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06-27-08
REV -1500 ............................................................................................................... OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN DEPARTMENT OF REVENUE RESIDENT DECEDENT FILE NUMBER 2006-00836 DEPT. 280601 21 O6 0836 HARRISBURG, PA 17128-0601 COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER KEITER, DEAN C. 162-20-8724 DATE OF DEATH DATE OF BIRTH THIS RETURN MUST BE FILED IN DUPLICATE WITH THE AUGUST 1s, 2006 NOVEMBER 17, lsza REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSES NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER KEITER, MARGARET, J. 236-48-2806 X 1. Original Return 2. Supplemental Return 3. Remainder Return ~da,e o,~a,h „a, ~a,z-,~ea~ 4. Limited Estate 4a. Future Interest Comprise (dale oraeatn aRer ~z-~z-azl 5. Federal Estate Tax Return Required Check 6. Decedent Died Testate (Attach copy of wiu) 7. Decedent Maintained a Living Trust (A~,ach a copy or rn,sc) 8. Total Number of Safe Deposit Boxes 9. Litigation Proceeds Received 10. Spousal Poverty Credit (sate or Beam between ~z-a~-ai aoc i-~-ss> 11. Election to tax under Sec. 9113(A) (Attach Sch O) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHIOULD BE DIRECTED TO: Co NAME COMPLETE MAILING ADDRE:iS PETER J. RUSSO LAW OFFICES OF PETER J. F;USSO FIRM NAME (If Applicable) 5006 E. Trindle Road, Suite 10(1 LAW OFFICES OF PETER J. RUSSO Mechanicsburg, PA 17050 TELEPHONE NUMBER 717-591-1755 1. Real Estate (Schedule A) (1) 1,500.00 OFFICIAL USE ONLY r_. 2. Stocks and Bonds (Schedule B) (2) $0.00 ~ ~ ~ ~' ~-:: Q cis 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) $0.00 ~ -~ j ~-.. ~ - __ ~ .. , -- ,-- 4. Mortgages & Notes Receivable (Schedule D) (4) $0.00 = ~ ~~ ,~, (\; R , ; , ~.~ 5. Cash, Bank Deposits & Misc. Personal Property (Schedule E) (5) $300.00 _ { - - ~.{- - 6. Jointly Owned Property (Schedule F) (6) 1,444.41 ~ _. - ~ ~ -- ==i rv , Separate Billing Requested L~ 7. Inter-Vivos Transfers & Misc. Non-Probate Property (7) $0.00 -- (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) (8) $3,244.41 9. Funeral Expenses R Administrative Costs (Schedule H) (9) $8696.12 10. Debts of Decedent, Mortgage Liabilities & Liens (Schedule I) (10) $76,549.06 11. Total Deductions (total Lines 9 & 10) (11) $85,245.18 12. Net Value of Estate (Line 8 minus Line 11) (12) -582 000 77 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) $0.00 made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) -$82 000 77 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of line 14 taxable at the spousal tax -82000.77 x 0 (15) $0.00 rate, or transfers under Sec. 9116 (a)(1.2) a 16. Amount of line 14 taxable at lineal rate 1,444.41 x .045 (16) $65.00 x 17. Amount of line 14 taxable at sibling rate x 12 (17) $0.00 18. Amount of line 14 taxable at collateral rate x 15 (18) $0.00 19. Tax Due (19) $65.00 20. > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Decedent's Complete Address: STREET ADDRESS 122 PEACH STREET CITY CARLISLE STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) $65.00 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments $65.00 C. Discount Total Credits (A + g + C) (2) $65.00 InteresUPenalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) $0.00 4. If line 2 is greater than line 1 + line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) $0.00 5. If line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5) $0.00 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) $0.00 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN X IN THE I~PPROPRI ATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; X b. retain the right to designate who shall use the property transferred or its income; X c. retain a revisionary interest; or X d. receive the promise for life of either payments, benefits or care? X 2. If death occurred on or before December 12, 1982, did decedent within two years preceding death transfer property without receiving adequate consideration? If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? X 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? X 4. Did decedent own an individual retirement account, annuity, or other non-probate property? IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer other than the personal representative is based on all the information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ~(~ 1 a~ l 08 AD SS n A SIGNATUAEZ7F'1'R£PARER OTH EPRESENTA DATE ADDRESS 5006 E. Trindle Road, Suite 100 Mechanicsburg, PA 17050 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. §9116 (a) (1.1) (ii)]. The statute does no exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116(a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. VERIFICATION I, Margaret J. Keiter, verify that the statements made in the foregoing document(s) are true and correct. I understand that false statements made herein are subject to the penalties of 18 Pa.C.S. § 49.04 relatin~~ to unsworn falsification to authorities. ~' c~ ~ Date: f ° %/-d Margare J. Kei er • COMMONWEALTH OF PENNSYLVANIA SCHEDULE A INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF DEAN C. KEITER 2006-00836 FILE NUMBER 2006-00836 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is df~fined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly- owned with right of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH 1. 122 PEACH STREET, CARLISLE, PA (1972 Trailer) 1500.00 TOTAL (Also enter on line 1, Recapitulation) $1500.00 (If more space is needed, insert additional sheets of the same size) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN CASH, BANK DEPOSITS, & MISC. RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF DEAN C. KEITER FILE NUMBER 2006-00836 Include the proceeds of litigation and the date the proceeds were received by the estate. All property joi ntly-owned with the right of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH 1. Clothing $100.00 2. Money Holder (4) $20.00 3. Tie Clasps (4) $20.00 4. Cedar Chest $50.00 5 Silver Necklace with Cross $30.00 6 Watch $50.00 7. Ring $30.00 TOTAL (Also enter on line 5, Recapitulation) $300.00 (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF DEAN C. KEITER FILE NUMBER 2006-00836 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT 1. DEBRA KEITER 645 KNIGHTBRIDGE DRIVE, HAGERSTOWN, MD 2174G DAUGHTER 2. 3. JOINTLY-OWNED PROPERTY: ITEM LETTER DATE DESCRIPTION OF PROPERTY DAl'E OF DEATH % OF DATE OF DEATH NUMBS FOR MADE Include name of financial institution and bank account number or similar identifying VALUE OF ASSET DECD'S VALUE OF R JOINT JOINT number. Attach deed for jointly-held real estate. INTEREST DECEDENT'S TENANT INTEREST 1. 