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08-4484
MAJOR 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 MILTON S. HERSHEY MEDICAL CENTER P.O. Box 853 Hershey, PA 17033 VS STEPHEN LOGAN & PATRICIA LOGAN, h/w 1316 Zimmerman Road Carlisle, PA 17015 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. Dg _ 4y8q Clrvi ( -Tem 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 7 COMPLAINT - CIVIL ACTION COUNT I THE MILTON S. HERSHEY MEDICAL CENTER VS. PATRICIA LOGAN 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 April 11, 2007 thru June 7, 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 $340,585.78 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. STEPHEN LOGAN 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 April 11, 2007 thru June 7, 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 $340,585.78 plus six percent (6%) interest per annum from the date of discharge to the date of judgment, record costs and non-record costs. TABAS & ROSEN, P.C. LE IS C. UFFER, ESQUIRE Attorney for Plaintiff MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ----------------------------------------- ( ------------ Date Svc Code I ---- ' ------------- Descrition -- - - Units --- Debits Credits --------------- --------------- -------------------- -----------'--- 04/11/07 10144 I CRITLEVELICAL CAIIRETRA UNITUMA 1 ' 2935.00 04/11/07 16502 ADULT 1 04/11/07 44604 INTUBATE,ENDOTRACH EM 1 2945.00 04/11/07 46177 , COLLAR RIGID (ASPEN) 1 393.00 04/11/07 46473 04/11/07 ER,CRITICL CARE,30-75 1 105.00 1173.00 46479 04/11/07 46620 CLOSED DRAIN SYSTEM S ROUTINE VENIPUNCTURE 1 21.00 04/11/07 46630 ARTERIAL PUNCTURE 1 1 17.00 04/11/07 46673 04/11/07 4 BLADDER OATH, SIMPLE 1 44.00 139.00 6717 04/11/07 46932 NONINVAS PULSE OX MU 1 95.00 04/11/07 46933 IV INFU,HYDRAT;EACH H IV INF,THER PROPH DX 3 1 38 4.00 04/11/07 101003 , , , ABO BLOOD GROUP 1 207.00 04/11/07 101004 ANTIBODY SCREEN 1 21.00 04/11/07 101005 RH TYPE 47.00 04/11/07 .101021 COMPAT, IMMED SPIN 1 2 20.00 04/11/07 104009 AMYLASE, BLOOD 140.00 04/11/07 104014 ALKALINE PHOSPHATASE 2 44.00 04/11/07 104016 BILIRUBIN TOTAL 28.00 04/11/07 104042 CREATININE, BLOOD 1 28.00 04/11/07 104049 TROPONIN 1 14.00 04/11/07 104060 GLUCOSE, BLOOD 60.00 04/11/07 104110 BLOOD GAS PANEL 1 13.00 04/11/07 104111 BLOOD GAS PANEL W/02 1 128.00 04/11/07 104131 POTASSIUM (K) BLOOD 1 152.00 04/11/07 104145 , SODIUM (NA), BLOOD 1 14.00 04/11/07 104156 SGPT (ALT) 14.00 04/11/07 104438 RENAL FUNCTION PANEL 1 30.00 04/11/07 105052 04/11/07 PARTIAL THROMBOPLAS T 1 44.00 38.00 105059 04/11/07 105657 PROTHROMBIN TIME CBC W/PLT/DIFF A 1 23.00 04/11/07 111001 UTO GLUCOSE BEDSIDE MONIT 1 1 48.00 04/11/07 245483 DEXTROSE 5% 50ML 2 28.00 04/11/07 245491 04/11/07 2 SALINE 0.45% 1000 ML 1 12.50 3.00 45626 04/11/07 246162 NORMAL SERUM ALBUMIN FENTANYL CITRATE 2 1077 .30 04/11/07 246169 5 ML FOLIC ACID 5 MG/ML 3 1 9.55 04/11/07 246401 04/11/07 24 THIAMINE HCL 100 MG/M 1 10 .20 14.90 6487 04/11/07 246643 SUCCINYL CHOLINE 200 PHENYLEPHRINE 10 MG M / 10 1 6.75 04/11/07 246703 LORAZEPAM 2 MG 3.00 04/11/07 246841 SODIUM BICARBONATE 50 1 3.90 9 ------------------------------------ -------------------------.20 ------------------ - Continue - A- MS HERSHEY MEDICAL CENTER PAGE: 2 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ---=?- Svc - Code - I -------- Descri---------?-------------------------- Date Ption ? Units Debits---I---Credits ------------------------ 04/11/07 248225 SENNA 04/11/07 272205 SYRUP 1ML CLINDAMYCIN 600MG IV 5.95 04/11/07 273298 04/11/07 COMBIVENT INHALER 14. 2 1 34.35 282 14 273532 04/11/07 307101 PROPOFOL 10MG/ML 100M CHEST 1 . 41.90 04/11/07 307220 1 VIEW PELVIS 1-2 VIEWS 1 120.00 04/11/07 310515 04/11/07 3 CT THORAX UNENHANCED 1 158.00 722 00 10518 04/11/07 310560 CT ABDOMEN UNENHANCED CT C-SPINE UNENHANCED 1 . 885.00 04/11/07 310566 04/11/07 CT PELVIS UNENHANCED 1 1 837.00 815 00 511202 04/11/07 511354 VENTILATOR DAY INITIA MDI 1 . 510.00 04/11/07 511372 TREATMENT STARTER KIT 1 53.00 04/11/07 621044 04/11/07 6 I V SODIUM CHLORIDE 0 1 132.00 6 00 22024 04/11/07 661432 IRRIGATION SOD CHL 0. BAG URINE D 1 . 6.00 04/11/07 667765 RAINAGE SCD SLEEVES KNEE LEN 1 1 13.00 04/11/07 670520 04/12/07 , TRACH CARE SYSTEM 14 1 75.00 20 00 10144 04/12/07 101213 I CRITICAL CARE UNIT RED BLD CELLS 1 . 2935.00 04/12/07 102018 EA U BETA LACTAMASE 2 1 574.00 04/12/07 102019 GRAM STAIN 3 16.00 04/12/07 102100 CULTURE, BACTERIAL 78.00 04/12/07 102104 04/12/07 CULTURE, ANAEROBES ON 3 198.00 177 00 104000 04/12/07 104014 ACETAMINOPHEN ALKALINE PHOSPHATASE 1 . 78.00 04/12/07 104016 BILIRUBIN TOTAL 1 14.00 04/12/07 104017 BILIRUBIN DIRECT 14.00 04/12/07 104028 IONIZED CALCIUM 1 14.00 )4/12/07 104060 GLUCOSE, BLOOD 1 87.00 )4/12/07 104094 34/12/07 GAMMA GLUTAM TRANS G ( 13.00 17 00 104106 34/12/07 104110 MAGNESIUM BLOOD GAS PANEL 2 . 32.00 )4/12/07 104111 )4/12/07 BLOOD GAS PANEL W/02 2 256.00 304 00 104131 )4/12/07 104136 POTASSIUM (K), BLOOD PROTEIN SER 1 . 14.00 )4/12/07 104143 , UM SALICYLATE 1 13.00 )4/12/07 104145 14/12/07 SODIUM (NA), BLOOD 1 53.00 14 00 104155 4/12/07 104156 SGOT (AST) SGPT (ALT) 1 . 14.00 4/12/07 104433 4/12/07 BASIC METABOLIC PANEL 1 15.00 42 00 104438 RENAL FUNCTION PANEL 2 . ----------------------- 88.00 ------------------------------------------------------ - Continue - --- II °? MS HERSHEY MEDICAL CENTER PAGE: 3 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 -------- Date ------------ Svc Code --- -------------------- Description --- ------- 1-Units - ------- ----------- - - -- Debits --- I --------- -------------- Creds.ts 04/12/07 04/12-/07 105656 -- CBC W/PLT AUTO 1 ------------------- 30 00 04/12/07 105657 106046 CBC W/PLT/DIFF AUTO PREGNANCY . 48.00 04/12/07 04/12/07 111001 TEST, URINE GLUCOSE*BEDSIDE MONIT 1 10 43.00 280 00 04/12/07 245212 245483 LEVARTERENOL BITARTRA DEXTROSE 5% 1 . 2.50 04/12/07 245491 50ML SALINE 0.45% 1000 ML 2 62.50 04/12/07 04/12/07 245626 NORMAL SERUM ALBUMIN 8 6.00 4309 20 04/12/07 246049 246162 CALCIUM CHLORIDE 10 M FENTANYL CITRATE 2 . 13.10 04/12/07 246169 5 ML FOLIC ACID 5 MG/ML 5 1 19.05 04/12/07 04/12/07 246401 2 THIAMINE HCL 100 MG/M 1 10.20 14 90 04/12/07 46475 246493 SODIUM BICARBONATE 50 1 . 6.75 04/12/07 246643 DEXAMETHASONE 4 MG/ML PHENYLEPHRINE 10 MG/M 16 1 12.10 04/12/07 246703 LORAZEPAM 2 MG 3.00 04/12/07 04/12/07 246831 FENTANYL CITRATE 20 M 30 11.70 15 60 04/12/07 246836 246841 FENTANYL CITRATE 2 ML SODIUM B 1 . 3.00 04/12/07 247842 ICARBONATE 50 CAL GLUCONATE 10ML 4 36.80 04/12/07 247889 VECURONIUM BROMIDE 1 11.55 04/12/07 04/12/07 249220 MIDAZOLAM 5MGL ML 10M 50 1.10. 21 0 04/12/07 250986 251130 WHITE PETROLATUM CPD POTASSIUM 1 .5 5 4.5 04/12/07 251619 CHLORIDE 50 FLUCORAZOLE 400MG/200 110 52.10 04/12/07 04/12/07 272129 2 ROCURONIUM BROMIDE 5M 2 2 58.10 68 85 04/12/07 72205 273019 CLINDAMYCIN 600MG IV NAFCILLIN 6 . 103.05 04/12/07 273935 1 G PREMIX PANTOPRAZOLE 40 MG VI 4 68.00 04/12/07 04/12/07 274016 MAGNESIUM S04 1G/100 1 2 13.05 15 25 04/12/07 274138 274324 MOXIFLOXACIN 400MG IV HUMULIN R 8 . 80.30 04/12/07 04/12/07 274703 D10W + 0.9% NACI 1000 38.20 10 15 04/12/07 274865 275020 OXACILLIN 1000MG/IOML PEDIALYTE 32 . 26 2.40 04/12/07 307101, 240ML SOLN CHEST 1 VIEW 4 17.45 04/12/07 04/12/07 391101 3 OR TIME<=1HR EACH 15M 4 0 0.00 600.00 2284 00 04/12/07 91102 398230 OR TIME>lHR EACH 15MI SUTURE SINGLE 6 . 1566.00 04/12/07 04/12/07 398231 , ARM SUTURE, DOUBLE ARM 8 72.00 17 00 04/12/07 398654 502000 PBDS MAJOR ORTHO PACK ANESTHESIA TIME-HOSP 1 . 360.00 ------------- ----------- - ------------ ----- 10 - 784.00 - nue - Conti -------- ----------------------- H3 MS HERSHEY MEDICAL CENTER PAGE: 4 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ---Date---- I-Svc-Code- --------Description--- --------- I-Units ---Debits--- ---- Creditrelit---- s ------ 04/12/07 503129 BAIR HUGGER LOWER BOD 04/12/07 ____ __ 1 __ 42 00 -- ------------ 511203 VENTILATOR DAY SUBSEQ 04/12/07 511354 MDI 1 . 