i DD t YY GNAN (LMP FROM I TO i 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. 1.0. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RF.}ATED TO CURRENT SERVICES Bernard Zeliger B34196 MM i DO I YY IMM I DD 1 YY TO FAOA 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? S CHARGES YES [] NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO REM 24E BY LINE) --7 22. MEDICAID RESUBMISSION 723.1 Tf - CODE ORIGINAL PER. NO. 847.0 23. PRIOR AUTHORIZATION NUMBER I 2.4. ?._ 24. A 8 C D E F G H 1 J K ) 2 FrDATE(S) OF SERVICFT o Place f Typo f PROCEDURES. SERVICES, OR SUPPLIES l E l Ci i U DIAGNOSIS DAYS OR EPSD F il RESERVED FOR C_7 MIA DD YY MM DO YY o rv o rvi xp n nusua rcumstances) ( a CPTIHC DS MO IFIER CODE S CHARGES UNITS am y Plan EMG COB LOCAL USE ~ Q 171212007 s ; {O _ $88 T _ ! I o 1/1,2/2007 i 11 97112 I 1 2 $30.76 1 z I I 171--2720-0 1 i 11 I 97140 59 - , 1,2 27.67 1 a ` 171 21200 f 1-1- 370"1.2 112 $71T. z- to 1 I 1 i I c: -1-M-2/-2007- 1 i I I i 11 G0283 t -2 11-9II 1 1 0 1/1'2/2007 1 I 1- 97010 i I. 1;2 , -$11-7 i 1 N r I I I I i I I I ? I i z 125. FEOBP x Ip NUMBER SSN EIN 25. PATIrryry A COUNT NJ. 27. ACCEPT ASSIGNMENT? 2 x( Fcrgovt.ciaim s,Set) bach) 23 SbR3302 ? 11y24? I 8. TOT UNT PAID 3D. 6AL, ` $161II6:C ?3 + 1 ' ' I l 1 YES Lr 1 NO C S i S = __ 31. S1GNAi URE OF PHYSICIAN OR SUPPLIER 52. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 3 3. Pw SiciAN ,GNAME.ADDrESS.Zi?CODC INCLUOt14G DEGREESOR CREDENTIALS I RENDERE' 'T4XakP•A'R9hahild350n Services CemtaE'-PA Rehabilitation Services, Inc kmda 1YL9?Nk`k* mSPT;LTe"C&FtrR1D7) 39 16, Trind!e Road apply to I'vs 7S and atumado it pan tneroot,) 75 Evelyn Driv j License Number: PTO i5093L Camp H;II , PA 17011 Millersburg. PA 17061 ' Signature or, FiiO O1)2?/'J7 1 P st ;4ED DATE INe GRPe L ? APPROVEDBYAMA000NCILOfJME01CALSERYICEB168) APPrY--VEDOa1i-o93e-eooeFORMC,>&IWO(F2-aq, FOFWrARS-1500, PLEASE PRINT OR TYPE APPR^JE00"(1-1215-00.55 FORM OYlCP-1500. KPPR? EC OM&072 oP?t (C AMPJSj P PLEASE APPROV9 00.3.0938-0008 CO NOT STAPLE cc IN THIS LU AREA ec U PICA HEALTH INSURANCE CLAIM FORM PICA F ' M-GLARE MEDICAID S CHAMPV GRCUP ?ECA - A O ,ER PLAN BLK LUNG Ia. INSUR, D S !.D, NUMBER (FCR%ROGRAI.1 IN TEM 1) '. i IMOd.care / I'MocfCa(d 0)10(Sponsor'1SSN) U (vafile,) (SSNor1D) rSSN) Ira) 3$61636 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) ' Blinn Michael J. P,AA ENT-DS BIRTH DALE SEX ' 4 4- INSURER'S NAME ;Last Name, First Name, Midd'eln:;ial) , J/4 M F 196 Blinn, Michael I S. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7, INSURED-S ADDRESS (No., Slreat) 200 Hollywood Circle Selftq Spouse Child[j o,her -i 200 Hollywood Circle iCITY STATE S.PATIENTSTALUS CITY STATE CarnpHit! PA ${ngloa Mared' Oho Hill Cam PA LIP CODE TELEPHONE (Include Area Coda) p. ZIP CODE TELEPHONE (INCLUDE AREA CODE) 17011 ((717)p37-9343 Employed ?jj Ful lm Pan-Tim ni l $ludenl09 St d / 1 ) u e ? ? 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Iniuaq 10. IS PATIENT'S CONDITION RELATED TO: 11. INSUR20 S POLICY GROUP OR FECA NUMBER Blinn, Michael a. OTHER INSUREDS POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED's DATE OF BIRTH SEX PFP8004WO300 YES lvflNO ?L m"8141964 M LrJi F 4 ?I L t lJ I I b- OTHER INSURED S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (Slate) h. EMPLOYER'S NAME OR SCHOOL NAME MM , DO , YY I I M F e-., u I I YES ?No PA J G EMPLOYER'S NAME OR SCHOOL NAME S c. OTHER AC CI DENT? c. INSURANCE PLAN NAME OR PROGRAM NAME ! P.O. Box 779503 PA 17177-9503 YES Fvh No LISAA Insurance i d. INSURANCE PLAN NAME OR PACGRAM NAME Capital Blue CrosslCAIC 10d. RESERVED FOR _OCAL USE d. IfOERE ANM1ER HEALTH BENEFIT PLAN? ? I` 7 i °t J L YES NO H yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or onar,'Mormaeon nocessa i 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize f di l i to process this claim. I dso request Payment of government beno!L's either to myself or to tho party who accepts assignment payment o me ca benefits to the undersigned phys cian or supplior for services dmnbed below. below. Signature on File 1/22/2007 Signature on File SIGNED DATE SIGNED 14. DATE OF/CURRENT: ' ILLNESS (First symptom) OR I1n V/ 1 X20015 INJURY (Accident) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM i DD I YY I B. DATES PATIEN' UNABLE TO WORK IN CURRENT OCCUPATIO14 MM I DO I YY MM I DD I YY i PREGNANCY(LMP) FROM TO I I 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Bernard Z li 17a. I D. NUMBER OF REFERRING PHYSICIAN 834196 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES YY MM DD D ger e I I O I YY MM I FROM , TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES 1 YES ONO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, (RELATE ITEMS 1.2.30R 4 TO ITEM 24E BY LINE) 723.1 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 847.0 23. PRIOR AUTHORIZATION NUMBER 2. 1- - . _ 4• 24. A B C D E F G H I J K DATE(S) OF SERVICE From To Place of Type 01 PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) DIAGNOSIS C R DAYS OR 1E Fil C RESERVED FOR _ MM DD YY MM DD YY - S rvir $ rv4 CPTMCPC CPCS MODIFIER CODE HA GES UNRS Plan EMG COB LOCAL USE 1715/20 07 97110 1 2 7 i88 , . 4 3 C 1/1,5/2007 Ill 97112 I ! 1 2 I " $30.76 1 z , I I 1 , I ,152007 11 97140 59 1 2 r, $27 67 1 a r , . t1`5/2007 1"1 97012 1;2 14 1 N I 1 /1'Sf2007 11 ? G0283I ;2- ?-_ 10 $1 1 1 I . I Z 11-1?512007 I 11 9701" I 1 2 - 11-7 1 ?} , , - - i I I I t 1 + i 25. F-ED23 f ! T I NUMBER SSN FIN ! 25, PATIFIi??g ACCOUNT NO. 27, ACCEPT ASSIGNMEN77 2 ?8? 332 , I 11 ?J14a I X(For govt. dales, sea back) 3. TDT,'y'? 29. AMDJNT PAID 30. BALI r ,5 QT86c53 188i, 3 i J u YES NO S I S 5 i i { {z 92 7 171. SIGNATURE OF PHYSIC AN OR SUPPLIER 32 NAME AND ADDRESS OF FACIU Y WHERE SERVICES WERE 3 INCLUDtNGCEGREESORCREDENTIALS ?ENDERCCtYU?kr?ARI3hBt1ifiiatbR Services 3. PHYSCCIAr<' , UrFUE S 1f1 i _ING NAME, ADORE SS. ZIP CODE l Cen=LRA Rehabilitation Services, Inc ma r.' lmc FASPT AToda IL?0T apprito to INS bet end aremade apart inorecf,) 3916 TrindJe Road 75 Evelyn Driv License Number: PT015093L ' Camp Hill, PA 17011 Millersburg, PA 1761 Si9na:ure on File 0112 2107 , SGNED DATE P I INe _j GPPr P r L 1s L n r is 2 (APPROVED BY AMA COUNCIL ON MEDIC.A?_ SERVICE 8188) PLEASE PRIl1-r OR TYPE APPRORO APV'EDOMB0215-MO,5 FORMCM$-1500 (,2-00), APPROVED RR3-1501, VCTJ OM&i21SMa5 FORMG'.vCP-7501, APPRGfD OMt3-07:`01?01 fChfJA:1J5t PLEASE USAA LIFE 00 NOT FO BOX 659466 STAPLE i1 N THIS AREA SAN ANTONIO, TX 78265 " FIIII I r-1 IIVJV 1`11AlV1.C 11.L!'111V1 I-IL)NIVI PICA FT T? MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA O?HER 1a. INSURED'S I.D NUMBER (FOR ;40GRAM IN ITEM 1) I.D. ( ocitere 0) (Medlcafd q (Sponso/r SSN) (VA Fite (SSN or ID() N (SS V)NG r? 3 8 16 3 u 2. PATIENTS NAME (Last Name. First Name, Middle INtlal) , BLINN, MICHEAL A 3. PAT c A E ssx (?5 ;ODE ?1Y964 4, INSUREDS NAME LAsr Name Fr I Name, Mladlenitlal) BLINN MICHEAL A F M , 5. PATIENTS ADDRESS (rlo.. Street) 200 HOLLYWOOD CIRCLE B. PATIENT RELATIONSHIP TO INSURED 7. N Ua'c'S OP S Y tr eI) ?? ? F b?? Soil Spouse COVE] 0 H 1 LL J CIRCLE CITY HARRISBURG STATE PA B. PATIENT STATUS DHARRISBURG STATE SinploD Married [j Other o ZIP CODE 17111 7EPHCNE (include :Area Codet 71 %)) 7 3 7 9 3 4 3 Employed Fua•Tlme ? Part•Time Student Student ZIP DE 1 TELEPN NE fl U ARE OD 1G'?l ? 14 C 9. OTHER INSURED'S NAME Lest Name, Frst Nome, Me Inital) BLINN, MICHEAL A 10. iENT DITi 11. INSUREO'S POLICY GROUP OR FECA NUMBER tt ? c a. OTHER INSURED'S POLICY OR GROUP NUMBER PFP361 a. EMPLOYMENT? (CURRENT OR PREVIOUS) e. INSURE ' OATE OF BIR H SEX YES ?t40 D Y 64 M F 014 11 V b THER INSURED'S D E OF BIRTH t z AT SEX 9 ;Q»x If$64 b. AUTO ACCIDENT? PLACE (State) ( b. EMPLOYER'S NAME OR SCHOOL NAME M F I ' _(VES aNO ?J C MPLOYER'S NAM E OR SCHOOL NAME c. OTHER AC 7 c, INSURANCE PLAN f?} ffRQCCt VgAME f ?YES D ?Uf? fj?? 11 SURANCE P N NAME OR PROGRAM NAME 2304CAPITAL BLUE CRASS I OdRESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES D NO It yes, return to and complete t em B A-d. READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM. . PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE 1 authorize the release of any medical or other information necessary 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize f I to process this Balm. I also request payment of gmumment benefits either to myself or to the perry who accepts assignment payment o medical bannfits to the undersigned physician OF auppiior for services descrlbed below botow. Signature on File' 02 07 07 , Signature on file SIGNED DATE SIG NED 14. 011?R%Ig: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS d OR GIVEFIRSTDATE MM DO YY t JURY(A . 18. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY LntY i ' P CY i i TO MM 1 DD 1 YY FROM 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN BERNARD ZELIGER DO B34196 18. HOSPITALIZATION DATES RELAT?TO RENT SERVICES MM DO Y I Y M I DD I YY FROM I I i9. RESE RVED FOR. LOCAL USE 20.OUTS IDELAE37 $ CHARGES DYES DNO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,30R 4 TO ITEM 24E BY LINE) 7 2 9 5 22. MEDICAID RESUBMISSION . ] 2 3 1 CODE ORIGINAL REF. NO. 7 8 2 8 7 2 3. 4 23. PRIOR AUTHORIZATION NUMBER 2. L_ . 4. L____._ . _ 24, A B C D E F G H I J K DATE(S) OF SERVIC Place Type From ETo f I PROCEDURES. SERVICES, OR SUPPLIES l DIAGNOSIS DAYS EPSI r RESERVED FOR o o MM DO YY MM DD YY oM Same (Exp ain Unusual Circumstances) CPTIHCPCS MODIFIER CODE $ CHARGES OR UNITS Family Plan EMG COB LOCAL USE d 01, 17107 OL 171 07 11 95860 t 1234 250 00 1 N 1 I t 1 I a 011 1'7107 011 171 07 11 95900 1234 I 400 0C 4 N z 21 ¢ 011 17107 1 t 0L 171 07 11 I I 95904 1 t 1 1234 400 00 4 N a 9 . ( I d U) I U) I 1 1 I'- _ , ? 1 ? I A z Q I - 1 I ,I t I l F i 1 , 1 i = ' 26. FEUERA_ TAX I.D. NUMBER SSN EIN 25. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 251703:144 15595 ' vDc .^ams,N?uback) 28. TOT L CItA E g C??U 00 29. AMOUNT P ID 1 ?, 00' 3.;. 9A N;!E UE0 I 1 0i s $ I S j 31. SIGNATURE OF PHYSIIAN OR SUPPLIER ??{' ?{? c • 0 r}}'??•g,???j (?c ? rTy y r Sc(??,nr•cs op- INCLUDING DEGREES DR CREDEI'T1ALS ell t^^ iTt? hUo oN 71Li1? i , -3. P, .,, r boy r: c ??? r y?nq cc o C SS L iii f?tCRG 1??N ?A I.2 V F? v FC . I (Icon?yInatthestalemectsonthereverse 82S SIR THOMAS CT, SUITE opply t0 :1 bill end are mado a pat. thorecf.) 825 SIR THOMAS CT, SI:LTE 2 P70RP41,N HAUEISEN DO HARRISBURG, PA 17109 HARRISBURG, PA 17109 02/07/07 25-17031441 f SIGNEO DATE PIN* j rear ? ?. a ct rz U (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE &198) PLEASE PRI!VT OR TYPE APPROVED OMB-09:8-0,006 FORM CMS-1 S00 (12-90), FORM RRB-15:X: Pdntoc on Rocyclod Paper APPROVED OMB-1215-0055 FORM OWCP-ISM APPROVED OMB-0720-"l (CHAMPUS) APPRO0 CM8 )938-0008 HEALTH INSURANCE CLAIM FORM FICA t. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FTcCA OTHER 'a, INSURE fi I.D. NUMBER (FC"RCGRAM IN iT d t) J (Spor+sc/'s SSN) !n? (VA File Af (Tj-! (SSN SJEALTH or 10J PLAN SLK LUNG (SSN) (10) (Medicare rJl (At9dcad #tN J 3861636 2. FATIENT'S NAME (Last Name, First Name. Middle tnil!ap , 3. PATIENTS DATE SEX J. INSURED'S NAME (Last Name, First Name, Midde Initial; I Blinn, Michael 4 M i l F( 5/4!196 Blinn, Michael j 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No, Street) i 200 Hollywood Circle tw sel? spouss rr -71.1 Chi; rt C ho(? 200 Hollywood Circle CITY STATE PATIENT STATUS B. CITY STATE Camp Hill PA Single MardedKV, OtheQ Camp Hill PA ZIP CODE TELEPHONE (Include Area Coda) ZIP CODE TELEPHONE (INCLUDE AREA CODE) 17011 (717) 37-9343 FuI4Ti M rlt EmployerCol, P art • I l 1 ' IT] ? dent `? Stu ent? St ud 1 1 9. OTHER INSURED IS NAME (Last Name, First Name. Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO, 11. INSURED 'S POLICY GROUP OR FECA NUMBER Blinn, Michael a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX PFP80046460300 01 YES W1 NO M45/4PP964f M F b OTHER INSUREDS DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State ) I 1 b. EMPLOYER'S NAME OR SCHOOL NAME MM I DD I YY F 1 .0 El 27 IYES IMNOPA CUJ t_J - c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME l P.O. Box 779503 PA 17177-9503 I YES WhNo [P] USAA Insurance i d. INSURANCE PLAN NAME OR PROGRAM NAME Capital Blue Cross/CAIC I Od. RESERVED FOR LOCAL USE d. I?HERE ANIF ER HEALTH BENEFIT PLAN? I O YES NO Myers. return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING 8 SIGNING THIS FORM. ' ' 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE 1 authorize the release of any medical or other information necessary payment of modcca! bonotits Io the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the parry who accepts assignment services described below below. . Signature on File 2/5/2007 Signature on File SIGNED DATE SIGNED _ 14. DATE OF CURRENT: d ILLNESS (First symptom) OR 3y1200.6 INJURY (Accident) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM I DO I YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I DO I YY MM I DD YY A PREGNANCY(LMP) I 1 I FROM I I TO I l I,. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. 1.0. NUMBER OF REFERRING PHYSICIAN IB. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES I Bernard Zeliger 834196 MM 1 OD I YY MM , DO , YY FROM 1 TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES ONO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BYLINE) --? 22. MEDICAID RESUBMISSION 723.1 CODE ORIGINAL REF. NO. 1. L_.. 3. L,.. 847.0 23. PRIOR AUTHORIZATION NUMBER 2. ( _ 4. I_ . . 24. A B C D E F G H I J DATE(S) OF SERVICE From To Place f Type f PROCEDURES, SERVICES, OR SUPPLIES E l ' DIAGNOSIS DAYS EPSD RESERVED FOR C MM DD YY MM OD YY o Servl o Servic ( zp a n Unusual Circumstances) e CPT/HCPCS MODIFIER - CODE S CHARGES OR UNITS Famil y Plan EMG COB LOCAL USE I Q 1 1 I I 1 !111 , r • 1 I I _ 1/1.8/2007 - 1 1 1 97112 1,2 I $30.76 1 Z f Tf 8= I 7140 5 1,2 7.?i? I a. 1171-x/200 I I 'i 1 1 f2 1 1;2? I? n It 9 /2G 1 5028-3 J I I I I , Ia /4 s/?oo I 1 ?--- I I --moo I I --,2-l- $14,74- ; 4- (? -r?- ' I 1 ! I a r R 25. FEDERAL TAX l.D. NUMBESSN EIN 26. PA T iENT'S ACCOUNT NO. 27. ACCEPT ASSISNMENT? 2 23-28333132 X 119246 For 0ovl claims. see back} 29. AMOUNT PAID ! 30. BALI 8. TOT. V3653 $ ?? 7 r}3 U I j YES 0 NO S $ i S 7 7 I 31. SIGNATLIP7 CF PHYSICIAN OR SUPPLER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 3 ??e q 3. PHYS':,IAN'"', FC,ER7? 't NAME AJDreSS Zip CODE INCLUDING DEGR=E OR CnEDENTIA.S HENDER?ht?lFrrAl ?lj 66h Services , . CtRI?1ETM Rehabilitation Services Inc mania "`h'1 UlSP t"7i? Ce't `4?iFFf a;v ;o bu and are made a earl tnerbc}.) 3916 Trindle Road , 75 Evelyn Driv License t4umbec PT0:5093L I Camp Hill , PA 17011 Millersburg, PA 17061 Signature On File 02/05107 1 1 SI;;!:ED DATE - P IN# GRP# ( APPR iAPPRCVECBYA`J,F000NCILONMED;OALSERY;CE8/6s) PLE,4SEPRINTORTYPE OVECOMB-L'9W,MFDRMCMS-1500(12.80;, FORK+RH&1500, APPROVED 0M3- 1215-0055 FORM OVJCP-1500. APPi70VE D CJ.IB-0720-q^a' I (CI/A rIJS.I PLEASE CO NOT S T API_E IN THIS AREA _ TnPkCA APPROVED OMB-0933-C0e8 HEALTH INSURANCE CLAIM FORM PICA t cc w rx (J ! I I 'Y I. MEDICARE MEDICAID CHAMP! 5 CHAMPVA GROUP FECA OTH ER Ia. !NSURED'S I.D. NUMBER (FOR PROGRAM, N ITEM 1) , ,7 ( (j T} 15porsars ssN) r .Nod;care x.! 6lr3diG3id rr <. HEALTH PLAN SLK LUNG 111i (VA de if) (ssn or tot'' (ssrv1 ?j.,? rr?) 3261636 12. PATIENT'S NAME (Last Name. First Name, Middle iwual) 3. PATi ENT'S BIRTH ATE SEX 4. INSUREC'S NAMc (Last Nana, First Name, MiWU Inil,ap Blinn, Michael 5%4/1964 M 1 F R71 Blinn, M chael 5. PATIENT'S ADDRESS (Na., Street) 6. PATIENT RELATIONSHIP TO INSURED 7, INSUREDS ADDRESS (No., Street) 200 Hollywood Circle Sol, spouscT chikM O raM 20O Hollywood Circle CITY STATE 8. PATIENT STATUS CITY STATE Camp Hill PA sir,pc f?? Ma r e! j she f[? it PA ZIP CODE TELEPHONE (Inc!ude Area Code) ZIP CODE TELEPHONE (INGIUDE AREA ODE) 17011 ((717) Y37-9343 Employe EP-I Full•T!mg r}-1 Part-Ti e? ` ``? r J Sludant _j Student ' 17011 1 9. OTHER INSUREDS NAME (Last Name, First Name, Middle initial) 10. IS PATIENT S CONDITION RELATED TO, 11. INSURED'S POLICY GROUP OR FECA NUMBER Blinn, Michael a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSUREDS DATE OF BIRTH SEX PFP80046460300 r1YES V1 NO ((-? M`t/4ff96Z Mrr?? L?'JI F1A ' I I LL-J? L?J} i b. OTHER INSURED S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b EMPLOYER'S NAME OR SCHOOL NAME MM , DD I YY 1 I M F ®J YES ?NOP I c. EMPLOYERS NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME P.O. Box 779503 PA 17177-9503 YES ?J]ND ??L.JJJ USAA Insurance t i d. INSURANCE PLAN NAME OR PROGRAM NAME Capital 8100 Cross/CHIC too. RESERVED FOR LOCAL USE d. 1$. THEPE AN(2 1IR HEALTH BENEFIT PLAN? h I / L_j YES ? NO It yes, return to and complete itam 0 a -d. r READ BACK OF FORM BEFORE 12. PATIENT'S OR AUTHORIZED PERSOMS SIGNATURE COMPLETING 6 SIGNING TMIS FORM. I authorize the release of any medical or other information nocessary 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE I au:horuo payment 01 medical benefas to the undersigned physician or supplier for I to process this clam. I also request payment of government benefits either to myself or to the party who accepts assignment Services described below. below. Signature on File 215/2007 Signature on File SIGNED DATE SIGNED 14. ?yATE OF CURRENT: 4 ILLNESS (First symptom) OR j()/1:'/20n INJURY (ACddent)OR IS. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM 1 00 1 YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I DO I YY MM 1 DD I YY PREGNANCY( MP) ! ! FROM I r TO r i 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 170.1.0. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Bemard Zellger B34195 MM 1 DD I YY MM , DD , YY FROM 1 1 TO , 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAS? $ CHARGES YES 0 NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) --? 22. MEDICAID RESUBMISSION 723.1 CO ORIGINAL REF. NO. 847.0 23. PRIOR AUTHORIZATION NUMBER 2. 1-, _ 4. L- . . 24, A B C D E F G H I J K -+ DATE(S) OF SERVICE From To Place of Typo 01 PROCEDURES, SERVICES. OR SUPPLIES (Explain UnusualCircumsanc03) DIAGNOSIS DAYS OR fCHARGE EP D Femil Y RESERVED FOR MM OD YY MM DD YY Sevlc Se CPTMCPCS MODIFIER CODE S UNITS Plan EMG COB LOCAL USE Q 1 19!2007 1 11 197110 12 $88 74 3 0 1 . 1/19/2007 1 1 97112 1 7,2 $30.76 1 i5 _ cc 1;19/2007 1 f 97140 69 , 1,2 $27.67 1 1 I i I l ! 1 r I 9/2bDT 11 -. ; 97012 { 1,2 $15.64 1 1 f?t9/200- 1 83 z 14/4-9/200-7- 1 ! 1 1 970-18 1 ? 1; 2-: ? I 1 1-74 1 I -- U ;? t + 1 I I 1 i i I I I 25 FEDERAL TAX I.D. NUMBER SSN EN 23-2833302 L 26. PATIENT'S ACCOUNT NO, ' 27. ACCEPT ASSIGNMENTI 2 119246 X roc govt. claims. zoo Dock) I YES 0 NO LL 9 . 707p gp 29. AMOUNT PAID 10. SAL .p ! U X53 186? rJ3 $ $ 5 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR C.R_OENTIALS 32. NAME AND ADCRESS OF FACILITY WHERE SERVICES WERE 33 RENOEF(. g)Ip?aRi?7ggYS;i[a!1Ch Services . PHYSICIAN U LE S ,LLING NAM , ADOR ESS, ZIP COLE (SfftttsaJERA Rehabilitation SCfVICes Inc an2y a. Illy Ic IK,s bi'1 and a•e a d3r11f .rf.) 3916 Trirdte Road 75 Evelyn Driv i License Number- PT015093L Camp Hill , PA 17011 Millersburg, PA 17061 1 .,y,.a.- V" . is ULU5107j -- ? I MSIGZ'ED DATE PING GRIPS (APPROVED BY AMACOUNCIL ON MEDICAL SERVICE 8186) PLEASE PRINT OR TYPE APP (0VM ?Me-0938-X708 FORM CMS-1500 (12.90). FORM RR31500. APPROVED OM6- 1215.4;055 FORM ONCP•1500, APPROVED CWS-0720-OC)C1(CHA14f*.JS) PLEASE OG 'JOT STAPLE ;N -HIS AREA F7-'r,"`lP!CA APPROVA CMB-C9 3-0C03 HEALTH INSURANCE CLAIM FORM PICA I w U .? FT-T-, 1. MEDICARE MEDICAID CHAMPGS ? CHAMPVA GROUP FECA OTH ER 1a.INSUREDSI.D.NUMBER (FOFPRCGRAM IN ITEM ,) HEALTH PLAN BILK LUNG (dyed care r)u (ASedcad x) ( (Sronsa's SSAI) (VA Frio r) C (SSN or ID) (SSN) (rD) 3$61636 I f2. PATIENT'S NAME (Last Name, First Name, ALdd!6 Ininall 3. PATIENT'S BIRTH DATE SEX M 4, INSURED S NAME (Last Name, First Name, Midas Initial) Blinn, Michael 5/4/1964 M ? Fol B!Inn, Mietlael 5. PATIENT'S ADDRESS (NO., Street) b. PATIENT RELATIONSHIP TO INSURED 7. INSUREDS ADDRESS (No., Street) 200 Hollywood Circle self`] spousrn chilg7 Othe 200 Hollywood Circle CITY STATE S. PATIENT STATUS CITY STATE Z Camp Hill PA S: IC MarriedZ,] 01he lM CAMP Hill PA C F ZIP CODE TELEPHONE (Include Area Code) _ ZIP CODE TELEPHONE (INCLUDE AREA CODE) C 17011 (717) ?37-9343 Employe c?j Full. -,;m' Part-Ti ? L 'Cc ? f Sludenl m Student l 1 C 9. OTHER INSURED'S NAME (Last Name, First Name. M dare Initial} 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUM 85a Z Blinn, Michael o a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) e. INSUREDS DATE OF BIRTH SEX a PFP8004WO300 YES NO nn? "t/4F?96T M? p f LLLLLJJJJJ b. OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME Q MM I DO I YY t r M F ?l YES N Q tz j u c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT7 c. INSURANCE PLAN NAME OR PROGRAM NAME f- 2 P.O. Box 779503 PA 17177-9503 IM YES ?NO USAA Insurance w . INSURANCE PLAN NAME OR PROGRAM NAME d E OR LAN N 1Od. RESERVED FOR LOCAL USE d. I WHERE AN T ER HEALTH BENEFIT PLAN? 0. Capital Blue Cross/CAIC YES NO It jets, return to and complete i;am g a-d. READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM. 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release o1 any medical or older Information necessary payment of medical benefits 10 the undersigned physician or suppler for to process thb claim. I also request payment or government benef:rs either to myself or o !he parry who accepts assignment servicas described below. below. Signature on File 2/5/2007 Signature on Fite SIGNED DATE SIGNED 14. GATE OF CURRENT: ILLNESS (First symptom) OR 15, IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS . 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION j INJURY(Aaddent) 01 To/is/200'6 GIVE FIRST DATE MM I DD r YY MM , DD IYY MM t DD I YY - PREGNANCY(LMP) I I FROM + I TO I I 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Bernard Zellger 834196 MM I DD , YY MM t DD 1 YY FROM I r TO t I 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES DYES nNO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RE LATE ITEMS 1,2.3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION 723.1 CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 847.0 2.1 4. 24. A B C D E F G H I J K z DATE(S) OF SERVICE From To Place Type PROCEDURES, SERVICES, OR SUPPLIES DIAGNOSIS AYS EP 0 RESERVED FOR - MIA DO YY MM DD YY MIA of of of (Explain Unusual Circumstances) PTMCPCS MODIFIER CODE SCHARGES OR LIMITS Fa ^ 1 y Plan EMG COB LOCAL USE I- Q 1/25/2007 1 I 97110 1 2 I $88 74 3 cc , . 1/25/2007 t 1 1 197112 1,2 $30.76 1 LL I 1 ['i)i2L5-/2d07 I 1 I i 97140 59 ? 1 2 $27.67 1 2 -.1 r 1 125Il2-CLO7 n r 1 r I ?`? TS i n -1 f25f200- ? - ? _ E128-3 1, ? I I ( I 1 125?2.00 ; 9741 q 1- ; ! 1, I i $1 ?_{ E n 25. FEDERAL TAX :.D. NUMBER SSN EIN 2C PATIENT'S ACCOUNT NO, 27, ACCEPT ASSIGNMENT? 23-2883302 119246 XForgw;. clams, see back} 28. TOT q 29. AMOUNT PA:D I'8,53 ?D. BAL. I v ?? YES LJ NO S S i S i 21 SIGNATURE OF Ptj'SICJAIl OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. PiiYSICU AN`S?SII?.' ?C'i'S"C7LLING ADDRESS. ZIP CODE NAME INCLUDING DEGREES OR CR'E'DENTIALS I RENOE enlrati fi'R tiattifta??sn Services , 6ertt M PA Rehabi6tabon Serric-es Inc ? una^a i`?1(54? , t I j r 3916 Tn.'ndfe Road 75 Evelyn Dnv I License Number. P -4015093L Camp Mill , PA 17011 Millersburg, PA 17061 li Signature on File 02/05/07' SIGNED DATE I PINT ( GRPS 0 APPROVW (APPROVED °t't\MA COUN'CILON MEDICAL SERVICE &B6) PLEASE PRINT OR TYPE OMB09?9?0:/Y FORM CMS ISM it2, FORMRPS-15,0. APPRMFCDMB-1215-0C65 FORM OSYCli APPFIDVEDOMD-0'e)-OMI(CHA.V,-US) APPROVED OMB-0938-0003 HEALTH INSURANr: rl A40 c'npaA 77-1 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECn OTHE - -- ---- - - ..-- ..... , , P. f a. iNSUREO'S l.D. NUMBER (FOR°RCGRAM IN ITEM 1) r I rMedip:ra sl Medratid ) HEALTH PLAN } B1.X LUNG . i I ( )U (Sponsor's SSN r T? (VA Frio jr) (SSN or 10 7 (SSN) ? (ID) A 4-1J 3861636 2. P TIENTS NAME (Last Name, First Name. Middle Initwl; 3. PATIENTS 618TH DATE SEX M 4. INSURED'S NAME (Las Name, First Name, %dOa Initial) Blinn, tvSidlaQl 5/4/1964 M F LLgD Blinn, Michael 5. PATIENT'S ADDRESS (No., Street) 6 PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) ZOO HOIIyWCOd CirCIQ SalW-1 Spouss? chilr Frj_j Other 200 Hollywood Circle :;ITY STATE 8. PATIENT STATUS CITY STATE Camp Hill PA Sing1`D Marriw othXg7 L i m HIII PA ZIP CODE TELEPHONE (Include Area Code) - ZIP CODE TELEPHONE (INCLUDE AREA CODE} 17011 (717) ?37-9343 Employe FuR•Tim Pan-Ti a(] Student " Stude nt L 17rl 11 OTHER INSUREDS NAME {Las! Name, First Name. Middle Irutiap 10. IS PATIENTS CONDITION RELATED TO: 11. INSUREDS POLICY GROUP OR FECA NUMBER Blinn, Blinn, Michael a. OTHER INSUREOSS POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX PFP80046460300 ((I YES ZI NO Mt/, M964Y M? F ?l r S LLL........ L1 I I LLL b. OTHER INSURE D S OATS OF 01R TN MM , OD YY SEX , b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME M F Ott-YES NOPA c. EMPLOYERS NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME ! P.O. Box 779503 PA 17177.9503 YES NO LISAA Insurance d. INSURANCE PLAN NAME OR PROGRAM NAME Capital Blue Crass/CAIC IOd. RESERVED FOR LOCAL USE d. I HERE AN ER HEALTH BENEFIT PLAN? _ YES NO K yes, rolum to and Complete item 9 e4. READ BACK OF FORM BEFORE COMPLETING 8 SIGHING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I aulhodie tine release of any medical or other information necessary 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier !or to process this claim. I also request payment of government benefits either to myself or to the parry who accepts assignment services described below below. . Signature On File 215/2007 Signature on File I SIGNED DATE SIGNED IC 14 DATE OF CURRENT: ILLNESS (First symptom) OR 1?{ x ' NJURY (Accident) OR ?1 O ? "ll 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM I DD I YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I DD I YY MM I OD YY V V PREGNANCY(L r FROM I TO r 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SE RVICES Bemard Zeliger 834196 MM OD , YY MM , OD , YY FROM TO 19. RESERVED FOR LOCAL USE 20, OUTSIDE LAB? $ CHARGES 11 YES 11 NO 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2.3 OR 4 TO ITEM 24E BY LINE) 22. MPOICAID RESUBMISSION 723. 1 CODE ORIGINAL REF. NO. 847.0 23. PRIOR AUTHORIZATION NUMBER 2. L-.- 4. I_.. 24. A 0 C D E F G H I J K DATEjS) OF SERVICE From To Place of Type of PROCEDURES, SERVICES. OR SUPPLIES (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSD OR l F RESERVED FOR Cj MM DD YY MM pD YY 17 67 667 Serv 1 CPTMCPCS MODIFIER 97110 CODE 1 2 7 $ CHARGES $-7 S y U Plan EMG Coa LOCAL USE - F cc o 1/26/2007 1 97112 1,2 l1 $30.76 1 s 2 26 002002 7 1 97140 59 1,2 27.67 1 FL - 0 i i f fi12-612 1 t 70 1 2 -5 6 - i , . ` -f261-200- ' 0283-? 2 r 41-9 cc I I I I I , I 1-/-2fi>r2®0- 1- ; 9741-0 I : -$? 1-4 J -- I 1 r ? I I j I - Il 25. FEDERAL TAX I.D. NUMBER SSN E'N 26. PATIENT'S ACCOUNT NCI 127. ACCEPT ASSIGNMENT? 2 -28333^uZ 119246 X or Vovt. c!a ma. sou Deck) 23 8. TOT a 219.., MOUNT PAID ?30.13AL118 $ 1? ?3 ?.5? i 1 L-j Y,5 ln..l NO S i $ r S i J I- SIGNATURE OF Pr1YS'- AN OR SUPPLIER 132. N,"V' AND ADDRESS OF FACILITY WHERE SERVICES WERE 33 INCLUDING DEGREES OR CREDENTIALS f RENDERCZ-ijt( }rcxa RC858yNfit?!70r1 Se:viCeS 7 . PHYSICIAN'S ,169P ER ILL iNG NAtAE, ADDRESS, ZIP CODE Ct, VINEP'A Rehabilitation Services Inc i ;marif3" y` t'rk ^?e '' 1` aowr ?C 1r? ? Nino ae??do a ?r•edL1 3916 Trindle Road , 75 Evelyn Cr•'v License Number: PT015093L ' Camp Hilt , PA 17011 Millersburg, PA 17061 i Signature on File 02105107? f SIGNED DATE.,e,.?,.n .w?. PI Ne GRP# i A T U.1_ LS !Y L) I `f O 1= Q 3 .U Al 2: (APPROVED BY AMACOUNCIL ON Mi:Cr.A'„ SERVICE 813°} PLEASE PRINT OR TYPE 'r`PPF''?,'r?OM6-0?J8-0? FORM CMS150C (t2•AC), FORM RR&ISQ^. APPfKNEG OMD-12!5005.5 FORtt OVy(;P•tiOC, APPR?DOMB-072G?1 (CHNURR51 PLEASE De NOT STAPLE IN THIS AREA APPRCVED OMB-0938.0008 .k X L" X X d r? !- i'P!CA HEALTH INSURANCE CLAIM FORM PICA r ; r ? r. U?htn HEALTH PLAN BILK LUNG iD. mJUntu J:.U.vUMtltH (FC4(1HpCiHAM iNi1 EM 1) I I (Alodrare r) [a (PA*Jra C x),L7 (Sponsor's SSN) ( 1l (VA File 7) [1] (SSN or 0) I ? (SSN) ? (1Df 3861636 2. PATIENTS NAME (Lzst Name, rust Name, Mlod!e Iniml) 3. PATIENTS BIRTH OATS SEX MM I DO , YY 4. INSUREDSS NAME (Last Name, First Name, Midd's Inma!) Blinn, Michael 5!4/1964 M U71 F[7 Blinn, Michael 5. PATIENT'S ADDRESS (No., SuoeQ 6. PATIENT RELATIONSHIP TO INSURED 7. INSUREDS ADDRESS {No., Street) 200 Hollywood Cirde Seth spous j Child Clhegj 200 Hollywood Circle C;TY STATE S. PATIENT STATUS CITY STATE Camp Hill PA Sing!d hlarried? Otllo? r C ZIP CODE TELEPHONE (Include Area Code) - i ZIP CODE TELEPHONE (INCLUDE AREA CODE) G 17011 (717)137.9343 E 1pI°ye ? Fuil•rm?-1 Pat•rni }, Sn,denl ` ' J ' 1 sl?aent " / 1 1 ?j C B, OTHER INSUREDS NAME (Last Namo, First Name. Middle Inniall ? ` 10. IS PATIENT'S CONDITION RELATED TO: 17W 1 -- - 1. INSUREDSS POLICY GROUP OR FECA NUMBEa U. Z Blinn, Michael , C7 a. OTHER INSUREDS POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSUREDSS DATE OF BIRTH SEX w ? PFP80046460300 YES ?NO Cv? ?j /4/1SV?f M F 0 S L J z b. OTHER INSURED B DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (Slate) b. EMPLOYER'S NAME OR SCHOOL NAME to MM I OD YY , i I M F YES U]NOP L?J I Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME a I Z P.O. Box 779503 PA 17177.9503 01 YES ? NO USAA Insurance f w I ti d. INSURANCE PLAN NAME OR PROGRAM NAME Capital Blue Cross/CAIC 100. RESERVED FOR LOCAL USE d. 1$;HERE AN ER HEALTH BENEFIT PLANT , a a n YE n YE M S S NO It ysa. return to andcomplete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. .2. PATIENT'S OR AUTHORIZEO PERSON'S SIGNATURE I authc ze the release of any medical or other information noco=ry 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE 1 authorize payment of medical benefits to the undersigned physidan °r supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. Signature on Fife 2/5/2007 Signature on File SIGNED DATE SIGNED 14. DATE OF CURRENT: / ILLNESS (FieW symptom) OR OR 11?/131FZOQ6 PR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM + DD I W 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I DD I YY MM I DO I YY EGNAtaCY{Lh1P r FROM I I TO I I 17. NAME CF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.O. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Bemard Zeliger 834196 MM I 00 I YY MM I DD t YY FROM I I ( I TO 19. RESERVED FOR LOCAL USE 20, OUTSIDE LAB? $CHAAGES 0 YES E]NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR !NJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BYLINE) --y _ 723.1 ? 22 MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. T 847.0 23. PRIOR AUTHORIZATION NUMBER 2. L- 4, L- . T 24. A B C D E F G H I J K -j z FrorDilATE(S) OF S:RVICETo Place of Type a1 PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSO Family RESERVED FOR F" MM DO YY MM DD YY rv' - CPTIHCPCS MODIFIER CODE $ CHARGES UNITS Plan EMG COB LOCAL USE d 1/29/2007 1 , 97110 1 2 $88 74 3 I , . 0 1/29/2007 1 97112 1,2 ? $306 1 z I I I , I ? W 1/29/2007 1 97140 59 1 2 $27 67 1 1172-T 7012 , 12 ( . T-$1 5 6 - a co I I f2Jf20(? I 1? I - (328 1 I . I rt1-98 z -1-29/2.007- L 97(31-0 ? , - -- ---- 1, 2 $ 4 I I 1 I r I I I a 25. FEDERAL TAX LD. N'J!JBFR SSN EIN 23-288330X El D 1 26. PATIENT'S ACCOUNT NO, 27, ACCEPT ASSIGNMENT? 2 119.246 Ix For pout. cams. Goa track) YES [] NO 29, AMOUNT PAID d. TOT 1"86-M S $ 1 30. 8A'_ 1??53 $ ) 31. SIGNATURE OF PHYSICIAN 0-, SUPPLIER 32. NAME AND ADDRESS OF FACL ITY WHERE SERVICES WERE 3 INCLUDING DEGREES OR CREDENTIALS RENDEFG rltFnILPVRWTalllitftroh Ser'AceS . 77 3. PHYSICIAN' . Nr9L2iE S +LLING NAME, ADDRESS. ZIP 000E i CB?ttraliRA Rehabilitadon Services Inc Imar?? ?yp apGlr o 1Ks16;(: ax! alcmede a pa?lhdruot.t 3816 Trindle Road , 75 Evelyn Oriv I Licenss Number. PT015093L I Camp Hill, PA 17011 Millersburg, PA 17061 Signature on File 02/05/07 1 SIGNED DATE P INX GRPS (APPROVED BYAMACOUNCIL ON MEDICAL SERVICE 8180 PLEASE PRINT OR TYPE- MPRCVEDOMC-0039-OMOFORMCk4S-15W(12-90t, FORMRR&1506, APPROVED OMB- 1215.OD55 FORM OWCP-1500, APPROVED OMB-0720- OD1 (CHA.V-JS) _ PA^ENTCONTACL W. y i325 SIi2 VIOMAS CT - ' ( = ; A R R r S BURG, PA 171C9 5 FED. T AX NO. r5&'FT two 6 aTA FFICAM HERS PE i 7 COV ?. , d NL O. d Ca O. 10 L-R 0. - 11 (7:,7; 901-5008 _3 19 1 1 I 1, P&.1-c}jTNAUE 13 PATIE TAXIPESS ? `N, MIC"EA'" 1 200 HOLLYWOOD CIRCLE HARRISBURG, PA 17111 14 i'CATE t5?^t t6LS ,_ TV is m ttrew M 210iR 22VAY=NE:ICA:RECORDN0. S M M J1 -77--j I, L 1U A A J. OJ>J I DATE .. wr¢ 36 OCCURR cE SPAR nw c,1 ?ox RON 11U1 V? / B I yr s ?? q? 7 V L LI C o a ,?? - - c vxjx CODES km 41 VALUE CODES hfaffl C= AWJkff 3LINN, MICHEAL e j 200 HOLLYWOOD CIRCLE } { b HARRISBURG, PA 17111 d 1 42 REV. CO. o DESCRIPTION M HCPCSIRATES 45 SERY. DATE 18 SM. L*M e7 TOTAL CWGES td NON',-D ED CNATT;,ES 48 t t , L i 4 E I 1 F t f 1 I - 2 w 001 otal Charges 1 5.00 co z - J ? 