12-1-95 MEMBERS 1ST FCU ACCOUNT # XXXXX0332-00 821.76 50% 410.80 2, 8-17-01 MEMBERS 1ST FCU ACCOUNT # XXXXX0332-11 2067.22 50% 1033.61 TOTAL (Also enter .in line 6, Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size,l ~....:.,.; ~ rt ,... ..:4.,,.~,,,, :.~. ~.. , ~ ~ l~za INFORMATION NO~z f FILE f~O. Z7. Db-fiE's~i ~,w of INOSvia~'e~ T6%ES AND sue"°T' ~D6o1 TAXPAYER RESPONSE ACN 06154D29 HARRISBURG, PA 17129-D6D1 17JA1~ iv-2~-c.^~vo new.ss+s LM ~ cb4-on DEBRA RILEY 645 KNIGHTBRIp6E DR HA6ERSTOi~1R i~1D 2E i 48 CUMBERLAND CO COURT HOUSE CARLISLE, PA 1413 MF.MeERS 1,ST FCU nos provided t+w Depestront +~&th she deter®taah 119tod bolo. rhleh hoe Db~an urod Sn c..leuleting the potaetial teY due. 71rir raaords indleete that et fam death e~F the above dacodent, you rera a ~°init ornsr/twnaflci,nry of tfi,ls eceount. If you feel thls lnfarmelion is Lx:orrect, please obtain rrltton cerr+!ctlon from the fineneial lnstl;4a+tlon, ettbch a copy !o this ions and return 3t to 'the ~bpvp addr~as- This acoetmt fit taxable 4n eesordence rlth thv INieritante Tex Ltirs of tS1o Cooenonraelth of Pennsyivnnia. quastia~+s eey be ensaerad bpr celli~m [T17) TBT--ail.-.---' - -_ ~ ----- - - -.-"' _ - -~ - . - COMPLETE PART 1 BELON ~ >a ~E S66 REVERSE SIpE FOR FILING ANfl PAYMENT INSTRUCTIONS Accaaa+it No. 160332-DO Dots 12-OL-199S To Ensure roper crodlt to your ecco~mt twa Establl~~ed Aunt 8slanes $23.76 Percent Taxebis X 50,DD0 Amount Subject #o Tex ~1D,Flg T:uc Rats X , D45 ?oteartiai Ts:e ~ 18.49 P I , t7J copies of ifiis notitre swat aaoaapany your peywmt ee tl+o Ropis#mr of Wilt=. Mako onock peyeble tax '9tegficter of tiliia, Ag°nt-. i !¢iTE: It tax payments nro mode rlthln them (~) eraths of t!!e ,das~dmnt's data of loath, you my dgduet a SY. dlsamant of the tax due_ Iwty Inheritance tax due rzii bosoms delinqucxit nine t97 mantas after file dote of deetfi• e_ ~ The abew infareselon end taY due is oorrect_ 1. Yw qey dw°ar ~-resit Paysent ;o +!ro Ragisinr of ~allls rith tw, eaplps of thas ~tiee to oEleSn CHECK a aismeunt ar erold interest, ar you may a~dac box ^a^ end roturn tfiix notice ~o the Register of L ~E ~ Mile and en efficfal eawsonent rill. De issued by Me Ps Depertaannt of RevaeNl6. LL BLOCK B. ~ Tho above asset ABS soon or Mill be rapor~d and tax poll ~lth [he P~aratisyl~.nio Inheritacv -re,c ~,~nrn ONLY to be filed by the decedent's r~resmn~tive. [_ ~ The above lnfernQtion le lnoernet and/or daD#s mid deduttfnns t+ArG iss#d ~ yea:. Yeu cost uorpleta PART in and/or PORT 3~ balaw. PART If you indicate rs].stiomship to T~~C _ _ ~a LIKE x. Dote Es#eblfshce a d3,ffarent lax rate, piae~ sts to yz:lr decedent: 2. iCeo:t± b°sLe.~s 3. Psrtent Tsx9bie 4. Ae-eunt Sub~ect to Tax b. A*bts and Dxductions 6. ADioaatt Taxsbxe i. Tax Rata B. Tex Dim 7. 3 X 4 6 r 6 ~_x 8 PART DEBTS AND DEDUCTIONS fiLA3~h'e;D DATE PAID PAYEE DESCRIPTION I AiiPi3iiT i-AiD 7i1TAL fEntsr atY 11nr 5 of Tax Compu#atllonl 6 -~~ Under P~ai~'fies of 1der9urY, 3 '~isrse that tl~n fscts I hem reported sbe~ve ors tru6, corrse# and nampie4e to the l+sst t,t any knowledge and be1laf. HpME C ) MIORK C ) ..~,..~ n~~Tw TELEP NE NU D ~ '.TYPE OF ACCOUNT EST. OP DEAN C _KE:[TER ~ ®sa.vl~s S,S. N0. 162-216-8724 ^ tiiSCKI-'1G DA?C Og DEATH 04'-19-2006 ~ ^ TAT COUNTY CUMHERI.AND ~ ~ ~E~tTYF. REMIT PiIYNEAIT''AND FORMS To: RE6ISTIER OF WILi5 r, CGr1?fai:.cALTH ~ PE~'SYS.'~IA '`~ e~PaaYl~xr of iw SNFORMATION NOT7~C@ FILE N0. 21 a6-D83A tlIJREW GF 1,7iDxvID[lAt TalcES AND our, zsn6al ACN 06154030 nARJt:scups, pA l'7128-iron TAXPAYER RE,SPOPISE i1ATE iu-25~c'uu`o e:v-~3 E1 :ws ea9.an 'TYPE of ACCOUNT E'ST. aF AE;AN C KEI:TER ~ ^ sA'uINBs S.S. ~i0. 1b2-20-8724 ~ ChECJCINJ3 DATE OF DEATI[ 09-19-2006 ^ T1RvsT COQNTY CUMBEF;LAND ^ 4"~EliTIF• DEBRA RILEY 645 KNIGHTBRID6E DR F~At~ER~ T D'~ MtB 21»0 REHIT !'AYhENT'AND FOJtlfS T0: REC~ISTE?R OF LlIL1:5 CUMBERLAND CO COURT HOllSE CARLI5l.E, PA 17013 11EM~EliS 1ST FCU Inns providwd tnm Dmpertmrne ritfi thm Informs}tion listrd hmlaa,r rh3oh has barn used In eale+rleting ttw potantlal tas due. Thmlr rrccras indleab: that et t1+n IIaaath ~# the etwvs dn:.s~..gr. t, ye~u xere a 4alnt awtprihmneflelrry of thAs meeamt_ if you feel this lnfarmatlmn fs Anoorree#, plmese obtain wrltton aorrmctiwti from the fJ.nancial J.nstitutien, eeteeh a aapy to thJs Perm end rrturn it tQ thm eeove addrass_ This eecous~t is texe07,r !n aewraanem with thn Inheri#mrao Tex Lis of the C:emmanweelth of Permal,ivanie. iAArs#inns eROr~~ ~ ~ ~~3'iwg Z717~ ~I ~2T-- - -"-- ~'-' --- ~. _ _ _. _ . COMPLETE i~ART 1 HBLON ~ 1[IF SEE REVERSE SIDE FdR FILING AHD PAYMENT INSTRUCTIOKS Aooovnt No. 368332-ii ~a±~ ~-8-17-~QDl Te i~~sra ~rxpnr credit to year eceeunt, twe ES~k~li6Ned C27 enpAos off' this netiea must eecempernr year A~~;+~t "-sla~^-! 2, 067.22 Remit to tr+s Rr~stnr rf w>ixl.s. tie a,mek payaelm te: "Rmplster of Ville, a9W'rt". Percent Ta:able J! 5 0, 0 0 0_ ]. 033.5]. NOTE: Lf tay payments am ~ rithln tfirek Aeount Subject to Tac , ~ t3) months oi' the dneadent~s data mf de~tn, Te:c Rats JS . 04~ - you p,ay deduct a az dlsto~.# ~ u,>3 tax d.re. Potential Tax Due 45.51 Any lydmrltenire tax due will hmaerre delinaumnt nine C9? meneris aftrr !ho Hate 4f dc,eth. PArrr TAXPAYER RESPONSE , .,,•; ~ ~;;~, jia•n: tit ~' i... ;j~. ~o ~ a . ' ,., n. ~ TIm abmw infermatlen c+nd ter due is eerraet. , 1. You aey dwoso to rant paWmmne to #.r Ro9lster o4 Yiila wlth ewo cepi,bs of thta netlea to v6tein CHECK a dlseoestt or evmld Ynlarast, or you sray ehrdc tr,r `it' ~ r-e~drfl ~!s eutfeg to shm Ragfstrr of ONE ~ Mflls ane en affielal essesssmnt rill de Issued by the PA DrparLaant of Raunnud. $~~~~ $_ ~ TfRy :ipe`rm BsSSt -has -Been cr asiil ~ -rxpnrtea ~ tai pei4 vlth thr Psnn~ylvania IMI.~lloncr Tex return ONLY to hm filed py thm dea+dont's raprasantetive. G ~ the abate fnforwetlon 1s Sneerr~t ee:d/or is end deduotians ^arw p,eid Aa you, You wsi anmpictr PART ~ s:d/er Pa11T 3~beler- pgaT xf you indicate a di'Fferent tax refs, please state your f~l 1^olationshiP to decedMft: T~j~ RETt,»~~cn~u~QYie~ _o.E._~oh .fez~'~r~uczt errs LINE 1. Date Estabiiahe,d 1 2- oeeount Balance 2 3. J'areent Taxable 4. Aelo<,nt s.~i.~t to Tax s• p.at~ and veauct3ons 6. Amount Texabl. ' . Tsz ~±s 8. Tex Due ~ x _ a s -._..,_ 1 ~ e . ~~ DE8T5 AMD D~AUCTION9 CLAIMER 3 DATE PAYD PA1fEE L~ESCIQT.PTTnN ~..