510.00 TREATMENT 04/12/07 511371 ADD ON KIT 6 318.00 04/12/07 521211 12 LEAD ELECTROCARDIO 1 132.00 04/12/07 620109 INFUSION CATHETER SIL 04/12/07 2 117.00 28.00 621012 IV DEXTROSE 5%-WATER 04/12/07 621054 2 12.00 IV LACTATED RINGERS 1 04/12/07 621100 CANISTER SUCT HARDSHE 3 18.00 04/12/07 621113 KIT BLOOD GAS ART LIN 04/12/07 6 3 3 15.00 15.00 22023 IRRIGATION SOD CHL 0. 04/12/07 622024 IRRIGATION 1 6.00 SOD CHL 0. 04/12/07 625010 SET BLOOD SOLUTION 2 2 12.00 04/12/07 626081 IV DILUENT NML SALINE 04/12/07 62 3 48.00 24.00 7069 ST EXT MICRO 60" IML 04/12/07 630502 INTRODUCER 1 7.00 SHEATH KIT 04/12/07 636899 SWAN GANZ OATH FLOW 2 1 104.00 , 04/12/07 670330 IV INFUSION SET, UNIV 04/12/07 6 8 80.00 128.00 70832 COLLAR RPLMT PAD ASPE 04/13/07 10144 I 1 30.00 CRITICAL CARE UNIT 04/13/07 102019 GRAM STAIN 1 293 5.00 04/13/07 102100 CULTURE, BACTERIAL 1 26.00 04/13/07 102104 CULTURE, ANAEROBES ON 04/13/07 1 1 66.00 59 00 02118 SMEAR, FLUOR/ACID FAS 04/13/07 102303 CULTURE FUNG 1 . 36.00 , US OTHER 04/13/07 104009 AMYLASE BLOOD 1 40.00 , 04/13/07 104014 ALKALINE PHOSPHATASE 1 44.00 04/13/07 104016 BILIRUBIN TOTAL 1 14.00 04/13/07 104049 TROPONIN 14.00 04/13/07 104092 LACTIC ACID 3 180.00 04/13/07 104096 LDH 1 61.00 04/13/07 104097 LIPASE 2 32.00 04/13/07 104106 MAGNESIUM 1 45.00 04/13/07 104110 BLOOD GAS PANEL 4 5 64.00 04/13/07 104156 SGPT (ALT) 640.00 04/13/07 104438 RENAL FUNCTION PANEL 04/13/07 4 15.00 176.00 105052 PARTIAL THROMBOPLAS T 04/13/07 105059 PROTHROMBIN 3 114.00 TIME 04/13/07 105656 CBC W/PLT AUTO 3 3 69.00 04/13/07 111001 GLUCOSE BEDSIDE MONIT 04/13/07 22 90.00 616 00 245207 LIDOCAINE 1 ML 04/13/07 245212 LEVARTERENOL BITARTRA 2 . 3.00 ------------------- 1 9.50 - Continue - ------ ------------- ------------- MS HERSHEY MEDICAL CENTER PAGE: 5 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM i Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient:. LOGAN PATRICIA Visit 8289451 I---- Date __________ - I Svc Code ---------- I Descri Ption ?-------- Units ------------------------- Debits --------- __ _______------ Credits 04/13/07 04/13/07 245483 -- -------- DEXTROSE 5% 50ML --------- 3 ------------------- ------ 50 00 04/13/07 245489 245626 SODIUM CHLORIDE 0.9% NORMAL SERUM 2 . 11.10 04/13/07 246037 ALBUMIN BISACODYL 10 MG 4 2154.60 04/13/07 246169 FOLIC ACID 5 MG/ML Z 3.00 04/13/07 04/13/07 246401 2 THIAMINE HCL 100 MG/M 1 10.20 14 90 04/13/07 46703 246831 LORAZEPAM 2 MG FENTANYL CITRATE 2 . 7.80 04/13/07 246849 0 M FUROSEMIDE 10 MG/ML 40 2 20.80 04/13/07 04/13/07 249220 MIDAZOLAM 5MGL ML 10M 100 4.00 43 20 04/13/07 251130 251619 POTASSIUM CHLORIDE 50 FLUCORAZOLE 400MG/200 30 4 . 16.10 04/13/07 04/13/07 272205 2 CLINDAMYCIN 600MG IV 6 116.20 103 05 04/13/07 72960 273298 BUMETANIDE 2.5MG/10ML 10 . 17.95 04/13/07 273935 COMBIVENT INHALER 14. PANTOPRAZOLE 40 1 28 2.14 04/13/07 274069 MG VI DROTRECOGIN ALFA 20 M 1 2 13.05 04/13/07 274138 MOXIFLOXACIN 400MG IV 4 7720.30 04/13/07 04/13/07 274356 MAGNESIUM SULFATE 4G 8 40.15 16 30 04/13/07 274703 274865 D10W + 0.9% NACI OXACILLIN 1000MG/IOML 1000 2 . 10.15 04/13/07 04/13/07 275035 3 KPHOS 30MMOL/500ML D5 4 1 196.80 19 05 04/13/07 06555 307101 PERC CHOLECYSTOSTOMY 1 . 484.00 04/13/07 307501 CHEST1 VIEW PERCUT DRAIN W/CATH S 360.00 04/13/07 308102 US ABDOMEN LTD/FOLLOW 1 1 282.00 04/13/07 04/13/07 310501 CT HEAD UNENHANCED 1 260.00 755 00 04/13/07 511203 511354 VENTILATOR DAY SUBSEQ MDI TREATMENT 1 . 510.00 04/13/07 04/13/07 621113 KIT BLOOD GAS ART LIN 9 265.00 45 00 04/13/07 625010 626081 SET BLOOD SOLUTION IV DILUENT NML SALINE . 24.00- 04/13/07 04/13/07 670330 IV INFUSION SET, UNIV 2 1 16.00 16 00 04/13/07 737019 737048 JEFFREY SET ROSEN WIRE GUIDE WIRE 1 . 246.00 04/13/07 737070 NON IONIC CONTRAST 1 86.00 04/13/07 737146 CVIR ANGIO TRAY 1 224.00 04/13/07 04/14/07 737148 MULITPURPOSE DRAIN CA 89.00 222 00 04/14/07 10144 102019 I CRITICAL CARE UNIT GRAM STAIN 1 . 2935.00 04/14/07 04/14/07 102100 CULTURE, BACTERIAL 1 26.00 66 00 ------------- 102103 ---- CULTURE, BLOOD FOR FU - 1 . 59.00 - Continue - --------- ---- ------------------- MS HERSHEY MEDICAL CENTER PAGE 6 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 --- Date -I Svc Code ----------- I Description -------- ? Units ------------------------- Debits - - - Credits 04/14/07 04/14/07 102105 1 CULTURE, BLOOD - ------------ 174 00 04/14/07 02214 104049 CULTURE, URINE QUANT TROPONIN 1 . 40.00 04/14/07 104106 MAGNESIUM 3 180.00 04/14/07 104110 BLOOD GAS PANEL 2 32.00 04/14/07 04/14/07 104131 POTASSIUM (K), BLOOD 2 128.00 28 00 04/14/07 104438 105656 RENAL FUNCTION PANEL CBC W/PLT AU 1 . 44.00 04/14/07 04/14/07 111001 TO GLUCOSE BEDSIDE MONIT 14 30.00 392 00 04/14/07 245212 245483 LEVARTERENOL BITARTRA 1 . 9.50 04/14/07 245489 DEXTROSE 5% 50ML SODIUM CHLORIDE 0 9% 37.50 04/14/07 04/14/07 245491 2 . SALINE 0.45$ 1000 ML 4 1 22.20 3 00 04/14/07 45985 246435 ACETAMINOPHEN 600 MG POTASSIUM CHLORIDE 2 2 . 6.00 04/14/07 246703 LORAZEPAM 2 MG 20 2 3.00 04/14/07 04/14/07 246831 2 FENTANYL CITRATE 20 M ' 30 8 157.60 60 04/14/07 49220 251130 MIDAZOLAM 5MGL ML 10M POTASSIUM 100 . 43.20 04/14/07 251619 CHLORIDE 50 FLUCORAZOLE 400MG/200 60 2 32.25 04/14/07 272205 CLINDAMYCIN 600MG IV 6 58.10 04/14/07 04/14/07 273935 2 PANTOPRAZOLE 40 MG VI 1 103.05 13 05 04/14/07 74069 274138 DROTRECOGIN ALFA 20 M 4 . 1544 0.60 04/14/07 274356 MOXIFLOXACIN 400MG IV MAGNESIUM SULFATE 4G 4 40.15 04/14/07 04/14/07 274703 2 D10W + 0.9% NACI 8 1000 16.30 10 15 04/14/07 74865 275020 OXACILLIN 1000MG/10ML PEDIALYTE 24 . 196.80 04/14/07 307101 240ML SOLN CHEST 1 VIEW 8 34.85 04/14/07 04/14/07 511203 VENTILATOR DAY SUBSEQ 1 120.00 510 00 04/14/07 511354 621101 MDI TREATMENT SUCT CATH KT 14F . 318.00 04/14/07 621112 NLTX KIT BLOOD GAS SAFT ND 10 -2 50.00 04/14/07 04/14/07 626081 6 IV DILUENT NML SALINE 2 16 00 10.00- 04/15/07 27069 10144 ST EXT MICRO 60" IML I CRITICAL CARE UNIT -2 . 14.00- 04/15/07 104106 MAGNESIUM 1 2935.00 04/15/07 04/15/07 104110 BLOOD GAS PANEL 1 1 16.00 128 00 04/15/07 104438 105656 RENAL FUNCTION PANEL CBC W/PLT A . 44.00 04/15/07 04/15/07 111001 UTO GLUCOSE BEDSIDE MONIT 13 30.00 3 64 00 ------------ 245483 ---------- DEXTROSE 5% 50ML 0 - .25 ..0 0 - Continue _ -------- ----------------------- /? W MS HERSHEY MEDICAL CENTER PAGE: 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 Date ---=I-- Svc-Code-I--------Description -- ? ------?-------------------------- Units Debits Credits ----------------- 04/15/07 245489 SODIUM ------------------ 04/15/07 245491 CHLORIDE 0.9% SALINE 0.45% 1000 ML 3 16.65 04/15/07 04/15/07 246435 POTASSIUM CHLORIDE 2 1 20 3.00 00 3 04/15/07 246703 246831 LORAZEPAM 2 MG FENTANYL CITRATE 20 . 11.70 04/15/07 04/15/07 249220 2 M MIDAZOLAM 5MGL ML 10M 30- 100 15.60 43 20 04/15/07 72205 273298 CLINDAMYCIN 600MG IV COMBIVENT 6 . 103.05 04/15/07 273935 INHALER 14. PANTOPRAZOLE 40 MG VI 1 282.14 04/15/07 274069 DROTRECOGIN ALFA 20 M 1 3 13.05 04/15/07 04/15/07 274703 D10W + 0.9% NACI 1000 11580.45 10 15 04/15/07 274865 307101 OXACILLIN 1000MG/10ML 16 . 131.20 04/15/07 310515 CHEST 1 VIEW CT THORAX UNENHANCED 240.00 04/15/07 04/15/07 511203 VENTILATOR DAY SUBSE Q 1 1 722.00 510 00 04/15/07 511354 511371 MDI TREATMENT ADD ON KIT 6 . 318.00 04/15/07 511372 STARTER KIT 1 66.00 04/15/07 04/15/07 600510 PULSE OXIMETER SNSR A 1 66.00 11 00 04./15/07 626081 627069 IV DILUENT NML SALINE ST EXT MICRO " 2 . 16.00 04/15/07 661717 60 IML CVP 3LUMEN OATH SET 1 1 .00 04/15/07 04/15/07 662362 BRACE NIGHT SPLINT LG 2 51 1 .00 150 00 04/15/07 670330 670390 IV INFUSION SET, UNIV HEMOSTAT ABSORB 4 . 64.00 04/16/07 10144 , SURGI I CRITICAL CARE UNIT 2 1 64.00 04/16/07 101003 ABO BLOOD GROUP 1 2935.00 04/16/07 04/16/07 101004 ANTIBODY SCREEN 21.00 47 00 04/16/07 101005 101021 RH TYPE COMPAT IMMED SPIN . 20.00 04/16/07 104106 , MAGNESIUM 2 140.00 04/16/07 04/16/07 104110 BLOOD GAS PANEL 2 32.00 384 00 04/16/07 104438 105656 RENAL FUNCTION PANEL CBC W/PLT AU 2 . 