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HomeMy WebLinkAbout08-3496MAJOR CASE/NON-JURY ASSESSMENT OF DAMAGES HEARING NOT REQUIRED TABAS & ROSEN, P.C. BY: LEWIS C. TRAUFFER, ESQUIRE Attorney I.D. #60267 1601 Market Street, Suite 2300 Philadelphia, PA 19103 (215) 569-5050 THE MILTON S. HERSHEY MEDICAL CENTER P.O. Box 853 Hershey, PA 17033 VS CLIFFORD VARNER & SARAH J. VARNER, h/w 643 Highland Avenue Mt. Holly Springs, PA 17065 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. DR- Sggjo 0,wi it erm CIVIL ACTION COMPLAINT - CIVIL ACTION 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. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717)249-3166 or(800)990-9108 COMPLAINT - CIVIL ACTION COUNT I THE MILTON S. HERSHEY MEDICAL CENTER VS. CLIFFORD VARNER 1. Plaintiff is a non-profit corporation located at the address indicated in the caption hereof. 2. Count I defendant is an individual who resides at the address indicated in the caption hereof. 3. As the result of a certain medical condition, Count I defendant was treated at the plaintiff hospital on Feb. 8, 2007 thru July 26, 2007. 4. The amounts, quantities and nature of the medical care rendered, the date on which said medical care was rendered, and the charges therefore are set forth in Exhibit "A", which is incorporated herein as if set forth at length. 5. Said medical care was commensurate with the condition of Count I defendant and was necessary for the health and welfare of Count I defendant. 6. At or about the time of Count I defendant's treatment at the plaintiff hospital, implied, constructive and oral con- tracts arose between Count I defendant and plaintiff by the terms of which Count I defendant became obligated to pay plaintiff the charges incurred for the medical care rendered by plaintiff to Count I defendant. 7. Count I defendant refuses to pay the balance due although plaintiff has made demand that Count I defendant do so. 8. As a result of the foregoing, there is due and owing from Count I defendant to plaintiff the sum indicated in Exhibit "All WHEREFORE, plaintiff demands judgment against Count I defendant for the sum of $182,404.32 plus six percent (6%) interest per annum from the date of discharge to the date of judgment, record costs and non-record costs. COUNT II THE MILTON S. HERSHEY MEDICAL CENTER VS. SARAH J. VARNER 9. The foregoing paragraphs are incorporated herein as if set forth at length. 10. Count II defendant is an individual who resides at the address indicated in the caption hereof. 11. Count II defendant is the spouse of Count I defendant. 12. Defendant's spouse was treated at the plaintiff hospi- tal on Feb. 8, 2007 thru July 26, 2007. 13. Said medical care was commensurate with the condition of defendant's spouse and was necessary for the health and welfare of defendant's spouse. 14. Count I defendant is indigent. 15. Count II defendant is financially able to pay for the medical care of Count I defendant. 16. By virtue of the marital relationship, the Act of 1937, June 24, P.L. 2045, Sec. 3, as amended, 23 Pa. Cons. Stat. Ann. Sec. 4603 and Article 1, Sec. 28 of the Pennsylvania Constitution and all other applicable statutes, laws and ordinances, Count II defendant has a duty to support Count I defendant. 17. Count II defendant has been unjustly enriched by plain- tiff's discharge of Count II defendant's duty to support Count I defendant, which duty Count II defendant failed to perform. 18. Count II defendant refuses to pay the balance due, although plaintiff has made demand that Count II defendant do so. 19. As a result of the foregoing, there is due and owing from Count II defendant to plaintiff the sum indicated in Exhibit "A". WHEREFORE, plaintiff demands judgment against Count II defendant for the sum of $182,404.32 plus six percent (6o) interest per annum from the date of discharge to the date of judgment, record costs and non-record costs. TABAS & ROSEN, P.C. LEWIS C.` TRAU R, ESQUIRE Attorney for Plaintiff MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:14 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit ##: 8097275 ------------------------------------------------------------------------- Date I Svc Code I Description I Unitsl Debits I Credits 02/21/07 101111 POOL BLD PRODUCT 3 318.00 02/21/07 101120 THAW FROZ PLASMA/U 18 378.00 02/21/07 101219 CRYOPOOR PLASMA EA U 18 1260.00 02/21/07 101534 THER APHERESIS, PLASM 1 1660.00 02/21/07 104096 LDH 1 16.00 02/21/07 105657 CBC W/PLT/DIFF AUTO 1 48.00 02/21/07 246130 DIPHENHYDRAMINE SO MG 1 3.00 02/21/07 246842 HEPARIN SODIUM 10000 10 3.00 02/21/07 247831 ACETAMINOPHEN 325 MG 1 3.00 02/21/07 247842 CAL GLUCONATE 10ML 2 23.•10 06/13/07 900011 PATIENT PAY CHECK -1 50.00- 07/11/07 900011 PATIENT PAY CHECK -1 50.00- 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 3612.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 3612.10 * - Not posted l Balance: l 3612.10 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 11/19/07 at 11:36 AM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8103270 ------------------------------------------------------------------------- Date I Svc Code I Description I Units Debits I Credits 02/22/07 101111 POOL BLD PRODUCT 3 `'318.00 02/22/07 101120 THAW FROZ PLASMA/U 20 ' 4.20.00 02/22/07 101219 CRYOPOOR PLASMA EA U 20 " 1400.00 02/22/07 101534 THER APHERESIS, PLASM 1 1660.00 02/22/07 104096 LDH 1 16.00 02/22/07 105656 CDC W/PLT AUTO 1 30'.'00 02/22/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 02/22/07 246842 HEPARIN SODIUM 10000 10 3.00 02/22/07 247831 ACETAMINOPHEN 325 MG 1 3.00 07/31/07 980090 HOSPITAL BAD DEBT W/0 -1 3853.00- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 3853.00 09/24/07 900011 PATIENT PAY CHECK -1 50.00- 11/09/07 900011 PATIENT PAY CHECK -1 50.00- * - Not posted Balance: I 3753.00 ------------------------ I' - ?- MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 12/14/07 at 08:23 AM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8097268 ------------------------------------------------------------------------- Date I Svc Code I Description I Unitsl ;Debits Credits 02/23/07 101111 POOL BLD PRODUCT 3 318:.00 02/23/07 101120 THAW FROZ PLASMA/U 18 378.00 02/23/07 101219 CRYOPOOR PLASMA EA U 18 '1260.00 02/23/07 101534 THER APHERESIS, PLASM 1 1660.00 02/23/07 104096 LDH 1 16 . 00 02/23/07 105656 CDC W/PLT AUTO 1 . .3..0-.00 02/23/07 245207 LIDOCAINE 1 ML 1 3.-.00 02/23/07 246057 CEFAZOLIN 1 GM/5 ML 2 4.25 02/23/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 02/23/07 246836 FENTANYL CITRATE 2 ML 1 3.00 02/23/07 246842 HEPARIN SODIUM 10000 20 6.00 02/23/07 247831 ACETAMINOPHEN 325 MG 1 3.00 02/23/07 247842 CAL GLUCONATE 10ML 2 23.10 02/23/07 272425 MIDAZOLAM 1MG/ML 2ML 2 :..3.00 02/23/07 306856 CI EVAL CVAD UNDER FL 1 512.00 02/23/07 308281 REPL COMPL TUNNEL VEN 1 81.1.00 02/23/07 737031 HEMOGLIDE CATHETER 1 1534.00 02/23/07 737070 NON IONIC CONTRAST 1 224.00 02/23/07 737089 UTILITY DRAPE 1 28.00 02/23/07 737146 CVIR ANGIO TRAY 1 89.00 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 6908.35- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 6908.35 12/07/07 900011 PATIENT PAY CHECK -1 50.00- * - Not posted Balance: I 6858.35 ------------------------ 19-3 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:15 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8103277 ------------------------------------------------ Date Svc Code Description Units Debits - Credits 02/25/07 101111 POOL BLD PRODUCT 2 212.00 02/25/07 101120 THAW FROZ PLASMA/U 11 231.00 02/25/07 101219 CRYOPOOR PLASMA EA U 11 770.00 02/25/07 101534 THER APHERESIS, PLASM 1 1660.00 02/25/07 104096 LDH 1 16.00 02/25/07 105656 CBC W/PLT AUTO 1 30.00 02/25/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 02/25/07 246842 HEPARIN SODIUM 10000 10 3.00 02/25/07 247831 ACETAMINOPHEN 325 MG 1 3.00 02/25/07 247842 CAL GLUCONATE 10ML 2 23.10 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 2951.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 2951.10 * - Not posted I Balance: 2951.10 ------------------------ Ry MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:15 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8103279 --------------------------------------------?