~~~uT s. T.. ~nv.r ~.naltles 4f per9ury, Z declare that the ?acts I have reported ebowe 9i•8 trU~, carrect and easplete to the best of ley knatladga end belief. HOME C ) WDRK ( l TARP SIeNA RE TELL oi~PE MU R I - per ° - - ,-~ ~- `~' :,,REV-1162 E%I11-96} COMMGNw:~~TH OP f'@NNSYLVAN~~ • OEPafiThAENT QF RCVENU'c @unFAU CP INRrVIGUaI Tr,xEs SEPT. ?.f3QG~ 1 rnPF~=-eurao, r, c`i2e-c•~oi PENNSYLVANIA RECElvEO FRAM: INHERITANCE AND ESTAT>='f'AX OFFICIAL RECEIPT Np ~~ pp~ 504 ICEITER DEBRA R{LEY fi4S iC1~iiI:~HTRniGGE DRIVE HAGirRSTOWN, MD 21740 ACN ASSCSSMI=NT ~P~IOUNT CONTROL NU MBi=R ESTATE INFORMATION: ssiv: 1sz-20-a72a FILE NUM6ER_ 2106-0836 DECEDENT NAME: I<EITER DEAN C DATE OF PAYMENT: 1 2J04JZGDfi PaSTMARK DA i t: 1 1130/2006 C oUNTY: CUMBERLAND DATE pF DEATM; 08J19/2006 0615A-029 ~ ~ 18.49 46154030 ~ $46.51 I 70TAL AMOUNT PAID: REMARKS: DEBRR RILEY $fi5.00 CHECIC# 667 INITIALS: W2 ~~HL RECEIVED BY: GLENDA FAI~NER STF~ASBAUGH REGISTER 01= WILLS TAXPAYER COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DEAN C. KEITER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: 1. Myers Funeral Home SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS DESCRIPTION FILE NUMBER B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) / EIN Number of Personal Representative(s) Street Address City State ~?ip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State 7_ip Relationship of Claimant to Decedent 4. Probate Fees - $87.00 -Probate $233.62 -Advertising 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Taxes Paid TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size:) 2006-00836 AMOUNT 8,110.50 320.62 200.00 65.00 8,696.12 Myers Funeral Home, Inc. Boyd L. Myers Jr., Supervisor ~, 37 East Main Street Mechanicsburg, Pennsylvania 17055 (717) 766-3421 Fax (717) 795-7291 A standard of excellence in Central Pennsylvania since 1910 Wednesday, August 30, 2006 Mrs. Margaret J. Keiter 122 Peach Lane Carlisle, Pa. 17015 Dear Mrs. Keiter, __ _ _ _ _ _ _ Thank you for selecting our funeral home to provide services foryour family during your bereavement. _ hope that you found our services to be of the highest standards and that they met your needs and those of your family and friends. The following is a summary of the service charges as previously explained and provided in written form on the services for: Dean C. Keifer SUMMARY OF EXPENSES TOTAL OF SERVICE RENDERED $8,110,50 LESS: Credits granted 1,595.00 LESS: Total Payments 2,748.54 CURRENT BALANCE $3,766.96 Credits Granted: X1,595.0 Package Price Discount interest at the rate of i.5 % per month (18 % per annum) will be added to balance alter 30 days. if there are any questions or concerns that remain unanswered, please call me. Sincerely, ~ o ~~ ~~~ S.~A~~~ Vim' 1 ~A~1't'~.i ~~ JZ.~~~~iC+' j1~J~.~• ii(11/~ ~ !V}\fP)'C TT.- IlPP1RJ FC I~T• ~7 Fact A.4ain Str~~t R~Aarh~nirchllr^. PCn1?S`.~I~r~n~a ~7QSG d ctw~{l a~•~ of Pv~pllPtirn in ~'Artral Pe^ns~~l .'O, ^,:.°. SLrICe 1 Q1 fJ C3tJrd8V. CeQterT:ber Zn 2vlnfj 11~Arg. ~1/larnurct 1 Kciter 177 Dca~h Lane C3rllsle. Pa. ~ 7(1'1 rlo~r AArc tloitar Fuv /71?l 70G..?701 Thank you for selecting our funeral home to provide services for your family during your bereavement. ! hope that you found our services to be of the highest standards and that they met your needs and thcs~ of your family and friends. The following is a summary of the service charges as previously explained and provided in written form and herein indicated as PAID-IN-FULL. Dean C. Keiter SUMMARY OF EXPENSES TOTAL OF SERVICE RENDERED $8,'110.50 LESS: Credits granted 1 „195.00 LESS: Total Payments 6,`.115.50 CURRENT BALANCE $0.00 Credits Granted: $1,595.0 Package Price Discount if there are any questions or concerns that remain unanswered, please call me. Sincerely, ~; r' !- -! 1 n f i1 /,% 7 1 tI / f I/ % J'" A ""i ^r -.- y~-.,R, ~,~--q ,~'i~ f iJ L. 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Ou[rr huri ~; ton[ainrt ... - ... . - - . - -- 1 tma4ld n cErt+ ~r-~~ R ~t ccr h , rF ~J - -- - t ra ~caa'< ........ ............ :1. Proir++ianai 5rr,icrs. Fari€'stir:i and r~;[r,r 1 n arm ~., ant>ri4r 3 ~~ 5 L ._. . • • .......... .... ~ L y1-~Vt .ai. a.. ... .__._ _ -__... ..... ~-J~- PAif) :'s" T7AiE f)F ();i Ps°tIi)I( TG t~~tL~'.C:Cc Bt:E .................................. S ~wn (l~ ~ ~L S j t`~F-- ~U .gr.'t ~ y i E z Ei [rse .an..:..t. :.rne.::;;re reGnircmcnts hate rec;aired the pexrehase ttt s^=: f ~. ;".m '+..;E? .r?x>•~r tftx• I.nr or rrtlttiremrnt is explained beksn'. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DEAN C. KEITER Include unreimbursed medical expenses. ITEM NUMBER 1. Department of Public Welfare 2. Claremont Nursing and Rehabilitation SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS DESCRIPTION FILE NUMBER 2006-00836 AMOUNT 76,439.06 110.00 TOTAL (Also enter on line 10, Recapitulation) 76,549.06 (If more space is needed, insert additional sheets of the same size) F COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 November 7, 2007 PETER J RUSSO ESQUIRE 3800 MARKET ST CAMP HILL PA 17011-4327 Re: DEAN KEITER CIS #: 870174035 SSN: 162-20-8724 Date of Death: 08/20/2006 Dear Mr. Russo: Please be advised that the Department of Public Welfare maintains a claim in the amount of $107,940.17 against the above-mentioned estate. This claim is fo.r restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $31,501.11, w~3s incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $76,439.06, is to be entered as a priority Class 6 claim against the estate.. Please acknowledge receipt of this letter and advise whE~ther the Commonwealth's claim is admitted and when payment may be expE~cted. If the estate accounting is complete, please provide a copy. If thE~ estate contains real estate, please provide copies of the deed, the latest t~lx assessment, and a current appraisal, if available. Sincerely, ,~ Jessica L. Strawbridge TPL Program Investigator 717-772-6238 717-772-6553 FAX Enclosure P, ~;~Q~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 November 1, 2006 STATEMENT OF CLAIM SUMMARY NAME Estate of KEITER, DEAN ID 870 174 035 MEDICAL CLASS 3' -.CLASS 6 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 31,464.61 68,647.53 100,112.14 DRUG 36.50 7,791.53 7,828.03 REIMBURSEMENT TO DPW 31,501.11 76,439.06 107,940.17 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 LVIVIIVIVIV VVtHLit'i VI' YtIVIVJYLVHIVIH DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 CUMBERLAND CO COMMRS 1000 CLAREMONT RD :ARLISLE PA 17013 DATE OF SERVICE 'PAYMENT DATE ORIGWAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 02/24/05 - 02/28/05 05(16!05 20051314020600001 641.05 688.49 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 03/01!05 - 03/31/05 05/23/05 51051384020490001 5,570.51 5,464.30 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 04!01!05 - 04/30105 05(23/05 51051384020500001 5,663.40 5,557.19 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 05/01/05 - 05!31/05 06/13105 20051574034910001 5,852.18 5,745.97 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 06/01/05 - 06/30!05 07/11105 20051884053300001 5,663.40 5,557.19 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC PROC CODE : 000000 07/01!05 - 07/31!05 03!27/06 55060804396280001 5,852.18 5,849.66 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC PROC CODE : 000000 08!01/05 - 08!31/05 03/27106 55060804398320001 