88.00 04/16/07 04/16/07 111001 TO GLUCOSE BEDSIDE MONIT 17 60.00 476 00 04/16/07 245212 245483 LEVARTERENOL 13ITARTRA 1 . 9.50 04/16/07 245489 DEXTROSE 5% SOML SODIUM CHLORIDE 0 9% 1 37.50 04/16/07 04/16/07 245491 . SALINE 0.45 1000 ML 1 5.55 3 00 04/16/07 245552 245626 EPHEDRINE SULFATE 50 NORMAL SERUM 1 . 3.00 04/16/07 246037 ALBUMIN BISACODYL 10 MG 2 1 1077.30 -------------------------------------------------------------3.00 ------------------ Continue - A? MS HERSHEY MEDICAL CENTER PAGE: 8 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMER.MAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 --- Date -------_--_ = ? Svc Code ------ I Descri on Pti ?------ Units ? - ----------- Debits -------------- --- ------- ----- Credits 04/16/07 04/16/07 246057 ---- --- -- CEFAZOLIN 1 GM/5 ML -- 2 4 25 ----- 04/16/07 246162. 246435 FENTANYL CITRATE 5 ML POTASSIUM C 3 . 9.55 04/16/07 246703 HLORIDE 2 LORAZEPAM 2 MG 20 3.00 04/16/07 04/16/07 246831 FENTANYL CITRATE 20 M 20 11.70 10 40 04/16/07 249220 251619 MIDAZOLAM SMGL ML 10M FLUCORAZOLE 200 . 86.40 04/16/07 272129 400MG/200 ROCURONIUM BROMIDE 5M 2 1 58.10 04/16/07 04/16/07 272205 2 CLINDAMYCIN 600MG IV 4 34.45 68 70 04/16/07 73401 273935 ZOSYN 3.75GM BAG PANTOPRAZOLE 15 . 331.75 04/16/07 274069 40 MG VI DROTRECOGIN ALFA 20 M 1 1 13.05 04/16/07 274138 MOXIFLOXACIN 400MG IV 4 3860.15 04/16/07 04/16/07 274597 CALCIUM GLUCONATE 1G/ 5 2450.45 45 04/16/07 274703 274865 D10W + 0.9% NACI OXACILLIN 1000MG/10ML 1000 2 . 10.15 04/16/07 307101 CHEST 1 VIEW 4 196.80 04/16/07 04/16/07 391101 3 OR TIME<=1HR EACH 15M 4 360.00 2284 00 04/16/07 91102 398230 OR TIME>IHR EACH 15MI SUTURE SINGLE 2 . 522.00 04/16/07 398410 , ARM DURA PREP SOLUTION 2 1 18.00 04/16/07 398521 CAUTERY PENCIL 10.00 04/16/07 04/16/07 502000 5 ANESTHESIA TIME-HOSP 6 15.00 58 00 0 04/16/07 11203 511354 VENTILATOR DAY SUBSEQ MDI TREATMENT 1 . 51 0.00 04/16/07 621054 IV LACTATED RINGERS 1 1 265.00 04/16/07 04/16/07 621100 CANISTER SUCT HARDSHE 2 6.00 10 00 04/16/07 622024 626080 IRRIGATION SOD CHL 0. IV 2 . 12.00 04/16/07 626081 DILUENT NML SALINE IV DILUENT NML SALINE 1 8.00 04/16/07 04/16/07 627085 SET ADMIN-BIFUSE MEDE 1 1 8.00 13 00 04/16/07 670330 670334 IV INFUSION SET, UNIV IV INFUSION 4 . 64.00 04/17/07 10144 SET, UNIV I CRITICAL CARE UNIT 1 1 8.00 04/17/07 16681 INITIAL EVALUATION-PT 1 2935 .00 04/17/07 102100 CULTURE, BACTERIAL 1 159.00 04/17/07 104106 MAGNESIUM 66.00 04/17/07 104110 BLOOD GAS PANEL 1 1 16.00 04/17/07 04/17/07 104438 RENAL FUNCTION PANEL 128.00 44 00 04/17/07 105656 111001 CBC W/PLT AUTO GLUCOSE BEDSIDE MONIT 1 . 30.00 04/17/07 245212 LEVARTERENOL BITARTRA 3 2 364.00 ------------- ----------- - - - 18.95 - Continue - ----- --- ------ ---- ------------- A _Iw MS HERSHEY MEDICAL CENTER PAGE: 9 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 I---- -- -I_ Svc - Code -------- Description --- 1--------------------- Date --- --- Units --- Debits --- --- Credits I 04/17/07 ..245489 SODIUM------------------------------------------------- 04/17/07 CHLORID 0. 9% 245491 SALINE 0.4455% 11000 ML 1 22.20 04/17/07 04/17/07 245626 NORMAL SERUM ALBUMIN 4 3.0 60 64 2154 0 04/17/07 246021 BACITRACIN 15 GM 246435 POTASSIUM CHLORIDE . . 4.60 04/17/07 2 246703 LORAZEPAM 2 MG 20 0 3. '04/17/07 04/17/07 246831 FENTANYL CITRATE 20 M 60 6 15 .60 31 20 04/17/07 247784 DEXTROSE 50 ML 249220 MIDAZOLAM 5MGL . 3.00 04/17/07 ML 10M 272811 DALTEPARIN 2500U/0 2M 200 2 86.40 04/17/07 04/17/07 . 273401 ZOSYN 3.75GM BAG 1 64.80 5 26 40 04/17/07 273935 PANTOPRAZOLE 40 MG VI 274069 1 . 13.05 04/17/07 DROTRECOGIN ALFA 20 M 274138 MOXIFLOXACIN 4 15440.60 04/17/07 400MG IV 274324 HUMULIN R g 80.30 04/17/07 307101 CHEST 1 VIEW 200 38.20 04/17/07 04/17/07 310516 CT THORAX ENHANCED 3 i 240.00 1565 00 04/17/07 10702 OMNIPAQUE 300MG/ML 75 511203 VENTILATOR D 1 . 60.00 04/17/07 AY SUBSE 511354 MDI TREATMENT Q 1 510.00 04/17/07 04/17/07 621012 IV DEXTROSE 5%-WATER 1 318.00 6 00 04/17/07 621054 IV LACTATED RINGERS 1 621106 YANKAUER SUCT TB W/O 2 1 . 12.00 04/17/07 04/17/07 626081 IV DILUENT NML SALINE 1 8 00 00 04/17/07 670330 IV INFUSION SET, UNIV 670520 TRACH CAR 1 . 6. 16.00 )4/17/07 E SYSTEM 14 670722 FEEDING BG ENTERAL 10 1 20.00 )4/17/07 )4/18/07 712011 CV CATH PLACE,PERC,> 1 1 4.00 449 00 )4/18/07 10144 I CRITICAL CARE UNIT 104106 MAGNESIUM 1 . 2935.00 )4/18/07 104110 BLOOD GAS PANEL 1 16.00 )4/18/07 )4/18/07 104438 RENAL FUNCTION PANEL 2 384.00 88 00 )4/18/07 105656 CBC W/PLT AUTO 111001 GLUCOSE BEDSIDE MONIT . 30.00 )4/18/07 )4/18/07 245212 LEVARTERENOL BITARTRA 13 1 364.00 9 50 )4/18/07 245431 METOCLOPRAMIDE 5 MG/M 245489 3 . 9.00 14/18/07 SODIUM CHLORIDE 0.9W 245551 ERYTH. ETHYL SUCC 2 1 5.55 14/18/07 X4/18/07 . . 246037 BISACODYL 10 MG 90 27.00 3 00 4/18/07 246176 FUROSEMIDE 10 MG/ML 246703 LORAZEPAM 2 2 . 6.00 4/18/07 MG 246831 FENTANYL CITRATE 20 M 20 11.70 ------------------------------ 10.40 ------------------------------------------------- 7 Continue - A.q MS HERSHEY MEDICAL CENTER PAGE: 10 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ----------- - ------ ------ Date---- ?-Svc -Code-I--- Description Units ---------------- Debits 04 18/07 04/18/07 246849 --- FUROSEMIDE - 10 - MG/ML 2 _ 00_ 4 04/18/07 247784 252014 DEXTROSE 50 ML REGULAR ADULT TPN . 3.00 04/18/07 04/18/07 272811 DALTEPARIN 2500U/0.2M 1360 1 457.55 32 40 04/18/07 273298 273401 COMBIVENT INHALER 14. ZOSYN 1 . 282.14 04/18/07 273935 3.75GM BAG PANTOPRAZOLE 40 MG VI 19 9.05 04/18/07 274069 DROTRECOGIN ALFA 20 M 1 1 13.05 04/18/07 274324 HUMULIN R 3860.15 04/18/07 307101 CHEST 1 VIEW 200 38.2 0 04/18/07 04/18/07 511203 VENTILATOR DAY SUBSEQ 1 2 0.0 510 00 04/18/07 511354 600510 MDI TREATMENT PULSE OXIMETER SNSR . 212.00 04/18/07 04/18/07 621100 6 A CANISTER SUCT HARDSHE 1 2 11.00 10 00 04/18/07 21386 622023 IV KCL 20MEQ+D5 NACL IRRIGATION 1 . 9.00 04/18/07 623016 SOD CHL 0. SET IV EXT W/1.2 MICR 1 1 6.00 04/18/07 04/18/07 661602 6 CATH PREP TRAY CENT L 1 20.00 12 00 04/18/07 70330 703322 IV INFUSION SET, UNIV IP NUTR 15 MIN 1 . 16.00 04/19/07 10144 , ,ORL/TB I CRITICAL CARE UNIT 1 79.00 04/19/07 104106 MAGNESIUM 1 2935.00 04/19/07 104110 BLOOD GAS PANEL 1 1 16.00 04/19/07 04/19/07 104438 10 RENAL FUNCTION PANEL, 128.00 44 00 04/19/07 5656 111001 CBC W/PLT AUTO GLUCOSE BEDSIDE MONIT . 30.00 04/19/07 245431 METOCLOPRAMIDE 5 MG/M 5 5 140.00 04/19/07 04/19/07 245551 ERYTH. ETHYL. SUCC. 2 40 15.00 12 00 04/19/07 246176 246703 FUROSEMIDE 10 MG/ML LORAZEPAM 2 3 . 9. 0 04/19/07 246831 MG FENTANYL CITRATE 20 M 70 6 15 .60 04/19/07 04/19/07 249220 MIDAZOLAM 5MGL ML 10M 50 36.35 21 60 04/19/07 251130 252014 POTASSIUM CHLORIDE 50 REGULAR ADULT 20 . 10.75 04/19/07 272.811 TPN DALTEPARIN 2500U/0 2M 1 399 2 45 7.55 04/19/07 04/19/07 273298 . COMBIVENT INHALER 14. 1 64.80 282 14 04/19/07 273401 273935 ZOSYN 3.75GM BAG PANTOPRAZOLE 40 12 . 265.40 04/19/07 04/19/07 274138 MG VI MOXIFLOXACIN 400MG IV 1 8 13.05 80 30 04/19/07 275020 307101 PEDIALYTE 240ML SOLN CHEST 8 . 34.90 04/19/07 51120-4 1 VIEW iTF!ATTTT_mm?n „a., ?.., .?_ 1 120.00 Credits -------------- ---------------------------------------------xl---y--i-----71U.UU ------------------ - Continue - /f _/0 MS HERSHEY MEDICAL CENTER PAGE: 11 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ----------------------------------------- Date ( Svc Code ------- Description - - - - - - - - -Unit-s- - - - - - - - -Debit-s- - - - - - - - --Credits -------------- ---------------- ----------- -------------------------- 04/19/07 --- 511354 MDI T 04 /19/07 621043 REATMENT I V SODIUM CHLORIDE 0 7 1 371.00 04/19/07 04/19/07 623016 SET IV EXT W/1.2 MICR 1 6.00 20 00 04/19/07 626080 670330 IV DILUENT NML SALINE IV INFUSION 2 . 16.00 04/20/07 10144 SET, UNIV I CRITICAL CARE UNIT 5 80.00 04/20/07 04/20/07 16691 THER EXERCISES 15 MIN 1 1 2935.00 53 00 04/20/07 101003 101004 ABO BLOOD GROUP ANTIBODY SCREEN 1 . 