--- Credits Date Svc Code Description Units Debits 02/27/07 101111 POOL BLD PRODUCT 2 212.00 --- ------ - 02/27/07 101120 THAW FROZ PLASMA/U 11 231.00 02/27/07 101219 CRYOPOOR PLASMA EA U 11 770.00 02/27/07 101534 THER APHERESIS, PLASM 1 1660.00 02/27/07 104096 LDH 1 16.00 02/27/07 105656 CBC W/PLT AUTO 1 30.00 02/27/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 02/27/07 246842 HEPARIN SODIUM 10000 10 3.00 02/27/07 247831 ACETAMINOPHEN 325 MG 1 3.00 02/27/07 247842 CAL GLUCONATE 10ML 1 11.55 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 2939 55- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 2939.55 . * - Not posted Balance: I 2939.55 ------------------------ fi- 75- MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:16 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8120169 ----------------------P-------------------------------i------ Date Svc Code Description Units Debits I Credits 02/28/07 101111 POOL BLD PRODUCT 2 212.00 02/28/07 101120 THAW FROZ PLASMA/U 11 231.00 02/28/07 101219 CRYOPOOR PLASMA EA U 11 770.00 02/28/07 101534 THER APHERESIS, PLASM 1 1660.00 02/28/07 104096 LDH 1 16.00 02/28/07 105656 CBC W/PLT AUTO 1 30.00 02/28/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 02/28/07 246842 HEPARIN SODIUM 10000 10 3.00 02/28/07 247831 ACETAMINOPHEN 325 MG 1 3.00 02/28/07 247842 CAL GLUCONATE 10ML 1 11.55 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 2939.55- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 2939.55 * - Not posted Balance: 2939.55 - ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:16 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8120172 -------------------------------------------------------------------------- Date Svc Code Description Units Debits + Credits 03/01/07 101111 POOL BLD PRODUCT 2 212.00 03/01/07 101120 THAW FROZ PLASMA/U 12 252.00 03/01/07 101219 CRYOPOOR PLASMA EA U 12 840.00 03/01/07 101534 THER APHERESIS, PLASM 1 1660.00 03/01/07 104096 LDH 1 16.00 03/01/07 105656 CBC W/PLT AUTO 1 30.00 03/01/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 03/01/07 246842 HEPARIN SODIUM 10000 10 3.00 03/01/07 247831 ACETAMINOPHEN 325 MG 1 3.00 03/01/07 247842 CAL GLUCONATE 10ML 2 23.10 03/17/07 920014 MCARE HOSP LATE CHRG -1 32.10- 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 3010.00- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 3010.00 * - Not posted Balance: I 3010.00 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:16 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8120179 ------------------------------------------------------------------------- Date Svc Code Description Unitsl Debits Credits 03/02/07 101111 POOL BLD PRODUCT 2 212.00 03/02/07 101120 THAW FROZ PLASMA/U 12 252.00 03/02/07 101219 CRYOPOOR PLASMA EA U 12 840.00 03/02/07 101534 THER APHERESIS, PLASM 1 1660.00 03/02/07 104096 LDH 1 16.00 03/02/07 105656 CBC W/PLT AUTO 1 30.00 03/02/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 03/02/07 246842 HEPARIN SODIUM 10000 10 3.00 03/02/07 247831 ACETAMINOPHEN 325 MG 1 3.00 03/02/07 247842 CAL GLUCONATE 10ML 2 23.10 07/31/07 980090 HOSPITAL BAD DEBT W10 -1 3042.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 3042.10 * - Not posted Balance: 3042.10 ------------------------- fi - 9 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:16 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8142711 ------------------------------------------- - -------------------- ebits- - - --- Credits Date Svc Code Description--- escription Units --- Debits--- 03/05/07 101111 POOL BLD PRODUCT 2 212.00 03/05/07 101120 THAW FROZ PLASMA/U 11 231.00 03/05/07 101219 CRYOPOOR PLASMA EA U 11 770.00 03/05/07 101534 THER APHERESIS, PLASM 1 1660.00 03/05/07 104096 LDH 1 16.00 03/05/07 105656 CBC W/PLT AUTO 1 30.00 03/05/07 109804 VENIPUNCTURE 1 17.00 03/05/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 03/05/07 247831 ACETAMINOPHEN 325 MG 1 3.00 03/05/07 247842 CAL GLUCONATE 10ML 2 23.10 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 2965.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 2965.10 * - Not posted Balance: 2965.10 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:17 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8157584 ------------------------------------------------------------------------- Date I Svc Code I Description I Unitsl Debits i Credits 03/08/07 101111 POOL BLD PRODUCT 2 212.00 03/08/07 101120 THAW FROZ PLASMA/U 11 231.00 03/08/07 101219 CRYOPOOR PLASMA EA U 11 770.00 03/08/07 101534 THER APHERESIS, PLASM 1 1660.00 03/08/07 104096 LDH 1 16.00 03/08/07 105656 CBC W/PLT AUTO 1 30.00 03/08/07 246127 DIPHENHYDRAMINE 25 MG 1 3.00 03/08/07 246842 HEPARIN SODIUM 10000 10 3.00 03/08/07 247831 ACETAMINOPHEN 325 MG 1 3.00 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 2928.00- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 2928.00 * - Not posted I Balance: I 2928.00 ------------------------ Iq -/0 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:17 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8170464 ---------------------------------------------------------------- ebits- - - --- Credits Date Svc Code Description--- escription Unitsl --- Debits--- 03/12/07 101111 POOL BLD PRODUCT 2 212.00 03/12/07 101120 THAW FROZ PLASMA/U 12 252.00 03/12/07 101219 CRYOPOOR PLASMA EA U 12 840.00 03/12/07 101534 THER APHERESIS, PLASM 1 1660.00 03/12/07 104096 LDH 1 16.00 03/12/07 105656 CBC W/PLT AUTO 1 30.00 03/12/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 03/12/07 246842 HEPARIN SODIUM 10000 10 3.00 03/12/07 247831 ACETAMINOPHEN 325 MG 1 3.00 03/12/07 247842 CAL GLUCONATE 10ML 2 23.10 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 3042.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 3042.10 * - Not posted Balance: 3042.10 ------------------------ 14-1/ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:18 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8174973 ------------------------------------------------------------------------- Date I Svc Code I Description I Unitsl Debits I Credits 03/13/07 101111 POOL BLD PRODUCT 2 212.00 03/13/07 101120 THAW FROZ PLASMA/U 12 252.00 03/13/07 101219 CRYOPOOR PLASMA EA U 12 840.00 03/13/07 101534 THER APHERESIS, PLASM 1 1660.00 03/13/07 104096 LDH 1 16.00 03/13/07 105656 CBC W/PLT AUTO 1 30.00 03/13/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 03/13/07 246842 HEPARIN SODIUM 10000 10 3.00 03/13/07 247831 ACETAMINOPHEN 325 MG 1 3.00 07/31/07 980090 HOSPITAL BAD DEBT W/0 -1 3019.00- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 3019.00 * - Not posted I Balance: I 3019.00 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:18 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit ##: 8181274 ------------------------------------------------------------------------- Date Svc Code ( Description Units Debits Credits 03/14/07 101111 POOL BLD PRODUCT 2 212.00 03/14/07 101120 THAW FROZ PLASMA/U 11 231.00 03/14/07 101219 CRYOPOOR PLASMA EA U 11 770.00 03/14/07 101534 THER APHERESIS, PLASM 1 1660.00 03/14/07 104096 LDH 1 16.00 03/14/07 105656 CBC W/PLT AUTO 1 30.00 03/14/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 03/14/07 246842 HEPARIN SODIUM 10000 10 3.00 03/14/07 247831 ACETAMINOPHEN 325 MG 1 3.00 03/14/07 247842 CAL GLUCONATE 10ML 1 11.55 07/31/07 980090 HOSPITAL BAD DEBT W/0 -1 2939.55- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 2939.55 * - Not posted Balance: 2939.55 ------------------------ Iq '/3 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:19 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit ##: 8191218 -------------------------------------------------------------------.------ Date Svc Code ' Description Units Debits I Credits 03/16/07 101111 POOL BLD PRODUCT 2 212.00 03/16/07 101120 THAW FROZ PLASMA/U 12 252.00 03/16/07 101219 CRYOPOOR PLASMA EA U 12 840.00 03/16/07 101534 THER APHERESIS, PLASM 1 1660.00 03/16/07 104096 LDH 1 16.00 03/16/07 105656 CBC W/PLT AUTO 1 30.00 03/16/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 03/16/07 246842 HEPARIN SODIUM 10000 10 3.00 03/16/07 247831 ACETAMINOPHEN 325 MG 1 3.00 03/16/07 247842 CAL GLUCONATE 10ML 2 23.10 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 3042.