2; PA YER 51 PROVIDER NO. 54 PRIOR PAYMENTS 55 EST. AUOtQ4T DUE 56 E?PITAL •B: UE CROSS Y• rJ 1 :.8^ IWIED'S NAME 9 PJU 60 CERT. • SSN • WC. • ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. L 'LINN, MICHEAL 18 PFPS0046460300 PFP361 B C M- REATMMAUTHORLZAT)DNC00ES 64 ESC 65 DAPLOYER NAME 80 EMPLDYERLOCATION r1i A u B C 6' PRIN. DUD. CD. b woe -RDIAa CCOES m woe r. rnoc No= 76 A711. DUG. CD. 77 E•COCE 78 rL 5 P.C. 80 ?NGPAL P ROLE R TF CCOE • ••''°'f 17 ATTT3MG PITYS Q lFI. _ n ; ?h 0 R PF x E7URU ?c re PODC 63 l71}ER PFi1 S ID ?, .. t v v G4' MAR!(S OTKR PHYS. D - a ?T U ,;AA LIFE hAu n is .n •+ 1 h PO ECX 659466 SAN ANTON O, TX 78265 X HARRISBURG INTERVENTIONAL PA 03/04%57 ---rte.-- W+ PMtod Dn Rocycled Paper oc vniucnu. 'Corr" r4 CMV1C MC*6 ON MMr'VW AMY rODO Wt AM APS kOle APOT HMVW. PLEASE USAA LIFE ;JU NOT I J, ! STAPLE PO BOX --59466 a .N :HIS }?? i u( AREA EA.? AlViCNIO, X 7o 5265 r U , ,PICA HEALTH INSURANCE CLAIM FOPU Dtrl I-I I 1 1 '. MEDICARE MECICAID GRAMPUS CHAMPVA GROUP FECA CTHER HEALTH PLAN LX LUNG `4 - to INSJR D'$' p NUMBER J FOR PPOGRAM !N 1 EM 1 3 S 6 6 6 ( ) ! , t- Ej (Modtrars e) (Medkaid /) ($poasc?a SSN) F 1 (VA Fr1e J) {SSN or 10) (SSN) (ID) L.1 3 i _ 3 t 1 , 2 PATIENT'S NAME (Last Name. First Narno, Middle In¢ial) sEx BLINN, MICHEAL A (7B 04 1 1r964 iNSURED'S NAME (t t Nam FI I Name, MiddifInItial) BLINN Mi?CFiA F M , A 5. PATIENT •S ADDRESS (No., Street) 8, PATIENT RELATIONSHIP TO INSURED 200 HOLLYWOOD CIRCLE s us 7. INSU E0' A P S / o strAot) zulj , G?C5Z7D CIRCL- a p° se? cn:ld? Ohe ? '-IT'/ STATE 8. PATIENT ST:iTUS HARRISBURG PA ?--7 ? Cl ST R IARRISBURG? z -•- -• - - S(ngle? M¢rded Other ZIP CODE T EP E HONF (Include Area Code) 1 71 1 1 ??7 1 ?) 7 3 7- 9 3 4 3 Employed I- Full•Tlme ? Part•Time I LIP CQOE 1/ 1 1 1 TEL Pf(Q ?E?jt (C?RE?RE? Cq J $ I 4 , l 1 K w? 1' a L Student Student ' S I O 8. OTHER INSUHED S NAME fast Name, first Name, Middle initial) T0. CONDIT BLINN MICHEAL 11. INSUREDS POLICY GROUP OR FECA NUMBER I , A z ¢ OTHER INSURED'S POLICY OR GRO P I F, . U NUMDER a. EMPLOYMQYESU ) RRENT OROPREVIOUS) P F P 361 (?t - B .T?15 4 a INSURE&'AjOA I 4j T QF, y`j SEX Q t X L J M F b. OTHER INSURED'S DATE OF BIRTH b AUTO ACCIDENT r 1 z . ? PLACE (Smte) &Z 104 1964 SEX pA t M F, E b. EMPLOYER'S NAME OR SCHOOL NAME A z I E ?0 t u' L J' ,? ER'S NAME SC Q OR HOOL NAME c. OTHER ACCIDENT7 ?- ( ?YES I NO LJ XIl T ME c. INSURANCE PLAN NAJ?'c""1 I !it RA CE P N NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL. USE 45 CAPITAL BL?TE CROSS d.iSTH EANOTHERHEALTHDENEFIrpIJW? i YES NO tf ysr. return to and complots Item g ad. Q a r READ BACK OF FORM BEFORE COMPLETING b SIGNING THIS FORM. 'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of an y medical or other Information necess 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE' I authorize ary e this claim. I also roquest payment of government benefits either to myself or to the part' who accepts assignment payment of medical benefits t° the under-signed physician or supplier lot services de scribed below Signature on File 03 07 07 , Signature on file DATE SIGNED CLRR"V.1z ILLNESS (Firer symptom) OR 15. IF PATIENT HAS HAD SAME OR IMILAR ILLNESS. ) i Y1LI tD INJURY (Acddonq OR GIVE FIRST DATE VIM I DDS I YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY PREGNANCY(LMP) I I I I MM DO r YY FROM I I TO I r 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a 1.0 NUMBER OF REFERRING PHYSICIAN WALTER PEPPELMAN JR 242228 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM I DO I YY MM I DD , FROM TO 18. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? S CHARGES ! ?YES NO 21. CIA 05 5 OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 12.3 OR 4 TO ITEM 24E BY LINE) 22 MEDICAIO RESUBMISSION 1 CODE ORIGINAL REF. NO. 23. PRIOR AJTHORIZATION NUMBER A 8 C DE FroDATE(S) OF SERVICEETo• Place Type PROCEDURES, IES, OR SUPPLIES I DIAGNOSIS or F G H 1 J KI DAY EP D RESERVED FOR O o CPT(Explain Unusuallrcumsancos) CODE DD YY MM DD YY MC S MODIFIER F $ CHARGES OR Family EMG COB LDCAf USE UNITS Plan Q Q 1 211 07 02 2-If 0 1 99243 25 1 1 225 0 1 N 1 I I s t O r I t I 1 r r r I r I I , ? z - 1 ? I ! tz r w :3 I I t I I I I ; 1 I ' t o- l ? 1 I I ? I I I , 1! I I j a o 1 I I I 1 t I I ? ? r 1 U I 1 1 r n I i j I j S 12521=?-DE76T LD. NUMBER SSN El 14 - , ( 2B. PATIG COUNT NO. 16 9 21. ^CEFT ASSIGNMSNT7 z8, TOTAL C claims, 9o^ ims see back) 0 29. AMOUNT PbD O 3D. BAt.A:JCE?UEo 1 I ( YES L l L - ! NO S S i S I 31, SIGNATURE CF PHYSCAN CR SJPPLIER IfiCLUD:NG DEGREES OR CREDENTIALS 3,'t?AI, SS ^Fw W F R AYEF;F S 4?A?? } ?L (s?{ ? rV M? "' P. ? ,r yt C . 4;?J1Y G r I (Icorutyfrutthe etatemonlson the reverse a:,WY 10 Ihie bill and are made a part thorooL! 825 SIR THOMAS CT, SUITE 825 SIR THO;iAS CT, SUITE B NOi'MADi HAUEISEN DO HARRISBURG, PA 17:09 HRRRISBURG, PA 17109 i 03/07/07 SI,^,N;ED DATE 25-170314 i PINS GRP# ...- vn r r r-c A-NUVIZU UMB•0938-0006 FORM CMS-1500 (12.80), FORM RRB-1500 0 Printed on Recycled Paper APPROVED OMB-1215-0D55 FORM OWCP•150Q APPROVED OMB-07207 (CHAMPU;) i +_ r I PLEASE `IS A L_' F E 71r ?JOT, STAPLE PC BCR 659466 THIS A -70J ANTONIO, T:=: 73265 I - rt>=ril_ I n 11'10 UY1A11%.,C I. LAHYI f'l KNI PICA f 7. ;.IE0ICARE MEDlCAIJ C' AMPUS CHAMPVA GROUP FECA O NER Ia. IN :J E7'SI.D.NUAIBER (FOR iaOGRAM4N(TEM 1) HEALTH PION LK LUNG (Wodlraros)(-)rModkaid F) (SparlsoreSSN) El - (v,9FBe i) ( (S Na;CJ SJA) (ID) M J 3 6 6 16 3 6 I I' 2. PATIENTS NA E ILns1 Name, First Name, Mlddla Innlal) 3. PAT!E6TS Ir - SEX BLINN MICHEAL A (5 CF4 f564 4, INSU'R cD'S NAME (tasl Namo, Firs: Name, MidolslNtla) ' , 1 1 M BLTNN, MICHEAL ? A ? 5. PATIENTS ADDRESS (No.. Stroot) S. PATIENT RELATIONSHIP TO INSURED 200 HOLLYWOOD CIRCLE 7. INSURED'S ADDRESS INC., Straeq 2 00 HOL YWOOD CIRC E Sag ?Spou.[] Child[] Oth.C] ! L L IT"Y STATE 8. PATIEh F STATUS vARRISBURG PA M I d n Sin le[] d CITY HARRISBURG STATE PA o g ar o Other ? I ZIP CODE TELEPHONE (Indude Area Code) 17111 71 )) 73 7 - 934 4 3 Employed ? FuIFT+me ? Pe t-Ttma O S d 1 ZIP COGS TELEPHONE rINCWOE AREA CODE) 17111 (71 ) 73 7 - 9 3 4 3 1 r?C tu ent Student 9. OTHER INSUREO'S NAME (Lest Name, Fkal Name, MlOdlo Initial) 10. A. N I BLINN, MICHEAL A 11. INSURED'S POLICY GROUP OR FECA NUMBER 2 I ° a OTHER INSURED'S POLICY OR GROUP NUMBER EMP OYM - . a. L ENT 7 (CURRENT OR PREVIOUS) PFP361 a. INSURED'S DATE OF BIRTH SEX cc DYES Elf 0 015; (?14 i n64 M F in b OTHER INSUREO'S DATE OF BIRTH 1 I © z . SEX b. AUTO ACCIDENT? PLACE (Slate) 09 DS 11964 b. EMPLOYER-S NAME OR SCHOOL NAME U : I M F k `(fES (-}t0 LPA, I Q P ' LJ c. EM LOYER S NAME OR SCHOOL NAME c. OTHER ACCIDENT? C. INSURANCE PLAN NAME PROGRAM AME DYES L jjO I FE W ? d. !NSURANCE PLAN NAME OR PROGRAM NAME 100. RESERVED FOR LOCAL USE (23045) CAPITAL BLUE CROSS d. IS THERE ANOTHER HEALTH BENEFIT PLAN7 I OQ DYES D NO n yes, return to gill complel6 Item 9 ad. READ BACK OF FORM BEFORE COMPLETING A SIGHING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of arty medical or other Information necessary 13. INSURED'S OR AUTHORIZED PERSON'S SIGNA7URE I authorize i f i 10 ProCess INS Ctaft. I also requaca Payment of govemmenl bonahU either to mysarl or to the party who accepts assignment below pavmen o med cal benaRb to the undersigned phyddan or evppAor for services deacribod below. I( . signature on File 03 07 07 Signature on fileI SIGNED DATE SIGNED Y 14. DA OF qq N ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 6f11, t7j Y? INJURY (Accident) OR GIVE FIRST DATE MM 1 OD 1 YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT DOCUPATION MM DO PREGNANCY(LMP) i I 1 1 YY MM f DO 1 j 1 FROM 1 TO 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17s. I.D. NUMBER OF REFERRING PHYSICIAN WALTER PEPPE LMAN JR B42228 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DO YY D , , ID , MM , FROM i i TO I 10. RESERVED FOR LOCAL USE 2 0. OUTSIDE LA87 $ CHARGES I I DYES NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO REM 24E BY LINE) 22. MEDICAID RESUBMISSION 7 2 3. 4 722.0 CODE ORIGINAL REF. NO. 1. L____._ _ 3. 1? 23. PRIOR AUTHORIZATION NUMBER 723.0 721.0 2. ?---.- . - 4. 24' A B C D E F G H I J KI From ATE(S) OF SERVICETo Place Type PROCEDURES. SERVICES, OR SUPPLIES CIAGNOSIS DAYS EPSD RESERVED FOR M},{ YY MM DD yy of of (Explain Unusual Circumstances) CPTMCPC$ MODIFIER CODE $ CHARGES OR UNIT Family Plan EMG COB LOCAi. USE Q 021 21 07 02 211 07 24 62310 1234 ) 600 00 1 N 1 1 o 021 211 07 02 211 07 24 '1'77003 25 I I I 1 1234 I 100 00 1 N , t L z 2 I I , I 1 i ? w i I 1 I I 1 I t I I i C I L 3 1 l 1 1 I L I 1 J 1 N' 1 1 I I i 1 I I , 1 f 1 ? I I I 1 I 1 O I 1 1 1 I f I 1 I ? g I I S 1 1 `? 1 I 1 I j 1 i f I to 1" I I 1 1 i I I 1 1 a. 25. FEL'EP.A(-TAX I.D. NUM9ER SSN EIN 251703144 (? L D 28. PATIENTS ACCOUNT NO. e7. ACCEPT ASSQNMENT7 28, TOTAL CHA',CE 129. A1d0U4T PAID 13C. OALaNQE JE _ 16595 0?1. Iims,aoobackJ 700 001 7bU 00, 0 00 YES NO S J L? 1 5 1 I I S 31. S-GNAIURC OF PHYSICIANOR SUPPLIER INCLUDING DEGREES OR CREDENTIALS y1 *?:4,MT- A,,N.11! ,?A,,jj---$ [? F4CyI:?1 `?} ` qc ?r-g ylC y?i uyv?c+-ri c I?(FR g_p U q ?q? [q$p? C rWkl-;.03yrsbL? tsm `Lidlf7i17i? fn&a' ?F1fy 6p , -- 1`l t1 V LL . Y E M1 DP ? C J I pry ty tothe! the a bra made Iho reverse a 1 a: p to1t1Ls bi!I and d aro made a part 1M: roo1.J C Iti , & . . . N 825 SIR TH OPLAS CT 825 SIR THOMAS CT, SUITE H NOPMlAN HAUESSEN DO J 'F.ARRISBURG, PA 17109 HAP.RIS3UR13, PA 17109 03/07/07 441 25 -17031 1 SIGNED DATE - PINk I QpP• ? ? (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8!88) PLEASE PRINT OR TYPE APPROVED OMB-0938-0608 FORM CMS-1500 (12-90), FORM RRB-1.%'M I ®Printod on Rocyc)ed Paper APPROVED OM13-1215.0055 FORM 0WCF1500 APPROVED OMB-C720000 1 (CHAWUS; FL"-ASE DC NOT STAPLE ,N THIS AREA ---,PICA INV: 000=662051 03/09/2007 H USAA PO BOX 6594 60 SAN ANTONIO, TX 78265 APP?Eii 09 9 0 U HEALTH INSURANCE CL41M FnPM r -r .t MEDICARE MECICAID CHAMPUS CHAMPVA GROUP FECA OTHER ta.INSURED 81A.NUMBER (FGHiROGRAMIN ITEM t) HEALTH PLAN BILK LUNG ( (Wedlcare J,l ? (Medicaid 0) E. (Sponsa's SSN) (VA F.;e #) (SSN or 1D) 11 rSSN) "X X 1110) I L- 194-50-3018 12. sATIENPS NAME (La9I Nana. First Name, Middle tmtlR!J 3. FPM ENTpp IRT DATE SEX a. INSURED 'S NAME (Last Name Middialnitlal) Fust Name Y BLINN, MICHAEL 05 04 1 1964M F , , BLINN, MICHAEL 5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'SADDRESS (No., Street) 200 HOLLYWOOD CIR Self X {Spouse[] Chili Other[] SAME AS 5 CITY STATE 8. PATIENT STATUS CITY STATE CAMP HILL PA Single Married [] Omer El G ZIP CODE TELEPHONE (Include Area Code) 1 ZIP CODE _ TELEPHONE UNCIUDE AREA CODE) 117011-2627 (713 -737-9343 Employed Fuil-Time Pan Time ? Student 171 St d t ? :? ( ' u en O 9. OTHER INSURED S NAME (Last Name. First Name, Middle InitiaQ 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER z I 003861636 0 a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX cc ?YES go MM : DD YY 0 5 04 11964 MDPC F ? Z) b THER I N SURED's DATE OF BIRTH U) M D D SEX b. AUTO ACCIDENT? PLACE (State) p. EMPLOYER'S NAME OR SCHOOL NAME z I I M F .` YES ?NO LJ x Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME I. I ?YES NO USAA W ii d. INSURANCE PLAN NAME OR PROGRAM NAME 10d_ RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? Q Ia ? YES ? NO H yea. return to and ciNno fete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING 8 SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authonze the release of any modi6al or other information necessar 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE 1 authorize {I y to process this claim. I also request payment of government benefits 091101 10 myself Of to the party who accepts assignment payment of medical benefits to the undersigned physician or suppi,or for services described below below. . SIGNED_S.IGNAT.URE_0N_FILE DATE_0.31-0.912.0.0_7 SIGNED_SI.GNATURE_ON_FILE t4. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. IM/y?1 r ' INJURY (Accident) OR ACCT DEN GIVE FIRST DATE MM i DD I YY 'S 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM T 1 V :I V606 PREGNANCY(LMP) 1 1 I DO I YY MM r DO I YY FROM t I I I TO 17. NAME OF REFERRING PH1fSICWN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HCSPITALIZATION DATES RELATED TO CURRENT SERVICES PEPP MAN, WALTER JR. B42228 FROM MM 1 DD 1 YY TO MM 1 DD 1 YY 19. RESERY. FOR LOCAL USE 20.OUTSIDE LAB? $ CHARGES .7 ? YES g?NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1.2.3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION 722) 0 -CERVICAL DISC DISPLACXNT _ T L CODE ORIGINAL REF. NO. 1. L_.,.. 3. L_- . . 23. PRIOR AUTHORIZATION NUMBER _ 7?f n C -SPASM OF lP'SCLE O . - l ? O J 2 l L 24. A 8 C 0 E F G H I K Z ATE(S) Of SERVICETo o Place Type PROCEDURES, SERVICES, OR SUPPLIES Fror-r ! of (E¦pain Unusual Circumstances) DIAGNOSIS DAYS OR EPSD Family RESERVED FOR MM DO YY MM DO YY $erv Seri CPTfHCPCS MODIFIER CODE $ CHARGES UNITS Plan EMG COB LOCAL USE C I 1 1 .; ?I 1 1 I 1 t I ? 1 Ir 03 0T., 07 I 1 04 07 07 12 R E1399 RR 12 250 100 1 z " "?)1 i ; KS41 4CH HONi TOR CONBo NHs/IF I . 1 03 018 07 104 07 07 12 9 A4556 NU 12 80J00 8 J 1 1 I t t 1 I I L'i.ECTR00E 2X GAPY.%RT I CL 03 08- 07 041 07107 12 9 A4557 NU 12 40.100 1 I Lyl 1 1 I CABLESET GARMENT 4' PRONG I I f 1 I (? 031 061107 04 07 07 12 9 99002 12 15 100 1 a 1 ' I 1 t 1 ii 1 1 1 SHIPPING./ILIN?LTNG . I I I 1 ? I • v}- I 1 I 1 I I I I t ? 25. FEDERAL TAX L0. NUM3ER SSN EIN i 26. PATIE'NT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT 2 For govt. dams, see bac+) 8. TOTAL CHARGE 29. AMOUNT PAID 30- BA(h1:CE DUE 91-1490213 ?Y,Z9 _.0 C0000802112 ?JYES ND [ S X851 00 s 0'..00 S 385' O0 I 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 132. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 3 INCLUDING DEGREES OR CREDENTIALS RENDERED IV Other than home or aflicel . 3. PHYSICIANS, SUPPLIER'S B!LjNG NAME. ADDRESS. ZIP CODE , a PH (I the statements on the reverse 7 i 1^'^i d f dth CNi # i ?'.P S MEDICAL ;360 -892-0339 p y .) f~, oq ra eapa ereo R`? L ? ??,af 805 SIR THOMAS CT ? P.O. ROX 872650 / 1 YARRISBJRG PA 17109-9834 SIGNED X1 ;' - -DATE 0310 9 / 2007 I) `JANCOUE%ER NIA 98687-2 650 PI DIE SUPPLIED f / 1'ir 4 _ 1 P; . T O Na 9 11 ?• i 9 V l_1? GRP# (APPROVED BY AMA CDUNCIL ON AIEDICAL SERVICE 833) PLEASE PRINT OR TYPE A'PROVED OWI 38-W FORM CMS-1500 {t2-901. FORM Rfit3-1,°,00, APPROVED OMIii 'rORM OV ?P•iSpC, Ai'PRCV?O OMB-0?2C,00(?! (CHkmpP,Sj PLEASE DO NOT STAPLE IN THIS AREA INV- 0001567052 03/09/2007 0ICH70P4 Y jT,,PICA USAA PO BO 6594,"O SAN ANTONIO, TX 78265 APPROVI CM80938.0006 HEALTH INSURANCE CLAIM FORM PIr,A w CL cc ?c 17 -1 ; 1. MEDICARE Y.EOICA.0 CHAMPUS CHAMPVA GROUP FECA 0 11ER la, INSURED '5IA. NUMBER (FORrRCGRAM iN iTEM 1) (MeCKare r) (MeQka,d t) D (Sponsor's SSN) HEALTH PLAN BLXLUNG (VA File 0) (SSN of 0) (SSN) TX (10) 194-50-33018 • 2. PATIENT'S NAME ilasl Name. First Nam a, Middle iniul) 3. PA MIENT'DS9 !RTH ATE SEX 4. INSUREDS NAME (Las; 'lame, Flrs! Name, M?d*Imtial) BLINN, MICHAEL 05 !04 ;1964Mn F BLINN, MICHAEL 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSUREDS ADDRESS (No., Street) 200 HOLLYWOOD CIR sell9 spouse El ChlidD 01he,0 SAME AS 5 CITY STATE 8. PATIENT STATUS CITY STATE Z CAMP HILL PA Single Married [] Other D 9 ZIP CODE TELEPHONE (include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) 49 17011-2627 (71 ?- 7 3 7 - 9 3 4 3 Employbd Fun• Time ^ Part-Time 0 ( } « Student Student 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO; tI. INSUREDS POLICY GROUP OR FECA NUMBER 0 u' 2 003861636 0 a. OTHER INSUREDS POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX cc DYES P NO MM i DO i 05 104 1964 Mid F O In b OTHER tNSUR T F BIRTH ' L - •r , Z . ED S OA S O SEX MM , DO I YY b. AUTO ACCIDENT? PLACE (State) D. EMPLOYER'S NAME OR SCHOOL (LAME O I M F YES LJ Lr 11 Z a C. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? C. INSURANCE PLAN NAME OR PROGRAM NAME f- [] YES ,/] NO U SAA w d. INSURANCE PLAN NAME OR PROGRAM NAME 1 Od. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? 4 a DYES D NO If yes, reNm to and complete ilem 9 ad. READ BACK OF FORM BEFORE COMPLETING d SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any modical or other Information necessary Q. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE I authorize f to process this claim, t also request payment or government benefits eimer to myself or ;o the party who accepts assignment payment o medical benefits to itm undersigned physician or supplier for services described below I tlelcw. , I SIGNED_SIGNAT.URE_ON_FILE DATE_0.3.40.9.42.C'.O_7 SIGNED_S.IaNAT.URE_ON_FILE }I 14, DATE OF CURRENT; ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. M Yx INJURY (Accident) OR GIVE FIRST DATE MM i DO I YY f 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM /? ACCIDENT 1 ? !1 J '2 V V 6 PREGNANCY(LMP) 1 OD 1 YY MM 1 DD I YY FROM t TO I I 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES PEPPF,-LMAN WALTER JR B42228 MM , OD I YY MM I DO I YY FROM , . 1 r TO 19. RESERVE FOR LOCAL USE 20. OUTSIDE LAB? S CHARGES D YES NO U 21. DIAGNJSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2.3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION 2`) -CERVICAi DISC DISPLAOCt7 CODE ORIGINAL REF. NO. 1. 1 Z3. PRIOR AUTHORIZATION NUMBER J 728 8 C -SPASM OF MUSCLE 2 L 4 L_._ J 24. A . s 8 C D E F G H I J K Z D E S OF SERVIC 1) ET Fro ! o Piaco of S of 01 PROCEDURES, SERVICES. OR SUPPLIES J (Explain Unusual Circumstances) IAGNOSIS I DAYS EPSDT F E OR V E R p MM O YY MM DO YY ServtC Serftc CPTJHCPCS MODIFIER S CHARGES S UN T amily EMG C08 A L US LOC Q I I r , 1 rr 0 03108/07 ? 031 08107 12 R E0731 NU 12 350.10 0 1 z 1 t i 1 PSrar FULL CN CONDUCTV W MEM 'r I (r W 1 (`.t t I t J , ,• 1 I 1 I' -1 1 I 1 I 1 1 I I V) ? 0 I I I I , I I I E Q I I I I 1 ' Ii i 1 N 1 I I I r I I t 1 I , 1 I I l y a `25. FEDERAL TAX I.D. NUMBER SSN EIN 2fi. PATIENT'S ACCCUNT NO. 27. ACCEPT ASSIGNMENT? 2 For gm claims see back! 0. TOTAL CHARGE U211D 30. BALANCE DUE . , 9?1-1490213 DENS, x'00000802112 [j YES D NO 31 . SIGNATUR$ OF PHYSCIAN OR SUPPLIER 3Z NAME AND ADDRESS OF FACILIT` WHERC : RV $ 3501.000 S 350'.OC!, . C ICES WERE 3 RJC'_UDIN^ D°GREESOR CREDENTIALS I RENDE AEC (if other than home or office) 3. PHYSICIAN) S. SUPPLIER'S BILLING NAME. ADDRESS, ZIP CODE 6 PHONE (I certry tna the s! a;ema is on the roversc it h d n i i 1 Y R S MEDIC L (360)-692-0339 z e a pa orec l i 40 p ti? a s a RH L Ti 805 SIR THOMAS CT P.O. BOX 872650 U.r (HARRISBURG , PA 17109-4330 SIGNED r vl^+?'?() Q11,P \. _---paTE03?D_ f .._007 VANCOUVER, 6;A 98687-2650 ?I INY Q, 1 4 ?021GAPS (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE &88) PLEASE PRINT OR TYPE APPROVCD0u8-0938d7C8 FORM LMS-1500 (121K,, =ORU RRG-1:40, APP90VEDOMS-1215-00S'_ FORM OWCP-1500, APP;'OVED OMB457200001 (CHAMPUS) APP/%7/'2Ou7/F^ I 03:41 PM 04/23/0 7 OC er . AH Z:Rs # 232139809 BLn,w, NISCHAE'L A 200 HOLLYWOOD CIRCLE CAMP HILL, PA 17011 statement P. 003 Page: 1 THE ARLI<7GT0N GROUP PO BOX 6507 805 SIR 'HOM HARRwSBURG, P.A 17112 Tel : 71716-52-9015 Acct: 10103706-1 /AU 194503018 Pat : BLINK MICFiALEL A 05104164 Tel : 717/73 7- 93 43 Ins,Z: USAA 38616367101146836 Ins2: CAPITAL BLUE CROSS CAIC PFP60046460300 Ref Diag .Date C_P_T^ Qt Procedure^----------- _AR- P1 -Prv- -Amt _____ _Ba1^- _ -- __J-_ 11/20/06 847.0 J 99202 -- 1 _ NEW/EXPANDED PROBLEM AU 0 ,8Z 90.00 0.00 12127106 AUP AUTO PAYMENT O BZ -68.07 USAF 12127106 ADDS AUTO INS DISALLOWANCE 0 BZ -21.93 11/20/06 847.0 72040 1 XR CFRV SPINE 2 VWS AU O BZ 88.00 0.00 12127106 AUP AUTO PAYMENT O BZ -36.05 USAA 12127106 AUDS AUTO INS DISALLOWANCE 0 BZ -53.95 01/15/07 847.0 RS 1 RESCHEDULE APPOINTMEN AU 0 BZ 0.00 1, 0.00 01/04/07 847.0 99212 1 EST PT/PROBLEM FOCUS AU 0 BZ 55,00,-, 0.00 02/14/07 AUP AUTO PAYMENT 0 B.Z -40.07 C K# 5.3 8 3 7641 USAA 02/14/07 AUDS AUTO INS DISALLOWANCE 0 BZ -14.93 ; 01122107 847.0 99212 1 EST PT/PROBLEM FOCUS AU 0 BZ 55.00 ? 0.00 02120107 AUP AUTO PAYMENT 0 BZ -40.07 CK;#54 13 6 0 3 6 USAA 02120107 AUDS AUTO 'INS DISALLOWANCE O BZ -14.93 02/07/07 847.0 99080 1 MEDICAL RECOP.DS AU 0 BZ 24.79 0.00 02102107 ATP ATTORNEY PAYMENT 0 BZ -24.79 CK#42 0 74 SERRATELLI 02119107 847.0 99215 1 EST PT OFFICE/OUTPATI AU 0 WP 155. DD 0.00 03113107 AUP AUTO PAYMENT 0 WP -126.30 CK#55601280 USA..A 03133107 DUDS AUTO INS DISALLOWANCE 0 wp -28.90 / 03/07/07 847.0 99213 1 EST PT/EXPANED PF EX-1 AU 0 WP 70.00? 0.00 03130107 AUP AUTO PAYMENT O WP 54.88 CK#5657973 6 USAA 03/30/07 AUDS AUTO INS DISALLOWANCE O WP -15.12 03/28/07 847.0 99213 1 EST PT/EXPANED PV EXA AU 0 WP 70.00 70.00 Next appointment: 06120107 2:30P9 DR PFPPELMAN HBG OFFICE Regular Balance: S 70.00 021C6107 Statement Page: 1 %per: AH IRS 9 232189809 BL INN, MICHAEL A 200 HOLLYWOOD CIRCLE CAMP HILL, PA 17011 THE ARLINGTON CROUP PO BOX 6507 805 SIR Z'HOM HARRISBURG, PA 17112 Tel : '7171652-9015 Acct: 10103706-1 /AU 194503018 Pat : BLIIVN, MICHAEL A 05104164 Tel : 7171737-9343 Ins1: USAA 38616367101146836 Ins2: CAPITAL BLUE CROSS CAIC PF13 004 64 603 0 0 Date ---- Diag Ref C.P.T Ot Procedure AR P1 Prv Amt Bal ----- 11/20/06 -------- 847.0 ---------- 99202 ---- 1 ---------------------- NEW/EXPANDED PROBLEM --- AU --- 0 ----- BZ --------- 90.00 ------- 0.00 12127106 AUP AUTO PAYMENT 0 BZ - 68. 07 USAA 12127106 AUDS AUTO INS DISALLOWANCE 0 BZ -21.93 11120106 847.0 72040 1 XR CERV SPINE 2 VWS AU 0 BZ 88.00 0.00 12127106 AUP AUTO PAYMENT 0 BZ -36.05 USAA 12127106 AUDS AUTO INS DISALLOWANCE 0 BZ -51195 01/15/07 847.0 RS 1 RESCHEDULE APPOINTMEN AU 0 BZ 0.00 0.00 01/04/07 847.0 99212 1 EST PT/PROBLEM FOCUS AU 0 BZ 55.00 55.00 01122107 847.0 99212 1 EST PT/PROBLEM FOCUS AU 0 BZ 55.00 55.00 Next appointment: 02/14/07 2:00PM DR PEPPELMAN HBG OFFICE Regular Balance: $ 110.00 S T A T E M E N T Davi.3 W. Gerhart, DC 303 S 32nd St 02-06-2007 Camp Hi11, PA 17011 717-761-2273 BALANCE: $370.00 ACCOVWT NUMBER: 1000-1168 MICHAEL BLINK PIS LAST CLAIM: 01-31-2007 200 HOLLYWOOL) CIRCLE LAST PAYMENT: 01-30-2007 CA,JP KILL PA 17011 LAST CHARGE: 02-06-2007 Date Description Code Charge Credit Adjust Balance 10-23-2006 *NP History & Exam Co 99203 72 00 00 10-23-2006 *Full Spine AP/LAT 72010 , 115 00 ' 00 •00 72.00 10-24-2006 *Chiro manip Tx 3-4 Re 98941 . 40 00 . 00 .00 187. 00 10-24-2006 *Elec Stim 97014 . 20 00 . .00 227.00 10-25-2006 *Chiro manip Tx 3-4 Re 98941 . 40 00 .00 00 .00 247.00 10-25-2006 *Elec Stim 97014 . 20 00 . cc .00 287.00 10-27-2006 *Chiro manip Tx 3-4 Re 98941 . 40 00 . Co .00 307.00 10-27-2006 *Elec Stim 97014 . 20 00 . . 00 347. 00 10-30-2OG6 *Chiro manip Tx 3-4 Re 98941 . 40 00 .00 .00 367.00 10-30-2006 *Elec Stim 97014 . 20 0 .00 • 00 407. 00 11-01-2006 *Chiro manip Tx 3-4 Re 98941 . 40 00 00 00 00 427.00 11-01-2006 *E1ec Stim 97014 . 20 00 . 00 .00 467.00 11-03-2006 *Chiro manip Tx 3-4 Re 98941 . 40 00 . 00 .00 487, 00 11-03-2006 *E1ec Stim ? 97„14 . 20 00 . .C0 527.00 11-06-2006 *Chiro manip Tx 3-4 Re 98941 . 40 00 .00 00 .00 ' 547. 00 11 -06-2006 *Elec Stiim 97014 . 20 00 . G 0 587. 00 1 i -08-2006 *Chiro manip Tx 3-4 Re 98941 . 40 00 . 00 . 00 607, OQ 1-08-2006 *Elec Stim 97014 97014 . 20 00 .00 . 647.00 11 -10-2006 *Chiro manip Tx 3-4 Re 98941 . 40 00 .00 .00 6C7.00 11 -1 0-2006 *Elec Stim 97014 . 20 00 • 00 . CO 707. 00 11 -13-2006 *Chiro manip Tx 3-4 Re 98941 . 40 00 .00 .00 727.00 12-13-2006 *Elec Stun . . 00 . CO 767.00 11 -15-2006 *Chiro manip Tx 3-4 Re 98941 00 - a GO . 00 787.00 11 -15-2006 *Elec Stim 97014 20 00 GO . 00 827.00 1'L-17-2006 *Chiro manip Tx 3-4 Re 98941 . 40 00 .00 .00 847.00 11 -1 7-2006 *Elec Stun 97014 . 20 00 . DO . 00 887. CO 11-20-2006 *Chiro manip Tx 3-4 Re 98941 . 40 00 .00 .00 907.00 11 -20-2006 *Elec Stim 97014 . 20 00 GO • 00 947.00 11-22-2006 *Chiro manip Tx 3-4 Re 98941 . 40 00 .00 .00 967.00 1 1-22-2006 *?lec Sti1;? 97014 . 20 00 • 00 . OG IOC7. 00 11-27-2006 7;JS CY CISAA 49037586 . .00 .00 1027.00 11-27-2006 I7s Pd: 10-23-2006 > L CO 54 8.41 • G0 478.59 11-27- ,. 2006 I.„s Pd: ,j_01-2006 > 1 .00 . 00 19.53 459-C6 Continued... 00 00 1°•53 439.53 S T A T E M E N T Da-• d W. Gerhart, DC 303 .3 32nd St 02-06-2007 Camp Hi.11, PA 17011 717-761-2273 BALANCE: $370.00 ACCOUNT NUMBER: 1000-1168 I^TICHAEL BLI AT PI+ LAST CLAIM: 01-31-2007 200 HOLLYWOOD CIRCLE LAST PAYMENT: 01-30-2007 CAMP HILL PA 17011 LAST CHARGE: 02-C6-2007 Date Description Code Charge Credit Adjust Balance 11 -27-2006 Ins Pd: 10-27-2006 > 1 .00 .00 19 53 420 00 11-27-2006 *Chiro manip Tx 3-4 Re 98941 40.00 .00 . 00 . 460 00 11-27-2006 *Elec Stim 97014 20.00 .00 . 00 . 480 00 11-29-2006 *Chiro manip Tx 3-4 Re 98941 40.00 .00 . 00 . 520 00 11-29-2006 *E1ec Stim 97014 20.00 .00 . 00 . 546 00 12-01-2006 *Chiro manip Tx 3-4 Re 98941 40.00 .00 . 00 . 580 00 12-01-2006 *Elec Stim 97014 20.00 .00 . 00 . 600 00 12-05-2006 *Chiro manip Tr 3-4 Re 99941 40.00 • OC . 00 . 640 00 12-05-2006 *E1ec Stim 97014 20.00 .00 • 00 . 660 00 12-08-2006 *Chiro manip Tx 3-4 Re 98941 40.00 .00 . 00 . 700 00 12-08-2006 *E1ec Stim 97014 20.00 .00 . 00 . 726 00 12-12-2006 *Chiro manip Tx 3-4 Re 98941 40.00 .00 . 00 1. 760 00 12-12-2006 *E1ec Stim 97014 20.00 .00 . 00 . 780 0C 12-15-2006 *Chiro maniP Tx 3-4 Re 98941 40.00 .00 GO . 820 GD 12-15-2006 *E1ec Stim 97014 20.00 .00 . 00 . 84C 00 12-19-2006 *Chiro manip Tx 3-4 Re 98941 40.00 .00 . 00 . 880 00 12-19-2006 *Elec Stim 12-27-2006 N 97014 20.00 00 .00 . 900.00 I S CK USAA 50796594 12-27-2006 Ins Pd: 11-08 2 .00 601.81 .00 293.19 - 006 > 12-27-2006 1 .00 .00 47.61 L50. 58 12-29-2006 *Chiro manip Tx 3-4 Re 98941 00 40 00 .00 10.58 240.00 12-29-2006 *E1ec Stim 97014 . 20 00 ,00 .CO 280.00 07 -05-2007 *Chiro manip Tx 3-4 Re 98941 . 40 00 .00 .00 300.00 01-05-2007 *Elec Stim 97014 97014 . 20 00 .00 . 340.00 01-12-2007 *Chiro manip Tx 3-4 Re 98941 . 40 00 .00 00 .00 360.00 01 -12-2007 *Elec Stim 97 014 . 20 00 . .00 400.00 01 -19-2007 *Chiro manip Tx 3-4 Re 96941 . a 0 00 .00 00 . 00 420.00 01 -19-2007 *-P CV Limited 99212 . 35 00 . .00 460.00 01-19-2007 *Full Spine APiLAT 72010 . 11 s 00 . L0 .00 495.00 01-19-2007 *Elec Stim 97014 20 00 00 • 00 00 61 6.00 0-1-26-2007 *Chiro manip 3-4 Re 98941 . 40 00 . • 00 630.00 01-26-2007 *E1ec Stim 97014 . 20 00 • CC .00 670.00 0-7-30-2007 INS CK USAA 52846662 . .00 .00 696.00 Con tinued... .00 328.26 .00 361. 74 Davi '. W. Gerhart, DC 303 J 32nd St Camp Hill, PA 17011 717- 7 61-22 73 MICHAEL BLINN P1+ 200 HOLLYWOOD CIRCLE CAMP HILL PA 17011 Date Description Code 01-30-2007 Ins Pd: 12-08-2006 > 1 01-30-2007 Ins Pd: 01-05-2007 > 0 02-06-2007 Chiro manip Tx 3-4 Reg 98941 TOTALS S T A T E M E N T 02-06-2007 BALANCE: $370.00 ACCOUNT NUMBER: 1000-1166 LAST CLA11%1: 01-31-20C7 LAST PAYMENT: 01-30-2007 LAST CHARGE: 02-06-2007 Charge Credit Adjust Balance .00 .00 26.45 335.29 .00 .00 5.29 330.00 40.00 .00 .00 370.00 1997. 00 1478.48 143.52 For proper credit, please enclose this portion with your payment. MICHAEL BLINN BALANCE: $370.00 200 HOLLYWOOD CIRCLE PAY THIS AMOUNT: $ 370.00 CAMP HILL PA. 17011 AMOUNT ENCLOSED: Please fill in blank. DATE DUE: No Pmt Rqd David W. Gerhart, DC THANF< YOU. 303 S 32nd St C rp ::i?1, PA 17011 ACCOUNT NUMBER: 1000-1168 r? 7 T ^- ':PE .: I U1 c JF DATE JF 0.' LL L - G .. ." 3. H osp I- _ _ ^iIEl7' NAHE PAT!El:T NUMBER ISEX j .A.3a j ADHi'JSION DATE D?E,'C!V, CE DATE DAYS i I 9 - - - - - - - C.0.H.? :'•7SUR,'JICE COMPANY NAMc' IORG'1P NUHHER POLICY NL'HEF? OUARAU-rOR '? ?:']E. A S, 71J',? _ •'?U.'J _NS 10038 61 636C NAME AFiD :;,ITT `?? 100D CIRCL - A.GDRE55 ^?_J aIL? ? ? 1 ? O 11 DA_^,_E: FA 4 AMOUNT OF S PAYMENT E OF 1).7 DESCRIPTION Of SERVICE 'TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE E:;T. COVERAIE StI1' PAT! 1 ERVICE HOSPITAL SERVICES CODE CHARGES INS. CO. NO. 1 INS.CO. NO. 2 INS.C0. N0. 3 2S.C0. N0. 4 AHOUN7- 7- 1a 0 CU:-cRT CHAFG7-S, FAY ,ENTS AN , JUST- TS 10/13 CER,II?AL sF_?E 0136502086 ; 390.00 90 co 10/13 LEVEL I-- rC 0117105727 104.00 104.00 PALM cE E, ID N P.D 0. 00 :,U?flI? , RY CJF 1T Cri P.CES 3?0 390.00 390.00 Ei`1Ec ?D Y .,?Gi9 4 0 104. 00 10' . 00 SUE - C - 'A -, C F CRR. C1 R.GES 494.00 494.00 DIA: NCS1 S: 047.0 V71.4 i i t r•t NT _S DUE P0N RE? IPT 0 T H i 5 STA T EPJ;ENT. C; RFT^9 '7 RSEMEN,T. ?- _ - 4 y0l 4;94 00 PA. '': L:7 bJH'riEF: ICE.S_L F'.:: ER ?O PATIENT ADDITIGNAL PAT: ENT BILL1 NO, W,Y HE NECESSARY G r _. .. ` JMBCF ALL It :CIF: ES FOR ISY CM'.RGES ti(-T P]STEU WHEN THIS STATE- .. - ?, C, - ! 7?- 1 ,- _ Hi17T WAS .,. ..,?f D. OR IF INSJf WCE CE CO.EP_.?E. ?• . .-. 7 D7 7 ` PA?F :"FE r CAI, r' r C I'E OF DI L LL PREV.31 LC 7 7 1 -7 _ FA: IPl.T I E:T NUMBER ?SE?, A_ ADM: S:, iDA:F CIS:HAPOE DATE LA`3 L2 7 2 6 n 7, C.O.R It7S;1R,'.NCE CCNPrLNY NA}1E IGRDUP NL'M SEP pcICY MJM?ER 1, I711, vNTlR s_CEir?7 ? bLICI".d I??S •`'vi v.J.C?61636C t:AhE ? :A L CrOD CIRCLE , I AND . , L ADCRESS C 7 T .. E-a 171011 DARD? "rl P::._ AMOUNT OF S PAYMENT C•ATE OF UESCIt I!'T I IN uF SERVICE I TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE C'3T. COVERAG E PATIEdT SERVICE HOSPITAL SERVICES CODE CHARGES INS. CO. NO. I INS.C0. NO. 2 INS.CC. N0. 3 I INS. CO. N0. '7 AMOUNT DETr OF CURRENT_ CHARGES, PAt 'EN':S AN ADJUSTME ,]I'S 10/13 CERVICAL SPINE 013650208 6 390.00 390.00 10!13 LEVEL II FC 01"17105727 104.00 104. C0 S:JMM I .R? CF CURRENT CHARGES EX X-RA7 320 390.00 390.00 EMERGENCY ROOM 450 104.00 104.00 S:;3- OTAL rl'F C7 RR. CHARGES 494.00 494.00 I GUA. . RELATIO"ASH?: S SEX M GUAR N0: ACC Cn.TE: 10/13/06 TYPE: A TIC S: 5:15 PM PL _CE: ENPL F.EI N D1r.. NI S 15: 247 . 0 V71.4 PAIMENT IN FULL IS EXPO CTED YlI H IN 30 DAY S. r I 'AI IENf tf MSEM FLEA E F "k TO I'A.IENT IIOITIONA PAT)Etir BILLING MAY BE NECESS.IRY :7UMD R G: ALL I: UIFIES E-R ANY CHARGES N2T POSTED WHEN THIS STRTE- J AND COF RCSPOt:DEh__. MLIIT WAS PREPARED. OF. IF INSUP-0:C-1 11 11. - ` IMATLO r INSUFAN_E :c COVEP_4GE 4-1-11 UNDER EST M.T -ENT '... -- - - - - .-. _ - -I 5 FED. TAX `.;0 7 7 T PA_....G NA:._ :3 PA : El.a AP, E RE5S - ADM[:.'SI ONa - _}!Ci0 3R _ _ _7 CL.,.,,- 1 - OD-:' '._ II 1 c?¦ ??,.. q 'r J ., 1 2 4._NC -? '{' « 31 OCCURR_LICE 7e O C xc E.;CE A?! c TOAOn.^^ Al . ` ' I I i, ? I 1 lol IyI I .. T '1 : ]9 V,:LUE C.^.D°5 .' «++. .. - W 4 t- { J I 'OPF.S .. ? .. .. ? : CJnr_ AEI_JLT 9 - ,E _nnE AM L: 7 ' TYcdOO? C?RC?, ?? 3 C?.i:P ui7 L b' I l I dI c J I f 42 RF%-CO 43 DESCRTPTIOI7 41 HCPCSiRn':ES 45 SEPV.DATE 16 EEIIV.IR;:75 47 TOTAL CIIARCES 1D N'rN-COV'3 CHRGS 14S I 2C D X-? AY 720 0 101306 1 3901CC I 1 ..??. E?4E?G R00IN.. . 10 4;0 0 .. 3 5 I li I I: 1 1 I i - I CO' 'rO .'.L C HT.PGES - c ay 0 m II 50 PAYER 51 PRO VIDER T10. 54 PR IOR PAYYEt7S 55 EST. AWAW DIIE Sf. AUTO ` y j I 4 99 p0 57 6'76 9 M811-ICSG I 5tl IIdSURED'S NA14E P. .EL 60 CERT. - ZEN - HIC. - 10 N0. 61 GROUP NAME ?NS(,BACICE GPOUP [10. 18 0 03 TREAIME.N-I AMICIP.ICATMZ CODES ESC 65 EMPLOYER NAME 66 EMPLOYER LOCA'T'ION COMMONWEALT 3 O F,- . - f7 PRiN DIA.i CII - - - a CCPt -- j?$}?,? _? :'.?'.i-. - illt{:.li 1)1 Ali .' - -'71 ='DIIE - -r4 ^OJf: - -777777- -17G 1Je LI1G C L E-l'10E 711 • )9 P r:0 PRINCIPAL PP. OCEDV :tE 31? OTH-R PP. rEDUFF l'COF. OI.lE r, }-__ - -- '' - 02 ATTENllINO - II1,..:?-:?n N262 3rr..L I DARDEN PAM C ^O- iEN P'. 1'ED+1RE <r,E -E ;U'_^.ER PHO 93 pTfi`R rlrs . TD _ A - - .' )TYrp P-P.'S . IFI - OS-PROS D P REPA [TIATIvE P.6 01 1.- 7 -- ;C. S P=. -LP CC' ------------------------------------ r) 7 .'.i?' 0v ll T c'C C? S ?D-DES CF I -OPT; CC IIS?.i? _ vA: =_I?OJIdP _ ,._ .. .-0 30 _ 1 AUTO !NS CA-GP - 8 . 6? -------------------------------------------------------------------------------- SEv PT ! (PF3) SELECT DTL (PF11) ACCT CASH F.ETTjFI i TO PT OVERVIEW ! (EF10) ACCT CMNTS PF16 D/E Pn_;-.7LC1 SEP/19/2007/WED 11:11 AM F,TV00S6B 09/19/07 Oper: ER IRS # 232189809 )3LINN, MICHAEL A 200 HOLLYWOOD CIRCLE CAMP HILL,PA 17011 Statement 002/003 j e ??.3 iLf Page: 1 THE ARLI1gGTON GROUP PO BOX 6507 805 SIR THOM HARRISBURG, PA 17112 Tel: 717/652-9015 Acct: 10103706-1 /AU 194503018 Pat : BLINN,MICHAEL A 05/04/64 Telt 717/737-9343 Insl: USAA 38616367101146836 Ins2: CAPITAL 13LUE CROSS CAYC PFP80046460300 Date Diag Ref C.P.T Qt Procedure AR P1 Prv Amt Bal ------------------- 11/20/06 847.0 --------- 99202 --- 1 ---------------------- NEW/EXPANDED PROBLEM --- AU --- 0 ----- BZ --------- 90.00 ------- 0.00 12/27/06 AUP AUTO PAYMENT 0 BZ -68.07 USAA 12/27/06 AUDS AUTO INS DISALLOWANCE O BZ -21.93 11/20/06 847.0 72040 1 XR CERV SPINE 2 VWS AU 0 BZ 88.00 0.00 12/27/06 AUP AUTO PAYMENT O BZ -36.05 USAA 12/.27/06 ADDS AUTO INS DISALLOWANCE O BZ -51.95 01/15/07, 847.0 RS 1 RESCHEDULE APPOINTMEN AU 0 BZ 0.00 0.00 01/04/07 847.0 99212 1 EST PT/PROBLEM FOCUS AU 0 BZ 55.00 0.00 02/14/07 AUP AUTO PAYMENT 0 BZ -40.07 CK#53837641 USAA 02/14/07 AUDS AUTO INS DISALLOWANCE 0 BZ -14.93 01/22/07 847.0 99212 1 EST PT/PROBLEM FOCUS AU 0 BZ 55.00 0.00 02/20/07 ATJP AUTO PAYMENT O BZ -40.07 CK##54136036 USAA 02/20/07 AUDS AUTO INS DISALLOWANCE 0 BZ -14.93 02/07/07 847.0 99080 1 MEDICAL RECORDS AU 0 BZ 24.79 0.00 02/02/07 ATP ATTORNEY PAYMENT 0 BZ -24.79 CK#42074 SERRATELLI 02/19/07 847.0 99215 1 EST PT OFFICE/OUTPATI AU O WP 155.00 0.00 03/13/07 AUP AUTO PAYMENT 0 WP -126.10 QK##55601280 USAA 03/1.3/07 AUDS AUTO INS DISALLOWANCE O WP -28.90 03/07/07 847.0 99213 1 EST PT/EXPANED PF FXA AU O WP 70.00 0.00 03/30/07 AUP AUTO PAYMENT O WP -54.88 CK#56579736•USAA 03/30/07 A=$ AUTO INS DISALLOWANCE 0 WP -15.12 06/28/07 PEND PENDING CLAIM PER BOB 0 WP 70.00 PENDING-OUTCOME OP PEERE REVIEW AND MEDICAL NEC 03/28/07 847.0 99213 1 EST PT/EXPANED PF EXA AU O WP 70.00 0.00 04/24/07 AUP AUTO PAYMENT 0 WP -54.88 USAA 58104594 04/24/07 ADDS AUTO INS DISALLOWANCE O WP -15.12 58104594 06/28/07 PEND PENDING CLAIM PER BOB 0 WP 70.00 PENDING OUTCOME OF PEERE REVIEW AND MEDICAL NEC 04/23/07 847.0 99080 1 MEDICAL RECORDS AU O WP 32.29 0.00 04/27/07 ATP ATTORNEY PAYMENT O WP -32.29 042499 06/20/07 847.0 99213 1 EST PT/EXPANED PF EXA AU O WP 70.00 70.00 RECEIVED TIME SEP.19. 