21.00 04/20/07 101005 RH TYPE 1 47.00 04/20/07 04/20/07 101021 COMPAT, IMMED SPIN 2 20.00 140 00 04/20/07 102019 102100 GRAM STAIN CULTURE BACTERIAL 1 . 26.00 04/20/07 04/20/07 102104 , CULTURE, ANAEROBES ON 1 66.00 59 00 04/20/07 102215 104106 CULTURE TYPE IMM/ANTI MAGNESIUM 1 . 27.00 04/20/07 104110 BLOOD GAS PANEL 1 16.00 04/20/07 104438 RENAL FUNCTION PANEL 1 384.00 04/20/07 105656 CBC W/PLT AUTO 44.00 04/20/07 04/20/07 111001 GLUCOSE BEDSIDE MONIT g 30.00 224 00 04/20/07 245212 245431 LEVARTERENOL BITARTRA METOCLOPRAMIDE 2 . 19.00 04/20/07 245551 5 MG/M ERYTH. ETHYL. SUCC 2 2 40 6.00 04/20/07 246037 . BISACODYL 10 MG 12.00 04/20/07 04/20/07 246057 2 CEFAZOLIN 1 GM/5 ML 2 3.00 4 25 04/20/07 46130 246162 DIPHENHYDRAMINE 50 MG 1 . 3.00 04/20/07 246176 FENTANYL CITRATE 5 ML FUROSEMIDE 10 MG/ML 3 1 9.55 04/20/07 246703 LORAZEPAM 2 MG 3.00 04/20/07 04/20/07 246831 2 FENTANYL CITRATE 20.M 40 3.90 20 80 04/20/07 49220 252014 MIDAZOLAM 5MGL ML 10M REGULAR ADULT 150 . 64.80 34/20/07 272425 TPN MIDAZOLAM 1MG/ML 2ML 1416 2 457.55 )4/20/07 )4/20/07 272811 DALTEPARIN 2500U/0.2M 1 3.00 32 40 )4/20/07 273401 273935 ZOSYN 3.75GM BAG PANTOPRAZOLE 1 . 265.40 )4/20/07 274325 40 MG VI HUMULIN N 1 13.05 )4/20/07 )4/20/07 307101 CHEST 1 VIEW 1 33.40 120 00 14/20/07 391101 398230 OR TIME<=1HR EACH 15M SUTURE SINGLE 3 . 1713.00 4/20/07 398410 , ARM DURA PREP SOLUTION 1 18.00 4/20/07 502000 ANESTHESIA TIME-HOSP 3 10.00 ------------------------------------ ----------------------301_00 ?______ Continue - ------ ft-0 MS HERSHEY MEDICAL CENTER PAGE: 12 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ---Date----I-Svc Code --------Description ---? -Units----Debits ----------------- --- -------------------I Credits 04/20/07 511203 VENT ----------------------- 04/20/07 511354 ILLAIOR DA MDI TREATMENTY SUBSEQ 1 510.00 04/20/07 04/20/07 511812 6 END TIDAL C02 DISP CU 1 230.00 04/20/07 21012 622023 IV DEXTROSE 5%-WATER IRRIGATION SOD CHL 1 6.00 04/20/07 622024 0. IRRIGATION SOD CHL 0 1 1 6.00 04/20/07 04/20/07 623016 . SET IV EXT W/1.2 MICR 1 6.00 28. 00 04/20/07 626081 640322 IV DILUENT NML SALINE CONTAINER ANAEROBIC S 1 8 .00 04/20/07 670330 , IV INFUSION SET UNIV 1 3 9.00 04/20/07 703322 , IP NUTR,.15 MIN ORL/TB 1 48.00 04/21/07 04/21/07 10144 1 , I CRITICAL CARE UNIT 1 79.00 2935.00 04/21/07 04106 104438 MAGNESIUM RENAL FUNCTION PANEL 1 1 16.00 04/21/07 105656 CBC W/PLT AUTO 1 44.00 04/21/07 04/21/07 111001 2 GLUCOSE BEDSIDE MONIT 6 30.00 168.00 04/21/07 45431 245551 METOCLOPRAMIDE 5 MG/M ERYTH E 4 10.85 04/21/07 246176 . THYL. SUCC. 2 FUROSEMIDE 10.MG/ML 40 2 12.00 04/21/07 246703 LORAZEPAM 2 MG 3 6.00 04/21/07 04/21/07 246831 25 FENTANYL CITRATE 20 M 40 11.70 20.80 04/21/07 2014 272811 REGULAR ADULT TPN DALTEPARIN 2500U/0 2M 1421 2 457.55 04/21/07 273401 . ZOSYN 3.75GM BAG 9 64.80 04/21/07 273935 PANTOPRAZOLE 40 MG VI 1 199.05 04/21/07 274138 MOXIFLOXACIN 400MG IV 4 13.05 04/21/07 307101 CHEST 1 VIEW 1 4 0.15 04/21/07 04/21/07 511203 51 VENTILATOR DAY SUBSEQ 1 120.00 510.00 04/21/07 1354 670520 MDI TREATMENT TRACH CARE SYSTEM 14 6 318.00 )4/21/07 670722 FEEDING BG ENTERAL 10 1 1 20.00 )4/22/07 )4/22/07 10144 10 I CRITICAL CARE UNIT 1 4.00 2935.00 )4/22/07 2019 102100 GRAM STAIN CULTURE BACTERIAL 1 26.00 )4/22/07 102105 , CULTURE, BLOOD 1 3 66.00 )4/22/07 )4/22/07 102118 10 SMEAR, FLUOR/ACID FAS 1 261.00 36.00 )4/22/07 2214 102215 CULTURE, URINE QUANT CULTURE TYPE IMM/ANTI 1 1 40.00 )4/22/07 14/22/07 102303 1 CULTURE, FUNGUS OTHER 1 27.00 40.00 4/22/07 04009 104014 AMYLASE, BLOOD ALKALINE PHOSPHATASE 1 44.00 4/22/07 104016 BILIRUBIN TOTAL 1 14.00 1 -4.00 ---------------------------------- - Continue - fi ` 0-1 MS HERSHEY MEDICAL CENTER PAGE: 13 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit ##: 8289451 ----------------- ----------------------- Date Svc Code Description Units 04/22/07 104097 LIPASE -------------------- 04/22/07 104106 MAGNESIUM 1 04/22/07 104156 SGPT (ALT) 1 04/22/07 104438 RENAL FUNCTION PANEL 1 04/22/07 105656 CBC W/PLT AUTO 1 04/22/07 106011 URINALYSIS-BASIC & MI 1 04/22/07 111001 GLUCOSE BEDSIDE MONIT 5 04/22/07 245212 LEVARTERENOL BITARTRA 1 04/22/07 245431 METOCLOPRAMIDE 5 MG/M 5 04/22/07 245551 ERYTH. ETHYL. SUCC. 2 40 04/22/07 245985 ACETAMINOPHEN 600 MG 1 04/22/07 246176 FUROSEMIDE 10 MG/ML 3 04/22/07 246703 LORAZEPAM 2 MG 3 04/22/07 246831 FENTANYL CITRATE 20 M 20 04/22/07 249220 MIDAZOLAM SMGL ML 10M 50 04/22/07 252014 REGULAR ADULT TPN 1421 0 04/22/07 273298 4/22/07 272811 DALTEPARIN 2500U/0.2M 3 04/22/07 273401 ZOSYN3N75GM INHALER 14? 12 V 04/22/07 273935 PANTOPRAZOLE 40 MG VI 1 04/22/07 274138 MOXIFLOXACIN 400MG IV 4 04/22/07 307101 CHEST 1 VIEW 1 04/22/07 511201 STERILE WATER UP TO 5 400 04/22/07 511203 VENTILATOR DAY SUBSEQ 1 04/22/07 511354 MDI TREATMENT 6 04/22/07 600510 PULSE OXIMETER SNSR A 1 04/22/07 621043 I V SODIUM CHLORIDE 0 1 04/22/07 622023 IRRIGATION SOD CHL 0. 1 04/22/07 626080 IV DILUENT NML SALINE 1 04/22/07 669952 DRESS DUODERM 4X4 2 04/22/07 670722 FEEDING BG ENTERAL 10 1 04/23/07 10144 I CRITICAL CARE UNIT 1 04/23/07 102003 SENSI, DISK METHOD/PL 1 04/23/07 102019 GRAM STAIN 04/23/07 102020 SENSI, VANCO AGAR DIL 1 04/23/07 102100 CULTURE, BACTERIAL 2 04/23/07 102104 CULTURE, ANAEROBES ON 1 04/23/07 102118 SMEAR, FLUOR/ACID FAS 1 04/23/07 102215 CULTURE TYPE IMM/ANTI 1 04/23/07 102303 CULTURE, FUNGUS OTHER 1 04/23/07 104006 AMMONIA, BLOOD 1 04/23/07 104106 MAGNESIUM -------------- ---------------------- -------------------------------- Debits 45.00 16.00 15.00 44.00 30.00 38.00 140.00 9.50 13.85 12.00 3.00 9.00 11.70 10.40 21.60 457.55 97.20 282.14 265.40 13.05 40.15 120.00 5.00 510.00 318.00 11.00 6.00 6.00 8.00 12.00 4.00 2935.00 41.00 52.00 30.00 132.00 59.00 36.00 27.00 40.00 60.00 16.00 ? Credits Continue ?+ /3 MS HERSHEY MEDICAL CENTER PAGE: 14 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 I___Date___ _I_Svc-Code- I-- -----Description--- ---------- I _Unitsl ------ Debits Credits 04/23/07 04/23/07 104438 ---- RENAL FUNCTION PANEL 1 -- __________ 44 00 04/23/07 105656 111001 CBC W/PLT AUTO GLUCOSE BEDSIDE MONIT . 30.00 04/23/07 245431 METOCLOPRAMIDE 5 MG/M 3 6 168.00 04/23/01 04/23/07 245551 ERYTH. ETHYL. SUCC.2 40 9.00 12 00 04/23/07 245985 246037 ACETAMINOPHEN 600 MG BISACODYL 10 2 . 6.00 04/23/07 246703 MG LORAZEPAM 2 MG 2 6.00 04/23/07 04/23/07 246831 FENTANYL CITRATE 20 M 70 7.80 36 35 04/23/07 251130 252014 POTASSIUM CHLORIDE 50 REGULAR 20 . 10.75 04/23/07 272811 ADULT TPN DALTEPARIN 2500U/0 2M 1426 1 45 7.55 04/23/07 04/23/07 273401 . ZOSYN 3.75GM BAG 12 32.40 265 40 04/23/07 273935 274274 PANTOPRAZOLE 40 MG VI 1 . 13.05 04/23/07 307101 VANCOMYCIN HCL INJ CHEST 1 VIEW 10 151.00 04/23/07 310516 CT THORAX ENHANCED 1 120.00 04/23/07 310702 OMNIPAQUE 300MG/ML 75 1 1565.00 04/23/07 04/23/07 511203 5 VENTILATOR DAY SUBSEQ 1 60.00 510 00 04/23/07 11354 621012 MDI TREATMENT IV DEXTROSE 5%-WATER . 371.00 04/23/07 04/23/07 621043 6 I 'V SODIUM CHLORIDE 0 1 2 6.00 12.00 04/23/07 21044 621054 I V SODIUM CHLORIDE 0 IV LACTATED RINGERS 1 6.00 04/23/07 04/23/07 621115 1 SUCT CATH MINI-BAL NO 1 1 6.00 78 00 04/23/07 622023 623016 IRRIGATION SOD CHL 0. SET IV EXT W/1 2 MI 1 . 6.00 04/23/07 04/24/07 670330 . CR IV INFUSION SET, UNIV 1 2 20.00 32 00 04/24/07 10144 16691 I CRITICAL CARE UNIT THER EXERCISES 1 . 2935.00 04/24/07 101003 15 MIN ABO BLOOD GROUP 1 1 53.00 04/24/07 101004 ANTIBODY SCREEN 1 21.00 04/24/07 101005 RH TYPE 47.00 04/24/07 101021 COMPAT, IMMED SPIN 2 20.00 04/24/07 104106 MAGNESIUM 140.00 04/24/07 04/24/07 104438 RENAL FUNCTION PANEL 1 16.00 44 00 04/24/07 104591 105036 VANCOMYCIN LEVEL HEMATOCRIT 2 . 72.00 04/24/07 105656 CBC W/PLT AUTO 1 18.00 04/24/07 04/24/07 111001 GLUCOSE BEDSIDE MONIT 6 30.00 168 00 04/24/07 245431 245551 METOCLOPRAMIDE 5 MG/M ERYTH 4 . 