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 3042.10 * - Not posted Balance: 3042.10 ------------------------ 4 -/V MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:19 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8195596 ------------------------------------------------------------------------- Date I Svc Code I Description I Units Debits I Credits 03/19/07 101111 POOL BLD PRODUCT 2 212.00 03/19/07 101120 THAW FROZ PLASMA/U 12 252.00 03/19/07 101219 CRYOPOOR PLASMA EA U 12 840.00 03/19/07 101534 THER APHERESIS, PLASM 1 1660.00 03/19/07 104042 CREATININE, BLOOD 1 14.00 03/19/07 104065 UREA NITROGEN (BUN), 1 13.00 03/19/07 104096 LDH 1 16.00 03/19/07 105656 CDC W/PLT AUTO 1 30.00 03/19/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 03/19/07 246842 HEPARIN SODIUM 10000 10 3.00 03/19/07 247831 ACETAMINOPHEN 325 MG 1 3.00 03/19/07 247842 CAL GLUCONATE 10ML 2 23.10 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 3069.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 3069.10 * - Not posted I Balance: I 3069.10 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:19 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit ##: 8207407 ------------------------------------------------------------------------- Date l Svc Code I Description I Unitsl Debits i Credits 03/21/07 101111 POOL BLD PRODUCT 2 212.00 03/21/07 101120 THAW FROZ PLASMA/U 12 252.00 03/21/07 101219 CRYOPOOR PLASMA EA U 12 840.00 03/21/07 101534 THER APHERESIS, PLASM 1 1660.00 03/21/07 104096 LDH 1 16.00 03/21/07 105656 CBC W/PLT AUTO 1 30.00 03/21/07 246127 DIPHENHYDRAMINE 25 MG 1 3.00 03/21/07 247831 ACETAMINOPHEN 325 MG 1 3.00 03/21/07 247842 CAL GLUCONATE 10ML 2 23.10 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 3039.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 3039.10 * - Not posted I Balance: l 3039.10 ------------------------- R i?2 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:19 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8103273 ------------------------------------------------------------------------- Date I Svc Code I Description I Unitsl Debits I Credits 03/26/07 101111 POOL BLD PRODUCT 2 212.00 03/26/07 101120 THAW FROZ PLASMA/U 11 231.00 03/26/07 101219 CRYOPOOR PLASMA EA U 11 770.00 03/26/07 101534 THER APHERESIS, PLASM 1 1660.00 03/26/07 104096 LDH 1 16.00 03/26/07 105656 CDC W/PLT AUTO 1 30.00 03/26/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 03/26/07 246842 HEPARIN SODIUM 10000 10 3.00 03/26/07 247831 ACETAMINOPHEN 325 MG 1 3.00 03/26/07 247842 CAL GLUCONATE 10ML 2 23.10 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 2951.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 2951.10 * - Not posted I Balance: I 2951.10 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:20 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8112853 ------------------------------------------------------------------------- Date I Svc Code I Description I Unitsl Debits I Credits 03/28/07 101111 POOL BLD PRODUCT 2 212.00 03/28/07 101120 THAW FROZ PLASMA/U 11 231.00 03/28/07 101219 CRYOPOOR PLASMA EA U 11 770.00 03/28/07 101534 THER APHERESIS, PLASM 1 1660.00 03/28/07 104096 LDH 1 16.00 03/28/07 105656 CBC W/PLT AUTO 1 30.00 03/28/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 03/28/07 246842 HEPARIN SODIUM 10000 10 3.00 03/28/07 247831 ACETAMINOPHEN 325 MG 1 3.00 03/28/07 247842 CAL GLUCONATE 10ML 1 11.55 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 2939.55- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 2939.55 * - Not posted I Balance: 1 2939.55 ------------------------- MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:20 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8112803 -------------------------------------------------------------------_------ Date I Svc Code Description Unitsl Debits I Credits 03/29/07 101111 POOL BLD PRODUCT 2 212.00 03/29/07 101120 THAW FROZ PLASMA/U 12 252.00 03/29/07 101219 CRYOPOOR PLASMA EA U 12 840.00 03/29/07 101534 THER APHERESIS, PLASM 1 1660.00 03/29/07 104096 LDH 1 16.00 03/29/07 105656 CBC W/PLT AUTO 1 30.00 03/29/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 03/29/07 246842 HEPARIN SODIUM 10000 10 3.00 03/29/07 247831 ACETAMINOPHEN 325 MG 1 3.00 03/29/07 247842 CAL GLUCONATE 10ML 2 23.10 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 3042.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 3042.10 * - Not posted l Balance: l 3042.10 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:20 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8244634 ------------------------------------------------------------------------- Date I Svc Code I Description I Unitsl Debits I Credits 03/30/07 1017.11 POOL BLD PRODUCT 2 212.00 03/30/07 101120 THAW FROZ PLASMA/U 12 252.00 03/30/07 101219 CRYOPOOR PLASMA EA U 12 840.00 03/30/07 101534 THER APHERESIS, PLASM 1 1660.00 03/30/07 104096 LDH 1 16.00 03/30/07 105656 CBC W/PLT AUTO 1 30.00 03/30/07 246127 DIPHENHYDRAMINE 25 MG 1 3.00 03/30/07 246842 HEPARIN SODIUM 10000 10 3.00 03/30/07 247831 ACETAMINOPHEN 325 MG 1 3.00 03/30/07 247842 CAL GLUCONATE 10ML 1 11.55 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 3030.55- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 3030.55 * - Not posted I Balance: I 3030.55 ------------------------ A-„1o MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:20 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8249790 -------------------------------------------------------------------------------- I Date I Svc Code I Description I Unitsl Debits i Credits I -------------------------------------------------------------------------------- 04/02/07 8349 CC OUTPATIENT VISIT E 1 04/02/07 101111 POOL BLD PRODUCT 3 04/02/07 101120 THAW FROZ PLASMA/U 12 04/02/07 101219 CRYOPOOR PLASMA EA U 12 04/02/07 101534 THER APHERESIS, PLASM 1 04/02/07 104042 CREATININE, BLOOD 1 04/02/07 104065 UREA NITROGEN (BUN), 1 04/02/07 104096 LDH 1 04/02/07 105656 CBC W/PLT AUTO 1 04/02/07 109804 VENIPUNCTURE 1 04/02/07 246130 DIPHENHYDRAMINE 50 MG 1 04/02/07 246842 HEPARIN SODIUM 10000 20 04/02/07 247831 ACETAMINOPHEN 325 MG 1 04/17/07 920014 MCARE HOSP LATE CHRG -1 07/31/07 980090 HOSPITAL BAD DEBT W/0 -1 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 94.00 318.00 252.00 840.00 1660.00 14.00 13.00 16.00 30.00 17.00 3.00 6.00 3.00 94.00- 3172.00- 3172.00 -------------------------------------------------------------------------------- * - Not posted I Balance: l 3172.00 I if a?. MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:20 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8253727 ------------------------------------------------------------------------- Date I Svc Code I Description I Unitsl Debits I Credits 04/05/07 101111 POOL BLD PRODUCT 2 212.00 04/05/07 101120 THAW FROZ PLASMA/U 11 231.00 04/05/07 101219 CRYOPOOR PLASMA EA U 11 770.00 04/05/07 101534 THER APHERESIS, PLASM 1 1660.00 04/05/07 104096 LDH 1 16.00 04/05/07 105656 CBC W/PLT AUTO 1 30.00 04/05/07 109804 VENIPUNCTURE 1 17.00 04/05/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 04/05/07 246842 HEPARIN SODIUM 10000 20 6.00 04/05/07 247831 ACETAMINOPHEN 325 MG 1 3.00 04/05/07 247842 CAL GLUCONATE 10ML 1 11.55 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 2959.55- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 2959.55 * - Not posted i Balance: l 2959.55 ------------------------ /L - 2 )--- MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:21 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8269543 ------------------------------------------------------------------------- Date i Svc Code Description I Unitsl Debits Credits 04/06/07 101111 POOL BLD PRODUCT 2 212.00 04/06/07 101120 THAW FROZ PLASMA/U 17 357.00 04/06/07 101220 FFP SINGLE DONOR EA U 17 2754.00 04/06/07 101534 THER APHERESIS, PLASM 1 1660.00 04/06/07 104096 LDH 1 16.00 04/06/07 105656 CBC W/PLT AUTO 1 30.00 04/06/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 04/06/07 246842 HEPARIN SODIUM 10000 10 3.00 04/06/07 247831 ACETAMINOPHEN 325 MG 1 3.00 04/06/07 247842 CAL GLUCONATE 10ML 1 11.55 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 5049.55- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 5049.55 * - Not posted l Balance: 5049.55 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:21 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit ##: 8271701 ------------------------------------------------------------------------- Date Svc Code I Description 11 Unitsl Debits Credits 04/07/07 101111 POOL BLD PRODUCT 2 212.00 04/07/07 101120 THAW FROZ PLASMA/U 15 315.00 04/07/07 101220 FFP SINGLE DONOR EA U 15 2430.00 04/07/07 101534 THER APHERESIS, PLASM 1 1660.00 04/07/07 104096 LDH 1 16.00 04/07/07 105656 CBC W/PLT AUTO 1 30.00 04/07/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 04/07/07 246842 HEPARIN SODIUM 10000 10 3.00 04/07/07 247831 ACETAMINOPHEN 325 MG 1 3.00 04/07/07 247842 CAL GLUCONATE 10ML 2 23.10 07/31/07 980090 HOSPITAL BAD DEBT W/0 -1 4695.