11:09AM SEP/19/2007/WED 11:11 AM 09/19/07 Oper: ER IRS # Statement Page: 2 THE ARLINGTON GROUP PO BOX 6507 805 SIR THOM 232189809 HARRISBURG, PA 17112 Tel: 717/652-9015 BLINN,MICHAEL A Acct: 10103706-1 /AU 194503018 200 HOLLYWOOD CIRCLE Pat : BLINN,MICHAEL A 05/04/64 CAMP HILL,PA 17011 Tel: 717/737-9343 Insl: USAA 38616367101146836 Ins2: CAPITAL BLUE CROSS CAIC PFI?80046460300 Date Dia.g Ref C.P.T Qt Procedure AR Pl Prv Amt Bal --------- 07/11/07 ----------- 847.0 -------- 99213 --- 1 ------------------------- EST PT/EXPANED PF EXA AU ---- O ---- WP -------- 70.00 -------- 70.00 08/24/07 AUDN AUTO DENIED NOT RELAT 0 WP 70.00 PEER REVI EW INDICATES NO FURTHER ORTHO TX MED NEC 09/04/07 847.0 63075 1 DISKECTOMY CERVICAL A AU IH WP 3300.00 3300.00 09/04/07 847.0 63076 1 DISKECTOMY CERV ADDL AU IH WP 1550.00 1550.00 09/04/07 847.0 2255451 1 ARTHRODESIS ANT (.A.CDF AU IH WP 3200.00 3200.00 09/04/07 847.0 22585 1 ARTHRODESIS ANTERIOR AV YH WP 1531.00 1531.00 09/04/07 847.0 22845 1 ANT INSTRUM 2-3 VERT AU IH WP 2640.00 2640.00 09/04/07 847.0 22851 1 APPLIC VERT CAGES AU TH WP 1000.00 1000_00 09/04/07 847.0 2285159 1 APPLIC VERT CAGES AU IH WP 1000.00 1000.00 Regular Balance: $ 14361.00 P, 003/003 RECEIVED TIME SEP,19. 11:09AM '----nc TFZZ?uUIJy/y-iYT-AUK-y/4/GUUI 13'_'12 And W! ite - 9111/2CC C.(7 14 7 PINNACLE HEAL`_ H HOSPITAL l??,i+-1 J H. I PAGE NO NO. I 77PE OF BILL DATE OF DATE OF BILL PREV.BILL FINAL 9/11/07 P.O. BL?% 2-::) 3 EARRISB7RG, PA 17105-235-3 717 23C-3717 B -DAT HOSP.NO. FEI 4 251778644 05/)4/6 A S PATIENT NAME PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE DAYS ?ST-iNN MICHAEL 1280015979 M 43 09/04/07 09/05/07 1 C 0.0 INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER GUARANTOR MICHAEL A BLINN I AUTO - USAA 861036 NAME 200 HOLLYWOOD CIR -2 BLUE CROSS 361 300 FP80046460 AND ADDRESS CAMP HILL PA 17011 EPPELMAN WALTER AMOUNT OF 5 PAYMENT ATE OF DESCRIPTION OF SERVICE TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE PATIENT SERVICE HOSPITAL SERVICES CODE CHARGES IUS.CO. NO. 1 INS.CO. NO. 2 INS.CO. NO. 3 INS.CO. NO. AMOUNT DETA L OF CURRENT CHARGES, PAY ENTS AN ADJUSTME TS 07/19 001 CBC & AUTO DI 0115071 75.00 75.00 07/19 001 BASIC METABOL 0117038 93.00 93.00 07/19 001 VENIPUNCTURE 0151500 18.00 18.00 07/19 001 EKG 4171001 166.00 166.00 09/04 004 OR TIME 1/2 H 4110014 1884.00 1884.00 09/04 001 OR CASE 4112000 09/04 002 SUTURE 4118029 40.00 40.00 09/04 001 SOL .9% SOD C 4118040 3.00 3.00 09/04 002 DRAPE C-ARMMI 5440349 12.00 12.00 09/04 001 DRAPE LAPAROT 5440361 18.00 18.00 09/04 001 DRAPE LARGE 5440364 5.00 5.00 09/04 001 DRESSING 4 X 5440378 1.00 1.00 09/04 001 DRESSING STER 5440394 3.00 3.00 09/04 001 ELECT BOVE BL 5440404 21.00 21.00 )9/04 001 ELECTRODE BOV 5440406 22.00 22.00 )9/04 001 HALTER HEAD D 5440509 7.00 7.00 )9/04 001 MASTISOL 5440580 4.00 4.00 )9/04 001 PACK MINOR 5440647 178.00 178.00 )9/04 001 PAD GROUNDING 5440670 9.00 9.00 )9/04 001 PLUG BONE CEM 5440790 285.00 285.00 )9/04 001 BOVIE CORD BI 5441113 9.00 9.00 )9/04 001 STAPLER SKIN 5441223 20.00 20.00 )9/04 001 SUCTION CANIS 5441227 4.00 4.00 )9%04 001 SURGI KIT 5441232 6.00 6.00 )9/04 002 TAPE ZONAS 3" 5441235 14.00 14.00 )9/04 002 GLOVE TRIFLEX 5441551 8.00 8.00 )9/04 002 GLOVE TRIFLEX 5441551 8.00 8.00 )9/04 001 PREP EZ WET S 5441678 14.00 14.00 )9/04 001 TAPE MEDIPORE 5441813 27.00 27.00 )9/04 001 CATHETER COUN 5441916 51.00 51.00 )9/04 001 GOWN SURGICAL 5441973 23.00 23.00 )9/04 001 PLATE CERVICA 5442292 3118.00 3118.00 )9/04 006 PLATE CERVICA 5442292 -8708.00 18708.00 PATIENT NUMBER PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY NUMBER ON ALL INQUIRIES FOR ANY CHARGES NOT POSTED WHEN THIS STATE- AND CORRESPONDENCE. NENT WAS PREPARED. OR IF INSURANCE CARRIERS UNDER ESTIMATED INSURANCE COVERAGE. Page 1 of 8 _?L1NN, M:CFAEL A-Enc #230015979-IPT-AGR-9/4/2007 Blue And White - 9/11/2007 - 1 pg r`_CI PINNACLE HEALTH HOSPITALS PAG E NO. OF ?P DATE OF P. 0. BOX 2 3 5 3 DATE OF BILL BILL PREV.BILL HARRISBURG, _PA 17105-2353. FINAL 9/11/07 717 230=3717 BIRTH-DATE MosP.NO. ?. FZI # 231778644 05 04/6' A J PATIE-47 NAME PATIENT NUMBER ISEX I AGE ADMISSION llATE DISCHARGE DATE DAYS BLINN , MICHAEL 280015979 ?M 43 09/ 4/07 09/05/07 1 GUAR PH: (7171)737-9343 IC:O.B INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER GUARANTOR MICHAEL A BLINN 1 AUTO - USAA 861036 NAME AND 200 HOLLYWOOD CIR 2 BLUE CROSS 361 300 FP80046460 ADDRESS CAMP HILL PA 17011 PEPPELMAN WALTER AMOUNT OF q O VE G E PAYMENT ATE OF SERVICE DESCRIPTION OF HOSPITAL SERVICES SERVICE CODE TOTAL CHARGES EST. COVERAGE INS.CO. N0. 1 ESL. COVERAGE INS.CO. NO N0. . 2 EST. COVERAGE INS.CO. NO. 3 EST. COVERAGE INS.CO. NO. PATIENT AMOUNT 09/04 001 KIT CLEAN OP 5442648 43.00 43.00 09/04 002 SPACER IMPLEX 5443077 7862.00 7862.00 09/04 001 COLLAR CERVIC 5443081 187.00 187.00 09/04 001 CATH SECURE 5446325 18.00 18.00 09/04 002 IV SOLUTION 4120086 48.00 48.00 09/04 001 PACU CASE 4122000 09/04 001 ANGIOCATH 4128057 3.00 3.00 09/04 004 PACU 1/2 HR 4129800 716.00 716.00 09/04 001 TUBING SECOND 4129809 3.00 3.00 09/04 001 IV START 4129818 162.00 162.00 09/04 001 PREOP PREPARA 4129904 423.00 423.00 09/04 001 VENIPUNCTURE 0151500 18.00 18.00 09/04 001 ANTIBODY SCRE 0256012 64.00 64.00 09/04 001 ABO & RH TYPI 0256048 09/04 001 ABO BLOOD TYP 0256049 28.00 28.00 09/04 001 RH BLOOD TYPI 0256050 24.00 24.00 09/04 001 SPINE SINGLE 4142020 81.00 81.00 09/04 001 SPINE SINGLE 4142020 81.00 81.00 09/04 001 TECH TIME UP 4143990 09/04 001 TECH TIME UP 4143990 09/04 001 PORTABLE 4146130 203.00 203.00 09/04 001 PORTABLE 4146130 203.00 203.00 09/04 001 SLIPPERS 4121254 2.00 2.00 09/04 001 BETADINE SCRU 4128017 6.00 6.00 09/04 001 ANESTHESIA CA 4132000 39/04 004 ANESTH SVCS E 4136003 840.00 840.00 39/04 001 AIRWAY NASAL 4136010 23.00 23.00 )9/04 001 CIRCUIT VENT 4136015 7.00 7.00 )9/04 001 HEADREST FOAM 4136023 33.00 33.00 )9/04 001 MASK TRACH AD 4136030 4.00 4.00 )9/04 001 THERMISTOR PR 4136098 198.00 198.00 )9/04 001 THERMO-VENT 4136100 4.00 4.00 )9/04 001 TUBE ENDOTRAC 4136105 5.00 5.00 )9/04 001 VENTILATOR TU 4136110 3.00 3.00 PATIENT NUMBER PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY NUMBER ON ALL INQUIRIES FOR ANY CHARGES NOT POSTED WHEN THIS STATE- - AND CORRESPONDENCE. MENT WAS PREPARED. OR IF INSURANCE CARRIERS DO NOT PAY ANY PARS OF THE AND[niTC sunwl UNDER ESTIMATED INSURANCE COVERAGE. Page 2 of 8 ., ..?., .?1.....n i, 1, n I' . +t C'uu l j71 y-Lrl-[-SV tt-7/4/GVV / 'd- Iue A-la WPit? pQ HCI # PINNACLE HEALTH-EOSPITALS - - PAGE NO. TYPE OF BILL DATE OF BILL DATE OF PREV.BI LL FINAL 9/11/07 1i P.O. BOX x_'53 HARRISBURG, -PA 17105-2353 717 230-3717 BTR.T-I-PA-E HOSP.NO. FEI 251773644 C5/014S4 A S PATIENT NAME 'PATIENT NUMBER SEX AGE IADMISSION DATE IDISC HARGE DATE DAYS BLINN MICHAEL 1280015979 I M 1 43 09/04/07109/05/07 1 v10_'An rn: l/1fi;_? T-7_?' ?i J C.C,B INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER GUARANTOR MICHAEL A BLINN =I AUTO - USAA 861036 NAME AND 200 HOLLYWOOD CIR BLUE CROSS 361 300 FP80046460 ADDRESS CAMP HILL PA 17011 - PEPPELMAN WALTER AMOUNT OF 5 PAYMENT ATE OF SERVICE DESCRIPTION OF SERVICE HOSPITAL SERVICES CODE TOTAL CHARGES EST. COVERAGE INS.CO. N0. I EST. COVERAGE INS.CO. NO. 2 EST. COVERAGE INS.CO. NO. 3 EST. COVERAGE INS.CO. N0. PATIENT AMOUNT 09/04 001 TUBE NASOGAST 4139792 15.00 15.00 09/04 001 SOLUTION LACT 4139797 2.00 2.00 09/04 001 CANNULA NASAL 4139811 12.00 12.00 09/04 001 BREATHING CIR 4139820 5.00 5.00 09/04 001 BACITR VL 7350109 55.25 55.25 09/04 001 FENTAN 5ML AM 7350510 7.00 7.00 09/04 001 GLYCOPY 4MG V 7350579 7.00 7.00 09/04 001 LIDO 10 5ML V 7350742 7.00 7.00 09/04 001 METOCL 10MG V 7350853 7.00 7.00 09/04 002 MIDAZ 2MG VL 7350866 14.00 14.00 09/04 001 MORPH 10MG VL 7350886 7.00 7.00 09/04 001 MORPH PCA VL 7350890 40.70 40.70 09/04 001 MORPH PCA VL 7350890 40.70 40.70 09/04 001 NEOSTIG VL 7350944 7.00 7.00 09/04 001 ONDANSET 4MG 7350995 7.00 7.00 09/04 001 PROPOFOL 20ML 7351150 16.80 16.80 09/04 002 ROCURON 50MG 7351196 154.70 154.70 09/04 001 CEFAZ 2GM PMB 7354695 41,35 41.35 09/04 002 CEFAZ 1GM PMB 7358586 88.30 88.30 39/04 001 SEVOFL 60ML B 7359068 287.10 287.10 09/04 001 OSCAL 500 TB 7350172 3.00 3.00 )9/04 001 ART TEARS BTL 7350652 10.50 10.50 )9/04 004 SENOKOT-S TB 7354697 12.00 12.00 )9/04 001 IV PUMP SETUP 4201740 121.00 121.00 )9/04 001 PCA PUMP SETU 4201741 160.00 160.00 )9/04 001 TRAY PROCESSI 4209807 70.00 70.00 )9/04 001 TRAY PROCESSI 4209807 70.00 70.00 )9/04 001 TRAY PROCESSI 4209808 142.00 142.00 )9/04 001 TRAY PROCESSI 4209809 284.00 284.00 )9/04 001 TRAY PROCESSI 4209809 284.00 284.00 )9/04 001 02 RECOVERY R 4165179 101.00 101.00 )9/04 001 NURSING UNIT 3301235 99.00 99.00 )9/04 001 ROOM 218- 3300001 990.00 990.00 )9/05 002 CEFAZ 1GM PMB 7358586 88.30 88.30 PATIENT NUMBER PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY NUMBER ON ALL INQUIRIES FOR ANY CHARGES NOT POSTED WHEN THIS STATE- - AND CORRESPONDENCE. MENT WAS PREPARED, OR IF INSURANCE CARRIERS nn unr osv nuv vanr nc rvc avnnvr? o„nw, UNDER ESTIMATED INSURANCE COVERAGE. Page 3 of 8 BLINM, MIC3A-L A-Enc '2"0015979-IPT-AOR-9/4/2007 Blue And White - 9/11/2007 - 1 pg HCI # PINNACLE, HEALTH HOSPITALS PAGE NO. TYPE OF DATE OF BILL BILL DATE OF PREV BILL FINAL 9/11/07 1 O. BCY 2353 E: 7:1 HARRISBURG, PA =7105-2353 717 230-3717 BIRTH-DATE HOSP.NO. AEI # 251778044 05/04/6: A S PATIENT NAME PATIENT NUMBER SEX ? AGE ADMISSION DATE DISCHARGE DATE DAYS BLIDN MICHAEL 280015979 M143 09/C4/C7 09/05/07 1 GUAR PH: (71=)737-9343 C.O_H INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER GUARANTOR MICHAEL A BLINN 1 AUTO - USAA 861036 NAME AND 200 HOLLYWOOD CIR 2 BLUE CROSS 361 300 FP80046460 ADDRESS CAMP HILL PA 17011 PEPPELMAN WALTER AMOUNT OF PAYMENT ATE OF DESCRIPTION OF HOSPITAL SERVICES SERVICE CODE TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE PATIENT SERVICE CHARGES INS.CO. NO. 1 INS.CO. NO. 2 INS.CO. NO. 3 INS.CO. NO. AMOUNT 09/05 001 OSCAL 500 TB 7350172 3.00 3.00 09/05 004 TYL #3 TB 7350309 12.00 12.00 09/05 001 MVI THP TB 7350906 3.00 3.00 09/05 001 IV PUMP DAILY 4208087 90.00 90.00 09/05 001 PCA PUMP DAIL 4208088 125.00 125.00 09/05 001 IV OR IPID CH 6290909 25.00 25.00 T 0 T A L S 9660.70 39660.70_ PATIENT NUMBER PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY 280015979 NUMBER ON ALL INQUIRIES FOR ANY CHARGES NOT POSTED WHEN THIS STATE- n Y THIS AMOUNT AND CORRESPONDENCE O O O . MENT WAS PREPARED, OR IF INSURANCE CARRIERS .. nn mn PAY ANY P- nr 'n.r surnnirc evnuv . PINNACLE HEALTH HOSPITALS HARRISBURG, PA UNDER ESTIMATED INSURANCE COVERAGE. Page 4 of 8 3LINI, MICHAE:, A-Enc T281101_5979-I2T-ACR-9/4/2007 Blue And White - 9/11/2007 - 1 pg "CI PIUN__CLE IE_.LT HOSPITAL P- q0 TYPE OF BILI DATE OF DATE OF BILL PREV.BILL FINAL 9/11/07 l; . c.-0 BOX 235? HARR_sBuR:;, PA 17105-2353 717 230-3717 5TPT-H-DATA Has?.ND. FET 0 251778644 v5/(]a/64 S PAT=ENT NAME PATIENT NUMBER ' SEX AGE ALMISSION DATE DISCI LAMOE DATE DAYS ?LIMN M1C.?AIL 28(]015979 ? M143 09/04/0709/0-i07 1 GUAR PH. f717), '137-9343 C.O,H INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER GUARANTOR MICHAEL A BLINN 1. UTO - USAA 861036 AND NAME AND 200 HOLLYWOOD CIR 2LUE CROSS 361 300 FP80046460 ADDRESS CAMP HILL PA 17011 PEPPELMAN WALTER AMOUNT OF g .. PAYMENT 'ATE OF SERVICE DESCRIPTION OF HOSPITAL SERVICES SERVICE CODE TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE PATIENT CHARGES INS.C0. NO. I INS.CO. N0. 2 INS-CO. NO. 3 INS.CO. NO. 41 AMOUNT SUMMARY OF CHARGES R&C EMI-PR 1DAYS@ 990.00 990.00 990.00 SURGICAL 20 2612.00 32612.00 RECOVERY ROOM 1355.00 1355.00 LABORATORY 89 320.00 320.00 RADIOLOGY RD 568.00 568.00 SURGICAL DIAG 25 8.00 8.00 .ANESTHESIA 1151.00 1151.00 PHARMACY 919.70 919.70 MEDICAL DIAG AZ 166.00 166.00 MED/SURG SUPPLIES 1346.00 1346.00 IV SOL/SUPPLIES 25.00 25.00 OXYGEN/RESP AZ 101.00 101.00 NURSING ADM 99.00 99.00 SUB-JOTAL OF CHARGES GUA RELATIONSHIP: S ACC DATE: TYPE: DSC /FINAL DIAGNOSIS: 722.4 ADM DIAGNOSIS: 722.4 THANK YOU FOR CHOOSING SUBMITTED A CLAIM TO T ABOVE. AFTER YOUR INS WILL BILL YOU FOR THE INFORM US OF ANY CORRE HAVE INSURANCE, PLEASE 9660.70139660.70 B STIdE:M rUAR N0PLJCE945030lEMPL RE PINNACE HEALTH. WE HAVE E INSU NCE CAR RI R NOTED RANCE C MPANY PAY US, WE MOUNT Y U OWE. P EASE TIONS. IF YOU DO NOT PAY OR ]ALL TO DI CUSS. C T A L S 9E?0.7.0 3966'?.7Q PATIENT NU}IB ER PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY 2 8 0 0 IJC 9 7 9 NUMBER ON ALL INQUIRIES FOR ANY CHARGES NOT POSTED WHEN THIS STATE- EZT ?I S 7 7 AND CORRESPONDENCE. WENT WAS PREPARED, OR IF INSURANCE CARRIERS yT?10 U N T 0. 00 DO NOT PAY ANY PART OF THE AMOUNTS SHOWN PINNACLE HEALTH HOSPITALS UNDER ESTIMATED INSURANCE COVERAGE. HARRISBURG, PA Page 5 of 8 E C 4 J) xklbl ?: -Bo_ 756 - 10i13%? U DE A L _i;i.i 'f PE OF I OA7E GE. I JA2E.. OF 77E-7-11 . BCCL I dLLL PREY. dI LL - _ I_ / X06! F, __ -- --------------- _ ._ 40SP .N0. FAT_:ENS NAME j?AT; E97 ,xvEER 1s Fx ? AGE ? AONISSION DA:iS DISCHARGE i:A-E I DAY: ?_V 2?6 375^y' 140 ; 10; 13 C.O.B INSURANCE COMPANY NA4E GROUP NUMBER i PGLCY NUMBER N A?Jy+n NJ J HOLLYWOOD CIRCLE i.. ?? AODRESS = ? 7011 ? 301 PF3G0454cC FAJAR.DO AMY M AMOUNT OF S PAY MENT ATE Or SERVICE DESCRIPTION OF I SERVI HOSPITAL SERVICES CO . ES - EST. ^OVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE PATIENT INS.CO. NO_ I INS.CO. NO. 2 INS.CO. NO. 3 INS.CO. NO. ANOUNI OETA L CF CURRENT CHARGESN ADJUSTk!E ITS 10/13 KETOROLAC 60MG 01442 T .55 3.55 '0/1 3 DERMABOND 01141 7 7 .75 87.75 10/13 C-SPINE/LIMITED01365 .00 327.00 1C/13 LEVEL III FC 01171 .00 44500 3 THERAPEUTIC INJ01171 .00 71.00 EALA,IC E FORWARD 1 0. 00 SUMM.?RY OF CURRENT CHARGES PHARMACY 250 3.55 3.55 M/S SUPPLIES 270 87.75 87.75 DX X-RAY 320 327.00 327.00 EMERGENCY ROOM 450 445.00 445.00. CLINIC 510 71.00 71.00 S;JB-'OTAL OF CURR. CHARGES 934.30 934.30 DIAGNOSIS: 873.20 V71.4 PAYMENT IS DUE UPON RE EIP'T OF THIS STATEMENT. YOU MAY SUBMIT THIS c0 M TO YOUR INSURANCE CARR ER FOR REIMBURSEMENT. 0 1 ' S A. EITI N'.1MBER PLEASE REFER TO PATIENT ADDITIONAL PATIENT OI LGINC NAY BE NECESSARY f I. ,? y NUHDER GN ALL INQUIRIES FOR ANY CHARGES NOT POSTED WliEH THIS STATE- AND CORRESPONDENCE. REM' WAS PREPARED. OR IF INSURANCE CARRIERS i ?1 T ` I ^ U =i ?J IJ DO NOT PAY ANY PART OF THE AMOUNTS SHOWN L4 O L f S P I R I T H O S P I TA.L UNDER ESTIMATED INSURANCE COVERAGE. CAMP HILL, PA ?g631 3 G9 'G U39 :i'S _ ?J /7C PAT-ENT CUTPO:. NC J rJ 2 JT _ - 0 1 _ °E7. :A% !IC ^ROl - , ^7R4J4H 7 '01 ?. B N-c D. L 11 !-R f - 3 - v 12 7 _ __ r _ rl_ PA-:ENT NAME ?AT:ENT A."DRESS i _ 7 J ? :JT ,(,.D 7 _ ]i '16 i :.: ;.` ADMSSSICb2y. ' 2Ur. ;I HR U 17 i11 R--HDATE ?' 23 MEDICAL RECORD NO. CONCfT? )N-.:CODES -;i 31 O o 61 t M 101300' 19 01 183535= I 000L'2RENCe !