12.00 ------------- ----- . ETHYL. SUCC. 2 30 9.00 - Continue - -------- -------- ----------- --- A iLf MS HERSHEY MEDICAL CENTER PAGE: 15 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 --- Date------Svc-Code --------Description --- I - Units----Debits-------Credit-------s--- --- -------------- -------------------- 04 24/07 245626 NO --------- 04/24/07 246703 LOR ZEPAMRUM ALBUMIN 2 2 1077.30 04/24/07 04/24/07 246831 2 FENTANYL CI TRATE 20 M 2 40 . 7 80 2 0 0 04/24/07 49220 272811 MIDAZOLAM 5MGL ML 10M DALTEPARIN 2500U/0 2M 50 2 6 2 1 .60 04/24/07 273298 . COMBIVENT INHALER 14 1 2 14 04/24/07 273401 . ZOSYN 3.75GM BAG 12 28 . 04/24/07 273935 PANTOPRAZOLE 40 MG VI 1 265.40 04/24/07 274274 VANCOMYCIN HCL INJ 4 13.05 04/24/07 307101 CHEST 1 VIEW 1 60.40 04/24/07 511354 MDI TREATMENT 120.00 04/24/07 600510 PULSE OXIMETER SNSR A 1 2 04/24/07 621043 I V SODIUM CHLORIDE 0 3 11.00 04/24/07 04/24/07 621100 CANISTER SUCT HARDSHE 2 18.00 10.00 04/24/07 621105 621385 YANKAUER SUCT TB W/O 1 5.00 04/24/07 667410 IV KCL 20MEQ+D5 NACL HEAD SUPPORT GEL ADU 2 16.00 04/24/07 04/24/07 670330 67 ; IV INFUSION SET, UNIV 1 4 16.00 64.00 04/24/07 0334 670520 IV INFUSION SET, UNIV TRACH CARE SYSTEM 1 8.00 04/24/07 670722 , 14 FEEDING BG ENTERAL 10 1 2 20.00 04/24/07 04/24/07 670727 7 PCA ST INTEGRAL NOSIP 1 8.00 24.00 04/25/07 03322 IP NUTR,15 MIN,ORL/TB 1 79.00 04/25/07 10144 104106 I CRITICAL CARE UNIT MAGNESIUM 1 2935.00 04/25/07 104110 BLOOD GAS PANEL 1 1 16.00 04/25/07 04/25/07 104433 1 BASIC METABOLIC PANEL 1 128.00 42.00 04/25/07 04438 105656 RENAL FUNCTION PANEL CBC W/PLT AUT 1 44.00 04/25/07 04/25/07 111001 2 O GLUCOSE BEDSIDE MONIT 1 7 30.00 196.00 04/25/07 45431 2 METOCLOPRAMIDE 5 MG/M 5 15.00 04/25/07 45551 245652 ERYTH. ETHYL. SUCC.2 FERROUS SULFATE 3 40 12.00 04/25/07 245900 00 M ACETAMINOPHEN 650 MG/ / 3 1 9.00 04/25/07 246703 LORAZEPAM 2 MG 3.00 04/25/07 04/25/07 246831 FENTANYL CITRATE 20 M 10 11.70 5.20 04/25/07 246849 272811 FUROSEMIDE 10 MG ML DALTEPARIN 2500U/0 2M 2 3 4.0 0 04/25/07 )4/25/07 273401 . ZOSYN 3.75GM BAG 12 97 .2 265.40 )4/25/07 273935 274274 PANTOPRAZOLE 40 MG VI VANCOMYCIN HCL INJ 1 13.05 34/25/07 275035 KPHOS 30MMOL/500ML D5 4 2 60.40 38 10 --------------------- I ------------------------------- - Continue - MS HERSHEY MEDICAL CENTER PAGE: 16 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ----------------------------- Date Svc - Code - -------- Description--- Units 04/25/07 307101 CHEST 1 VIEW 1 ------------------ 04/25/07 511203 VENTILATOR DAY SUBSEQ 1 04/25/07 511354 MDI TREATMENT 4 04/25/07 600510 PULSE OXIMETER SNSR A 1 04/25/07 620148 STATLOCK PICC PLUS PI 1 04/25/07 621043 I V SODIUM CHLORIDE 0 1 0 04/25/07 621113 KIT 4/25/07 621105 YANKAUER SUCT TB W/O 1 BLOOD 04/25/07 623014 ULTRASITE NJ CAP BRA 3 04/25/07 661602 CATH PREP TRAY CENT L 1 04/26/07 10144 I CRITICAL CARE UNIT 1 04/26/07 56619 THER EXERCISE 15 MIN 1 04/26/07 104106 MAGNESIUM 1 04/26/07 104438 RENAL FUNCTION PANEL 1 04/26/07 105657 CBC W/PLT/DIFF AUTO 1 04/26/07 111001 GLUCOSE BEDSIDE MONIT 5 04/26/07 245431 METOCLOPRAMIDE 5 MG/M 3 04/26/07 245551 ERYTH. ETHYL. SUCC. 2 30 04/26/07 245652 FERROUS SULFATE 300 M 3 04/26/07 246703 LORAZEPAM 2 MG 3 04/26/07 246831 FENTANYL CITRATE 20 M 20 04/26/07 272811 DALTEPARIN 2500U/0.2M 2 04/26/07 273298 COMBIVENT INHALER 14. 1 04/26/07 273401 ZOSYN 3.75GM BAG 12 04/26/07 273935 PANTOPRAZOLE 40 MG VI 1 04/26/07 274274 VANCOMYCIN HCL INJ 4 04/26/07 307101 CHEST 1 VIEW 1 04/26/07 511203 VENTILATOR DAY SUBSEQ 1 04/26/07 511354 MDI TREATMENT 4 04/26/07 600510 PULSE OXIMETER SNSR A 1 04/26/07 621043 I V SODIUM CHLORIDE 0 1 04/26/07 623014 ULTRASITE INJ CAP BRA 1 04/26/07 627069 ST EXT MICRO 60" IML 1 04/26/07 670330 IV INFUSION SET, UNIV 2 04/26/07 670722 FEEDING BG ENTERAL 10 2 04/27/07 10144 I CRITICAL CARE UNIT 1 04/27/07 16691 THER EXERCISES 15 MIN 2 04/27/07 104006 AMMONIA, BLOOD 1 04/27/07 104014 ALKALINE PHOSPHATASE 1 04/27/07 104016 BILIRUBIN TOTAL 1 34/27/07 104106 MAGNESIUM 1 )4/27/07 104156 SGPT (ALT) 1 -------------------------------------------------------------------------------I Debits 120.00 510.00 212.00 11.00 8.00 6.00 5.00 10.00 30.00 12.00 2935.00 53.00 16.00 44.00 48.00 140.00 9.00 9.00 9.00 11.70 10.40 64.80 282.14 265.40 13.05 60.40 120.00 510.00 212.00 11.00 6.00 10.00 7.00 32.00 8.00 2935.00 106.00 60.00 14.00 14.00 16.00 15.00 ----Credits-- Continue 4 -jj MS HERSHEY MEDICAL CENTER PAGE: 17 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 - - Date - - - - - Svc - Code - -------- --Debit------s ---- I --- Descripti---on --- ?- Unitel Credits--I ---------- - - -- - -------------------------------------------------------------------------------- 04/27/07 ---_ 04/27/07 104438 REN --------------------------------------- 04/27/07 105656 CBC W/PLTCAUTO PANEL 1 44.00 04/27/07 111001 04/27/07 2 GLUCOSE BEDSIDE MONIT 4 30.00 112.00 45431 04/27/07 245652 METOCLOPRAMIDE 5 MG/M 1 3.00 04/27/07 246703 FERROUS SULFATE 300 M LORAZEPAM 2 MG 2 6.00 04/27/07 246706 MORPHINE SULFATE 2 MG 1 3.90 04/27/07 248356 METOPROLOL 5MG/5ML 2 3.00 04/27/07 272117 ATROVENT .02-W 2 5ML 4 22.30 04/27/07 272811 04/27/07 . DALTEPARIN 2500U/0.2M 2 12.00 64 80 273401 04/27/07 274101 ZOSYN 3.75GM BAG PANTOPRAZOLE 40MG SYR . 199.05 04/27/07 274274 04/27/07 2 VANCOMYCIN HCL INJ 1 4 8.30 60 40 74651 04/27/07 307101 ALBUTEROL 2.5MG/0.5ML 12 . 12.00 04/27/07 511203 CHEST 1 VIEW VENTILATOR DAY SUBSEQ 1 1 120.00 04/27/07 511351 AEROSOL TREATMENT 3 510.00 04/27/07 511354 MDI TREATMENT 159.00 04/27/07 627069 ST EXT MICRO 60" IML 1 159.00 04/27/07 670334 04/27/07 IV INFUSION SET, UNIV 1 7.00 8.00 670722 04/28/07 10144 FEEDING 13G ENTERAL 10 1 4.00 04/28/07 104106 I CRITICAL CARE UNIT MAGNESIUM 1 2935.00 04/28/07 104110 BLOOD GAS PANEL 1 1 16.00 04/28/07 104438 04/28/07 RENAL FUNCTION PANEL 128.00 44 00 105656 04/28/07 111001 CBC W/PLT AUTO GLUCOSE BEDSIDE MONIT . 30.00 04/28/07 245431 METOCLOPRAMIDE 5 MG/M 5 2 14 .00 04/28/07 245652 D4/28/07 2 FERROUS SULFATE 300 M 3 6 6.00 9.00 45900 D4/28/07 246176 ACETAMINOPHEN 650 MG/ 1 00 D4/28/07 246703 FUROSEMIDE 10 MG/ML LORAZEPAM 2 MG 2 6.0 0 D4/28/07 246706 )4/28/07 MORPHINE SULFATE 2 MG 5 11.70 15.00 246849 )4/28/07 248356 FUROSEMIDE 10 MG/ML METOPROLOL 5MG/5ML 2 6 4.00 )4/28/07 272117 )4/28/07 2 ATROVENT .02% 2.5ML 5 66.90 15.00 72811 )4/28/07 273401 DALTEPARIN 2500U/0.2M ZOSYN 3 75GM 1 32.40 )4/28/07 273778 . BAG LINEZOLID 600 MG INJ 12 6 265.40 )4/28/07 274101 )4/28/07 2 PANTOPRAZOLE 40MG SYR 1 463.00 8.30 74274 )4/28/07 274651 VANCOMYCIN HCL INJ ALBUTEROL 2.5MG/0.5ML 4 15 60.40 15 ------------------------------------ -------------------------.00 I ------------------ - Continue - R - I'1 MS HERSHEY MEDICAL CENTER PAGE: 18 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ------_ ------------------------ Date Svc Code Description --- I Unite 04/28/07 307101 CHEST 1 VIEW 0 04/28/07 4/28/07 511351 AEROSOL TREATMENT 6 621043 1 V SODIUM 10144 I CRITICAL CCARERUNIT O 1 04/29/07 101003 ABO BLOOD GROUP 1 04/29/07 101004 ANTIBODY SCREEN 1 04/29/07 101005 RH TYPE 1 04/29/07 101021 COMPAT, IMMED SPIN 3 04/29/07 101213 RED BLD CELLS EA U 3 04/29/07 102019 GRAM STAIN 1 04/29/07 102100 CULTURE, BACTERIAL 1 04/29/07 102105 CULTURE, BLOOD 2 04/29/07 104106 MAGNESIUM 1 04/29/07 104438 RENAL FUNCTION PANEL 1 04/29/07 105656 CBC W/PLT AUTO 1 04/29/07 111001 GLUCOSE BEDSIDE MONIT 6 04/29/07 245431 METOCLOPRAMIDE 5 MG/M 4 04/29/07 245652 FERROUS SULFATE 300 M 2 04/29/07 245900 ACETAMINOPHEN 650 MG/ 1 04/29/07 246176 FUROSEMIDE 10 MG/ML 4 04/29/07 246703 LORAZEPAM 2 MG 5 04/29/07 246706 MORPHINE SULFATE 2 MG 3 04/29/07 248356 METOPROLOL 5MG/5ML 6 04/29/07 251727 POT CHL ORAL SOL 10% 2 04/29/07 272117 ATROVENT .02% 2.5ML 6 04/29/07 272811 DALTEPARIN 2500U/0.2M 3 04/29/07 273401 ZOSYN 3.75GM BAG 12 04/29/07 273778 LINEZOLID 600 MG INJ 6 04/29/07 274101 PANTOPRAZOLE 40MG SYR 1 04/29/07 274274 VANCOMYCIN HCL INJ 4 04/29/07 274651 ALBUTEROL 2.5MG/0.5ML 18 04/29/07 307101 CHEST 1 VIEW TREATMENT 04/29/07 1 511351 AEROSOL 04/29/07 621044 1 V SODIUM CHLORIDE 0 1 04/29/07 623014 ULTRASITE INJ CAP BRA 1 04/29/07 625010 SET BLOOD SOLUTION 1 04/29/07 625011 IV ADMIN SET BLOOD FI 1 04/29/07 669194 TAPE SURG SOFCLOTH RO 1 04/29/07 670330 IV INFUSION SET, UNIV 1 04/29/07 670722 FEEDING BG ENTERAL 10 1 04/30/07 10144 I CRITICAL CARE UNIT 1 04/30/07 ---16700 THERAPEUTIC ACTIV 15 1 ------------------------------------------------------------------- Continue 7 W Debits 120.00 318.00 6.00 2935.00 21.00 47.00 20.00 210.00 861.00 26.00 66.00 174.00 16.00 44.00 30.00 168.00 12.00 6.00 3.00 12.00 19.50 11.10 66.90 3.00 18.00 97.20 265.40 463.00 8.30 60.40 18.00 120.00 371.00 6.00 10.00 24.00 23.00 8.00 16.00 4.00 2935.00 53.00 ---Credits-_ MS HERSHEY MEDICAL CENTER PAGE: 19 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ---Date---- ?