5,852.18 5,913.87 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC PROC CODE : 000000 09!01/05 - 09/30/05 03(27/06 55060804400380001 5,663.40 5,723.10 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC PROC CODE : 000000 wivnvivrvvvtr+~ i n yr rciviva r wr~iwH DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 CUMBERLAND CO COMMRS 1000 CLAREMONT RD :ARLISLE PA 17013 DATE OF SERVICE- -PAYMENT DATE ORIGINALCRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 10!01/05 - 10/31/05 03127!06 55060804403180001 5,852.18 5,818.39 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC PROC CODE : 000000 11/01/05 - 11/30/05 03/27!06 55060804405190001 5,663.40 5,630.70 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC PROC CODE : 000000 12/01/05 - 12/31/05 03127106 55060804407330001 5,852.18 5,818.39 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 4359 TRANS CEREB ISCHEMIA NOS PROC CODE : 000000 01/01/06 - 01/31/06 03/27/06 55060804410040001 5,852.18 5,722.91 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 4359 TRANS CEREB ISCHEMIA NOS PROC CODE : 000000 02!01106 - 02/28106 03!27106 55060804412200001 5,285.84 5,157.37 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 4359 TRANS CEREB ISCHEMIA NOS PROC CODE : 000000 03/01/06 - 03/31/06 04117/06 20061014037190001 5,722.91 5,711.20 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 2859 ANEMIA NOS PROC CODE : 000000 04/01/06 - 04/30/06 05/29/06 20061294034540001 5,600.10 5,598.69 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 2859 ANEMIA NOS PROC CODE : 000000 05/01/06 - 05/31/06 07/03/06 20061594028560001 5,786.77 5,785.36 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 2859 ANEMIA NOS PROC CODE : 000000 VVIVIIVIVIV YYCHLIfIVi' I""CIVIVJi LVHIVIH DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 CUMBERLAND CO COMMRS 1000 CLAREMONT RD ARLISLE PA 17013 DATE OF SERVICE' PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES ` AMOUNT APPROVED 06/01/06 - 06/30(06 DIAGNOSIS 1 : 2900 DIAGNOSIS 2 : 3669 PROC CODE : 000000 07!01/O6 - 07/31/06 DIAGNOSIS 1 : 2900 DIAGNOSIS 2 : 2720 PROC CODE : 000000 08101/06 - 08119106 DIAGNOSIS 1 : 2900 DIAGNOSIS 2 : 2720 PROC CODE : 000000 08114106 20062004020750001 SENILE DEMENTIA UNCOMP CATARACT NOS 09/11/06 20062284020780001 SENILE DEMENTIA UNCOMP PURE HYPERCHOLESTEROLEM 10/16106 20062644025110001 SENILE DEMENTIA UNCOMP PURE HYPERCHOLESTEROLEM 5,600.10 5,786.77 2,986.71 5,598.69 5,785.36 2,985.31 PROVIDER SUB TOTAL CUMBERLAND CO COMMRS 100,747.44 100,112.14 03 100007309 0009 l~V1YIIYIVIVVYGHL i fl VI' !'CIVIVJ f LVHIVIH DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE ~iARRiSBURG PA 17112 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN ` USUAL CHARGES AMOUNT APPROVED 02/24/05 - 02/24(05 05!23105 25051165886570001 22.35 14.50 DIAGNOSIS 1 : 0 NDC CODE : 00378116001 GUANFACINE 1 MG TABLET - OTHER HYPOTENSIVES 02!24!05 - 02/24/05 05123!05 25051175235970001 106.45 88.29 DIAGNOSIS 1 : 0 NDC CODE : 00456320560 NAMENDA 5 MG TABLET - MISCELLANEOUS 02/24!05 - 02!24(05 05123105 25051175235990001 117.85 97.65 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 03/03!05 - 03/03/05 05/23/05 25051175235960001 78.00 64.87 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 03/03/05 - 03/03105 05/23/05 25051175235980001 70.60 54.79 DIAGNOSIS 1 : 0 NDC CODE : 00456320560 NAMENDA 5 MG TABLET - MISCELLANEOUS 03/03/05 - 03/03/05 05/23/05 25051175236010001 67.90 56.59 DIAGNOSIS 1 : 0 NDC CODE : 63653117101 PLAVIX 75 MG TABLET - ANTICOAGULANTS 03/03/05 - 03/03!05 05/23/05 25051175236020001 19.25 17.05 DIAGNOSIS 1 : 0 NDC CODE : 59930150201 ISOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 03/03/05 - 03/03/05 05!23105 25051175235040001 16.85 13.96 DIAGNOSIS 1 : 0 NDC CODE : 00186108805 TOPROL XL 25 MG TABLET SA - OTHER CARDIOVASCULAR PREPS I;VIVIIVIUIVVVtHLIhUf F'tIVIVJYLVHIVIH DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE ARRISBURG PA 17112 DATE OF SERVICE PRYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03/03!05 - 03103/05 05123105 25051175236060001 5.95 5.64 DIAGNOSIS 1 : 0 NDC CODE : 00781518010 LEVOTHYROXINE 25 MCG TABLET - THYROID PREPS 03/09!05 - 03/09/05 05123/05 25051175236070001 8.80 4.11 DIAGNOSIS 1 : 0 NDC CODE : 58177032418 NITROQUICK 0.4 MG TABLET SL - VASODILATORS CORONARY 03/15/05 - 03/15105 05/23105 25051175236090001 141.65 113.26 DIAGNOSIS 1 : 0 NDC CODE : 63653117101 PLAVIX 75 MG TABLET - ANTICOAGULANTS 03!15/05 - 03!15/05 05/23/05 25051175236110001 36.80 28.11 DIAGNOSIS 1 : 0 NDC CODE : 59930150201 ISOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 03115!05 - 03/15!05 05/23!05 25051175236130001 31.65 21.45 DIAGNOSIS 1 : 0 NDC CODE : 00186108805 TOPROL XL 25 MG TABLET SA - OTHER CARDIOVASCULAR PREPS 03115!05 - 03/15/05 05/23105 25051175236160001 7.85 3.29 DIAGNOSIS 1 : 0 NDC CODE : 00781518010 LEVOTHYROXINE 25 MCG TABLET - THYROID PREPS 03/18/05 - 03/18/05 05123/05 25051175236170001 29.70 19.92 DIAGNOSIS 1 : 0 NDC CODE : 00186109005 TOPROL XL 50 MG TABLET SA - OTHER CARDIOVASCULAR PREPS 03/21/05 - 03!21!05 05/23/05 25051175236190001 66.6D 51.51 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS . { - I..VIVIIVIVIVVYCHLII"l Vf i'CIVIVJiLVHIVIH i DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE iARRISBURG PA 17112 DATE OF SERVICE' PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES: AMOUNT APPROVED 03/21/05 - 03/21/05 05/23/05 25051175236210001 57.80 44.25 DIAGNOSIS 1 : 0 NDC CODE : 00456320560 NAMENDA 5 MG TABLET - MISCELLANEOUS 04/01!05 - 04/01/05 05/23105 25051175236250001 65.50 50.57 DIAGNOSIS 1 : 0 NDC CODE : 00456320560 NAMENDA 5 MG TABLET - MISCELLANEOUS 04(12105 - 04I12I05 05/23!05 25051165886590001 214.95 177.55 DIAGNOSIS 1 : 0 NDC CODE : 00002411560 ZYPREXA 5 MG TABLET - ATARACTICS-TRANQUILIZERS 04/12/05 - 04/12/05 05/23/05 25051175236260001 141.65 117.26 DIAGNOSIS 1 : 0 NDC CODE : 63653117101 PLAVIX 75 MG TABLET - ANTICOAGULANTS 04112105 - 04/12/05 05123105 25051175236270001 36.80 32.11 DIAGNOSIS 1 : 0 NDC CODE : 59930150201 ISOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 04/12105 - 04/12/05 05/23/05 25051175236280001 7.85 7,2g DIAGNOSIS 1 : 0 NDC CODE : 00781518010 LEVOTHYROXINE 25 MCG TABLET - THYROID PREPS 04!12105 - 04112!05 05/23/05 25051175236290001 163.35 131.11 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 04/12/05 - 04/12/05 05/23/05 25051175236310001 31.65 25.45 DIAGNOSIS 1 : 0 NDC CODE : 00186109005 TOPROL XL 50 MG TABLET SA - OTHER CARDIOVASCULAR PREPS I~VIViIVIVIV YYCNL I fl VI' 1'CIVIVJ Y LVNIVIN DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE iARRISBURG PA 17112 :DATE OF SERVICE PAYMENT DATE ORIGINALCRN ADJUSTED CRN ` USUAL CHARGES AMOUNTAPPROVED 04/14!05 - 04/14/05 05123105 25051175236330001 91.10 71.64 DIAGNOSIS 1 : 0 NDC CODE : 00456320560 NAMENDA 5 MG TABLET - MISCELLANEOUS 04/25/05 - 04/25/05 05/23/05 25051175306390001 35.20 26.73 DIAGNOSIS 1 : 0 NDC CODE : 58177022204 ISOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 04/30!05 - 04(30!05 05130/05 25051205425420001 12.90 11.38 DIAGNOSIS 1 : 0 NDC CODE : 00472110556 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 05/02/05 - 05/02/05 05/30/05 25051225749840001 4.05 4.03 DIAGNOSIS 1 : 0 NDC CODE : 00182146D01 GENASYME 80 MG TABLET CHEW - MISCELLANEOUS 05!10105 - 05110105 O6/O61D5 25051305229830001 141.65 117.26 DIAGNOSIS 1 : 0 NDC CODE : 63653117101 PLAVIX 75 MG TABLET - ANTICOAGULANTS 05/10/05 - 05/10!05 06!06/05 25051305229840001 7.85 7.25 DIAGNOSIS 1 : 0 NDC CODE : 00781518001 LEVOTHYROXINE 25 MCG TABLET - THYROID PREPS 05/10/05 - 05/10/05 06/06/05 25051305229850001 163.35 135.11 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 05!10/05 - 05/10/05 06106/05 25051305229860001 31.65 26.74 DIAGNOSIS 1 : 0 NDC CODE : 00186109005 TOPROL XL 50 MG TABLET SA - OTHER CARDIOVASCULAR PREI~S i,vmmvivvv~r~~ i n yr ruvrvo i wr~rv~r~ DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE HARRISBURG PA 17112 DATE OF SERVICE' PAYMENT DATE ORIGINAL CRN A[)JUSTED CRN USUALCHARGES AMOUNT APPROVED 05/10/05 - 05/10/05 06/06105 25051305229870001 147.45 122.00 DIAGNOSIS 1 : 0 NDC CODE : 00456320560 NAMENDA 5 MG TABLET - MISCELLANEOUS 05/10/05 - 05/10/05 06106/05 25051305229880001 214.95 177.55 DIAGNOSIS 1 : 0 NDC CODE : 00002411560 ZYPREXA 5 MG TABLET - ATARACTICS-TRANQUILIZERS 05110/05 - 05/10!05 06/06105 25051305229890001 60.95 48.81 DIAGNOSIS 1 : 0 NDC CODE : 58177022204 ISOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 06/06105 - 06/06/05 07/04/05 25051575450020001 9.50 8.49 DIAGNOSIS 1 : 0 NDC CODE : 00456201001 LEXAPRO 10 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 06107!05 - 06/07/05 07104/05 25051585230050001 141.65 117.26 DIAGNOSIS 1 : 0 NDC CODE : 63653117101 PLAVIX 75 MG TABLET - ANTICOAGULANTS 06!07105 - 06/07/05 07/04/05 25051585230060001 7.85 7.25 DIAGNOSIS 1 : 0 NDC CODE : 00781518001 LEVOTHYROXINE 25 MCG TABLET - THYROID PREPS 06/07/05 - 06/07/05 07/04/05 25051585230070001 163.35 135.11 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 06/07/05 - 06107/05 07104105 25051585230080001 31.65 26.74 DIAGNOSIS 1 : 0 NDC CODE : 00186109005 TOPROL XL 50 MG TABLET SA - OTHER CARDIOVASCULAR PREPS I~ViV11VIVIV YYCHLIfI Vt- I'CIVIYJ ILVHIVIH _ DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE iARRISBURG PA 17112 DATE OF SERVICE PAYMENT DATE ORIG{NAL'CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 06/07/05 - 06/07/05 07/04/05 25051585230090001 60.95 52.81 DIAGNOSIS 1 : 0 NDC CODE : 58177022204 ISOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 06/07/05 - 06!07/05 07/04/05 25051585230100001 214.95 177.55 DIAGNOSIS 1 : 0 NDC CODE : 00002411560 ZYPREXA 5 MG TABLET - ATARACTICS-TRANQUILIZERS 06/07/05 - 06107/05 07104105 25051585230110001 147.45 122.00 DIAGNOSIS 1 : 0 NDC CODE : 00456320560 NAMENDA 5 MG TABLET - MISCELLANEOUS 06/07/05 - 06/07/05 07/04/05 25051585256290001 80.40 62.85 DIAGNOSIS 1 : 0 NDC CODE : 00456201001 LEXAPRO 10 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 07!05/05 - 07105105 08101/05 25051865236690001 7.85 7.25 DIAGNOSIS 1 : 0 NDC CODE : 00781518001 LEVOTHYROXINE 25 MCG TABLET - THYROID PREPS 07/05/05 - 07/05/05 08/01105 25051865236700001 141.65 117.26 DIAGNOSIS 1 : 0 NDC CODE : 63653117101 PLAVIX 75 MG TABLET - ANTICOAGULANTS 07/05/05 - 07/05/05 08/01/05 25051865236710001 163.35 135.11 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 07/05/05 - 07/05/05 08!01!05 25051865236720001 31.65 26.74 DIAGNOSIS 1 : 0 NDC CODE ; 00186109005 TOPROL XL 50 MG TABLET SA - OTHER CARDIOVASCULAR PREP'S I..VIVIIVIVIV VVtHLi t1 Vr YCIVIVJTLVHIVIH DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME` KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE iARRISBURG PA 17112 - DATE OF SERVICE. PAYMENT DATE -0RIGINAL CRN ADJUSTED CRN USUAL CHARGES .AMOUNT-APPROVED 07/05/05 - 07!05/05 08101!05 25051865236730001 147.45 122.00 DIAGNOSIS 1 : 0 NDC CODE : 00456320560 NAMENDA 5 MG TABLET - MISCELLANEOUS 07/05/05 - 07/05/05 08!01/05 25051865236740001 60.95 52.81 DIAGNOSIS 1 : 0 NDC CODE : 58177022204 ISOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 07!05!05 - 07!05!05 08!01/OS 25051865236750001 228.55 177.55 DIAGNOSIS 1 : 0 NDC CODE : 00002411560 ZYPREXA 5 MG TABLET - ATARACTICS-TRANQUILIZERS 07/05/05 - 07/05/05 08/01/05 25051865236760001 80.40 66.85 DIAGNOSIS 1 : 0 NDC CODE : 00456201001 LEXAPRO 10 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 07/14/05 - 07114/05 08/08/05 25051956009430001 58.10 44.51 DIAGNOSIS 1 : 0 NDC CODE : 00456202001 LEXAPRO 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 07/16!05 - 07/16/05 08/15!05 25051975349320001 17.35 15.41 DIAGNOSIS 1 : 0 NDC CODE : 49884092101 METFORMIN HCL ER 500 MG TAB - DIABETIC THERAPY 07127105 - 07/27!05 08/22/05 25052085294330001 51.55 36.73 DIAGNOSIS 1 : 0 NDC CODE : 00002411260 ZYPREXA 2.5 MG TABLET - ATARACTICS-TRANQUILIZERS 07/27!05 - 07!27/05 08/22/05 25052085294340001 58.80 45.09 DIAGNOSIS 1 : 0 NDC CODE : 00456200501 LEXAPRO 5 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS I.UMNIUIVVVtHLiFiUI-F'tIVIVbYLVN(VIH DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA 1000 CLAREMONT RD CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN' USUAL CHARGES AMOUNT APPROVED 07128!05 - 07/28/05 08122!05 25052095511980001 4.80 .67 DIAGNOSIS 1 : 0 NDC CODE : 49884092101 METFORMIN HCL ER 500 MG TAB - DIABETIC THERAPY 08/02/05 - 08!02!05 08/29/05 25052145233540001 31.65 26.74 DIAGNOSIS 1 : 0 NDC CODE : 00186109005 TOPROL XL 50 MG TABLET SA - OTHER CARDIOVASCULAR PF;EPS 08102/05 - 08/02/05 08/29/05 25052145233550001 60.95 52.81 DIAGNOSIS 1 : 0 NDC CODE : 58177022204 ISOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 08102/05 - 08/02/05 08/29/05 25052145233560001 147.45 122.00 DIAGNOSIS 1 : 0 NDC CODE : 00456320560 NAMENDA 5 MG TABLET - MISCELLANEOUS 08/02/05 - 08/02!05 08/29!05 25052145233570001 25.95 18.79 DIAGNOSIS 1 : 0 NDC CODE : 49884092101 METFORMIN HCL ER 500 MG TAB - DIABETIC THERAPY 08/02!05 - 08/02/05 08/29/05 25052145233580001 163.35 135.11 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 08102/05 - 08102105 08/29/05 25052145233590001 141.65 117.26 DIAGNOSIS 1 : 0 NDC CODE : 63653117101 PLAVIX 75 MG TABLET - ANTICOAGULANTS 08102/05 - 08/02/05 08/29/05 25052145233600001 7.85 7.25 DIAGNOSIS 1 : 0 NDC CODE : 00781518001 LEVOTHYROXINE 25 MCG TABLET - THYROID PREPS I.ViVIIVIVIV VVCHLIt1 Ur NtIVIVJTLVHIVIH DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE HARRISBURG PA 17112 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 08/02105 - 08/02/05 08!29!05 25052145233610001 223.20 180.35 DIAGNOSIS 1 : D NDC CODE : 00456200501 LEXAPRO 5 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 