_ < + •• '.34- DCCURRERCE'•': - + 76 OCCURRENCE SEAN 7 CU E I- CATE CCUE I FRCS I rP, RCU GH AI I of I O11 _Oi3Co" ? b ici 1 SZN'3 _A A BLI. NN O9DVALUE `ODES +] YMJE CODES 7U4 ,OpE OUhT 200 HOL7',",1CCD CI°•CL 9 1r0 ^_ 1800 C.yI1P HILL PA 17011 5I i ?I i I I 12 REV.CD 43 DESCRIPTION 44 HCPCS/RAES I.,1 SERV.DATE 46 SERV.ON ITS 47 TOTAL CHA-ZCFS 1D NJ4-C!i ?'J'l IRJS 19 ] 27 1, STERILE SUPPLY 101306 1 2 . r Liz x - P ri l -, -, , _ , - 4 l? ,M D „ l lll3p^ _ _ [ ? ` 5 6? _ ?? J!? ?T?I C J ?3? y s H , i r ,t I 1 I 21 00 TOTAL CHARGES 934j30 50 PAYER 51 PROVIDER NO, 54 PRIOR PAYMENTS a SS EST. AMOUNT DUE 56 A AUTO INS Y Y I 9341 O B -0 0. J 57 000028637569 M8IHOSG i •a 73 I I 58 INSURF.D'S NAME s e.RtE 60 CERT. - S5N - "IC. - ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. A BLINN,SANDRA A 18 a BLINi1.,?4,ICfi F Ji PEe??C464cC 1 7Q504o25 63 TREATMENT AUTHORIZATION couES 5 EMPLOYER NAME 66 EMPLOYER LOCATION 1 r AKWOOD BAPTIST DA CHESTNUT ST CAMP HILL PA 17011 , LIy_i _C,. ?.? HOST11S, _;-j r_L 67 PRIX DIAG c : _:".... :. ..: .- ...._-_.- -. _..:. OTHER. MAG . . • L•I4?-- D COPE - :,n :'.'.IZ CnU( "'--'4 ^CtI F,? - 76 ADN.DIIG. CD 77 E-CODE 70 873 0 8470 920 v714 r8 20 l9 P. BU PRINCIPA COUE L PROC EDUf2E + - • + _' ---- - -- K DATE 8]- VII3FR C-R'CEDIJRE (i?-.AL7ElTitNCI pHyp•yLBD4? 0 9 4 L 2181 1013061 FAJAR DO AMY Psi ::_C• -OTHER PROf.EDU[!E :. :; :; ' + + •i .. ".9TH..R'$ROCKUURk -- - .. l nATF .. ..+ : ?.:. .; .... .. '..'.:' F]3. OTiffR::PHY°.??[J+i B; O C "AJARDO AMY M 84 REMARKS ' ' r THLA Hi•fl. tel : 1Ul PAJV:DE? RE['RfSEtR'71T1': E. HDAI=. ?( _ L OP1 L J 0 G U C• o ..r to -- PAYER COPY ??_,.?•. ?-- _A.-- T-SE-L';;,-?.--,_.,.7 -AR; (^ ;Z.: j USAAINSURANCE PO BOX 569466 SAN ANTONIO, TX 78265 13: /I W h rr HEALTH INSURANCE CLAIM FORM PICA I MEDICAID CH.M PU3 CHAMPYA GROUP FECA OTHER ta. tNSUAED'S I.O. NUMBE.q PROGRAM :N ITEM t) 7 3861636 1 7 f`UPdkAW 0 rSpdit-es ssr4 (VA Atr (S-W a AD) .7 1 P IE.T'S' NAME (Asst Nam., Rn t Naar. Mdd. trAM 3. PATIENT'S GIRTH DATE SDC 4.:NSURED'S NAME tsti Nuns, Fret NuIR MIddY 1,03 BLINN, r SANDRA 03 M C8 X1966 M F X SAME 15. PA71ENT'S ADDRESS (No., Strsat) S. PATIENT RELAT)ONSFIIP TO INSURED 7. INSURED'S ACCAESS (No., Str.N) 200 HOLLY1JV000 CIRCLE ?rI? ? oe?? Crry STATE 0. PATIENT STATUS CITY BTATE Z CAMP HILL PA X B ? ? C coDE TELEPHONE t Ane Cade) 21P CODE 7ElEPHONE pNCLi1E AREA CODE) 17C11 1717 )737-9343 ?? ? Sk9lorl 1 1 / Q ER iNSi/RED'8 NAME (Laq Nsrtr. First Name. MWOY 1nIW11) 10. 19 PATIENTS tXNiDDT1pN RELATED TO: I I. WSURED'S POLICY GROUP OR FECA NUMSEA z NONE - E ' yQ 7 R iNSURED 8 POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) V a. INSURED'S DATE OF BIRTH cc (? YES I INO Ex yM OD i YY M ? F ? b-OTHEA INSURED'3 DATE OF BIRTH ?-J Z St7f b. AUTO AC NT? A,? may) CIIDE b. EMPLOYER'S NZE OR SCHOOL NAME MM i 00 I M F ( ? I "' U YES 0140 1 P Q C. LM LOYEWS NAME OR SCHOOL NAME c. OTHER ACCIDENT7 C. INSURANCE PLAN NAME OR PROGRAM NAME 0 YES El L F- d. INSURANCE PLAN NAME OR PROGRAM NAME 10.1. RESERVED FOR LOCAL USE d. t9 THERE ANOTHER HEALTH fiENEFTT PLANT Q YES IA ^ I NO H yrs, MUM to and CvVW* Item 9 .-d. READ BACK OF FORM BEFORE COMPLEMM i SlaNWO T143 FORf1. 12.PA71ENT`S OR ALITHORIZE0 PERSON'S SIGNATURE I auVvLze the release of any medical or o0W lMorrtaUn 13. !NSURED'S OR AUTHORIZED PERSON'S SIGAATURE I suUbAxt t Y l r sary to Process this cWm. I also rsgL" payment of gov "mant banaitts either to myself or to the parry *W t ee" psyrnem rYNd cal beneilu io the undersigned p Jelan or suppller for services wecrlbed below msM Wow. . D DATE SIGNED 14. lDATE OAF pCURRENT.- ILLNESS /(?oprdg6.ny?m?) OR ' R ?ff Y 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE //Y DD YY I& DATED PATIENT UNABLE TO WORK IN CUAAENT o=PATDN MM DD ri O 1 T J eO 6 PREO N lAlf'? -1 i i i i yy i D i YY FROM TO 17- NAME O REFE31FUNG PHYSICIAN OR OTHER SOURCE SE!.F?REFERRAL 17e- I.D. NUMBER OF REFERRING PHYSICIAN SLF000 18. HOSPfTA1JIATICN DATES RELATED TO CURRENT SERVICES FROM MM i DD i YY MM i DD ? YY _ TO q Uy£D?pB l M?1 b?LL A Mt 1 f1UU 4 - USE 20. OUTSIDE LAB7 $ CHARGES L 11 YES El NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2.31 OR 4 TO ITEM 24E BY LINE) 22. D RESUBMISSION M V3.20 WOUND, NOSE C OO ORpINAL REF. NO. rYk9 JAW PAIN 23. PRIOR AUTHORIZATION NUMBER 2. <.I_. 4. L?. r 24. P.• A B C D E F 0 H 1 J K 2 L:ti OATE(5) OF SERVICE From To p? A Type of PROCEDURES. SERVICES. OR SUPPLIES (Elrptsln Unusual Ctrwmstaron) DLAONCSiS I CHARGES DAYS OR EPS(r O RESERVED FOR My •) DO YY MM OD YY Sarvln I(?fstlt3E COQ UNrTS fendPYn EMG COB LOCAL USE Q 10 913 2,006 10. 13 2006 I 1 f 41 9A; A0429 SH J 1+2 I 390 00 1 ES t . ir 0 10 N13 2006 + ' 10. 13 2006 I 41 9A . MILEAGE A0425 SH i 1'2 1 45 00 6 ES X - z I 1 i . I to 1 I I I I 1 I 1 O ' Z 1 I Q ? I ' V I , i 1 N CL 25. FEDERAL TAX I.D. NUMBER SSN EIN 2: jj 389823 21 PATIENT'S ACCOUNT NO. 27. ACCEPT ASSXINMENTT 06-56641 Ic'1 dXj^p• ass, tom) 2t. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE 435 00 00 1 a Y- =NO . s I 0.00 435. t s 31. SIG RE OF PHYSICIAN OR SUPPLIER INq IDING DEGREES OR CREDENTIALS {1 ter•Jl th 32. NAME AND ADDRESS Of FACILITY WHERE SERVICES WERE Fro?rr`•NDLiGFtTt3kt` NI 'AZ'CWI??Dtsl M. PHYSICIAN'S, SUPPLIER'S BILLING NAME. ADDRESS. ZIP CODE ? Pf ri/1:R SP I y at V" sUlsments on 04 reverse R NG AMBULANCE 81 RESC :ppy w this bill and are made s put th.reot.) MECHANICSBURG, PA 17050 P.O. Box 726 717 214-6018 Connie Stone 11/08!2006 To: HOLY SPIRIT HOSPITAL New Cumberland, PA 17070-0726 CAMP HILL, PA 17011 23-7389823 23-7389823 In t4?D PATIE IGPP/ IlServerlViescvaNa:bi[II u+cieTSOOPAI.rpt WPROVEO Uy AMA CDUNC IL ON MEDICAL SERVICE &S8t PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM CMS-1500 (.Vb0)• FIDRM FLR9-1500, WHCFA-15DOCSNM (M5) APPROVED OMB-1215-OG65 FORM 0WCP-1500. APPRrwFnrsMB-U)20-0001 ICN.WPUS PLEASE CO NO STAPLE !N THIS AREA 'x1PICA C7-M1135847 USAA APPRCVED NS-0338-0098 00 BOX 65 94 6 6 SAN ANTONIO T'ri 76265- LU U HEALTH INSURANCE rL AIM Fna.n r? ?s- MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA HEALTH Pair Ut LUNG- OTHER PL tat INSURER'S I.D. NuMBE.R (F?,,R PSOG RAM .N ITEM !I (Madtcare /) F IC) (Medkis d S) (SporLsor'S SSNj (YA FJe I) (SIN of ISSN) E (10) 2. PATIENTS NAME (Last Name, First Name, Middle ihlltal) ' PATII R c SEX 4. fNSUREO'S NAME (Last Name, FL-A Name Middle At) BLINN 5ANDf?A A M 00 , 0 08 1966 M F , j 5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (Nc., Street) 200 HOLLYWOOD CIRCLE saifMspotrseDchd[j other0 CRY STATE 8. PATIENT STATUS CITY STATE Z LL C AM' P -HILL PA single0 Married F] OCer © C ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLLOE AREA CODE) 4 17 011 L C 17 ) 7 3 7 - 93 4 3 Employee ft a-Time 11 Par1•TimeO ) Student Student C RED'S NAME (Last Name, First Name, Middle tnldao 10. IS PATIENTS a 11. INSURED'S POLICY GROUP OR FECA NUMBER LL Z REO'S POLICY OR GROUP NUMBER e. EMPLOYMENT? (CURRENT OR PREVIOUS) e. INSURER'S DATE OF BIRTH SEX CLLI C DYES ?0 LJ MM i OD i W M? F RED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PUCE (Stale) I I b. EMPLOYER'S NAME OR SCHOOL NAME Z p W I M F L YES D o P• A I EIPLOYERS NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME ?YES fqO USAA LAN NAME OR PROGRAM NAME 10d, RESERVED FOR LOCAL USE d. 1S HERE ANOTHER HEALTH BENEFIT PLANT Q a ?YES ® NO 11 yea, retum to and complete horn B a-d. READ BACK OF FORM BEFORE COMPLETING 8 SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize ea rates" of any medca) or other Information necessary 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE 1 authorize f to process ;ids claim. I also request payment of government benefits either to mysed or to the parry who accepts assignment parr enl o medical benefits to the undersigned physiden or supplier for Services described below. below. SIGNATURE ON FILE 10 26 2006 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURAxENT: ILLNESS (First symptom) OR OR Y ?? 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST GATE MM DO YY 18. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM 1 OD 1 YY MM OD YY I V O 6 PREGNANCY(LMP ! i FROM TO 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM t DD t W MM I DD I YY FROM r TO r 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES DYES aN0 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 847 739 2 O 3. L-_ . 23. PRIOR AUTHORIZATION NUMBER 7( 37 ZQ 847 1 2 . . 4. (. . 24. A B C D E F G H I J K z DATE(S) OF SERVIC From ETo Place Type PROCEDURES, SERVICES. OR SUPPLIES DIAGNOSIS DAYS EPSD - RESERVED FOR 0 !dM OD W MM DO YY of Se al . ervi (Explain UnusualClrcumstanCas) CPTMCPCS MODIFIER CODE SCHARGES OR UNITS F ly Plan EMG COB LOCAL USE of 101$2006 ; 3 l j 99205 1 Il 2 3 4 ! 200 b0 001 2i ,x 0 10182006 11 I 1 t 97750 jl 2 3 4 I I ' 40 b0 00 LL w 10192006 i 11 1, I 99219 5 j ? ? 1 2 3 4 ( I I 75 b0 J a 1 001 n ! ( ( i to I I t l I I I I r ? . ? i ' ? I t t i cc z I t I r ? l i + i I ? Q I I I I I I I _U N I Y I 1 I I 1 I I 1 ( 1 j l I O. 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT1 For grn2 ims we back) 28. TOTAL CHARGE 2g. AMOUNT PAID 30. BALANCE DUE 232248610 102729-135847 , YES NO S 315 QO 0 QO 31 5100 s , s 31. SiGNATUR F PHYSICIAN OR SUPPLIER 32. NAME ANO ADDRESS OF FACILITY WHERE SERVICES WERE cLU"? 0 RE ES OR CREDENTIALS RENDERED (If aher thin borne or office) 33. PrH?YSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE ,g ;t I 1 B (I c R n W C , ZAR I NS KIr D.C. pr to 1" e I .) 3028 MARKET STREET SUITE 91 RORER --C. IN K 10 o? I CAMP HILL PA 17011 2775 O SIGNS pA; N GRPr (A"VHUVLU 8Y AMA-ZUIINCIL ON MEUICAL SERVICE Nab) PLEASE PRINT OR TYPE FORM CMS•1500 (12-60), FORM RRB-1500. Mid. by MecLCel Arty Fire-" FORM OWCP-1Soo Can tai free: 1-aoo328-2172 P intod on Recycled Paper se Ih Enve elpe R Arts 14145 (,gummed) ar 0 14148 (soh-seal) PLEASE CO:NCT MVA STAPLE IN TkS AREA APPRCf/Q aMEI-n9?,&,O^CCH UJJA 3 8cG'-I(p -3 W 4 PO BOX 6594E6 1Gf ?? r7 d SA,v ANI TI CNIO , -- X 78216 5 " {9? -? LU r o: ( U I PICA t'aVALli9 1014UP'{AMUt t.i..AU'd FCRVI jj Lrl I (??Y •{I? PICA '. MEDICARE MED:CAJO CHAMPUS CHAMPVA GROUP FECA OTHE R; +a. iNSUREO'S I.O. NUMBER $0A PROGRAM iN REM 1 ) ;'?? HEALTH P+1N BLt LUNG 4 [7 "... "U jAlk:dkjJd (1--ceI =,o Q (VA PYa (SSN W r0j (SSN) up) 3 8 616 3 5 , 2. PATIENT'S NAME (La:t Nar_ Flru Name, MIdWo Inhlall 3. PATIENTS BIRTH DATE . sex 4. INSUREDS NAME (Leal .Nar_ FirA Norm, Mkxf. dR1) BLINN, SPTdDRA 65 i08 ;1965" F X BLINN, SANDRA S. PATIENT'S ADDRESS (No. Slr"j RELATIONSHIP TO INSURED 4. PATIENT 7. INSURED'S ADDRESS (rfa., Sueet) 200 HOLLYWOOD CR ? S.I xsoora?cl?«>x+? ? NT 200 HOLLYWOOD CR. CITY STATE IIEN T STATUS Lk PAT CITY VAT.- CAMP HILL I PA Sir& VArnad-1 00e111 1 JJ CAMP HILL -PA ? ZIP CODE TELEPHONE (Irlduda Area Codo) ? ZIP CODE TELEPHONE (INCtUDE AREA CODE) C 17011 000-0000 F s 17011 000-0000 a 9. OTHER INSURED'S NA:JE (Las! Name, F zi Name, MkOa Intlal) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER C W a. OTHER t.NSURED'S POLICY OR GROUP NUMBER a. EMPLOYMEtfT? (CURRENT OR PREVIOUS) a. INSUREDSS DATE OF H:RTH SEX YY M M DD C ? YES a NO U ; M a F? i a P ' 5. OTHER INSUREFS DATE OF WRT F1 SO( e. AUTO ACCIDENT? PLACE (State) h. EkPLOYER'S NAME OR SCHOOL NAME ' Q MM ( DD YY IM F ? YES NO r7 G t. EMPLOYER'S NAME OR SCHOOL NAME C, OTHER ACCIDENT? a INSURANCE PLAN NAME OR PROGRAM NAME ? YES a NO USSA W S- e. rNSURANCE PLAN NM E OR PROGRAM NAME IOd. RESERVED FOR LOCAL USE If. IS THERE ANOTHER HEALTH BENEFIT PLAN? Q a X ? YES NO d yca, rW+m to en0 mrt+Gato itCm 9 0-0. READ BACK OF FORM BEFORE COMPLETINO 5 SIGNING THIS FORM. 13. INSURED'S CA AUTHORIZED PERSON'S SIGNATURE I aulhorlta 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Informatlon payment of medical benalits to the undersigned phys$dan or suppger for necessary to procass this claim. I also raqual payment of govommant benellts either to myself or to the party who accepts serAces described below. a=Ignment t4!o r. 27 SIGNATURE ON FILE I SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT, IL.3.NESS (Fr= vM4*om) OR 15. IF PATENT HAS HAD SAME OR SMdLAR ILLNESS. 10. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION INJURY (Aoc:dcnt) OR 1 ,( X (6 PREGNANCY (LMP) GIVE FIRST DATE MM 1 OD I YY i r MM I 00 r YY MM OD I YY FROM C i TO i '- r7. NAME OF REFERRING PHYSICIAN OR OTHER 90URCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 10. HOSPITALIZATION DATES RELATED TO CURRWSERVICES ZAB INSKI ROBERT C c T27628 MM DO , r YY MM r DD YY FROM i r TO i r 19. RESERVED FOR LOCAL USE 20. OUTSIDE UB? S CHARGES S ? YES ? NO ??Q{ 21. DIAGNOSIS OR NATURE OF ILLNESS OR IhLlURY. (RELATE ITEMS 1, 2 3 OR A TO ITEM 24E BY tJN7 22. MEDICAID RESUBMISSION _ t[ + 9 5 9 O 9 f 1 L 3 ? CODE ORIGINAL REF. NO. ?- - - 23. PRIOR AUTHORIZATION NUMBER 2.1721. 0 4.L- 24. A B C D E F C H I J K DATE(S) OF SERVICE From To Place of Type of PROCEDURES, SERVICES. OR SUPPLIES (Explain Unuaual Clrcumatancea) DIAGNCSIS S CHARGES DAYS OR EPSDT Famil EMO COB RESERVED FOR a MM OD YY MM OD YY Sowlce samce CPTAiCPCS MODIFIER CODE UNITS y Plan LOCAL USE - Q 104181;06 10/18/06 11 72052 1 2 170;00 1 a , LL 10418/106 1071BA06 11 70160 j 1 2 701 00 1 2 , 0l w I J I a 3 i i i i 1 I 7 i I Cn Cr 4 i a x c 5 i U - in I B r I I i i 0. 25. FEDERAL. TAX I.D NUMBER SSN EIN 28. PATIENTS ACCOUNT NO. 2'.. ACCEPT ASSIGNI(ENT7 2 6. TOTAL CHARGE 23. AMOUNT PAID 30. BALANCE DUE 134269349 X 145689 A92 Far pot cG.?, ree bank) X YES =NO s 240 100 $ 0 ;00 s 240 ;00 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 3 _ 3. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDR.E55, LP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED (It other "n nor" or otf ce) 8 PHONE wruy to crcb?-rr-b On. A Oro =do 11ef ftfc atY}Y to 1? tr I rs aro nutla a W thtrcoi) WSO IMAGING CENTER, LIP , WSO IMAGING CENTER, LP , DAVID GREENBERG MD 405 ST JOHNS CHURCH ROAD 2527 CRANBERRY HIGHW 11/06/06 CAMP HILL PA 17011 WAREHAM MA 0 2571 134269349 1 SIGUEO DATE P IN! ?CRP! (wP zoven BY AA AA COUNCIL Off MEDICAL seRwCE 8.7-9) PLEASE PRINT OR TYPE FOP.M FORA I OWC ?CFA P. I I WO WO (12-oil FOR. PA., 1500 W)-1 SCbCS-90 ($Q,93) PLEASE GC NOT S ;.APL IN THIS AREA P'CA USSA PO BCX 659466 S;.N AN70NIO, TX 78265 HEALTH INSURANCE CLAPO FORM APPgGF_ D OMB•0938-0008 4 x y g a U P!CA ry .. MECJCARE MEDICAID CHAMPUS CHA)APVA CACUP FECA ?TH ER !a. INSUREDS I.D. NUMBER IFCR PRCGRAm IN rrEm t) r HEALTH PLAN 8:J( I= I SSN ? G =+n n? xc-H S VA F? 0 kt s 0 3 86 2 63 6 Wn I ) ( n I ( z . or r n I rs:.+n nD 1 l 2. PATIEN-I S NAME (ln:t N=w, Fira Name, Wdde =!ao 3 PATIENT'S BIRTH DATE SEX N. )NSURED'S NAME (Last Nano, FlIsl Name, Mescla ") BLINN, SANDRA 63 ;0"9 :1l 664 F X BLINN, SANDRA 5. PATIENT'S ADDRESS (No.. Slroct) S. PAT RELATICNSHJP TONSURED Oc 7. INSUREDS ADORESS (No.. Strad) 200 HOLLYWOOD CR - ; ? W 1S sw , 0,. ? U 2 00 HOLLM)Ob CR I L`TY STATE I 8. PATIE STATUS CITY STA c CAMP HILL PA A F-] F CAMP HILL PA F F XF CCOE TELEPHONE ()r»? Arta Ccdo) ZIP CODE TELEPHONE (INCLUDE AREA CODE) 17011 000-0000 ,,Ea?? 17011 000-0000 C Swart OTHER INSUAED'S NAME (I.Jst Name, f7rL1 Namo. Ma'1db 1n1L-.Q I 10. S PATIENT'S CONDITION RELATED TO: tl. INSURED'S PCUCY GROUP OR FECA NUMBER u 2 ` 9 a. OTHER INSUREDSS POLICY OR GROUP NUIVJ)ER a. EMPLOYMENTS (CURRENT OR PREVIOUS) a. INSUREDS DATE OF BIRTH 9 LL o YES NO SEX MIA ( DD i rr M a P _ V 2S r b. OTHER INSURED-3 DATE OF BIRTH i gE,y b. AUTO ACCIDFJNTT PLAGE (St to) ta b. EMPLOYER'S NAME OR SCHOCL NAME C N i MM ; OD ' YY M F ' ?y? I ") YES NO L_J u a c. OWPLOYERS NAME OR SCHOOL NAME a OTHER ACCIDENT? C. INSURANCE PLAN NAME OR PACGRAM NAME F" YES NO 1:1 E? US SA W H b. INSURANCE PLAN NAME OR PROGRAM NAME 10d RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PUNT a ? YES [:?] NO H you, ratum to and OMPIMs Item 9 ad. READ BACK OF FORM BEFORE COMPLETING A SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSONS SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSCN'S SIGNATURE I authorize the release of any medical er other Information payment of medical benefits to the undersigned physician or supplier for necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts services described below. assignment below. SIGNATURE ON FILE ?IGNATURE ON FILE I SIGNED DATE s1GNE d 14. DATE /OFF CURREMNT: a LLNESS (Fl¢t.yraptom) OR V6 INJURY (Accicant) OR 10 ?C8 ?/ IS. IF PATIENT HAS HAD SAME OR SIM:LAA ILLNESS. GIVE FIRST DATE MM r DO YY 18. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM r DO r YY MM DO r YY V t ( ( PREGNANCY (IJNPI ; i FROM TO t7 NAS:E OF REFERRING PHYSICIAN OR OTHER SOURCE 170. 10 NUMBER OF REFERRING PHYSICIAN )B. HCSPITAL'ZATION DATES RELATED TO CURRENT SERVICES ZABINSKI ROBERT C T27628 MM Do YY MIA OD YY TO FROM 19. RESERVED FOR LIDCa1 USE Zfl. OUTSIDE LAB? S CHARGES YES ? NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITE.S 1.2. 3 OR A TO TIENI 14E BY UNE) Z2. MEDICAID RESUBMISSION 9 5 9 19 CODE ORIGINAL AEF. NO. 3.1 , 23. PRIOR AUTHORIZATION NUMBER 2.