-Svc Code Description UnitsIDebits Credits ----------------------- 04/30/07 104106 ----------------------------------- 04/30/07 104131 ULVI POTASSIUM (K) BLOOD 1 16.00 04/30/07 104438 , RENAL FUNCTION PANEL 1 4.00 04/30/07 105656 CBC W/PLT AUTO 1 4 4 4.00 04/30/07 04/30/07 111001 GLUCOSE BEDSIDE MONIT 7 30.00 196.00 04/30/07 245652 245900 FERROUS SULFATE 300 M ACETAMINOPHEN 650 MG/ 2 1 6.00 04/30/07 246176 FUROSEMIDE 10 MG/ML 2 3.00 04/30/07 246703 LORAZEPAM 2 MG 3 6.00 04/30/07 246706 MORPHINE SULFATE 2 MG 5 11.70 04/30/07 248356 METOPROLOL 5MG/5ML 5 15.00 04/30/07 04/30/07 251130 POTASSIUM CHLORIDE 50 30 55.75 16.10 04/30/07 272117 272811 ATROVENT .02%- 2.5ML DALTEPARIN 2500U/0 2M 5 1 15.00 04/30/07 04/30/07 273399 . ISOSOURCE 250ML CAN 18 32.40 90.67 04/30/07 273401 273778 ZOSYN 3.75GM BAG LINEZOLID 600 MG I 12 265.40 04/30/07 274101 NJ PANTOPRAZOLE 40MG SYR 6 1 463.00 04/30/07 04/30/07 274651 ALBUTEROL 2.5MG/0.5ML 15 8.30 15.00 04/30/07 305501 511351 CHEST SPECIAL VIEWS AEROSOL TREATMENT 2 246.00 04/30/07 621043 I V SODIUM CHLORIDE 0 4 1 212.00 04/30/07 669194 TAPE SURG SOFCLOTH RO 1 6.00 04/30/07 670722 FEEDING BG ENTERAL 10 1 8.00 04/30/07 05/01/07 703322 IP NUTR,15 MIN,ORL/TB 1 794.00 .00 05/01/07 10144 104106 I CRITICAL CARE UNIT MAGNESIUM 1 2935.00 05/01/07 104131 POTASSIUM (K) BLOOD 2 1 32.00 05/01/07 05/01/07 104438 1 , RENAL FUNCTION PANEL 1 14.00 44.00 05/01/07 05656 111001 CBC W/PLT AUTO GLUCOSE BEDSIDE MONIT 1 30.00 05/01/07 245431 METOCLOPRAMIDE 5 MG/M 6 5 168.00 05/01/07 05/01/07 245652 FERROUS SULFATE 300 M 4 15.00 12.00 05/01/07 246176 246703 FUROSEMIDE 10 MG/ML LORAZEPAM 2 4 12. 0 05/01/07 248356 MG METOPROLOL 5MG/5ML 5 6 15.60 05/01/07 05/01/07 251130 POTASSIUM CHLORIDE 50 10 55.75 5.40 05/01/,07 251727 272117 POT CHL ORAL SOL 10% ATROVENT 02% 3 9.00 05/01/07 272811 . 2.5ML DALTEPARIN 2500U/0 2M 6 3 1 8.00 05/01/07 05/01/07 273401 2 . ZOSYN 3.75GM BAG 12 97.20 265.40 73778 LINEZOLID 600 MG INJ 6 463 --------------------------------------------------------------00 ---------------- Continue - MS HERSHEY MEDICAL CENTER PAGE: 20 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 -------- Date ------------ Svc Code ---- ----- ----------- - --- 1 Description -Units - ------ -- Debits --- ( --- Credits--I. 05/01/07 05/01/07 274101 2 - PANTOPRAZOLE 40MG SYR 1 --------------- 8 30 05/01/07 74651 275020 ALBUTEROL 2.5MG/0.5ML 18 . 18.00 05/01/07 307101 PEDIALYTE 240ML SOLN CHEST 1 VIEW 4 17.45 05/01/07 05/01/07 511351 AEROSOL TREATMENT 6 120.00 318 00 05/01/07 621043 621100 I V SODIUM CHLORIDE 0 CANISTER SUCT 1 . 6.00 05/01/07 623014 HARDSHE ULTRASITE INJ CAP BRA 2 1 10.00 05/01/07 05/01/07 627069 ST EXT MICRO 60" IML 1 10.00 7 00 05/01/07 670330 670334 IV INFUSION SET, UNIV IV INFUSION 1 . 16.00 05/01/07 670722 SET, UNIV FEEDING BG ENTERAL 10 1 1 8.00 05/02/07 11662 81 ADULT IMC 1 4.00 05/02/07 05/02/07 56619 THER EXERCISE 15 MIN 1580.00 53 00 05/02/07 104106 104438 MAGNESIUM RENAL FUNCTION PANEL 1 . 16.00 05/02/07 105657 CBC W/PLT/DIFF AUTO 1 44.00 05/02/.07 05/02/07 111001 GLUCOSE BEDSIDE MONIT 6 48.00 168 00 05/02/07 245431 METOCLOPRAMIDE 5 MG/M 3 . 00 9 05/02/07 245652 246176 FERROUS SULFATE 300 M FUROSEMIDE 3 . 9.00 05/02/07 246703 10 MG/ML LORAZEPAM 2 MG 2 6.00 05/02/07 05/02/07 248356 METOPROLOL 5MG/5ML 2 10 7 1111.80 30 05/02/07 251129 251727 POTASSIUM CHLORIDE 10 10 . 11.10 05/02/07 272117 POT CHL ORAL SOL 10% ATROVENT 02% 2 5ML 2 .00 05/02/07 05/02/07 272811 . . DALTEPARIN 2500U/0.2M 5 1 15 5 .00 32 40 05/02/07 273401 273627 ZOSYN 3.75GM BAG CALMOSEPTIME 12 . 265.40 05/02/07 273778 OINT 2.5 LINEZOLID 600 MG INJ 1 6 13.85 05/02/07 05/02/07 274101 PANTOPRAZOLE 40MG SYR 1 463.00 8 30 05/02/07 274651 307101 ALBUTEROL 2.5MG/0.5ML 15 . 15.00 05/02/07 511351 CHEST 1 VIEW AEROSOL TREATMENT 120.00 05/02/07 05/02/07 521211 12 LEAD ELECTROCARDIO 6 1 318.00 117 00 05/02/07 620148 621010 STATLOCK PICC PLUS FI IV HEPARIN 9% N 1 . 8.00 05/02/07 05/02/07 621043 . ACL 5 I V SODIUM CHLORIDE 0 1 1 13.00 6 00 05/02/07 621100 623014 CANISTER SUCT HARDSHE ULTRASITE 3 . 15.00 05/02/07 661602 INJ CAP BRA CATH PREP TRAY CENT L 3 1 30.00 05/02/07 670722 FEEDING BG ENTERAL 10 2 12.00 --------- - -- 8.00 - Continue - -------- - ----------------- ----- 0 MS HERSHEY MEDICAL CENTER PAGE: 21 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 -------- Date ---------- - ----------- I Svc Code -------------7----------- Description Units ------- ' Debits ----------- -------------- I Credits 05/03/07 11672 _ _ _ _ _ _ _ _ __ 81 ADULT IMC _____ 1 ----------------- 05/03/07 05/03/07 16691 THER EXERCISES 15 MIN 1580.00 53 00 05/03/07 16700 104106 THERAPEUTIC ACTIV 15 MAGNESIUM 1 . 53.00 05/03/07 05/03/07 104438 RENAL FUNCTION PANEL 1 16.00 44 00 05/03/07 111001 245431 GLUCOSE BEDSIDE MONIT METOCLOPRAMIDE 5 MG/M 6 4 . 168.00 05/03/07 05/03/07 245652 2 FERROUS SULFATE 300M 3 12.00 00 9 05/03/07 46176 246703 FUROSEMIDE 10 MG/ML 3 . 9.00 05/03/07 248356 LORAZEPAM 2 MG METOPROLOL 5MG/5ML 11.70 05/03/07 05/03/07 251129 2 POTASSIUM CHLORIDE 10 12 10 133.50 11 10 05/03/07 51727 272117 POT CHL ORAL SOL 10% ATROVENT .02t 2 5ML 3 . 9.00 05/03/07 05/03/07 272811 2 . DALTEPARIN 2500U/0.2M 6 2 18.00 64 80 05/03/07 73401 274101 ZOSYN 3.75GM BAG PANTOPRAZOLE 15 . 331.75 05/03/07 05/03/07 274651 5 40MG SYR ALBUTEROL 2.5MG/0.5ML 1 18 8.30 18 00 05/03/07 11351 670722 AEROSOL TREATMENT FEEDING BG 6 . 318.00 05/04/07 11447 ENTERAL 10 I ADULT ICU/1:1 CARE 1 1 4.00 05/04/07 17776 SWALLOWING ORAL PUNC 1 2935.00 05/04/07 05/04/07 102003 SENSI, DISK METHOD/PL 1 365.00 41 00 05/04/07 102019 102100 GRAM STAIN CULTURE BACTERIAL 1 . 26.00 05/04/07 102105 , CULTURE, BLOOD 66.00 05/04/07 05/04/07 102214 CULTURE, URINE QUANT 1 174.00 40 00 05/04/07 102215 105656 CULTURE TYPE IMM/ANTI CBC W/PLT AU 1 . 27.00 05/04/07 05/04/07 111001 TO GLUCOSE BEDSIDE MONIT 4 30.00 112 00 05/04/07 245431 245652 METOCLOPRAMIDE 5 MG/M 3 . 9.00 05/04/07 245985 FERROUS SULFATE 300 M ACETAMINOPHEN 600 2 6.00 05/04/07 05/04/07 246176 MG FUROSEMIDE 10 MG/ML 1 2 3.00 6 00 05/04/07 246703 247784 LORAZEPAM 2 MG 3 . 11.70 05/04/07 248356 DEXTROSE 50 ML METOPROLOL 5MG/5ML 3.00 05/04/07 05/04/07 251727 POT CHL ORAL SOL 10t 12 2 133.50 6 00 05/04/07 251753 272117 MULTIVITAMIN LIQ5ML U 1 . 3.00 05/04/07 272199 ATROVENT .02t 2.5ML ONDANSETRON 2MG/ML 2M 5 15.00 05/04/07 272811 DALTEPARIN 2500U/0 2M 4 2 3.00 -------------- ---------- . ---------- -- - 64.80 - Continue - --------- ------------- ---------- rl ?- MS HERSHEY MEDICAL CENTER PAGE: 22 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 82B9451 Date - I Svc Code - ------? I Description ------?- Units ------------------------- Debits I _-- ----- -------- Credits 05/04/07 05/04/07 273401 273627 ----- ZOSYN 3.75GM BAG 12 ___________ ----------- 265.40 05/04/07 273778 CALMOSEPTIME OINT 2.5 LINEZOLID 600 MG I 1 13.85 05/04/07 05/04/07 274651 NJ ALBUTEROL'2.5MG/0.5ML 6 15 463.00 15 00 05/04/07 275010 307101 GASTROVIEW 1000ML SOL CHEST 1 . 20.25 05/04/07 310516 1 VIEW CT THORAX ENHANCED 1 120.00 05/04/07 05/04/07 310519 CT ABDOMEN ENHANCED 1 1565.00 1080 00 05/04/07 310524 310703 CT NECK ENHANCED OMNIPAQUE 300MG/ML 10 1 . 