08/02/05 - 08/02/05 08/29/05 25052145233620001 194.20 146.94 DIAGNOSIS 1 : 0 NDC CODE : 00002411260 ZYPREXA 2.5 MG TABLET - ATARACTICS-TRANQUILIZERS 08/29105 - 08129/05 09!26105 25052415526890001 9.70 8.48 DIAGNOSIS 1 : 0 NDC CODE : 00456202001 LEXAPRO 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 08/30/05 - OS/30/OS 09/26/05 25052425258620001 60.95 11.56 DIAGNOSIS 1 : 0 NDC CODE : 58177022204 ISOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 08!30/05 - 08/30/05 09/26/05 25052425258630001 147.45 116.76 DIAGNOSIS 1 : 0 NDC CODE : 00456320560 NAMENDA 5 MG TABLET - MISCELLANEOUS 08/30/05 - 08!30/OS 09/26/05 25052425258640001 163.35 129.28 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 08/30/05 - 08/30105 09/26/05 25052425258650001 141.65 112.23 DIAGNOSIS 1 : 0 NDC CODE : 63653117101 PLAVIX 75 MG TABLET - ANTICOAGULANTS 08/30/05 - 08/30/05 09/26/05 25052425258670001 7.85 6.74 DIAGNOSIS 1 : 0 NDC CODE : 00781518001 LEVOTHYROXINE 25 MCG TABLET - THYROID PREPS I.VIVIIVIVIV VVCHLII-Y Ur YtIViVJTLVHIVIH DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE iARRISBURG PA 17112 DATE OF SERVICE. PAYMENT DATE ORIGINALCRN °ADJUSTED CRN USUALCHARGES AMOUNT APPROVED 08130/05 - 08!30/05 09!26!05 25052425258680001 194.20 153.54 DIAGNOSIS 1 : 0 NDC CODE : 00002411260 ZYPREXA 2.5 MG TABLET - ATARACTICS-TRANQUILIZERS 08!30!05 - 08/30/05 09/26/OS 25052425258720001 25.95 19.66 DIAGNOSIS 1 : 0 NDC CODE : 49884092101 METFORMIN HCL ER 500 MG TAB - DIABETIC THERAPY 08/30(05 - 08(30!05 09126105 25052425258730001 31.65 25.73 DIAGNOSIS 1 : 0 NDC CODE : 00186109005 TOPROL XL 50 MG TABLET SA - OTHER CARDIOVASCULAR PREPS 08/30/05 - 08/30/05 09/26/05 25052425260190001 83.75 62.68 DIAGNOSIS 1 : 0 NDC CODE : 00456202001 LEXAPRO 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRES:iANTS 09!27105 - 09127105 10124/05 25052705256010001 60.95 11.56 DIAGNOSIS 1 : 0 NDC CODE : 58177022204 ISOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 09/27/05 - 09!27/05 10/24/05 25052705256020001 147.45 116.76 DIAGNOSIS 1 : 0 NDC CODE : 00456320560 NAMENDA 5 MG TABLET - MISCELLANEOUS 09/27/05 - 09127!05 10!24105 25052705256040001 163.35 129.28 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 09/27/05 - 09/27/05 10/24/05 25052705256050001 141.65 112.23 DIAGNOSIS 1 : 0 NDC CODE : 63653117101 PLAVIX 75 MG TABLET - ANTICOAGULANTS VVIVIIYIVItl YYLnLI l I VI I" LIVIVJ I LV/'11 VI!'1 DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE ARRISBURG PA 17112 DATE OF SERVICE ..PAYMENT DATE. ORIGINAL CRN ADJUSTED CRN U;iUAL CHARGES .:AMOUNT APPROVED 09/27!05 - 09/27/05 10/24/05 25052705256070001 7.85 6.74 DIAGNOSIS 1 : 0 NDC CODE : 00781518001 LEVOTHYROXINE 25 MCG TABLET - THYROID PREPS 09/27/05 - 09127!05 10/24/05 25052705256080001 194.20 153.54 DIAGNOSIS 1 : 0 NDC CODE : 00002411260 ZYPREXA 2.5 MG TABLET - ATARACTICS-TRANQUILIZERS 09/27/05 - 09/27/05 10124/05 25052705256100001 31.65 25.73 DIAGNOSIS 1 : 0 NDC CODE : 00186109005 TOPROL XL 50 MG TABLET SA - OTHER CARDIOVASCULAR PREPS 09/27!05 - 09/27!05 10!24/05 25052705256130001 83.75 66.68 DIAGNOSIS 1 : 0 NDC CODE : 00456202001 LEXAPRO 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRE;iSANTS 09/27/05 - 09/27!05 10124!05 25052705256140001 25.95 19.66 DIAGNOSIS 1 : 0 NDC CODE : 49884092101 METFORMIN HCL ER 500 MG TAB - DIABETIC THERAPY 10/03/05 - 10/03/05 10/31/05 25052765535030001 21.95 14.09 DIAGNOSIS 1 : 0 NDC CODE : 00456321060 NAMENDA 10 MG TABLET - MISCELLANEOUS 10/11105 - 10/11/05 11/07/05 25052845455400001 80.85 60.41 DIAGNOSIS 1 : 0 NDC CODE : 00456321060 NAMENDA 10 MG TABLET - MISCELLANEOUS 10/17/05 - 10/17105 11114/05 25052905757770001 10.30 4.47 DIAGNOSIS 1 : 0 NDC CODE : 49884092101 METFORMIN HCL ER 500 MG TAB - DIABETIC THERAPY ~,vmmvrvvv~r+~ i n yr rcivivo i wr~rvin DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE iARRISBURG PA 17112 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES I AMOUNTAPPROVED 10/25105 - 10(25/05 11!21!05 25052985250430001 163.35 129.28 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 10!25/05 - 10/25/05 11/21/05 25052985250470001 DIAGNOSIS 1 : 0 NDC CODE : 00781518001 LEVOTHYROXINE 25 MCG TABLET - THYROID PREPS 10125105 - 10/25105 11121/05 25052985250480001 DIAGNOSIS 1 : 0 NDC CODE : 00002411260 ZYPREXA 2.5 MG TABLET - ATARACTICS-TRANQUILIZERS 10/25/05 - 10125!05 11/21/05 25052985250500001 DIAGNOSIS 1 : 0 NDC CODE : 00186109005 TOPROL XL 50 MG TABLET SA - OTHER CARDIOVASCULAR PREPS 10/25/05 - 10125105 11121105 25052985250510001 DIAGNOSIS 1 : 0 NDC CODE : 58177022204 ISOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 10/25/05 - 10125!05 11/21/05 25052985260370001 DIAGNOSIS 1 : 0 NDC CODE : 00456202001 LEXAPRO 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 10/25/05 - 10/25/05 11/21/05 25052985260380001 DIAGNOSIS 1 : 0 NDC CODE : 00456321060 NAMENDA 10 MG TABLET - MISCELLANEOUS 10/25/05 - 10/25/05 11/21/05 25052985260390001 DIAGNOSIS 1 : 0 NDC CODE : 49884092101 METFORMIN HCL ER 500 MG TAB - DIABETIC THERAPY 7.85 6.74 194.20 153.54 31.65 25.73 60.95 11.56 83.75 66.68 147.45 112.76 47.85 31.32 l.VivllvlVIV YYCliLi rl vrf CIVIVJI LVh11Vi/1 DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE ARRISBURG PA 17112 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 10!29105 - 10/29/05 11/28/05 25053025412200001 122.00 96.77 DIAGNOSIS 1 : 0 NDC CODE : 63653117101 PLAVIX 75 MG TABLET - ANTICOAGULANTS 11/08/05 - 11/08/05 12/05/05 25053125545640001 33.15 24.81 DIAGNOSIS 1 : 0 NDC CODE : 45802046564 KETOCONAZOLE 2% SHAMPOO - FUNGICIDES 11/22/05 - 11/22/05 12/19/05 25053265245030001 163.35 129.28 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 11/22/05 - 11/22/05 12/19/05 25053265245050001 141.65 112.23 DIAGNOSIS 1 : 0 NDC CODE : 63653117101 PLAVIX 75 MG TABLET - ANTICOAGULANTS 11/22/05 - 11/22/05 12/19/05 25053265245060001 194.20 153.54 DIAGNOSIS 1 : 0 NDC CODE : 00002411260 ZYPREXA 2.5 MG TABLET - ATARACTICS-TRANQUILIZERS 11/22/05 - 11/22/05 12119/05 25053265245070001 7.85 6.74 DIAGNOSIS 1 : 0 NDC CODE : 00781518001 LEVOTHYROXINE 25 MCG TABLET - THYROID PREPS 11/22/05 - 11/22/05 12119/05 25053265245080001 31.65 25.73 DIAGNOSIS 1 : 0 NDC CODE : 00186109005 TOPROL XL 50 MG TABLET SA - OTHER CARDIOVASCULAR PREPS 11/22/05 - 11!22/05 12/19/05 25053265245090001 83.75 66.68 DIAGNOSIS 1 : 0 NDC CODE : 00456202001 LEXAPRO 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS I,VIVIIVIUIVVVCHLit1 Uh' Y'tIVIVJTLVHIVIH DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE -IARRISBURG PA 17112 DATE OF SERVICE PAYMENT DATE - ORIGINAL CRN ADJUSTED'CRN USUAL CHARGES AMOUNT,APPROVED 11(22105 - 11122105 12119/05 25053265245100001 155.90 116.76 DIAGNOSIS 1 ; 0 NDC CODE : 00456321060 NAMENDA 10 MG TABLET - MISCELLANEOUS 11!22/05 - 11/22105 12/19/05 25053265245110001 60.95 11.56 DIAGNOSIS 1 ; 0 NDC