(?___. _ 4.1_.. 7 24. A 8 C D E F G N I J K Z DATE(S) OF SERVICE From To P:m of Type of PROCEDURES. SERVICES, OR SUPPLIES (E gTt3m Uraruol QmunrVanoes) DIAOGN ODE OSIS S CHARGES DAYS OR EPSOT Famy FLAG GOB RESERVED FOR 0 P .V!A DO YY f: U DO YY ScWto SOP&* CPTA4CPCS MODIFIER UNITS Ilan LOGY, USE 10/18/;06 10118106 11 72072 I 1 100; 00 1 0 r LL r r r , r ? r ? r W r r J r In I i IY 0 U I ? r r r I ? :C ' ' 25. FECERAL TAX I.D. NUMBER SSN EIN 28. PAT!ENrS ACCOUNT NO. 27. ACCEPT ASSIGNMENT7 2 8. TCTAL CHARGE 20. AMOUNT PAID 30. BALANCE DUE 134269349 X 145689 A92 FOt govt. C1a M. see back) YES NO s 100 00 0 00 100 00 ; $ f 31, SIG14ATURC OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS I ' 32, NAME AND ADDRESS OF FACIUTY WHERE SERVICES WERE 3 RENDERED ?1 other lhan home Or once) 3. PHYSICIA.YS, SUPPLIERS 81 LING NAPE, ADDRESS. ZIP CCCE P 71E r ( camfy dial the cta!emenUOn the rovor- WSO IMAGING CENTER LP SO IMAGING CENTER LP apply 10 this d3 and are nude Open Ihoreol.) , DAVID GREENBERG MD 405 ST JOHNS CHURCH ROAD 2527 CRANBERRY HIGHW 11/46/06 CAMP HILL PA 17011 WAREHAM MA 02571 3rf.'rVED DATE PI 134269349 NX GRP7 (APPROVED BY AU COUNCIL ON MEDICAL SERVICE 8.138) PLEASE PR11VT OR TYPE FOW HCFA•1.AA (12-9c) ronu owCe rSCO rOPel nee +5m WHCFA-1500CS170 (t Ord3) - - -- 0]563-6 P19TCF0101001C01U / STATEMENT OF ACCOUNT (1) N Statement Date; NOVEMBER 22,: U CAMP HILL EMERGENCY P1711 IA PO BOX 13693 ACCOUNT NUMBER! PHILADELPHIA, PA 19101-3693 f CUENTAS DEL PACIENTE: HYP28537569 (?J Tax 1D # In A '73dA 111111Lrrlilrr????lirrtllrrl,itlLrtrlrllrrrllltrriLrr„!!rl U AA4 BWNJFDB 000028637569-06 3 Bc0163? #0000000HYP247315# SANDRA A BLINN ?4 )t 01= AL4aC4 200 HOLLYWOOD CIR 10/151"t, CAMP HILL PA 17011-2627 C1Aim Account Detail A=unt 3alanco: $1,319.00 Amcuni Pending Insurance: $0.00 Amount Due `tom Patient (Current): S1,019,CO Amount Due from Patient Past Duel $0.00 PayThls Amount: $1,018.0 PLEASE REMIT PAYMENTBY "PAYMENT DUE BY" DATE, THANBY CU. Please refer to coupon below forpwlrnsnt Ina tructions. PATIENT Nw By Pall By Pall By Anwurd Due From RALOCE pole G FkVins, W rIns. Prtlwd Adustsd Iruuranoa 10117106 I 99234-23 EMERO INJURY EVAL d 5641.00 SdOMT•LVLI D)C920. DR. FAJARDOMOLY SPIRIT HOSPI AL 10113106 2 ' ._.x111 WOUND REP 0.2.SCM NOSE 7.435.00 ? _ - 174[hi iKinri?OrHOLYoNILCHu r'fAL"-- - -"' -?- 1010M 3 94760.26-26 NONdNVA&VE PULSE N3.00 OXIMETRY - DX 673.%O M FAJARDOMOLY SPIRIT HQ AL THIa STATEMENT MAY NOT REFLECT ANY P YMENTS YO MADSATTI OF s1:R4icE Totals 51,019.00 10.00 $0.00 10.00 10.00 30.00 17.019.00 iroporidni 1Y7UZ4dytlSS u noen0j rsMW hem an EtrNrpener Pi+YSlctan of Hdy 6ptrt Ho=e TM fNa ra thr prlvab pftys?an Thb atatsmwd is for 6w &sd treatment ardlot s °ecv6 11, w billed separately (torn arty hasptsl rl+a or odwr mftubna aa for icll you may abo W rap°rtabla lherelcrs. thouN yov »ceM a bd han tha losptat or other physk:fus fof cNT" In oonnadlon w0 this As AL It sr01 nor k+duds the bms bbd on Otis staWwd "Payment Plans" Accepted 1 Aceptamos "Planes de Pago" Question about this statement? / Llame de Lunes a Ylernes? Call 1-800-355.2470 Monday through Friday 9:30AM -4:0013M. Your automated system access code Is 801-28637569, or you can send email to billing questlons@omcare.com. Please datach'and r6furn bottom portion with your remittance. Favor de separar y mandar la parts de abajo con el cheque. 440 SANDRA A BLINN 200 HOLLYWOOD CIR CAMP HILL PA 17011-2627 YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD PLEASE SEE REVERSE SIDE. Make Check/Money Ordor payable to: STATEMENT OF ACCOUNT Statement Date: NOVEMBER 22, 2006 ACCOUNT NUMBER/ CUENTAS DEL PACIENTE: H 8637569 Patient Name: SANDRA A BLINN lrrJll,LilltlllittttttlLrllttllrrltltrtrllrlttrll CAMP HILL EMERGENCY. PHYSIC IA-...'. PO BOX 13693 PHILADELPHIA, PA 19101-3693 Payment Due By/ FechaDo Vonctmlento: 12113106 Amount Duo/ Paguo Fsta Cantldad: $1,019.00 Amount Enclosed/ Cantldad Pago: PROMPT PAY DISCOUNTED BALANCE ; S 511.40 Insursnoa W matlon not on rk If your address has changed, check this box 40% Discount Offer and complete the reverse side of this form. Any balance not applJed to your Insurance carrier deductible, 13 eligible torapromptpay -- -------. - __. __-.. _ ---- dismunt. =r SASE ? • ?C NOT STAPLE I IN THIS A?EEA ?. APPRCYE CMEI-09:3.OC06 USAA ., / (40 ± ,PO BOX 6594 66 SA-N ANTONIO, TX 73255 HEALTH INSURANCE CLAIM CORM ?P,ca;7 ^ v MY MEDICARE MEO'!CAID CHAMPUS CiIAMPVA GROUP FECA OTHE R 1s. INSUREO'S I.D. NUMBER IfCpt 7f?CGRAM IN ITEM 1) HEAL ?;? » n? IAfadhjlR n (SOa+edl. ssro ? /VA FJe n fSSN TH or ID) PLAN E] W IJ")NB 138616367101146836 2. PAT!ENrS NAME ,Laa! Nuns, FTral Name, Middle Irdtlaq 3. PATIENTS BIRTM DATE SEX 4. INSUREDS NAME (tlst Name, Fire Name, Middle Irar) I BLINK SANDRA 03 09 I1?66A F X BLINN, SANDRA 9. PATtEN78 ADDRESS (No., S•uw1) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRES3 (No., Street) 200 HOLLYWOOD CIRCLE »??? otner? 200 HOLLYWOOD CIRCLE IX 1-1 STATE it. PATIENTSTATUS CITY STATE z CAMPHILL PA slm.F-1 MaMed7 om.r1 1 L CAMPHILL PA ° ! %,P CODE TELEPHONE (ledude Area Coax) ...' ZIP CODE TELEPHONE 715CLLDE AREA CODE) 17011 71 737-9343 Fjv"? F ?sao"y7 17011 717 737-9343 a sklowi LL ,% 9. OTHER INSURED-3 NAME (Last Name. First Name, Middle In'L%Q 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S PCLICY GROUP OR FECA NUMBER 2 p W a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSUREO'S DATE OF BIRTH SEX Ix ? YES © NO MM DO , YY M ? F a z o. OTHER INSURED'S DATE DF BIRTH SEX It. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME p MM I OD I YY M F 1 f YES ? NO L7 u Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDEN 7 © NO c INSURANCE PLAN NAME OR PROGRAM NAME USAA 1{{...... ? YES Q 1. INSURANCE PLAN NAME OR PROGRAM NAME !Od. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PL,AN7 D. YES 1E NO '11).M ntum 10 and do'^pisle hum 9 ad. READ SACX OF FORM BEFORE COMPLETING i SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE t au:horize '.2, PATIENTS OR ALITHCRIZED PERSON'S SIGNATURE i authorize the release of any medical or alter Information payment of medical benefits to the unders)prled physician or supplier for nxesaary 10 proc623 We Clalm. 111180 raquesl payment of yovemment benallts either to myself or io the parry who accepts serAka described below. aeetEnmonl below. SIGNATURE ON FILE t SIGNED DATE SIGNATURE ON FILE SIGNED 35 14. OA°E OF CURRENT: ILLNESS iFlnl symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ICINESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPAPON YY OD MM r OD I YY NJURY (Aaident) OR ' GIVE FIRST DATE MM ) DO YY ) MM i DO r YY MM FROM TO PREGNANCY (LMP) , r r r 17, hANE OF REFERRING PHYSICIAN OR OTHER SOURCE 178. I.D. NUMBER OF REFERRING PHYSICIAN Ia. HOSPfTAUZAT10N DATES RELATED TO CURRENT SERVICES ZELIGER BERNAR I B34196 FROM MM DD YY TO MM CD YY } h 19.RESERVED FOR LOCAL USE 20 . OUTS IDE LA8 7 $ CHARGES - E 0 YES NO j 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1, 2.3 OR 4 TO REM 24E BY LINE) 2Z MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 7210 1.L 23. PRIOR AUTHORIZATION NUMBER 2. 4. ?.__ . _. F 24. A B C O E F O H I J K = DATE(S) or SERVICE From To Pt" of Type of PROCEDURES. SERVICES, OR SUPPLIES (Eq%aln lknlsual ClrwmsUraxa) DIAGNOSIS D $ CHARGES DAYS OR EPSDT F" EMIG COB RESERVED FOR LOCAL USE O F MM DD YY MM DD YY SaMes S*Mcs CPT/HCPC9 MODIFIER E CO UNITS Plan 11/22/06 11V'221'06 11 72141 1 965; 00 1 a LL I i ) r r ? cc r w J f I 0. i i 0. I I ? i In ? . r r r i I I I i r r ) I I (r Q Z i Q I r r r r r I r i U r V) I ? 1 _C r r r r _ :S. FEDERAL TA% I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT'?' For 90vt. calms, lee back) 29. TOTAL CHARGE- 29. AMOUNT PAID 70. BALANCE DUE ?.32411259 ?0 47337 A95 X YE3ONO : 965; 00 s Oi 00 s 965;00 31. SIGNATURE CF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSQAN'S, SUPPLIER'S BILLING NAME, AOORES3. TIP CODE IL PHONE e INCLUDING DEORE ES OR CREDENTIALS 0 the amer.:sonthereverse t RENDERED (It odor than home or ohkel MRI CENTER CENTRAL PA CENTRAL PA MRI CENTER 1 y A;>a ty to U!e bill emnd en made s pen Ihe(ao!.) 4665 TRINDLE ROAD 2527 CRANBERRY HIGHW GEORGE S DURISEK MD MECF-?:ANICSBURG PA 17055 WAREHAM MA 02571 12/18/06 232411259 SIGNED DATE P IN$ GRPI FORM (APPROVED BY AAAA COUNCIL ON MEDICAL SERVICE. 6,W) PLEASE PRINT OR TYPE n?-xI TORN OrNcp'hCP. I Sf scA FORM PRO 1500 WHCFA-1.'.00!'.9-90 (10')3) Da-rid W. Gerhart, DC C63 S 32nd St Ca= Hill, PA 17011 `17-761-2273 S T A T E M E N T 02-06-2007 BALAD7CE : $. 00 ACCOUNT NUMBER: 1000-1163 SANDRA BLINN PI+ 200 HOLLYWOOD CIRCLE CAMP HILL PA 17011 Date Description LAST CLrIM: 11-29-2006 LAST PAL'1INT: 12-27-2COn' Code Charge Credit Adjust Balance 10-24-2006 *NP History & Exam Co 99203 10-27-2006 *Chiro manip Tx. 3-4 Re 98941 10-27-2006 *E1ec Stim 97014 10-30-2006 *Chiro manip Tx 3-4 Re 98941 10-30-2006 **EZec Stim 97014 11-01-2006 *Chiro manip Tx 3-4 Re 98941 11-01-2006 *Elec Stim 97014 11-03-2006 *Chiro manip Tx 3-4 Re 98941 '1-03-2006 *EZec Stim 97014 11-06-20C5 *Chiro manip Tx 3-4 Re 98941 -_1-06-2006 *Elec Stim 97014 11-08-2006 *Chiro manip Tx 3-4 Re 98941 11-08-2006 *Elec Stim 97014 11-10-2006 *Chiro manip Tx 3-4 Re 98941 21-10-2006 *El ec Stiim 97014 _71-13-2006 *Chiro manip Tx 3-4 Re 98941 11-13-2006 *Elec Stim 97014 11-15-2006 *Chiro manip Tx 3-4 Re 98941 11-15-2006 *Elec Stim 97014 11-17-2006 *Chiro manip Tx 3-4 Re 98941 11-20-2006 *Chiro manip Tx 3-4 Re 98941 11-20-2006 *E1ec Stim 97014 11-22-2006 *Chiro manip Tx 3-4 Re 98941 11 -22-2006 *Elec St.im 97014 11-27-2006 *Chiro manip Tx 3-4 Re 98941 11 -27-2006 *Elec Stim 97014 12--01 -2006 INS CK USAA 4 9226203 12-01-2006 Ins Pd: 10-24 -2006 > 1 12-01-2006 Ins Pd: 11-01 -2006 > 1 12-27-2006 INS CK USAA 50581996 12-27-2006 Ins Pd: 11-08 -2006 > 1 72.00 .00 .00 72.00 40.00 .00 .00 112.00 20.00 .00 .00 132.00 40.00 .00 .00 172.00 20.00 .00 .00 192.00 40.00 .00 .00 232.00 20.00 .00 .00 252.00 40.00 .00 .00 292.00 20.00 .00 .00 312.00 40.00 .00 .00 352.00 20.00 .00 .00 372.00 40.00 .00 .00 412.00 20.00 .00 .00 432.00 40.00 .00 .00 172.00 20.00 .00 .00 492.00. 40.00 .00 .00 532.00 20.00 .00 .00 552.00 40.00 .00 .00 592.00 20.00 .00 .00 612.00 40.00 .00 .00 652.00 40.00 .00 .00 692.00 20.00 .00 .00 712.00 40.00 .00 .00 752.00 20.00 .00 .00 772.00 40.00 .00 .00 812.00 20.00 .00 .00 832.00 .00 365.55 .00 466.45 .00 .00 2.58 463.87 .00 .00 3.87 460.00 .00 421.68 .00 38.32 .00 .00 38.32 .00 TOTALS 832.00 787.23 44.77 Continued... David W. Gerhart, DC 3C3 S 32nd St Ca= Hill, PA 17011 717-761-2273 S T A T E M E N T J2-06-200; BALAA7CE : $. 0 0 ACCOUNT NV3, R: 1000-1169 SANDRA BLINN PI+ 200 HOLLYWOOD CIRCLE C.I'VP HILL PA 17011 LAST CLAI:,:: 11-29-2006 LAST PAYMENT: 12-27-2006 Date Description Code Charge Credit Adjust Balance For proper credit, please enclose this portion with your payment. SANDRA BLINN 200 HOLLYWOOD CIRCLE CAMP HILL PA 17011 BALANCE: $.00 PAY THIS AMOUNT: AMOUNT ENCLOSED: Please fill in blank. DATE DUE: No Pmt Rad David W. Gerhart, DC 303 S 32nd St Camp Hill, PA 17011 Z 1-JA.NK YOU. ACCOUNT NUMBER: 1000-1169 /07 JCS IRS # 232189809 BL INN, SANDRA .400 HOLLYWOOD CIRCLE CAMP HILL, PA 17011 Statement Page: 1 THE ARLINGTON GRt3UP PO BOX 6507 805 SIR TJON HARRI-33URG, ?A 17112 Tel: 71711c552-9015 Acct: 10103733-1 /AU 2 024 84 4 3 7 Pat BLINV, _1ZAXDP_-A 03108166 Tel: 7171737-9343 Ins1 : USAA 38616367101146336 Ins2: CAPITAL BLUE CROSS CAIC PFP80046460301 AR P1 Prv Amt B Da t e Diag Ref C.P.T C)t Procedure - --- - ---- - ----- --------- ----- a _ ------ !1/21/06 847.0 -------- 99202 --- 1 ------------ NEW/EXPANDED PROBLEM AU O BZ 90.00 07 68 0.00 ' 12126106 AUP AUTO PAYMENT O BZ . - JSAA L2126106 AUDS AUTO INS DISALLOWANCE 0 BZ -21.93 00 88 0.00 L1121106 847.0 72040 1 XR CERV SPINE 2 VWS AU 0 BBZ . L2126106 AUP AUTO PAYMENT JSAA L2126106 AUDS AUTO INS DISALLOWANCE O BZ Z -51.95 00 55 0.00 L1128106 847.0 99212 1 EST PT/PROBLEM FOCUS AU 0 0 B BZ . 07 -40 L21'26106 AUP AUTO PAYMENT . :7SAA 126106 12 AUDS AUTO INS DISALLOWANCE 0 BZ -14.93 0.00 , L2104106 847.0 59090 1 DECOMPRESSION THERAPY AU O ZT 00 -188 )1116107 AUP AUTO PAYMENT . :!<:#519 75722 USAA )1116107 AUDS AUTO INS DISALLOWANCE 0 ZT -37.00 00 0 L2106106 847.0 59090 1 DECOMPRESSION THERAPY AU 00 148 . )1116107 AUP AUTO PAYMENT 0 ZT . - 7K#51975722 USAA )1116107 AUDS AUTO INS DISALLOWANCE 0 ZT - 3 7. 0 0 00 0 12108106 847. 0 59090 1 DECOMPRESSION THERAPY AU T 00 148 . )1116107 AUP AUTO PAYMENT 0 Z . - 7K#51975722 USAA )1116107 AUDS AUTO INS DISALLOWANCE 0 ZT - 3 7. 0 0 00 0 L2111106 847.0 59090 1 DECOMPRESSION THERAPY AU T 00 148 . )1116107 AUP AUTO PAYMENT 0 Z . - ;K#51975722 USAA )1116107 AUDS AUTO INS DISALLOWANCE 0 ZT - 3 7. 0 0 00 0 L21.13106 847. 0 59090 1 DECOMPRESSION THERAPY AU O ZT T 185.00 0 0 14 8 . )1116107 AUP AUTO PAYMENT 0 Z . - 7K#51975722 USAA )1116107 AUDS AUTO INS DISALLOWANCE 0 ZT - 3 7. 0 0 00 0 12118106 847.0 S9090 1 DECOMPRESSION THERAPY AU O ZT 185.00 . )1116107 AUP AUTO PAYMENT 0 ZT -14 8 . 0 0 7K#51844656 USAA )1116107 AUDS AUTO INS DISALLOWANCE 0 ZT -37.00 00 0 12120106 847.0 59090 1 DECOMPRESSION THERAPY AU 0 ZT 185.00 0 . )1116107 AUP AUTO PAYMENT 0 P _1 48.0 -K#51844656 USAA )1116107 AUDS AUTO INS DISALLOWANCE O ZT - 3 7. 0 0 00 0 22122106 847.0 59090 1 DECOMPRESSION THERAPY AU 0 ZT 185.00 . 2/ IRS # 2321.39809 BLINN, SANDRA 200 HOLLYWOOD CIRCLE CAMP HILL,PA 17011 Statement Paae: `' ^ TTiE A RL_7VGm? 0,\7 _n::<0 _ PO 30Y 6307 805 SIR 19-M F.ARRIS3URG, P=1 17112 Tel : 717 6 -9C15 Acct: 10103733-1 %AU 202484437 Pat : BLIN-,V, SANDR.zl 031108160' Tel : 717/73 7-9343 Insl: USAA 38j16367101140-836 Ins2 : CAPITAL BLUE CROSS CAIC PFP8C94 64 603 01 Date Diag Ref C. P. T Qt -- Procedure --------------- - AR --- PI -- Prv ----- Amt -- Bal _ _ _ _ --------------- ---- -------- AUP --- -------- AUTO PAYMENT 0 ZT -148.00 K#51844656 USAA )1116107 AUDS AUTO INS DISALLOWANCE O ZT -37.00 00 0 12129106 847.0 59090 1 DECOMPRESSION THERAPY AU 00 148 . )1/30/07 AUP AUTO PAYMENT O ZT . - :7K# 52 8 4 63 5 6 USAA 71/30/07 AUDS AUTO INS DISALLOWANCE O ZT -37.00 00 00 0 )1/02/07 847. 0 59090 1 DECOMPRESSION THERAPY AU 0 ZT 185. 00 148 . 31/30/07 AUP AUTO PAYMENT T Z . - :K#52846356 USAA 91/30/07 AUDS AUTO INS DISALLOWANCE 0 ZT - 3 7. 0 0 00 00 0 01/05/07 847. 0 59090 1 DECOMPRESSION THERAPY AU O ZT 185. 00 148 . 01/30/07 AUP AUTO PAYMENT O ZT . - 3K#52846356 USAA 91130107 AUDS AUTO INS DISALLOWANCE 0 ZT -37.00 00 00 185 12128106 847. 0 59090 1 DECOMPRESSION THERAPY AU 0 ZT 185. . Regular.Balance: $ 185.00 ExH;d;+ E ?. ?a {Uu 10 2007 9:52 AM FR TO 917175405481 P.02/05 00/09/2007 TV 10:29 FAX 6103929022 5 1 VALES71NO ®001 f STEVEN). VAL ENTINO, D.O., P.C. ftAZ CErtrAWD ORTNONOiC 6 MCONSr KTtYl SMNF S CERv RIC Maiou Build rr. Suiw 101 700 & Hendarun ROAd King n(Pru:,ia, PA IM06 lei. 610 tc- 265 It! 5795 Fmx 610 ;r!?99Z-'Y%2,2 p•ralil: drerakadno0a0LC= Disability Management Consultants, CLC 925 West Sproul Road Suite 202 Springfield, PA 19094 5t"ID4I. VAunlriNacm rL F.c URiKraity Executive ompuz 151 Fries mill Re'd Suite 405 Tivnert'due, TU Og012 .lulu 26 2047 ?i• 456 to 232!-,* 9100 Fix 856.' 222 r' 9090 NJ Cla-U roodenx reply m: °?Box 4pOK i) ATTN: Ms. Mellgsa McClure ' RE. Ic t ii? RATE Rt LOSS: 131 ??? 601 Oear Ma. McClure: i have reviewed the medical documentation for a Ps Act 6 Peer Review regarding the reasonableness and/or necessity of treatment provided by Walter Peppelman, Group, r). 