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 4695.10 * - Not posted Balance: 1 4695.10 ------------------------- A ay MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:21 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8271703 ------------------------------------------------------------------------- Date I Svc Code I Description I Units Debits I Credits 04/08/07 101111 POOL BLD PRODUCT 2 212.00 04/08/07 101120 THAW FROZ PLASMA/U 12 252.00 04/08/07 101220 FFP SINGLE DONOR EA U 12 1944.00 04/08/07 101534 THER APHERESIS, PLASM 1 1660.00 04/08/07 104096 LDH 1 16.00 04/08/07 105656 CBC W/PLT AUTO 1 30.00 04/08/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 04/08/07 246842 HEPARIN SODIUM 10000 10 3.00 04/08/07 247831 ACETAMINOPHEN 325 MG 1 3.00 04/08/07 247842 CAL GLUCONATE 10ML 1 11.55 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 4134.55- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 4134.55 * - Not posted Balance: 1 4134.55 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:21 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit ##: 8252107 ------------------------------------------------------------------------- Date I Svc Code I Description I Units Debits I Credits 04/09/07 8217 IV FLUIDS 1 14.00 04/09/07 8347 CC OUTPATIENT VISIT E 1 43.00 04/09/07 8519 COLLECT BLD VIA PORT/ 1 66.00 04/09/07 8524 IV TUBING-ALARIS 2 12.00 04/09/07 8527 SPIKE-CHEMO ADMIN-GLA 1 3.00 04/09/07 8550 CHEMO INF UP TO 1 HR 1 207.00 04/09/07 8664 CHEMO INF EACH ADDL H 3 384.00 04/09/07 104096 LDH 1 16.00 04/09/07 105657 CBC W/PLT/DIFF AUTO 1 48.00 04/09/07 246128 DIPHENHYDRAMINE 50 MG 1 7.50 04/09/07 247831 ACETAMINOPHEN 325 MG 2 7.50 04/09/07 247845 SODIUM CHLORIDE 250 M 1 13.45 04/09/07 273412 RITUXIMAB 100MG INJ 8 13118.50 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 13939.95- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 13939.95 * - Not posted Balance: 13939.95 ------------------------ 4i) (. MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:22 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit ##: 8272373 ------------------------------------------------------------------------- Date I Svc Code I Description Unitsl Debits I Credits 04/11/07 101111 POOL BLD PRODUCT 2 212.00 04/11/07 101120 THAW FROZ PLASMA/U 18 378.00 04/11/07 101220 FFP SINGLE DONOR EA U 18 2916.00 04/11/07 101534 THER APHERESIS, PLASM 1 1660.00 04/11/07 104096 LDH 1 16.00 04/11/07 105656 CBC W/PLT AUTO 1 30.00 04/1_1/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 04/11/07 246842 HEPARIN SODIUM 10000 10 3.00 04/11/07 247831 ACETAMINOPHEN 325 MG 1 3.00 04/11/07 247842 CAL GLUCONATE 10ML 2 23.10 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 5244.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 5244.10 * - Not posted Balance: 5244.10 ------------------------ 4--?,,) MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:22 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit ##: 8272375 ------------------------------------------------------------------------- Date I Svc Code I Description Unitsl Debits I Credits 04/13/07 101111 POOL BLD PRODUCT 2 212.00 04/13/07 101120 THAW FROZ PLASMA/U 18 378.00 04/13/07 101220 FFP SINGLE DONOR EA U 18 2916.00 04/13/07 101534 THER APHERESIS, PLASM 1 1660.00 04/13/07 104096 LDH 1 16.00 04/13/07 105656 CBC W/PLT AUTO 1 30.00 04/13/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 04/13/07 246842 HEPARIN SODIUM 10000 10 3.00 04/13/07 247831 ACETAMINOPHEN 325 MG 1 3.00 04/13/07 247842 CAL GLUCONATE 10ML 2 23.10 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 5244.10- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 5244.10 * - Not posted Balance: I 5244.10 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:22 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8298703 -------------------------------------------------------------------------------- Date Svc Code Description Unitsl Debits Credits -------------------------------------------------------------------------------- 04/17/07 105657 CBC W/PLT/DIFF AUTO 1 48.00 04/17/07 246128 DIPHENHYDRAMINE 50 MG 1 7.50 04/17/07 247831 ACETAMINOPHEN 325 MG 2 7.50 04/17/07 247845 SODIUM CHLORIDE 250 M 1 13.45 04/17/07 250369 HEPARIN 5000U/ML 1ML 10 15.00 04/17/07 273412 RITUXIMAB 100MG INJ 8 13118.50 04/17/07 292139 COLLECT BLD VIA PORT/ 1 66.00 04/17/07 292146 CHEMO INFUSION UP TO 1 207.00 04/17/07 292147 CHEMO INF EA ADDL HOU 3 384.00 04/17/07 292161 THER IV PUSH,EA ADDL 1 56.00 04/17/07 292164 PORT/IV FLUSH 1 56.00 04/17/07 623014 ULTRASITE INJ CAP BRA 2 20.00 04/17/07 623017 ADAPTOR, VENTED SPIKE 1 9.00 04/17/07 627070 IV EXT SET 90" W/FLAS 1 17.00 04/17/07 664051 SET, IV WINGED INF ZO 1 30.00 04/17/07 664055 NEEDLE,PORTAL SITE 20 1 10.00 -------------------------------------------------------------------------------- * - Not posted Balance: I 14064.95 /-1 . ) 9 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:23 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8311726 ------------------------------------------------------------------------- Date I Svc Code Description I Unitsl Debits I Credits 04/20/07 101111 POOL BLD PRODUCT 2 212.00 04/20/07 101120 THAW FROZ PLASMA/U 19 399.00 04/20/07 101220 FFP SINGLE DONOR EA U 19 3078.00 04/20/07 101534 THER APHERESIS, PLASM 1 1660.00 04/20/07 104096 LDH 1 16.00 04/20/07 105656 CBC W/PLT AUTO. 1 30.00 04/20/07 109804 VENIPUNCTURE 1 17.00 04/20/07 246130 DIPHENHYDRAMINE 50 MG 1 3.00 04/20/07 246842 HEPARIN SODIUM 10000 10 3.00 04/20/07 247831 ACETAMINOPHEN 325 MG 1 3.00 04/20/07 247842 CAL GLUCONATE 10ML 1 11.55 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 5432.55- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 5432.55 * - Not posted Balance: 5432.55 ------------------------ /?/ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:24 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8311586 ------------------------------------------------------------------------- Date I Svc Code Description I Unitsl Debits I Credits 04/25/07 8217 IV FLUIDS 1 14.00 04/25/07 8524 IV TUBING-ALARIS 1 6.00 04/25/07 8527 SPIKE-CHEMO ADMIN-GLA 1 3.00 04/25/07 8550 CHEMO INF UP TO 1 HR 1 207.00 04/25/07 8664 CHEMO INF EACH ADDL H 3 384.00 04/25/07 105657 CDC W/PLT/DIFF AUTO 1 48.00 04/25/07 246128 DIPHEN14YDRAMINE 50 MG 1 7.50 04/25/07 247831 ACETAMINOPHEN 325 MG 2 7.50 04/25/07 247845 SODIUM CHLORIDE 250 M 1 13.45 04/25/07 250369 HEPARIN 5000U/ML 1ML 5 7.50 04/25/07 273412 RITUXIMAB 100MG INJ 8 13118.50 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 13816.45- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 13816.45 * - Not posted Balance: 13816.45 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:24 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8280301 ------------------------------------------------------------------------- Date Svc Code Description Units Debits Credits 04/30/07 8217 IV FLUIDS 1 14.00 04/30/07 8524 IV TUBING-ALARIS 1 6.00 04/30/07 8550 CHEMO INF UP TO 1 HR 1 207.00 04/30/07 8664 CHEMO INF EACH ADDL H 1 128.00 04/30/07 104096 LDH 1 16.00 04/30/07 105657 CBC W/PLT/DIFF AUTO 1 48.00 04/30/07 246128 DIPHENHYDRAMINE 50 MG 1 7.50 04/30/07 247831 ACETAMINOPHEN 325 MG 2 7.50 04/30/07 247845 SODIUM CHLORIDE 250 M 1 13.45 04/30/07 273412 RITUXIMAB 100MG INJ 8 13118.50 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 13565.95- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 13565.95 * - Not posted Balance: 13565.95 ------------------------ )q .? Z MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:24 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8355706 ------------------------------------------------------------------------- Date I Svc Code I Description I Units) Debits I Credits 05/07/07 8504 TEGADERM DRESSING 1 6.00 05/07/07 8519 COLLECT BLD VIA PORT/ 1 66.00 05/07/07 104096 LDH 1 16.00 05/07/07 105657 CBC W/PLT/DIFF AUTO 1 48.00 05/07/07 250369 HEPARIN 5000U/ML 1ML 10 7.50 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 143.50- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 143.50 * - Not posted Balance: 143.50 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:24 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8381105 ------------------------------------------------------------------------- Date I Svc Code I Description Units Debits I Credits 05/14/07 8519 COLLECT BLD VIA PORT/ 1 66.00 05/14/07 104096 LDH 1 16.00 05/14/07 105656 CBC W/PLT AUTO 1 30.00 05/14/07 106011 URINALYSIS-BASIC & MI 1 38.00 05/14/07 250369 HEPARIN 5000U/ML 1ML 10 7.50 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 157.50- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 157.50 * - Not posted Balance: 157.50 ------------------------ j4 - ? I/ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:24 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8408017 ------------------------------------------------------------------------- Date I Svc Code I Description I Unitsl Debits I Credits 05/29/07 8519 COLLECT BLD VIA PORT/ 1 66.00 05/29/07 104096 LDH 1 16.00 05/29/07 104433 BASIC METABOLIC PANEL 1 42.00 05/29/07 105656 CBC W/PLT AUTO 1 30.00 05/29/07 250369 HEPARIN 5000U/ML 1ML 10 7.50 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 161.50- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 161.50 * - Not posted Balance: 161.50 ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:24 P M Guarantor: VARNER CLIFF ORD H 643 HIGHLAND AVE MT HOLLY SPR I, PA 17065-0000 Patient: VARNER CLIFFORD H Visit #: 8519974 ---------- Date ------------- Svc Code ------------------------ ( Description ----- --------- Unitsl --------- -------------- Debits -------------- ---------- Credits ---------- ---------- 06/14/07 --- ---------- 245207 ------------------- LIDOCAINE 1 ML 2 3.00 06/14/07 308286 REM TUNNELED CATH W/O 1 470.00 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 473.00- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 - --•- 473.00 ---------- ---- ---------- ----------------------- * - Not posted ------------------------ ----- -- Balance: I -------------- 473.00 ---------- ?b MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 08/15/07 at 02:25 PM Guarantor: VARNER CLIFFORD H 643 HIGHLAND AVE MT HOLLY SPRI, PA 17065--0000 Patient: VARNER CLIFFORD H Visit ##: 8461681 ------------------------------------------------------------------------- Date I Svc Code I Description Units Debits Credits 06/14/07 8519 COLLECT BLD VIA PORT/ 1 66.00 06/14/07 104042 CREATININE, BLOOD 1 14.00 06/14/07 104065 UREA NITROGEN (BUN), 1 13.00 06/14/07 104096 LDH 1 16.00 06/14/07 105657 CBC W/PLT/DIFF AUTO 1 48.00 07/31/07 980090 HOSPITAL BAD DEBT W/O -1 157.00- 07/31/07 980091 HOSPITAL BAD DEBT PLA 1 157.00 * - Not posted Balance: 157.00 ------------------------ p 37 April 08, 2008 Debtor Payments Page: 1 Code Case No Patient Name Payor Pmt Date Type Amount Prin. Costs Interest 407,The Milton S. Hershey Medical Center 137252 224509 Clifford Varner 01/22/08 DIRECT 137540 224509 Clifford Varner 02/13/08 FIRM 138142 224509 Clifford Varner -------------------- 03/11/08 FIRM --- TOTAL: 3 3 TOTAL DUE PAYMENT BALANCE DUE $157,524.40 150.00 $157,374.40 50. 00 50. 00 .00 .00 50 .00 50. 00 .00 .00 50 .00 50. 00 --- .00 ------- ---- .00 ------ --------- 150 --- --- .00 ------- 150. -- 00 --- .00 ------- ---- .00 ------ --------- 150 --- --- .00 ------- 150. -- 00 .00 .00 ?-33 PENNSTATE ' Milton S. Hershey Medical Center MSHMC PHYSICIANS GROUP BILLING SERVICES PO Box 843313, Plttsburgh, PA 15284-3313 P-00015 CLIFFORD H VARNER 643 HIGHLAND AVE MOUNT HOLLY SPRINGS PA 17065-1929 rr?lll?rrlll??rrlir?rlrlrr??lllrlrrr?lrll?lrr?lr?lrrll?rrll. Patient Name CLIFFORD H VARNER Statement Date 12/14/07 Account Number 1635135 Total Charges $ 26,946.00 Insurance Payments/Adjustments $ -3.08 Patient Payments $ -1,763.00 Pending with Insurance $ 67.00 Amount You Owe $ 25,179.92 1 st Statement Page 1 of 14 Thank you for allowing Penn State University Physicians Group to provide you with services. Please send your payment for the full amount. If you have any questions concerning how your insurance company processed your claim, please call them. If no insurance is listed on the back of this statement and one is available please contact our office with your information. Please note: To keep your account current, our policy is to apply your payment to the oldest outstanding balance. Special Holiday Hours: December 24 8:00 am to 2:00 pin, December 25 closed, December 26, 27, 28 8:00 am to 4:30 pm, December 318:00 am to 2:00 pm To make payntents,:billing questions or iusurancechanges: Para preguntas acerca de su factura o cambios de seguro contamos con representantes disponibles para asistir a la comunidad hispana. Phone: (717) 531-5069 or (800) 254-2619 In Person: Financial counselors are available in the Academic Support Building (on campus just east of the main hospital and University Physicians Center). Available hours: Monday, Tuesday & Wednesday 8:00 am to 5:30 pm Thursday & Friday 8:00 am to 4:30 pm Written Correspondence: Penn State Milton S. Hershey Medical Center Patient Financial Services Department PO Box 854, Mail Code A410 Hershey, PA 17033-0854 This new statement has been specially designed with . Department of Public Welfare 1-800-692-7462 you in mind. Let us know what other improvements . Children's Health; Insurance-Program (CHIP:) 1-800-543-7101 we should make. (Uninsured children and adolescents under age 19) . AduitBasic Program 1-800-543-7101 Please e-mail your ideas to: (Uninsured adults between the ages of 19 and 64) Statementideas?u h.mc,psu& U or write to us at: RNM3 Penn State Milton S. Hershey Medical Center Statement Ideas, PO Box 854, MC A410 Hershey, PA 17033 This stntermext is for your physic/mr services o?riy. The hospiral inay bill separately for their services. HERSHPHYSTI-01 ...................................................................................................................................................................................... PENNSIAIE Statement Date: 12/14/07 Milton S. Hershey Medical Center Patient.Narne' Account' Number 'D"ate Due CLIFFORD H VARNER 1635135 Up61 Receipf a Amou4You 01we AmduCtt"1?_aid r $ 25,179.92 1$ ?I I j Check here if your address or insurance information lies changed. Please indicate changes on the back of this page. To pay by credit card: For your convenience, you may pay by visa, MasterCard or Discover Card. Please Indicate your credit card preference, provide the account information, and sign below. MSHMC PHYSICIANS GROUP PO BOX 643313 PITTSBURGH, PA 15264-3313 IIIIIIIIII III IIIIIIII(IIIIl III III IIIull IIIIIII 1111111111111 ? V- ? ® ? [? Account No. Expiration Date Signature X 00001635135 UP A-3q CVV Code 0000000002517992121407 Page 2 of 14 Ii VARNER PATIENT NAME CLIFFORD VISIT NUMBER ,8056218 : . DOCTOR(S) JANET'A NEUTZE MD bW OF'DIAG RADIOLOGY LOCATION INPATIENT CPT Payments/ Pending Patient Date Code Diagnosis Descrl tion Charges Adjustments Insurance Balance 008/07 790 786.9 EST 1 VIEW $ 60.00 02/21/07 MEDICARE PAYMENT* 03108/07 THANK YOU FOR PAYMENT $ -60.00 TOTAL: $ 60.00 $ -60.00 $ 0.00 $ 0.00 PATIENT NAME "CLiFFORD,H VARNER VISIT NUMBER8056216 : ION INPATIENT LOCA DOC;TQR(S): iLESLfE,l3 SCORZA MD INTERVENTIONAL . T CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 02/08/07 77001 V58.81 FLUOR GUID CV ACC DEV PLC $ 124.00 02121/07 MEDICARE PAYMENT* 03108/07 THANK YOU FOR PAYMENT $ -124.00 02/08/07 36556 V58.81 INSERT NON-TUNNEL CV CATH $ 649.00 02/21/07 MEDICARE PAYMENT* 03/08107 THANK YOU FOR PAYMENT $ -649.00 TOTAL: $ 773.00 $ -773.00 $ 0.00 $ 0.00 PATIENT NAME CLIFFORD' H VARNER ; VISIT NUMBER 8056218 "- DOCTQR(S) 'ROBERT GATN{P MD VASCULAR SURGERY LOCA?`)ON INPATIENT CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance UNS/07 93970 453.41 DUPLEX SCAN EV - COMPLETE $ 242.00 02/21/07 MEDICARE PAYMENT* 03/08/07 THANK YOU FOR PAYMENT $ -242.00 TOTAL: $ 242.00 $ -242.00 $ 0.00 $ 0.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHHYSTI-02 ............................ .................. ....................................... ........................................ ........ . PLEASE COMPLETE IF YOUR ADDRESS OR INSURANCE HAS CHANGED NAME RELATIONSHIP TO PATIENT HOME TELEPHONE WORKTELEPHONE ADDRESS CITY STATE ZIP POLICYHOLDER'S NAME INSURANCE COMPANY NAME GROUP POLICY/PLAN NUMBER POLICYHOLDER'S IDENTIFICATION NUMBER CLAIM MAILING ADDRESS POLICYHOLDER'S DATE OF BIRTH RELATIONSHIP TO PATIENT CITY STATE ZIP POLICYHOLDER'S EMPLOYER NAME INSURANCE COMPANY TELEPHONE (Workers Compensation & Auto Insurance Claims Only) Adjusters Name: Claim #: DATES OF COVERAGE EEFECTIVE FROM: EFFECTIVE TO: 1- _#0 Page 3 of 14 PAtiENT NAME; CLII=FVV{51T NUMf3ER? $Q5g218r DOCTOR(' A JAMES BEMATOLQ GY ONCQLdG LOCA`fI07V 1N1??KTIENT CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 5270-8/07 =3 446.6 INITIAL HOSPITAL CARE $ 435.00 02/28/07 MEDICARE PAYMENT* 03/08/07 THANK YOU FOR PAYMENT $ -338.00 06/13/07 THANK YOU FOR PAYMENT $ -50.00 07116/07 THANK YOU FOR PAYMENT $ -47.00 TOTAL: $ 435.00 $ -435.00 $ 0.00 $ 0.00 PATIENT NAME: CLIFFOR©H VARNER VISIT'N.U. MBER: $06621$' DOCTORtSi: MICHAEL B.ONGIOVANNI MD DIV CLINICAL PATHOLQG LOCATION INPATIENT CPT Date Code Diagnosis Description 02/08/07 99252 446.6 INPT CONSULTATION 03/01107 MEDICARE PAYMENT* 07/16/07 THANK YOU FOR PAYMENT 08124/07 THANK YOU FOR PAYMENT 09/10/07 THANK YOU FOR PAYMENT 10/11/07 THANK YOU FOR PAYMENT 11/08/07 THANK YOU FOR PAYMENT 02/08/07 36514 446.6 THER APHERESIS, PLASMA 03/01107 MEDICARE PAYMENT* 11108/07 THANK YOU FOR PAYMENT 12/06/07 THANK YOU FOR PAYMENT TOTAL: Payments/ Charges Adjustments $ 173.00 $ -3.00 $ -50.00 $ -50.00 $ -50.00 $ -20.00 Pending Patient Insurance Balance $ 482.00 $ -30.00 $ -50.00 $ 402.00 $ 655.00 $ -253.00 $ 0.00 $ 402.00 PATIENT NAME: CLIPFORD H VARNER VISIT NUMI1ER 8056 18- DOCTOR(S): PETER ALAGONA MD GENERAL CARDIOLOGY LOCATION INPATIENT s CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 02%08/07 93010 426.82 ECG ELECTROCARD INTERP $ 68.00 03/30/07 MEDICARE PAYMENT* $ 68.00 02/08/07 93010 427.89 ECG ELECTROCARD INTERP $ 68.00 03/30/07 MEDICARE PAYMENT* $ 68.00 TOTAL: 136.00 $ 0.00 $ 0.00 $136.00 PATIENT NAME CLIF,FORD`ff VARNER VISIT 'NUMBER: 8056218, DOCTOR(S): KHURANI S KAZMI MD DIV OF DIAG RADIOLOGY LOCATION: INPATIENT CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 02%09/07 70450 446.6 CT HEAD UNENHANCED $ 278.00 02/21107 MEDICARE PAYMENT* $ 278.00 TOTAL: $ 278.00 $ 0.00 $ 0.00 $ 278.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYSTI-03 p -HI Page 4 of 14 PAl IEtJT NAME CLIFFORD H VARNER VISIT NUMBER ;$,056z?s _._. ,.. -`--''-.: , r .. : ,:r..?T i.r?nv"r??irni nr i r1r .inWIAIPeTiFNT. CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 02/09/07 99233 446.6 DAILY HOSPITAL CARE $ 230.00 02/28/07 MEDICARE PAYMENT* $ 230.00 TOTAL: $ 230.00 $ 0.00 $ 0.00 $ 230.00 PATIENT NAME CLIFFORD H VARNER VISIT NUMBER 8056218 DOCTOR(S) ,,RONALD E DOMEN MD DIV CLINICAL PATHOLOGY LOCATION "INPATIENT CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 0-2-70-9107 36514 446.6 THEIR APHERESIS, PLASMA $ 482.00 03/01107 MEDICARE PAYMENT* $482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 VARNER ' ' . PATIENT NAME. CLIFFORD H VISIT NUMBER 805621$ : ' , nrir.TnRfSi?!?nFB[iRAH L 1NOLBRETTE MD ELECTROPHYSIOLOGY ' LOCATION INPATIENT' ' CPT Date Code Diagnosis Description =9/07 93010 426.50 ECG ELECTROCARD INTERP 03/29/07 MEDICARE PAYMENT* TOTAL: 4 O DIV OF DIA6 Payments! Pending Patient Charges Adiustments Insurance Balance $ 68.00 $ 68.00 $ 68.00 $ 0.00 $ 0.00 $ 68.00 vIRIT',iUL1MBER':8056218 _. .. CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Ba ance 00-10/07 71010 511.9 CHEST 1 VIEW $ 60,00 02/21/07 MEDICARE PAYMENT* $ 60.00 TOTAL: $ 60.00 $ 0.00 $ 0.00 $ 60.00 PATIENT NAME CLIFFORD H VARNER ;' VISIT NUMBER 8056218.: I DOCT.OR(S): JAMES. $ALLARD MD DlV OF HEMATOLOGY ONCOLOG LOCATION INPATIENT:. CPT Payments/ Pending Patient " n Date Code Diagnosis Descriptio Char es -? Ad'IUsttii"ents Insurance- Balance 02/10/07 99233 446.6 DAILY HOSPITAL CARE $ 230.00 02/28/07 MEDICARE PAYMENT* $ 230.00 TOTAL: $ 230.00 $ 0.00 $ 0.00 $ 230.00 PATIENT NAME CLIFFORD H; VARNER VISIT NUMBER: 8056218', ?? ?? DOCTbR(S).: DONALD E bOMEN MD DI.V CLINICAL PATHCLO. LOC ATION, INPATIENT ' CPT Payments/ Pending Patient Date Code Dia cLosis Description Charges Adiustments Insurance Balance 02110107 36514 446.6 THER APHERESIS, PLASMA $ 482.00 03/01/07 MEDICARE PAYMENT* $482.00 TOTAL: $ 482.00 $ 0.00 • $ 0.00 $ 482.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYSTi-03 if 'l), um Ffrw ?? Page 5 of 14 PATIENT NAMI*: CLlFFORD`H VARNER VISIT NUMSER:,8056298` ` DOCTOR(S):'itAMES BALLARD MQ DIV OF HEMATOLOGY ONGOLOG LOCATION INPATII=NT CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments I nsurance Balance 02/11/07 99233 446.6 DAILY HOSPITAL CARE * $ 230.00 $ 230 00 02/28/07 MEDICARE PAYMENT . TOTAL: $ 230.00 $ 0.00 $ 0.00 $ 230.00 PATIENT NAME: CLIFFORD H VARNER VISIT NUMBER.8056218 DOCTORS} RONALD E DOMEN MD DIV CLINICAL PATHOLOGY LOCATION INPATIENT ` CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 02/11/07 36514 446.6 THEIR APHERESIS, PLASMA * $ 482.00 $ 482 00 03101/07 MEDICARE PAYMENT . TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME :GLIFORD N VARNER VISIT NUMBER:8056218' DOCTOR(S) HAMID ALMONDHIRY MD DIV OF HEMATOLOGY ONCOLO L©CATION INPATIENT CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 02/12/07 99233 446.6 DAILY HOSPITAL CARE * $ 230.00 $ 230 00 02128/07 MEDICARE PAYMENT . TOTAL: $ 230.00 $ 0.00 $ 0.00 $ 230.00 PATIENT NAME:'CEIFFORD H VARNER VISIT NUMBEI ;80562181 h AL PATHOLO ' LOCATION 1NPA§TIENT LIAM.I CASTELLANI MD Ply CLINIC DOCTOR(S) WIL iaeT? CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 02/12/07 36514 446.6 THEIR APHERESIS, PLASMA * $ 482.00 $ 482 00 03/01107 MEDICARE PAYMENT . TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 . PATIENT'NAME, cUFFORD F(VARNER VISIT NUMBER 805621& °- DOG70R(S}:,HAMID ALMONDHIRYMD DIV OF HEMATOLOGY ONCOLO LOCATION INPATIENT CPT Payments/ Pending Patient Date Code Diagnos!s Description Charges Adiustments ' Insurance Balance 02/13/07 99238 446.6 HOSP DISC DAY MGT <30 MIN * $ 147.00 $147 00 02/28/07 MEDICARE PAYMENT . TOTAL: $147.00 $ 0.00 $ 0.00 $147.00 PATII=N.TNAME. CLIFFORD H VARNER VISIT NUMBER: 8056218 DOCTdR(S): JHOMAS,P NIFONG MID DIV CLINICAL. PATHOLOGY L.OCATIOW: INPATIENT CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 02/13/07 36514 446.6 THEIR APHERESIS, PLASMA * $ 482.00 $ 482 00 03101107 MEDICARE PAYMENT . TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHY3T143 Page 6 of 14 JIM! PATIENT N?4ME CLIFFORD H VARNER VISIT.NUMBER,?8080235 DOCTOR(S) RONALD E DOMEN? MD' DIV CLINICAL PATHOLOGY ' LOCATION SPECIAL TREATMENT RM CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 02/15/07 36514 446.6 THEIR APHERESIS, PLASMA * $ 482.00 $ 482 00 03/01/07 MEDICARE PAYMENT . TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME CLIFFORD H WARNER VISIT NUMBER 8083626 DOCTOR(S) PETER`A MILLWARD MD DIV CLINICAL PATHOLOGY LOCATION SPECIAL TREATMENT RM CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 02/16/07 36514 446.6 THEIR APHERESIS, PLASMA $ 482.00 03/01/07. MEDICARE PAYMENT* $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME CLIFFORD.H VARNER DOCTOR{S) <PETER A MILLINARDM, D DIV CLINICAL PATHOLOGY VISIT NUMBER .8086921,° ' LOCATION SPECIAL TREATME?IT,RM, , v CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 02/17107 36514 446.6 THER APHERESIS, PLASMA $ 482.00 03/01107 . MEDICARE PAYMENT* $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME CL'IFFORD`N VARNER VISIT NUMBER 808770.6 DOCTOR.(S):"HARJlT51NGH MD INTERVENTIONAL LOC?ITIQN INPATIENT: CPT Payments/ Pending Patient Date Code Dia nq osis Description Charges Adiustments Insurance Balance 02/19/07 77001 V58.81 FLUOR GUID.CV ACC DEV PLC $ 124.00 03/02/07 MEDICARE PAYMENT* $124.00 02/19/07 36558 V58.81 INSERT TUNNLED CV CAT 5,> $ 1,243.00 03/02/07 MEDICARE PAYMENT* $ 1,243.00 TOTAL: $ 1,367.00 $ 0.00 $ 0.00 $ 1,367.017 CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 02/19/07 99223 287.5 INITIAL HOSPITAL CARE $ 435.00 03/02/07 MEDICARE PAYMENT* $ 435.00 TOTAL: $ 435.00 $ 0.00 $ 0.00 .$435.00 PATIENT NAME CLIFFORD H DARNER VISIT NUMBER. 