CODE : 58177022204 1SOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 11!22(05 - 11122105 12119105 25053265245120001 47.85 35.32 DIAGNOSIS 1 : 0 NDC CODE : 49884092101 METFORMIN HCL ER 500 MG TAB - DIABETIC THERAPY 12/12/05 - 12/12/05 01/09/06 25053465883500001 30.00 14.13 DIAGNOSIS 1 : 0 NDC CODE : 00093550101 BUDEPRION SR 100 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 12117105 - 12117/05 01/16/06 25053515347900001 30.00 9.39 DIAGNOSIS 1 : 0 NDC CODE : 00555010702 METFORMIN HCL 750 MG ER TABLET - DIABETIC THERAPY 12/20/05 - 12!20105 01/16/06 25053545269170001 163.35 129.28 DIAGNOSIS 1 : 0 NDC CODE : 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 12120105 - 12/20/05 01/16106 25053545269180001 30.00 6.50 DIAGNOSIS 1 : 0 NDC CODE : 00781518001 LEVOTHYROXINE 25 MCG TABLET - THYROID PREPS 12/20/05 - 12/20105 01!16(06 25053545269190001 83.75 66.68 DIAGNOSIS 1 : 0 NDC CODE : 00456202001 LEXAPRO 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS IrVIV11VIUIV VVCHLIh UI' YCIVIVJTLVHIVIH DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE ARRISBURG PA 17112 DATE OF SERVICE PAYMENT DATE: - ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 12/20!05 - 12!20/05 01(16106 25053545269200001 155.90 123.42 DIAGNOSIS 1 : 0 NDC CODE : 00456321060 NAMENDA 10 MG TABLET - MISCELLANEOUS 12/20/05 - 12!20/05 01/16/06 25053545269210001 60.95 7.08 DIAGNOSIS 1 : 0 NDC CODE : 58177022204 ISOSORBIDE MN 30 MG TAB SA - VASODILATORS CORONARY 12120/05 - 12/20105 01116/06 25053545269240001 194.20 153.54 DIAGNOSIS 1 : 0 NDC CODE : 00002411230 ZYPREXA 2.5 MG TABLET - ATARACTICS-TRANQUILIZERS 12/20/05 - 12/20/05 01/16/06 25053545269250001 53.65 25.30 DIAGNOSIS 1 : 0 NDC CODE : 00093550101 BUDEPRION SR 100 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRE SSANTS 12/20/05 - 12/20/05 01!16/06 25053545269260001 74.40 50.27 DIAGNOSIS 1 : 0 NDC CODE : 00555010702 METFORMIN HCL 750 MG ER TABLET - DIABETIC THERAPY 12/20!05 - 12120!05 01/16/06 25053545275300001 141.65 112.23 DIAGNOSIS 1 : 0 NDC CODE : 63653117101 PLAVIX 75 MG TABLET - ANTICOAGULANTS 12!20/05 - 12120!05 01/16/06 25053545275320001 31.65 25.35 DIAGNOSIS 1 : 0 NDC CODE : 00186109005 TOPROL XL 50 MG TABLET SA - OTHER CARDIOVASCULAR PREPS 01/09/06 - 01/09/06 02/1310fi 25060175532480001 4.80 4.57 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS 8 BLOOD CELL :iTIMULATORS I~ViVIIVIVIV VVCHLifI Vr I"CIVIVJTLVHIVIH DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA 1000 CLAREMONT RD ARLISLE PA 17013 DATE OFSERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 01/11/06 - 01/11/06 02113/06 25060175505820001 17.40 12.94 DIAGNOSIS 1 : 0 NDC CODE : 11701004514 BAZA ANTIFUNGAL 2% CREAM - FUNGICIDES 02/02!06 - 02/02/06 02127106 25060335258350001 8.45 7.07 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 02/06/06 - 02/06/06 03!06106 25060375266680001 4.80 4.57 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS 03/13106 - 03/13/06 04/10106 25060725448650001 4.05 4.02 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS 03/14106 - 03/14/06 04/10/06 25060735228450001 4.40 .26 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL. STIMULATORS 03/17/06 - 03/17/06 04/10/06 25060765473800001 7.15 5.50 DIAGNOSIS 1 : 0 NDC CODE : 00168015431 HYDROCORTISONE 1%CREAM - GLUCOCORTICOIDS 04/11/06 - 04/11/06 05/08106 25061015229540001 4.40 4.26 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL. STIMULATORS 05/09/06 - 05/09/06 06/05106 25061295230060001 4.40 4.26 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS LVIVIIYIVIV YY G/1L_III Vf rCIVIVJILV/11 VIf1 DEPARTMENT OF PUBLIC WELFARE November 1, 2006 STATEMENT OF CLAIM NAME KEITER, DEAN ID 870 174 035 PHARMERICA INC #22000 491A BLUE EAGLE AVE IARRISBURG PA 17112 "DATE OF SERVICE PAYMENT DATE ORIGINAL_CRN ADJUSTED CRN U~iUAL'CHARGES AMOUNT APPROVED. 06/06106 - 06/06/06 07/03/06 25061575228800001 4.40 4.26 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS 07!04/O6 - 07!04/06 07/31/06 25061865296210001 4.32 4.26 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS 07/20/06 - 07/20/06 08114!06 25062015272950001 5.66 5.42 DIAGNOSIS 1 : 0 NDC CODE : 00168015431 HYDROCORTISONE 1 % CREAM - GLUCOCORTICOIDS 08/01!06 - 08/01/06 08128/06 25062135239300001 4.32 4.26 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS PROVIDER SUB TOTAL PHARMERICA INC #22000 24 100751181 0013 10,109.15 7,828.03 cis CENIfR5loiMf0/CARf& Mf0/CA/DSfRVIC£S Medicare Reconsideration Decision - November 27, 2007 Federal Services Claremont Nursing and Rehabilitation Attn: Louise Eitelberg If you have questions, 1000 Claremont Drive ~, write or call: Carlisle, PA 17013 MAXiMUS Federal Services QIC Part A East 1040 First Avenue Suite 400 King of Prussia, PA 19406 Provider Inquiries Visit: www.g2a.orq Or ~ Cal1:484-688-2000 Beneficiary Inquiries Call: 1-800- MEDICARE Or 1-800-633-4227 Who we are: We are MAXIMUS Federal Services. We are experts on appeals. Medicare hired us to review your file and make an independent decision.', -~ '; `~ ',, RE: Beneficiary: D. Keiter HIC #: XXXXX8724A Appellant: Claremont Nursing and Rehabilitation Dates of Service: February 1, 2006 throuc~h February 28, 2006 Dear Ms. Eitelberg: This letter is to inform you of the decision on your Medicare Appeal. An appeal is a new and independent review of a claim. You are receiving this letter because you requested an appeal for the denial of coverage of Occupational Therapy services provided to the bE~neficiary, D. Keiter, on February 1, 2006 through February 28, 2006. The appeal decision is unfavorable. Our decision is that your claim is not covered by Medicare. More information on the decision is provided on the next page. You are not required to take any action. However, if you disagree with the decision, you may appeal to an Administrative Law Judge (ALJ). You must file your appeal, in writing, within 60 days of receipt of this letter. For more information on how to appeal, see the page titled "Important Information About Your Appeal Rights." Thz amount still in dispute is over $110. A copy of this letter was also sent to the beneficiary. MAXIMUS Federal Services was contracted by Medicare to review your appeal. Medicare Appeal Nurnber: 1-208749343 V 6.0 Summary of the Facts • On February 1, 2006 through February 28, 2006, the beneficiary received Occupational Therapy services (HCPCS codes 97110 and 97530) from 1:he provider, Claremont Nursing and Rehabilitation Center, for paroxysmal supraventric;ular tachycardia (ICD-9 code 427.0) and abnormal posture (ICD-9 code 781.92). • An initial determination was made on the claim on November 3, 2006. The Occupational Therapy services were denied coverage because the information/diagnosis submitted did not support the need for the services. • The affiliated contractor with jurisdiction, Highmark Medicare Services, received a request for redetermination on March 2, 2007 from the provider. • On April 9, 2007, the affiliated contractor issued an unfavorable decision. The Occupational Therapy services were denied because there was no documentation of the specific type of Therapeutic Exercises (HCPCS code 97110) ~~r Therapeutic Activities (HCPCS code 97530) performed. The provider was held responsible for the payment of the claim. • On April 6, 2006, MAXIMUS Federal Services received a request for reconsideration of the Occupational Therapy services from the provider. • The case was submitted to a panel of healthcare professionals for medical review to determine whether the services were medically reasonable and necessary in accordance with Medicare coverage criteria. Decision We have determined that Medicare does not cover the claim for th~~ Occupational Therapy services provided to the beneficiary on February 1, 2006 through Febri.