0/The Arlington ° 29s slue r rev ew 1. Appiicalion for Personal Injury Protection Benefits dated 10125/06; 2. Records from Pennsylvania Spine Institute, Wafter D. Pe 3/7/07, 3/28/07 and 6/201072nd report to USAA dated 4/18107; he D.O, elated 2/d 9/07, 7/25/07; Arlington Group dated 3; Arlington Orthopedics reports dated 11120/06, 1/4/07 and 1/29/07: 4• Ernergemcy Room records dated 10/13/06; 5. CPRS reports dated 11/20/06 through 2120/07; 6. Phyvical therapy peer review report from Jay D. Kauffman. PT 7. Mlacellaneous reports from Susquehanna Valley Pain Management, Ian . ?RS/Medical proscriptions, rental/purchase agreement, patfent usage reports and bills dated 2/21/107 through 518/07, records and copies of photographs of 2002 Dodge Grand Caravan. PUG 09 20evFCPiUn TiMF nilr, in ?n.FOh?a PU3 10 2007 9:52 AM FR oai09;2007 TBU 10:17 PAJ e;0e929o22 R ALB N 12 BGC _88 .76, M7 Ysdtc31 1-0 917175405431 P.03/05 S J VALENT;VO On 10/13/013 Mr. Michael Blinn's vehicle was involved in a motor vehicle accident wherein he was roar ended and then his vehicle struck the car in front. He subsequently complained of neck and back pain which was treated by Dr. Peppelman. Records from Arlington Orthopedics dated 11/20/06 Indicate Mr,'91inn presented complaining of pain referable to the cervical Spine and low back along with numbness and weakness especially in the right shoulder, arm and headache. There is a history of motor vehicle accident occurring 101131/D6. It was noted that -he did have a preexistent problem and was taking Tylenol with Codeine Physical examination revealed marked palpatery tenderness with restricted motion throughout the cervical spine. He had 50% of range of motion. Neurologic exam, however, is documented to be Completely normal. The diagnosis referable to the motor vehicle accident was cervical sprain end strain as a direct result of the injuries. A course of physical therapy wag recommended. Record from Dr. Zeliger of Arlington Orthopedics detect 1/4(07 noted that the neck pain had eased considerably "range o/ motion was improving. There were complaints referable to the occipital region as well as headaches, weakness in the right arm and some pain in the right arm, Examination, however, showed deep tendon reflexes of the upper extremities were normal with some weakness about the right biceps compared to the Left, Tha remaining muscle groups were noted to be normal. EMG/NCV.of both upper extremities was recommended despite no Rndings when compared to the left. Dr. Ztllger"s report dated 1/22107 indicated that EMG showed marked changes at C5-8 consistent with a disc and posterior kinking of the vertebral arch. There are complaints of pain In the neck on this date but lass in the arm. Record from Dr. Peppelman dated 2119107 revealed complaints of decreased strength in the triceps. Physical examination failed to neveal any spasm. Deep tendon re symmetric In both upper and lower extremities flexes wars equal and . Neuroinglc exam was documented as 100°!e normal, IX Peppelmen states he reviewed the MRI Of the cervical Spine which showed some small bulges at C5-6 and C6.7 on the right. But these were extremely small to be significant enough to cause the subjective complaints noted. EMG was suggestive of 9c live C6 radiculopathy, however, he found a discrepancy in that his subjective complaints were more Indicative of symptoms In the C7 area. Dr. Pew1mon's report of 317/07 revealed he underwent an epidural injection. Neurologic exam was documentOd to remain normal. His report of 3/28/07 reveafed no improvement from the sectind set of epidurals and medication. Clinical examination is documented once again to be normal. Dr. Peppelrnan stated he was hesirant to recommiond any siurgica) Intervention, He did not fool his aymptams were significant enough to warrant surgery nor did he feel Mr. Brinn would obtain a good result with surgery, AUG 09 2007 RFCFIVFD TIME AIIG.10 1n ?9AM ??AZ?Aara A'JG 10 20a7 9:52 AM FR 09/08/41007 THU 12:38 FAX 6108928012 S J VAUNTINO Ju1v 26.2007 TO 917175,405431 F. 04/e5 Report hom Dr, Peppelman dated 6/20/07 indicated the subjective complaints did not ccrrespoRd 100% with the EMG findings. Secondary emotional depression was noted. Re suggested discomstric evaluation of the cervical spine. Deep tendon reflexes were normal. There wasno evidence of clonus or Babinskl's. Hoffman's were negative. There was a mildly positive Spurlirg's and Ubermitte's noted. X-rays Of the cervical spine dated 10/25/06 revealed minimal Group disc margin hypertrophy at with no acute abnormartty, DYnamicx rays performed at the Arlington or the cervical spine na dated 11/20/08 were negative. PUG porfamned at Susquehanna Valley Pain Managsment was suggestive of acute right CS radiculopathy. ,ONTACT WITH PROVIDIj R 214DER REVIEW I also was asked to call Or_ Peppelman before 4:00 p,rn. today. I did call and left messages at 12:15 p.m. and 3:15 p.m. with Elaine and later in the day. However, I received no return phone call. CONCLUSION: The type of injury sustained as a result of the motor vehiclc accident of 10/13/08 was cervical strain. The, studies indicated preexistent cervical degenerative disc disease. The initial treatment of 11120/06 documented absence of veelable radicular symptornatology with normal neurologic exam and a recommendauan for two weeks of supervised therapy. Treatment beyond this fneluding the treatmentfrom Dr. Peppelmmn/TheArlington Group, however, cannot be construed as being reasonable or necessary for the 10/13/06 date of loss, The claimant would hove rearmed maximum medical improvernent two weeks afterthe 11120/06 visit. R ere eas The, Spine by Rothman and Simeone Campbell's Orthopedics Sincerely, Steven J. Valentino, D.O. Board Cortiatd In Orthopedic Surgery SJY:Jrnv AuG 09 20CRECEIVED TIME AUG. 10. 10:59AM 6103284014 core raG AUG 10 2907 9:53 AM FR Aug 09 2007 14:01 HP LASZRJET FrR-x TO 91717540548; 8103284014 Disability Management Consultants, !LC 920 W. Sproul Road, Suite 202 Springfield, PA 19064 866-444-0320 ACT 6 DIARY LOG Claimant: Michael Blinn Claim #: 3861636 Provider: The Arlington GrouplDr. Peppelruan DMC ##: 601288 Referral for, review received: 6/27/07 Letter of Acknowledgement to referral source: 6/27/07 Letter of Notification to Provider: 6/27/07 Medical records from provider received within 30 days: 7111107 Review Commenced: 7/11/07 Review Completed: 8/9/07 Review Forwarded: 8/9/07 Determination of Outcome: Treatment Not Appropriate P. 05/05 P.7 Reviewer Steven Valentino, b0 i INNQ &N, USAA® USAA CASUALTY INSURANCE COMPANY 9800 Fredericksburg Road, San Antonio,TX 78288 DR PEPPELMAN DO THE ARLINGTON CRP PO BOX 6507 HARRISBURG, PA 17112 August 10, 2007 Policyholder: Michael A. Blinn Reference Number: 3861636-7101-14-6836 Date Of Loss: October 13, 2006 Loss Location: Hampden Township, Pennsylvania Patient: Michael Blinn Patient Number: 10103706-1; A U Dear Sir; Madame: We have completed our review of the peer review organization's written analysis. We will not pay for the treatment after December 11, 2006 because the peer review organization found the medical treatment unnecessary and/or inappropriate. You have 30 days from the, date. of this letter to make a WRITTEN request to USAA for a reconsideration review. The writtcn'request must be directed to me and postmarked within the 30-day time frame or we will not initiate a reconsideration review. If we conduct a reconsideration review and the results concur with the initial review, you are responsible by law to pay for the cost of the reconsideration review. Since we initially pay the cost of the reconsideration review, we will expect reimbursement of these charges. If you have any questions, please feel free to contact the peer review organization or me. Sincerely, J IJ61-L Barbara Salas Casualty Claims Adjuster NORTHEAST & OVERSEAS REGION Phone: 1-800-531-8222 ext:61176 Fax Phone: 1-800-531-8669 cc: STEVEN J SCFIIFFMAN. 3861636 - 14 - PA - 10/13 131,06 - 6836 - 57 - P251 ?j?i6??' Sep 06 2007 12:28 HP LASERJET FAX 6103284014 STEVEN I. VALENTINO, D-o., P.C. DOW CF0F1W WTHCPF_ it b YECONSTRuMvi %PINE SURGERY .?r.? Th,, Merion Building Sulm 301 700 S. 14cndor6m (toad King Of pmssia, PA 19406 U. (110 20';: 5795 Fax 610 4' 99,2,-A 9022 E-taxi!: dr%va1tsafin04#z01.coa1 August 22, 2007 p.4 STEVEN J. VALEN7IN0, D0-NI. P•C Univaraity Executive, C`aropcus 131 Friw.Mill Road suira 405 Ttuncrsvilla. V1 08012 TO. 856 232:9 9100 Fax 856 231 W. 9090 N] ConcspuudeAcernplyto; R0. Box 9008 Tumcrsvilla. NJ 08012 x Ms. Melissa McClure Disability Management Consultants, LLC 920 West Sproul Road Suite 202 Spzingtold, PA 19064 RECEIVED SEP 0 6 7007 • S?+ndo lfnn ?" oCTj' 1i•?+ UMA?NFX1 M- §L6 LOSS: 10 6 Dear Ms. McClure, Thank you for forwarding the medical records regarding a PA Act 6 Pro Review on Be:nalyd Zelliger, D.O. with the Arlington Group in Harrisburg, PA. I have thoroughly reviewed all of the forwarded medical records in order to comment on the five issues per report dated 7/27/07. "REt ORDS RECEEM AND RMEW'ED: 1. Application for Personal Injury Protection Benefits; 2. Authorization for Disclosuxe of Medical Information to USAA; 3. •: Emergency Room records of 10/13/06; 4. ZabinsId Chiropractic Office records of 10/26/06, 10/19/06 and Health Insurance Claim Form for 10128/06 and 10/19/06; 5. Diagnostic Tests, itemized below; 6. Records tram Bernard I. 2eliger, D.O. dated 11/21/06 - 8/8/07; 7. Auto Appraisal from Brenner Collision West dated 10126/06 and photographs, SEP 06 2007 12:02 6103284014 PAGE. 04 Sep 06 2007 12:29 HP LASERJET FAX 6103284014 p.5 .RED _,Saudt? E1utu USAA .,? d?? 866 ?JA?"? OF LASS:.. IO/f ME RWIZIN OF DIAGNOSTIC STUDIES AND RECORDS: • X-rays of nasal bones and thoracic spine from Quantum Imaging & Therapeutic Associates, Inc. dated 10/18/08 revealed normal studies. X rays of the cervical spine from The Arlington Group dated 11/2 1/06 were within normal litnits except for nartowiog of the disc spaces at C5-6. • MM of the cervical spine from NUC (Magnetic Imaging Center) dated 11!22/06 revealed moderate spondylosis at C5-6 with eccentric changes toward the right .resulting in a mild degree of right foraminal steaosis. There may also hie a small :eight side disc protrusion or herniation. The east of the examination is normal. • X-rays of the cervical spine from The Arlington Group dated 6/28/07 revealed narrowing of the C5-6 disc in excess of that which was previously present. Otherwise, x-rays unchanged, Review of records reveals Ms. Sandra Blinn was the restrained driver of an automobile stopped in traffic on 10/13/06 when she was hit in the rear by another vehicle and pushed into the car that was in front of har. She had pain in her cervical spine and was taken by arnbulamce to Holy Spirit Hospital Emergency Room where she was examined. treated for neck pain and nose laceration and released. She saw Robert C, Zabinsld, D.C., who diagnosed cervical and thoracic spine sprain and strain injury. He did not provide treatment. She was examined and treated by Dr. Zetiger of Arlington Orthopedics with thermal modalities and therapy. Dr. Zeliger's reports on 1/6/07 that she has no complaints, is pain-free and exhibits a full and complete painless range of motion. He discharged her to full activity with no restrictions and ended the decompressive therapy. In the next report of 6/26/07 Dr. Zeliger reports she is having increasing neck pain. He recommended home cervical traction and on 8/8107 indicates she has significaz7ct imp:ervernent in her neck pain CONCLUSIQN., Dr. Zeligex's report of 11/21/06 indicates complaints as a result of the motor vehhile accident of 7.0/13/0 6 which would be most compatible with soft tissue injusq. Neurologic exam is documented to be normal. SEP 06 2007 12:03 6103284014 ' PAGE. 05 Sep 06 2007 12:29 HP LASERJET FAX i RF..Sandra Blinn USAA 11YfTl?IBER: 3861636 D= M._®10"®? 10/23/06 6103284014 p.6 Regarding the type of treatment required for the injury, typically four to six weeks of supervised therapy :followed by discharge to a. home program would be reasonable. . Recommended treatment for the motor vehicle accident of 10/13/06 was for an MRI respite evidence of neurologic emam being intact. The MRI did show only age related degenerative changes. Decompressive therapy was ordered by Dr. Zeliger. i'reatrnent by Dr. Zeligar does not appear medically necessary or appropriate for the injury of 10/13/06. Physical therapy for a four to sic week time period followed by discharge to a home program would be considered medically necessary and appropriate. In six weeks subsequent to the 10/13/06 motor vehicle accident she would have reached maxia um medical improvement. Sincerely, Steven J. Valentino, D.O. SJV;jmv SEP 06 200? 12:03 6103284014 PAGE. 05 Sep 06 2007 12;29 HP LASERJET FAX r 6103284014 Disability Management Consultants, LLC 920 W. Sproul Road, Suite 202 Springfield, PA 19064 866-444-0320 ACT 6 DIARY LOG Claimant: Sandra Blinn Claim #: 3861636 Provider: The Arlington Croup DMC #: 601333 Referral for review received: 8/1/07 Letter of Acknowledgement to referral source: 8/1/07 Letter of Notification to Provider: 8/1/07 Medical records from provider received within 30 days: 8/13/07 Review Commenced: 8/13/07 Review Completed: 9/6/07 Review Forwarded: 9/6/07 Determination of Outcome: Treatment Partially Appropriate Reviewer: Steven Valentino, DO p•7 SEP 06 2007 12:03 6103284014 PAGE. O Ex z a.. n r, u: L m d Urr, i F USAX USAA CASUALTY INSURANCE COMPANY 9800 Fredericksburg Road, San Antonio,TX 78288 DR BERNARD I ZELIGER DO THE ARLINGTON GRP 805 SIR THOMAS CT HARRISBURG, PA 17109 September 7, 2007 Policyholder: Michael A. Blinn Reference Number: 3861636-7101-14-6836 Date Of Loss: October 13, 2006 Loss Location: Hampden Township, Pennsylvania Patient: Sandra Blinn Patient Number: 10103733-1/AU Dear Sir,!Madame: We have completed our review of the peer review organization's written analysis. We will not pay for the treatment after December 13, 2006 because the peer review organization found the medical treatment unnecessary and/or inappropriate. You have 30 days from the date of this letter to make a WRITTEN request to USAA for a reconsideration review. The written request must be directed to me and postmarked within the 30-day time frame or we will not initiate a reconsideration review. If we conduct a reconsideration review and the results concur with the initial review, you are responsible by law to pay for the cost of the reconsideration review. Since we initially pay the cost of the reconsideration review, we will expect reimbursement of these charges. If you have any questions, please feel free to contact the peer review organization or me Sincerely, J 11dai- Barbara Salas Casualty Claims Adjuster NORTHEAST & OVERSEAS REGION Phone: 1-800-531-8222 ext:61176 Fax Phone: 1-800-531-8669 cc: STEVEN J SCHIFFMAN -??-off 3861636 - 14 - PA - 101113t'06 - 6836 - 57 - P251 q p4- - 00 (S) d 'G D to c- =i N 7 C7) n? `7 1 fir; ?:fit 0 I I THOMAS, THOMAS & HAFER, LLP 305 NORTH FRONT STREET P.O. BOX 999 HARRISBURG, PA 17108 Todd B. Narvol, Esquire Attorney ID #42136 (717) 237-713 Marc A. Moyer, Esquire (717) 441-3960 Attorney ID #76434 Attorneys for Defendant MICHAEL A. BLINN and SANDRA A. BLINN, Plaintiffs, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA V. USAA CASUALTY INSURANCE COMPANY, Defendant. NO. 07-5717 CIVIL ACTION - LAW JURY TRIAL DEMANDED PRAEC PE FOR ENTRY OF APPEARANCE TO THE PROTHONOTARY: Kindly enter the appearance of Todd B. Narvol, Esquire, Marc A. Moyer, Esquire, and Thomas, Thomas & Hafer LLP, 305 North Front Street, 6th Floor, Post Office Box 999, Harrisburg, PA 17108, on behalf of Defendant USAA Casualty Insurance Company. We are authorized to accept service of all documents in this matter. Respectfully submitted, Thomas & Hafer, LLP Date: /-66 /?? By: Todd B. arvol AttornID #42136 Marc . Moyer Attorney ID #76434 Attorneys for Defendant 00 CERTIFICATE OF SERVICE I, Marc A. Moyer, Esquire, do hereby certify that on this day I served a true and correct copy of the foregoing Praecipe for Entry of Appearance upon the following, by enclosing a true and correct copy in an envelope addressed as follows, postage prepaid: Charles E. Schmidt, Jr., Esquire Schmidt Kramer PC 209 State Street Harrisburg, PA 17101 Respectfully submitted, Thomas, Thomas & Hafer, LLP Date: j 31 --;' By: Todd B: of Attorne ID #42136 Marc A. Moyer Attorney ID #76434 Attorneys for Defendant ra ?} ? ?? " ? ; r ? Y',i _, ? te C? -?-r ij??. :- - r , rr + -ti t.<? ? ?. Y ??-; ,??? Y_ ..f ^ + :?? /rJ SCHMIDT KRAMER PC BY: CHARLES E. SCHMIDT, JR., ESQUIRE I.A. #19198 209 State Street Harrisburg, PA 17101 (717) 232-6300 cschrnidtC@,schmidtkramer.com MICHAEL A. BLINN and SANDRA A. BLINN, Plaintiffs, V. USAA CASUALTY INSURANCE COMPANY, Defendant Attorneys for Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND, PENNSYLVANIA CIVIL ACTION-LAW NO. 0?-.57r-? : JURY TRIAL DEMANDED PRAECIPE TO SETTLE, DISCONTINUE AND END TO THE PROTHONOTARY: Please mark the above-captioned action settled, discontinued and ended with prejudice. Date: May 13, 2009 Charles E. Schmidt, Jr., Esquire I.D. No. 19198 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiffs Respectfully submitted, t ? ° -ry MM- T`sL? 3