8087706 OCTOR(S) THOMAS P NIFONG MD DIV CLINICAL PATHOLOGY LdGATION INPATIENT CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 02/19/07 36514 446.6 THEIR APHERESIS, PLASMA $ 482.00 03/07/07 MEDICARE PAYMENT* $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYSTI-M A -NCI Page 7 of 14 PATIENT NAME: CLIFFORD 'H VARNER- VISIT NUMRER'.8087706i., DOCTOR(S): GERALD V NACCARELLI MD ELECTROPHYSIOLOGY ' LOCATION INPATIENT CPT Payments/ Pending Patient Date Code Diaqnosis Description Charge s Adiustments Insurance Balance 02/19/07 93010 786.50 ECG ELECTROCARD INTERP * $ 68.00 $ 68 00 03130107 MEDICARE PAYMENT . TOTAL: $ 68.00 $ 0.00 $ 0.00 $ 68.00 PNT NAFORD H VARNER V ISIT NUMBER:'i31T877 LMONDHIRY,MD DlV OF HEMATOLOGY ONCOLO LOCATLON INpATIE.NT CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 02/20/07 99238 287.5 HOSP DISC DAY MGT -30 MIN $ 147.00 03/02107 MEDICARE PAYMENT* $147.00 TOTAL: $147.00 $ 0.00 $ 0.00 $147.00 IT NAME: CLIFFORD H VARNER VISIT NUMBER: 8087706 )R(8k.WILlIAM J..CASTELLANI Mb DIV CLINICAL PATHOLO LOCATION. INI?ATIENT CPT Date Code Diagnosis Description 02/20/07 36514 446.6 THER APHERESIS, PLASMA 03107/07 MEDICARE PAYMENT* TOTAL: Payments/ Pending Patient Charges Adjustments Insurance Balance $ 482.00 $ 482.00 ?ii $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME'°CLIFFORD'I VARNER " VISIT NUMBER?'8?97268 ;? nnrroRtst_. MICHAEL BONGIOVANNt MD DIV CLINICAL PATHOLOG LOCATlf3N SPACIAL TREATMENT I M . CPT Date Code Diagnosis Description 02/23/07 36514 446.6 THER APHERESIS, PLASMA 03/07/07 MEDICARE PAYMENT* TOTAL: e? Payments/ Pending Patient Charges Adiustments Insurance Balance $ 482.00 $ 482.00 $ 482.00 $ 0.00 $ 0.00 $ 482.00 i a? ME; CLIFFORD H VARNER VISIT NUMBER: 809727x.1 - WILLIAM J CASTELLANI, MD DIV CLINICAL, PATHOLO LOCATION: SPECIAL T4EATMENT,RN1; CPT Date Code 'Diagnosis Description 02121/07 36514 446.6 THERAPHERESIS, PLASMA 03/07107 MEDICARE PAYMENT* TOTAL: Payments/ Pending Patient Charges Adiustments Insurance Balance $ 482.00 $4 1 82.00 $ 482.00 $ 0.00 $ 0.00 $ 482.00 VISIT NUMBI=R: 8103270 1 ` CLINICAL PATHOLOGY LOCATION: SPECIAL TREATMENT RIM CPT Date Code Diaqnosis Description 02122/07 36514 446.6 THER APHERESIS, PLASMA 03/07/07 MEDICARE PAYMENT* TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYSTI-03 Payments/ Pending Patient Charges Adiustments Insurance Balance $ 482.00 $ 482.00 l? ys - Page Bof14 PATIENT NAMECLIFFORD H VARNER- DOCTOR(S) PETER'A MILLWARD MD DIV CLINICAL PATHOLOGY VISIT NU.IfABER='8103273; LOCATION SPECIAL TREATMENT RM ". CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 03126/07 36514 446.6 THEIR APHERESIS, PLASMA $ 482.00 04/05107 MEDICARE PAYMENT* $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 H VARNER PATIENT NAME: CLIFFORD. DOGT.OR(S);_:T HOMAS P NIFONG.MD.D1V CLINICAL PATHOLOGY VISIT NUMBER -3103278 LOCATION SPECIAL TREATMENT RM ": CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 02/24/07 36514 446.6 THEIR APHERESIS, PLASMA $ 482.00 03107/07 MEDICARE PAYMENT* $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 I ENT NAME GLIFFORDVARNER O ' ` r VS SPECIAL TREATMENT RM CATICiN LOGY NIFONG MD DIV CLINICAL PATH THOM,AS P CTOR(S) D : LO t CPT Payments/ Pending Patien Date Code Diagnosis Description Charqes Adiustments Insurance Balance 02/25/07 36514 446.6 THEIR APHERESIS, PLASMA * $ 482.00 $ 482 00 03/07/07 MEDICARE PAYMENT . TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 02/27/07 36514 446.6 THEIR APHERESIS, PLASMA $ 482.00 03/08/07 MEDICARE PAYMENT* $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME CLIFFORD,.H VARNER?VC?L DbCYpR(S)` RQ?IALD E DQI4JIENNICAL PATHOLOGY VISIT NUMBER 8112803 LOCATION .SPECIAL TR..EAT,i'1A1 RM„ CPT Payments/ Pending Patient Dafe Code Diagnosis Descriptidri Charqes Adiustments Insurance Balance 03/29/07 36514 446.6 THEIR APHERESIS, PLASMA $ 4B2.00 04/12107 MEDICARE PAYMENT* $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME CLIFFORD H VARNER VISIT NUMBER: 8112853 ; DOC.TOR(S} '1?ETER A MILLWARD MD DIV CLINICAL PATHOLOGY LOCATIQ.N SPECIAL, TIZE,ATMENT. RM `; CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 03/28/07 36514 446.6 THER APHERESIS, PLASMA $ 482.00 04/12107 MEDICARE PAYMENT* $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYSTI-03 - 4/" Page 9 of 14 PATIENTNAMEVARNER " VISIT NUMBBR: 8114Q7 ?? DOCTOR(S) HMD INTERVENTIONAL LOCATfON: Op HOSPITAL CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 02/23/07 36598 996.1 CONTRAST INJ FOR RAD EVAL " $ 205.00 $ 205 00 03/07107 MEDICARE PAYMENT . 02123/07 36581 996.1 REPLC TUN CV CATH W/O $ 891.00 03/07/07 MEDICARE PAYMENT* $ 891.00 TOTAL: $1,096.00 $ 0.00 $ 0.00 $ 1,096.00 PATIENT NAME CLIFFORD H VARNER VISIT NUMBER: $120169 DOCTOR(S):, PETER A MILLWARD Mlj DfV CLINICAL PATHOLOGY - LOCATION: SPECIAL TREA1"MENt RM CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 02/28/07 36514 446.6 THER APHERESIS, PLASMA $ 482.00 03/08/07 MEDICARE PAYMENT* $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME: CLIFFORDH-VARNER DOGTOR(S)' PETER-A MILLWARD MD DIV CLINICAL PATHOLOGY - VISIT NUMBER: 81201 LOCATION' SPECIAL TREATMENT RM CPT Date Code Diagnosis Description 03/01/07 36514 446.6 THER APHERESIS, PLASMA 03116/07 MEDICARE PAYMENT* Payments/ Pending Charges Adiustments Insurance $ 482.00 Patient Balance $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME- CLIFFORDH VARNER VISIT NUMBER;' 8120179 DOCTOR(S); THOMAS P NIFONG NO DIV CLINICAL PATHOLOGY LOCATION: SPECIAL TREATMENT RM CPT Date Code Diagnosis Description 03/02/07 36514 446.6 THEIR APHERESIS, PLASMA 03/16/07 MEDICARE PAYMENT* Payments/ Pending Charges Adjustments Insurance $ 482.00 Patient Balance $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME CLIFFORD H VARNER VISIT NUMBER: 0142711 DOCTOR(S).. MCHAEL BONGIOVANNI MD DIV CLINICAL PATHOLOG LOCATION SPECIAL TREATMENT. Rl CPT Date Code Diagnosis Description 03/05/07 36514 446.6 THER APHERESIS, PLASMA 03/16/07 MEDICARE PAYMENT* Payments/ Pending Charges Adjustments Insurance $ 482.00 Patient Balance $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME: CLIFFORD'H VARNER DOCTOR(S):,PETER _A MILLWARD MD DIV CLINICAL PATHOLOGY VISIT NUMBER.' 8157584 LOCATION SPECIAL TREATMENT RM`. CPT Date Code Diagnosis Description 03/08/07 36514 446.6 THER APHERESIS, PLASMA 03123/07 MEDICARE PAYMENT* Payments/ Pending Charges Adiustments Insurance $ 482.00 Patient Balance $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYSTI-03 A -q7 Page 10 of 14 PATIENT NAME CLIFFORD H VARNER OGY ` VISIT NUMBER -917o4b4 LOCATION SPECIAL TREATMENT RM MD DIV CLINICAL PATHOL DOCTORS : THOMAS P NIFONG Payments/ Pending Patient CPT Date Code Diagnosis Description Charges Adjustments Insurance Balance 03/12107 36514 446.6 THEIR APHERESIS, PLASMA $ 482.00 $ 482.00 03/23/07 MEDICARE PAYMENT* TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME CLI FORD,'H VA"RNER RONALD E.DOMEN. MD,DIV CLINICAL PATHOLOGY DQGTOR(S). VISIT NUMBER ?8174973' LOCATION SPECIAL TREATMENT RK,; , CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 03/13/07 36514 446.6 THER APHERESIS, PLASMA * $ 482.00 $482.00 03/23/07 MEDICARE PAYMENT TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 -CL YAI?N ER ATIENT DOC OR(SA QETERA MLpWARD MD DiV:CLINICAL PATHOLOGY LOCATIONBSPECIAL TREATMENT f4 CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 03/14107 36514 446.6 THER APHERESIS, PLASMA $ 482.D0 $ 482.00 03/26107 BALANCE TRANSFER TO GUAR TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 UER 2101218 , PATIENT NAMES--CLIFFORUH VARNER VISIT N MB D DIV CLINICAL PATHOLOGY LOCATION SPECIAL. TREA?fMENT RNI O NALD E DQMEN M DOCTORS}:;R CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance U37T6/07 36514 446.6 THEIR APHERESIS, PLASMA $ 482.00 00 $ 482 03126/07 BALANCE TRANSFER TO GUAR . TOTAL: $ 482.00 $ 0.00 $ 0.00 $482.00 CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 03/19107 36514 446.6 THEIR APHERESIS, PLASMA * $ 482.00 $ 482.00 03130/07 MEDICARE PAYMENT TOTAL: $ 482.00 $ 0.00 $ 0.00 " $ 482.00 PATIENT NAME GLIFFORDH VARNER -' ORD H VISIT NUMBER f82074b7 ION SPECIAL' TR LOCA , EATMENT RM L?V ARD,MD IV CLINICAL PATHOLOGY DOCTORS}.;l?ETER,FA T CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 03/21/07 36514 446.6 THER APHERESIS, PLASMA $ 482.00 $ 482.00 04/05/07 MEDICARE PAYMENT* TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYSTI-03 4 J I V Page 11 of 14 PATIENT NAME. CLIFFORD H VARNER - VISIT NUMBER' 82446 4'-' DOCTOR(S): THOMAS P NIFONG MEI, PIy CLINICAL PATHOLOGY LOCATION SPEC,IAt TREATM M7 RM' CPT Payments] Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 03/30107 36514 446.6 THER APHERESIS, PLASMA $ 482.00 04/12107 MEDICARE PAYMENT* $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 :CLIFFORD H VARNER V15IT NUMBER: 8249415 PATIENT NAM. E . DOCTOR(S)-PETER A MILLWARD MD DIV CLINICAL PATHOLOGY LOCATION:, SPECIAL TREATMENT RM, _ CPT Payments/ Pending Patient Date Code Diagnosis Description Charge s Adiustments Insurance Balance 04/02107 36514 446.6 THEIR APHERESIS, PLASMA $ 482.00 04/12/07 MEDICARE PAYMENT* $ 482.00 TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME CLIFFORD H VARNER VISIT NUMBER `824$7$0," DOGTOR(S)t HAMIQ"ALMONDHIRY.MD DIV OF HEMATOLOGY ONCOLO LOCATION OP HOSPITAL ' ' CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 04/02/07 99215 446.6 OUTPATIENT VISIT EST $ 96.00 00 * $ 96 . 