~ary 28, 2006. We have also determined that the PROVIDER, Claremont Nursing and Rehabilitation, is responsible for payment for the Occupational Therapy services provided to the beneficiary on February 1, 2006 through February 28, 2006. Explanation of the Decision Rehabilitation services are covered by Medicare if they are reasonablE~ and necessary to treat a condition in the beneficiary, to restore functioning or to prevent furtf ier decline. There must be an expectation that the patient's condition will improve significantly in a reasonable and generally predictable period of time. The services provided must require the level of complexity and sophistication that can only be provided safely and effectively by or under the supervision of a skilled therapist. The services must relate directly and specifically to an active written treatment regimen. Progress notes, which should be submitted at least weekly, should contain the subjective status of the patient, a description of the nature of the treatment/service performed (e.g. modalities, training, education, etc.), the patient's resf-onse to the therapeutic intervention and its relevance to the goals indicated in the treatment plan. Additionally, the progress notes should be written using measurements and functional accomplishments. The provider must make the records available to Medicare to support the medical necessity for the V 6.0 IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS Your Right to Appeal this Decision If you do not agree with this decision, you may file an appeal. An appeal is a review performed by people independent of those that have reviewed your claim so far. The next level of appeal is called an Administrative Law Judge (ALJ) Hearing. At this hearing, you or your representative may represent your case before an ALJ. You must have at least $110 still in dispute. This appeal can be combined with others to reach this total, if the other claims were appealed and decided within 60 day of this new request for an appeal, and involve similar or related services. How to Appeal To exercise your right to appeal, you must file a request in writing within 60 days of receiving this letter. Under special circumstances, you may ask for more time to request an appeal. In your request you must include: (1) The name, address, and Medicare health insurance claim number of the beneficiary, (2) The name and address of the person appealing, if the person is not the beneficiary, (3) The name and address of the representative, if any, (4) The appeal number listed on the front page of this notice, (5) The dates of service, (6) The reasons why you disagree with the decision, (7) Any and all evidence you wish to submit and the date it will be submitted, (8) A statement that you have sent a copy of this request to the other parties to the appeal, and (9) If you wish to combine claims to meet the $110 amount, include a list of the claims. ALJ hearings are usually held by video- teleconference (VTC) to make sure you get a hearing and decision as fast as possible. VTC hearings reduce travel time for you, ALJs, and witnesses. If you do not want a VTC hearing, you may ask for a hearing in person, which will be granted for good cause. Your request must be in writing. Your request must give a good reason why you don't want a VTC hearing. If your request for an in-person hearing is granted, a hearing will be held and a decision issued as soon as possible. However, you give up the right to get a d~:cision in the 90-day time limit that usually applies to ALJ decisions. If you want to file an appeal, you should send your request, along with the first page of this decision to: HHS OMHA Field Office Cleveland, Olnio BP Tower & Garage 200 Public Square, Suite 1300 Cleveland, Ohio, 44114-2316 866236-5089 Who May File an Appeal You or someone you name to act for you (your appointed representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. If you want someone to act for you, you and your appointed repnssentative must sign, date and send us a staterent naming that person to act for you. Call 1-800-MEDICARE to learn more about how to name a representative. Help With Your Appeal If you want help with an appeal, or if you have questions about Medicare, you can have a friend or someone else help you with your appeal. You can also contact your State Health Insurance Assistance Program (SHIP). You can call 1-800-MEDICp~RE (1-800-633-4227) for information on how to contact your local SHIP. Your SHIP can answer questions about payment denials anti appeals. Other Important Information If you want copies of statutes, regulations, policies, and/or manual instructions we used to arrive at this decision, please write to us at the following address and attach a copy of this letter: MAXIMUS Federal Services QIC Part A East 1040 First Avenue, Suite 400 King of Prussia, PA 19406 If you need more: information or have any questions, please call us at the phone number rovided on the front of this notice. Other Res~~urces To Help You 1-800-MEDICARE (1-800-633-4227}, TTY/TDD: 1-800-486-2048 V6.0 SCHEDULE J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF DEAN C. KEITER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY NUMBER I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. Margaret J. Keiter 122 Peach Lane, Carlisle, PA 17015 2. Debra Keiter, 645 Knightbridge Drive, Hagerstown, MD 21740 FILE NUMBER RELATIONSHIP TO DECEDENT Do IVot List Trustee(s) Wife Daughter 2006-00836 AMOUNT OR SHARE OF ESTATE 50% 50% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 l'HROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00 (If more space is needed, insert additional sheets of the same size) ~~ ¢~ ' n $ o ~ ~ r ~- M ~ n ~~~ ~ _ ~ ~~ ~ a r ~ u.. _ ca -q q O .~-+ r: ~- ,,,~ _ C-3 ~ ~, C~ r.J ._ , f C' ~ ,~ ~ C'n ~ 0 N O ~ f ~ ~ ~~ a~+ ~ ~ t,N ~~v~ OG V ` U