1346.00 05/04/07 05/04/07 511351 5 AEROSOL TREATMENT 5 56.00 265 00 05/04/07 11372 600504 STARTER KIT AMBUBAG ADULT W/MASK 1 . 66.00 05/04/07 05/04/07 600510. 6 PULSE OXIMETER SNSR A 1 25.00 11 00 05/04/07 21010 621043 IV HEPARIN .9% NACL 5 I V 1 . 13.00 05/04/07 621044 SODIUM CHLORIDE 0 I V SODIUM CHLORIDE 0 1 6.00 05/04/07 05/04/07 621100 CANISTER SUCT HARDSHE 1 2 6.00 10 00 05/04/07 623014 661148 ULTRASITE INJ CAP BRA OST POWDER STOMAHESIV 2 . 20.00 05/04/07 05/04/07 669954 7 BARRIER FILM, NO STRI 1 25 9.00 75 00 05/04/07 6 0722 703322 FEEDING BG ENTERAL 10 IP NUTR 15 MI 1 . 4.00 05/05/07 10144 , N,ORL/TB I CRITICAL CARE UNIT 1 79.00 05/05/07 05/05/07 102100 CULTURE, BACTERIAL 1 1 2935.00 66 00 05/05/07 102105 102118 CULTURE, BLOOD SMEAR FLUOR/ACID F . 87.00 05/05/07 05/05/07 102214 , AS CULTURE, URINE QUANT 1 1 36.00 40 00 05/05/07 102303 104106 CULTURE, FUNGUS OTHER MAGNESIUM 1 . 40.00 05/05/07 05/05/07 104438 RENAL FUNCTION PANEL 1 16.00 44 00 05/05/07 105657 106011 CBC W/PLT/DIFF AUTO URINALYSIS-BASIC 1 . 48.00 05/05/07 05/05/07 111001 & MI GLUCOSE BEDSIDE MONIT 1 5 38.00 140 00 05/05/07 245431 245652 METOCLOPRAMIDE 5 MG/M 4 . 12.00 05/05/07 245900 FERROUS SULFATE 300 M ACETAMINOPHEN 650 MG/ 3 2 9.00 05/05/07 05/05/07 246176 FUROSEMIDE 10 MG/ML 2 6.00 6 00 D5/05/07 246344 246703 NYSTATIN 15 GM LORAZEPAM 2 MG 2 . 31.86 05/05/07 05/05/07 248225 SENNA SYRUP 1ML 3 11.70 5 95 _ ---- 248356 ----------- METOPROLOL 5MG/5ML - ------------ ------- - 12 ..50 133 - Continue - --------- ----------------------- `d- MS HERSHEY MEDICAL CENTER PAGE: 23 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ----------- - ------ ------ - ------- Date---- ?-Svc ------------------------- Credits 05/05/07 05/05/07 251619 ----------- FLUCORAZOLE 400MG/200 ------- 2 --------- 10 _ ------------- 58 05/05/07 251727 251753 POT CHL ORAL SOL 10% MULTIVITAMIN LIQ5ML U 2 . 6.00 05/05/07 05/05/07 272117 ATROVENT .02$ 2.5ML 1 5 3.00 15 00 05/05/07 272811 273401 DALTEPARIN 2500U/0.2M 2 . 05/05/07 273627 ZOSYN 3.75GM BAG CALMOSEPTIME OINT 2 5 15 331.75 05/05/07 05/05/07 273778 2 . LINEZOLID 600 MG INJ 1 6 13.85 463 00 05/05/07 74101 274651 PANTOPRAZOLE 40MG SYR ALBUTEROL 2 5MG/0 5ML 1 . 8.30 05/05/07 511351 . . AEROSOL TREATMENT 15 5 15.00 05/05/07 511372 STARTER KIT 265.00 05/05/07 05/05/07 600510 PULSE OXIMETER SNSR A 2 66.00 22.00 05/05/07 621044 621100 I V SODIUM CHLORIDE 0 CANISTER SUCT 2 12.00 05/05/07 627069 HARDSHE ST EXT MICRO 60" IML 1 1 5.00 05/05/07 05/05/07 670330 IV INFUSION SET, UNIV 1 7.00 16 00 05/05/07 670334 670722 IV INFUSION SET, UNIV FEEDING 1 . 8.00 05/06/07 10144 13G ENTERAL 10 I CRITICAL CARE UNIT 1 4.00 05/06/07 100025 CLOSTRIDIUM DIFFICILE 1 1 2935 .00 05/06/07 05/06/07 104438 1 RENAL FUNCTION PANEL 1 88.00 44 00 05/06/07 05656 111001 CBC W/PLT AUTO GLUCOSE BEDSIDE MONIT . 30.00 05/06/07 245431 METOCLOPRAMIDE 5 MG/M 2 4 112.00 05/06/07 05/06/07 245652 FERROUS SULFATE 300 M 3 6.00 9 00 05/06/07 245900 246127 ACETAMINOPHEN 650 MG DIPHENHYDRAMINE 2 . 6.00 05/06/07 246130 25 MG DIPHENHYDRAMINE 50 MG 1 1 3.00 05/06/07 246176 FUROSEMIDE 10 MG/ML 2 3.00 05/06/07 05/06/07 246590 BASIC OINTMENT 480 GM 1 6.00 11 00 05/06/07 246703 248356 LORAZEPAM 2 MG METOPROLOL 5MG/5ML ? . 3.90 05/06/07 249184 LACTOBACILLUS ACIDOPH 1 4 111.25 05/06/07 05/06/07 251129 POTASSIUM CHLORIDE 10 15 12.00 16 65 05/06/07 251619 251727 FLUCORAZOLE 4 00MG/200 POT CHL O 2 . 58.10 05/06/07 251753 RAL SOL 10W MULTIVITAMIN LIQ5ML U 4 1 9.00 05/06/07 05/06/07 272117 ATROVENT .02% 2.5ML 6 3.00 18 00 05/06/07 272811 273401 DALTEPARIN 25 OOU/0.2M 3 . 97.20 05/06/07 273778 ZOSYN 3.75GM BAG LINEZOLID 600 MG INJ 12 265.40 -------------- ----- - - 6 463.00 - Continue - -------- ---------------- ------ 6 )--3 Code Description Units Debits MS HERSHEY MEDICAL CENTER PAGE: 24 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 Date----?_Svc-Code----------Descri ------ - ---- ----I------------------------Units - ----- - D---ebi--ts - ----- I- --- -- Credits --- - 05/06/07 274101 P 7k ILT --------- 05/06/07 274290 VANCOMYCINLHCLOORALYS 8.30 05/06/07 274651 ALBUTEROL 2.5MG/0 5ML 7 18 40.50 05/06/07 511351 . AEROSOL TREATMENT 6 18.00 05/06/07 621044 I V SODIUM CHLORIDE 0 1 318.00 05/06/07 621105 YANKAUER SUCT TB W/O 2 6.00 05/06/07 667340 ABD BINDER 36-64 WAIS 1 10.00 05/06/07 669194 TAPE SURG SOFCLOTH RO 1 19.00 05/07/07 05/07/07 10144 I CRITICAL CARE UNIT 1 8.00 2935 .00 05/07/07 16691 16700 THER EXERCISES 15 MIN THERAPEUTIC ACTIV 1 53.00 05/07/07 104106 15 MAGNESIUM 1 1 53.00 05/07/07 104438 RENAL FUNCTION PANEL 16.00 05/07/07 105656 CBC W/PLT AUTO 44.00 05/07/07 05/07/07 111001 2 GLUCOSE BEDSIDE MONIT 4 30.00 112.00 05/07/07 45652 246130 FERROUS SULFATE 300 M DIPHENHYDRAMINE 3 9.00 05/07/07 246176 50 MG FUROSEMIDE 10 MG/ML 2 2 6.00 05/07/07 246703 LORAZEPAM 2 MG 6.00 05/07/07 248356 METOPR.OLOL 5MG/5ML 15 3.90 05/07/07 249184 LACTOBACILLUS ACIDOPH 2 166.90 05/07/07 251619 FLUCORAZOLE 400MG/200 2 6.00 05/07/07 251727 POT CHL ORAL SOL 10% 2 58.10 05/07/07 251753 MULTIVITAMIN LIQ5ML U 1 6.00 05/07/07 272117 ATROVENT .02% 2.5ML 6 3.00 05/07/07 272811 DALTEPARIN 2500U/0 2M 1 18.00 05/07/07 273401 . ZOSYN 3.75GM BAG 12 32.40 05/07/07 273778 LINEZOLID 600 MG INJ 6 265.40 05/07/07 274101 PANTOPRAZOLE 40MG SYR 1 463.00 05/07/07 274290 VANCOMYCIN HCL ORAL S 2 8.30 05/07/07 274651 ALBUTEROL 2.5MG/0 5ML 18 16.20 05/07/07 307101 . CHEST 1 VIEW 18.00 05/07/07 511351 AEROSOL TREATMENT 6 120.00 05/07/07 600510 PULSE OXIMETER SNSR A 1 318.00 05/07/07 05/07/07 600520 6 SPIRO INCENTIVE ADULT 1 17.00 7.00 05/07/07 21044 661432 I V SODIUM CHLORIDE 0 BAG URINE DRAINAGE 1 6.00 05/07/07 05/08/07 670722 FEEDING BG ENTERAL 10 1 2 13.00 8.00 05/08/07 11662 16700 81 ADULT IMC THERAPEUTIC ACTIV 15 1 1580.00 05/08/07 104106 MAGNESIUM 53.00 05/08/07 104438 RENAL FUNCTION PANEL 1 16.00 4 4 . 00 ------------------------------------ ------------------------ ------------------ - Continue - fl )-1 MS HERSHEY MEDICAL CENTER PAGE: 25 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ------ --------------------- Date-- -- Description Units Debits Credits ---------------- 05/08/07 05/08/07 105656 CBC W/PLT AUTO-------- ------- ---------- ----------------30 00 05/08/07 111001 245431 GLUCOSE BEDSIDE MONIT METOCLOPRAMIDE 5 MG/M 4 1 . 112.00 05/08/07 05/08/07 245652 FERROUS SULFATE 300 M 3 3.00 00 9 05/08/07 246176 246434 FUROSEMIDE 10 MG/ML 1 . 3.00 05/08/07 246703 TRIAMCINOLONE 15 GM LORAZEPAM 2 1 3.00 05/08/07 247032 MG CLOTRIMAZOLE 30 GM 1 3. 05/08/07 05/08/07 249184 2 LACTOBACILLUS ACIDOPH 3 63 11.63 00 9 05/08/07 51619 251727 FLUCORAZOLE 400MG 200 2 . 58.10 05/08/07 251753 POT CHL ORAL SOL 10% MULTIVITAMIN LIQ5ML U 2 6.00 05/08/07 05/08/07 272117 2 ATROVENT .02% 2.5ML 1 4 3.00 12 00 05/08/07 72811 273401 DALTEPARIN 2500U/0.2M 2 . 64.80 05/08/07 273627 ZOSYN 3.75GM BAG CALMOSEPTIME OINT 2 5 1 265.40 05/08/07 05/08/07 274101 . PANTOPRAZOLE 40MG SYR 1 1 13.85 8 30 05/08/07 274365 274502 METOPROLOL ORAL SUSP LINEZOLID 100MG/5ML 0 14 . 21.42 05/08/07 05/08/07 274651 ALBUTEROL 2.5MG 0.5ML 90 12 548.70 12 00 05/09/07 511351 11662 AEROSOL TREATMENT S . 265.00 05/09/07 16694 81 ADULT IMC GAIT TRAINING 15 MIN 1 1580.00 05/09/07 104106 MAGNESIUM 53.00 05/09/07 05/09/07 104438 RENAL FUNCTION PANEL 1 16.00 44 00 05/09/07 105656 111001 CBC W/PLT AUTO GLUCOSE BEDSIDE MONIT . 30.00 05/09/07 245431 METOCLOPRAMIDE 5 MG/M 3 4 84.00 05/09/07 05/09/07 245652 FERROUS SULFATE 300 M 3 12.00 00 9 05/09/07 246130 246703 DIPHENHYDRAMINE 50 MG 2 . 6.00 05/09/07 249184 LORAZEPAM 2 MG LACTOBACILLUS ACIDOPH 3 7.80 05/09/07 05/09/07 250057 2 MAGNESIUM OXIDE 400MG 1 9.00 3 00 05/09/07 51619 251727 FLUCORAZOLE 400MG/200 POT CHL 4 . 116.20 05/09/07 251753 ORAL SOL 10%- MULTIVITAMIN LIQ5ML U 2 1 6.00 05/09/07 05/09/07 272117 2 ATROVENT .02% 2.5ML 5 3.00 15 00 05/09/07 72811 272972 DALTEPARIN 2500U/0.2M 2 . 