04/20107 MEDICARE PAYMENT mom TOTAL: $ 96.00 $ 0.00 $ 0.00 $ 96.00 VISIT NUMBER: 825207 !, H VARNER I4AE: CLIFFORD PATIENT NA '^ . ; Y ONCOLO LOCATION OP HOSPITAL A ' TOLOG ALIVIONDHIRY MQ DIV OF HEM DOCTOR(S)` HAMIQ CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance = 04/05/07 99213 446.6 OUTPATIENT VISIT EST $ 44.00 00 * $ 44 . 06/06/07 MEDICARE PAYMENT i? TOTAL: $ 44.00 $ 0.00 $ 0.00 $ 44.00 PATIENT NAME: CLIFFORD H VARNER VISIT NUMBED: 825270T DOCTOR(S): HAND'ALMONDHIRY MD DIV OF HEMATOLOGY ONCOLO LOCATION OP HOSPITAL CPT Payments/ Pending Patient Date - Code Diagnosis Description Charges Adiustments Insurance Balance 04/09/07 99213 446.6 OUTPATIENT VISIT EST $ 44.00 00 * $ 44 . 04130/07 MEDICARE PAYMENT TOTAL: $ 44.00 $ 0.00 $ 0.00 $ 44.00 I MBER:`825372T PAMEER ?LO CA RS: TNG MD,.DIV CLINICAL PTHOLOY ON 5pEOlA L TREATMENT RM CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 04/05/07 36514 446.6 THER APHERESIS, PLASMA $ 482.00 00 * $ 482 . 04119107 MEDICARE PAYMENT TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYST1-0.3 Page 12 of 14 PATIENT NAME:?'CUFFORD H.VARNER' • T VISIT NUMBER: 8269543: " LOCATION: SPECIAL TREATMENT RM ' HOLO DOCTOR(S):;WILLIAM J CASTELLANI MD DIV CLINICAL PA CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 04/06/07 36514 446.6 THEIR APHERESIS, PLASMA * $ 482.00 $482.00 04/19/07 MEDICARE PAYMENT TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME CQFFORD H VARNER bOCTOR(S} WILLIAM J CASTELLANI MD DIV CLINICAL PATHOLO VISIT NUMBER 8271701' LOCATION SPECIAL, TREATMENT W' CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 04/07/07 36514 446.6 THEIR APHERESIS, PLASMA * $ 482.00 $ 482.00 04/19/07 MEDICARE PAYMENT TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME CLIFFORD ;H VARNER _ VISIT NUMBER 8271703 DOCTORS} )NILLIAM, J CAST>=LLANI MD DIV CLINICAL PATHOLO ' LOCATION SPECSI. 4J, RM CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 0470-8/07 36514 446.6 THER APHERESIS, PLASMA * $ 482.00 $ 482.00 04/19/07 MEDICARE PAYMENT TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 CPT Date Code Diagnosis Description 4111107 36514 446.6 THER APHERESIS, PLASMA 04/26/07 MEDICARE PAYMENT* TOTAL: Payments/ Pending Patient Charges Adjustments Insurance Balance $ 482.00 $ 482.00 $ 482.00 $ 0.00 $ 0.00 $ 482.06 VISIT NUIVIB7=R 827•?.375 and nGY LOCATION SPEGiAI_ TREATMENT R CPT Payments/ Pending Patient Date Code Diagnosis Descn • ?ptiori . . . Changes Adjustments Insurance ' Balance X3/07 36514 446.6 THEIR APHERESIS, PLASMA * $ 482.00 $ 482.00 04/26/07 MEDICARE PAYMENT TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 PATIENT NAME. CLIFFORD H VARNER VISIT NUMBER: 6311726; NT RM LOCATION SPECIAL THE-ME DOCT(OR(S)..t?ETER A MILLWARD:MD D?V-CLINICAL PATHOLOGY , CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 0)0/07 36514 446.6 THER APHERESIS, PLASMA * $ 482.00 $ 482.00 05/03107 MEDICARE PAYMENT TOTAL: $ 482.00 $ 0.00 $ 0.00 $ 482.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYSTI-03 I Page 13 of 14 'H VARNER ;CLIFFORD PAT-LENT NA ME VISIT NUMBER :8355706;" , . DOCTOR(Sj; HAMID ALMONDHIRY MD DIV OF HEMATOLOGY ONCOLO LOCATION OP HOSPITAL CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 07107 99213 446.6 OUTPATIENT VISIT EST $ 87.00 06/11/07 MEDICARE PAYMENT* $ 87.00 TOTAL: $ 87.00 $ 0.00 $ 0.00 $ 87.00 PATIENT NAMECLIFFORD H VARNER VISIT NUMBER: 6381105 DOCTOR(S). HAMID ALMONDHIRY MD DIV OF HEMATOLOGY ONCOLO LOCATION, OP HOSPITAL I CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 65114/07 99214 446.6 OUTPATIENT VISIT EST * $ 135.00 $ 135 00 06/11/07 MEDICARE PAYMENT . TOTAL: $135.00 $ 0.00 $ 0.00 $135.00 H VARNER D' PATIENT NAME: CLIFFOR 8408017 UMBER: VISIT N DOCTOR(S):.;HAMID ALMONDHIRY MD DIV OF HEMATOLOGY ONCOLO LOCATION OP HOSPITAL • CPT Payments/ Pending Patient j Date Code Diagnosis Description Charges Adiustments Insurance Balance 05/29/07 99213 446.6 OUTPATIENT VISIT EST $ 87.00 06/11/07 MEDICARE PAYMENT* $ 87.00 s TOTAL: $ 87.00 $ 0.00 $ 0.00 $ 87.00 PATIENT;NAME CLIFFQRD,H VARNER- VISIT NUMBER: 8461681 ' j DOCTOR(S) HAMID`ACMONDHIRY'MD DIV OF HEMATOLOGY ONGOLO LOCATION: OP HOSPITAL i CPT Payments/ Pending Patient Date Code Diagnosis Descri tp ion Charges Adjustments Insurance Balance - 00 $ 135 56/14/07 99214 446.6 OUTPATIENT VISIT EST $ 135.00 . TOTAL: $ 135.00 $ 0.00 $ 0.00 $135.00 PATIENT NAME CLIFFORD H VARNER VISIT NUMBER 8519974' ETER N WAYBILL INTERVENTIONAL DOCTOR(S)' P MD LOCATION 2OP H08PITAL • CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 05714/07 36589 V58.81 REMOVAL TUN CV CATH W/O P $ 589.00 06/21/07 BALANCE TRANSFER TO GUAR $ 589.00 TOTAL: $ 589.00 $ 0.00 $ 0.00 $ 589.00 PATIENT NAME"CLIFFORDH VARNER VISIT NUMBER:8520439: DOCTORS}-;; HAMID ALMONDHIRY MD DIV OF HEMATOLOGY ONCOLO LOCATION OP,HOSPITAL CPT Payments/ Pending Patient Date Code Diggnosis Description Charges Adiustments Insurance Balance 07/26/07 99213 446.6 OUTPATIENT VISIT EST $ 44.00 08/07/07 MEDICARE PAYMENT* 08/09/07 MEDICARE PAYMENT 08/D9/07 MEDICARE CONTRACTUAL ADJ * $ -3.08 92 $ 40 08/09/07 BALANCE AFTER INS . TOTAL: $ 44.00 $ -3.08 $ 0.00 $ 40.92 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL A 51 HERSHPHYSTI-03 ,. Page 14 of 14 GRAND TOTAL: $ 26,946.00 $ -1,766.08 $ 0.00 $ 25,179.92 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYSTI-03 4 a. r April 08, 2008 Debtor Payments Page: 1 Code Case No Patient Name Payor Pmt Date Type Amount Prin. Costs Interest 408,Milton S. Hershey Medical Center, t/a Milton S. Hershey Medical Center Physician Group 137256 224510 137541 224510 138143 224510 TOTAL: Clifford Varner Clifford Varner Clifford Varner 3 3 01/22/08 DIRECT 50. 00 50. 00 .00 .00 02/13/08 FIRM 50. 00 50. 00 .00 .00 03/11/08 FIRM 50. 00 50. 00 -- .00 ------ ---- .00 ------ --- ------ 150 --- --- .00 ------- 150. -- -- 00 .00 ------ ---- .00 ------- -- ------- 150 --- --- .00 ------- 150. -- ---- 00 .00 .00 TOTAL DUE PAYMENT BALANCE DUE $25,179.92 150.00 $25,029.92 R -?3 VAE.NF,,R,, CLIFFORD #1635135 $157,374.40 25,029.92 (Hosp) (Phys) VERIFICATION LINDA SCHLADER hereby states that she is the Team Manager, Customer Service of the Milton S. Hershey Medical Center and verifies that the statements made in the foregoing pleading are true and correct to the best of her knowledge, information and belief. The undersigned understands that the statements therein are made subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. LINDA SC LADER DATE : 6q14n1-- ,? oo ri 4 oo U1 O 't C- J r ?r 00 r- CASE NO: 2008-03496 P SHERIFF'S RETURN - REGULAR COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND MILTON S HERSHEY MEDICAL CTR VS VARNER CLIFFORD ET AL SHANNON SHERTZER Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE VARNER CLIFFORD was served upon the DEFENDANT , at 1252:00 HOURS, on the 14th day of June 2008 at 643 HIGHLAND AVENUE MT HOLLY SPRINGS, PA 17065 CLIFFORD VARNER by handing to a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge 18.00 6.00 .00 10.00 00 34 Sworn and Subscibed to before me this day So Answers: R. Thomas Kline 06/16/2008 TABAS & ROSEN By: I!, k T Deputy S riff of A. D. CASE NO: 2008-03496 P SHERIFF'S RETURN - REGULAR COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND MILTON S HERSHEY MEDICAL CTR VS VARNER CLIFFORD ET AL SHANNON SHERTZER , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon VARNER SARAH J the DEFENDANT at 1252:00 HOURS, on the 14th day of June , 2008 at 643 HIGHLAND AVENUE MT HOLLY SPRINGS, PA 17065 by handing to CLIFFORD VARNER, HUSBAND a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 6.00 Service .00 Affidavit .00 Surcharge 10.00 (.JlgDv q .00 16.00 Sworn and Subscibed to before me this of day So Answers: R. Thomas Kline 06/16/2008 TABAS & ROSEN By. D uty Sheriff A. D. David -D. Buell' Brothonotary Office of the PYOtidnbtai Cum6er[andfCounty, 'ennsyfvania xjrkS. Sohonage, ESQ Solicitor 3 91p CIVIL TERM ORDER OF TERMINATION OF COURT CASES AND NOW THIS 28TH DAY OF OCTOBER, 2014, AFTER MAILING NOTICE OF INTENTION TO PROCEED AND RECEIVING NO RESPONSE THE ABOVE CASE IS HEREBY TERMINATED WITH PREJUDICE IN ACCORDANCE WITH PA R.C.P.230.2. BY THE COURT, DAVID D. BUELL PROTHONOTARY One Courthouse Square 0 Suite100 ® CartisCe, • Phone 717 240-6195 0 r 'ax 717 240-6573