64.80 05/09/07 273399 TERBAFINE 250MG TAB ISOSOURCE 250ML CAN 2 78.60 05/09/07 273401 ZOSYN 3.75GM BAG 58 9 292.15 05/09/07 274101 PANTOPRAZOLE 40MG SYR 1 199.05 ------------- ------------ -------------------- - 8.30 - Continue - -------- ------------------------ MS HERSHEY MEDICAL CENTER PAGE: 26 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ------------------ ---Date- --_I_Svc-Code Description Units Debits --- ------------------- I Credits ------------------------ 05 09/07 274365 - ----------- 05/09/07 274502 METOPROLOL ORAL SUSP LINEZOLID 100MG/5ML 0 10 15.30 05/09/07 274651 ALBUTEROL 2.5MG/0 5ML 60 15 365.80 05/09/07 307101 . CHEST 1 VIEW 15.00 05/09/07 511351 AEROSOL TREATMENT 6 120.00 05/09/07 621043 I V SODIUM CHLORIDE 0 1 318.00 05/09/07 05/09/07 670330 6 IV INFUSION SET, UNIV 1 6.00 16.00 05/09/07 70334 670722 IV INFUSION SET, UNIV FEEDING BG ENTERAL 1 1 8.00 05/09/07 703322 0 IP NUTR,15 MIN ORL/TB 1 1 4.00 05/10/07 05/10/07 10144 1 , I CRITICAL CARE UNIT 1 79.00 293 5.00 05/10/07 6694 16700 GAIT TRAINING 15 MIN THERAPEUTIC ACTIV 1 53.00 05/10/07 104106 15 MAGNESIUM 1 53.00 05/10/07 104438 RENAL FUNCTION PANEL 1 16.00 05/10/07 105656 CSC W/PLT AUTO 1 44.00 05/10/07 05/10/07 111001 2 GLUCOSE BEDSIDE MONIT 4 30.00 112.00 05/10/07 45402 245652 CYANOCOBALAMIN VITB12 1 3.00 05/10/07 245900 FERROUS SULFATE 300 M ACETAMINOPHEN 650 MG/ 3 2 9.00 05/10/07 246130 DIPHENHYDRAMINE 50 MG 1 6.00 05/10/07 05/10/07 250057 2 MAGNESIUM OXIDE 400MG 1 3.00 3.00 05/10/07 51019 251727 CIPROFLOXACIN 400MG POT CHL ORAL 2 22.25 05/10/07 251753 SOL 10% MULTIVITAMIN LIQSML U 1 1 3.00 05/10/07 272117 ATROVENT .02% 2 5ML 4 3.00 05/10/07 272406 . NIACIN 50MG UD 12.00 05/10/07 05/10/07 272811 DALTEPARIN 2500U/0.2M 2 3.00 64.80 05/10/07 272874 272972 FLUCONAZOLE 400Z/ML 3 20 53.20 05/10/07 273401 TERBAFINE 250MG TAB ZOSYN 3 75GM BAG 1 39.35 05/10/07 273600 . RISPERIDOL .SMG TAB 3 1 66.35 05/10/07 274101 PANTOPRAZOLE 40MG SYR 1 10.55 05/10/07 274324 HUMULIN R 2 8.30 05/10/07 05/10/07 274365 2 METOPROLOL ORAL SUSP 15 38.20 22.95 05/10/07 74502 274651 LINEZOLID 100MG/5ML 0 ALBUTEROL 2 5MG/0 5ML 60 365.80 05/10/07 307101 . . CHEST 1 VIEW 12 1 12.00 05/10/07 307220 PELVIS 1-2 VIEWS 1 120.00 05/10/07 307300 HIP LTD 1 VIEW LEFT 158.00 05/10/07 511351 AEROSOL TREATMENT 5 123.00 05/10/07 621043 I V SODIUM CHLORIDE 0 1 265.00 -------------- 6.00 ? ----------------------- - Continue - MS HERSHEY MEDICAL, CENTER PAGE: 27 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ----------------- ---- ----------------- Date Svc - Code Description--- escription UnitE 05/10/07 667341 ABD BINDER ---------------- 42 WAIS 1 05/10/07 670330 IV INFUSION SET, UNIV 1 05/10/07 670334 IV INFUSION SET, UNIV 1 05/10/07 670722 FEEDING BG ENTERAL 10 2 05/10/07 703322 IP NUTR,15 MIN,ORL/TB 1 05/11/07 10431 1 1:1 CARE BED MED/SU 1 05/11/07 111001 GLUCOSE BEDSIDE MONIT 3 05/11/07 245402 CYANOCOBALAMIN VITB12 1 05/11/07 245431 METOCLOPRAMIDE 5 MG/M 2 05/11/07 245652 FERROUS SULFATE 300 M 3 05/11/07 246703 LORAZEPAM 2 MG 1 05/11/07 249184 LACTOBACILLUS ACIDOPH 1 05/11/07 250057 MAGNESIUM OXIDE 400MG 1 05/11/07 251019 CIPROFLOXACIN 400MG 4 05/11/07 272117 ATROVENT .02%- 2.5ML 1 05/11/07 272406 NIACIN 50MG LTD 1 05/11/07 272811 DALTEPARIN 2500U/0.2M 2 05/11/07 273600 RISPERIDOL .5MG TAB 1 0 05/11/07 274365 5/11/07 274101 PANTOPRAZOLE 40MG SYR 1 05/11/07 274651 AL13UTEROL20 MG/0.5ML 3 L 05/11/07 670722 FEEDING BG ENTERAL 10 2 05/12/07 10431 1 1:1 CARE BED MED/SU 1 05/12/07 104014 ALKALINE PHOSPHATASE 1 05/12/07 104016 BILIRUBIN TOTAL 1 05/12/07 104156 SGPT (ALT) 1 05/12/07 111001 GLUCOSE BEDSIDE MONIT 2 05/12/07 245402 CYANOCOBALAMIN VITB12 1 05/12/07 245431 METOCLOPRAMIDE 5 MG/M 3 05/12/07 245652 FERROUS SULFATE 300 M 3 05/12/07 245900 ACETAMINOPHEN 650 MG/ 1 05/12/07 249184 LACTOBACILLUS ACIDOPH 3 05/12/07 250057 MAGNESIUM OXIDE 400MG 1 05/12/07 251019 CIPROFLOXACIN 400MG 4 05/12/07 272406 NIACIN 50MG UD 1 05/12/07 272811 DALTEPARIN 2500U/0.2M 2 05/12/07 272874 FLUCONAZOLE 40OZ/ML 3 10 05/12/07 273600 RISPERIDOL .5MG TAB 1 05/12/07 274101 PANTOPRAZOLE 40MG SYR 2 05/12/07 274365 METOPROLOL ORAL SUSP 15 05/12/07 347062 MRI BRAIN UNENH & ENH 1 05/12/07 347246 GADOLINIUM 15ML 1 ----------------------------------------------------------------------------- Debits 17.00 16.00 8.00 8.00 79.00 1845.00 84.00 3.00 6.00 9.00 3.90 3.00 3.00 44.50 3.00 3.00 64.80 10.55 8.30 7.65 3.00 8.00 1845.00 14.00 14.00 15.00 56.00 3.00 9.00 9.00 3.00 9.00 3.00 44.50 3.00 64.80 26.60 10.55 16.60 22.95 2038.00 202.00 I Credits Continue -)-? MS HERSHEY MEDICAL CENTER PAGE: 28 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 Date -- Svc Code ------------ ----------- Description --- -------- ------- --- - -------------------- Units Debits --- Credits 05/12/07 621043 ------------ I V SOD M _____ ----------- IU CHLORIDE 0 1 05/12/07 627069 ST EXT MICRO 60" IML 6.00 05/13/07 10223 P PRIVATE MED/SURG RM 1 1 7.00 05/13/07 05/13/07 111001 2 GLUCOSE BEDSIDE MONIT 4 0.00 1112 .00 05/13/07 45431 245652 METOCLOPRAMIDE 5 MG/M FERROUS 2 6.00 05/13/07 246434 SULFATE 300 M TRIAMCINOLONE 15 GM 3 9.00 05/13/07 247032 CLOTRIMAZOLE 30 GM 1 1 3.00 05/13/07 05/13/07 249184 2 LACTOBACILLUS ACIDOPH 3 11.63 9.00 05/13/07 49819 250057 CIPROFLOXACIN 500MG MAGNESIUM O 2 6.00 05/13/07 251019 XIDE 400MG CIPROFLOXACIN 400MG 1 2 3.00 05/13/07 272406 NIACIN 50MG UD 22.25 05/13/07 05/13/07 272811 2 DALTEPARIN 2500U/0.2M 2 3.00 64. 0 05/13/07 72874 273600 FLUCONAZOLE 40OZ/ML 3 10 6 26 .60 05/13/07 274101 RISPERIDOL .5MG TAB PANTOPRAZOLE 40MG SYR 1 10.55 05/13/07 05/13/07 274365 6 METOPROLOL ORAL.SUSP 1 10 8.30 15.30 05/14/07 70722 10223 FEEDING BG ENTERAL 10 1 4.00 05/14/07 56627 P PRIVATE MED/SURG RM FUNCT THERAPY ACT 15M 1 1240 .00 05/14/07 56631 INSTR ADAPT EQUIP 15 1 1 53.00 05/14/07 104129 PHOSPHORUS, BLOOD 1 53.00 05/14/07 104435 COMP METABOLIC PANEL 14.00 05/14/07 105657 CBC W/PLT/DIFF AUTO 1 59.00 05/14/07 05/14/07 111001 2 GLUCOSE BEDSIDE MONIT 4 48.00 112.00 05/14/07 45652 249184 FERROUS SULFATE 300 M LACTOBACILLUS 3 9.00 05/14/07 249819 ACIDOPH CIPROFLOXACIN 500MG 3 2 9.00 05/14/07 05/14/07 250057 2 MAGNESIUM OXIDE 400MG 1 6.00 3.00 05/14/07 72406 272811 NIACIN 50MG UD DALTEPARIN 2500U/0 2M 3.00 05/14/07 05/14/07 272874 2 . FLUCONAZOLE 40OZ/ML 3 2 10 64.80 26.60 05/14/07 72987 273600 CEFAZOLIN 1 GM PRE-MI RISPERIDOL 8 47.80 05/14/07 274101 .5MG TAB PANTOPRAZOLE 40MG SYR 1 1 10.55 05/14/07 05/14/07 274365 62 METOPROLOL ORAL SUSP 10 8.30 15.30 05/14/07 2024 670722 IRRIGATION SOD CHL 0. FEEDING BG ENTERAL 1 1 6.00 05/15/07 10223 0 P PRIVATE MED/SURG RM 1 1 05/15/07 16694 GAIT TRAINING 15 MIN 3 1240.00 05/15/07 111001 GLUCOSE BEDSIDE MONIT 3 159.00 ------------------------------------ -----------------------84_00 ----------------- Continue - 4 -629 MS HERSHEY MEDICAL CENTER PAGE: 29 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ----------- - ------- Date- Code Description--_I-UnitsI----Debits----------- I ---------- -- _ I- Credits 05/15/07 2456 ----- 05/15/07 249184 LACTOBACILL STACIDOPH 9.00 05/15/07 249819 CIPROFLOXACIN 500MG 3 2 9 .00 05/15/07 05/15/07 250057 27 MAGNESIUM OXIDE 400MG 1 6.00 3.00 05/15/07 2406 272811 NIACIN 50MG UD DALTEPARIN 2500U/0 2M 1 4 3.00 05/15/07 05/15/07 272987 27 . CEFAZOLIN 1 GM PRE-MI 6 129.60 35.85 05/15/07 3600 274101 RISPERIDOL .5MG TAB PANTOPRAZOLE 40MG SYR 1 10.55 05/15/07 05/15/07 274365 62 METOPROLOL ORAL SUSP 1 10 8.30 15.30 05/15/07 1044 670722 I V SODIUM CHLORIDE 0 FEEDING BG ENTERAL 10 1 6.00 05/16/07 05/16/07 10223 11 P PRIVATE MED/SURG RM 1 1 4.00 1240.00 05/16/07 1001 245652 GLUCOSE BEDSIDE MONIT FERROUS SULFATE 300 M 5 140.00 05/16/07 246037 BISACODYL 10 MG 3 1 9.00 05/16/07 05/16/07 249184 24 LACTOBACILLUS ACIDOPH 5 3.00 15.00 05/16/07 9819 2 CIPROFLOXACIN 500MG 2 6.00 05/16/07 50057 272406 MAGNESIUM OXIDE 400MG NIACIN 50MG UD 1 3.00 05/16/07 05/16/07 272811 2 DALTEPARIN 2500U/0.2M 1 1 3.00 32.40 05/16/07 72987 273600 CEFAZOLIN 1 GM PRE-MI RISPERIDOL 5MG TAB 6 35.85 05/16/07 05/16/07 274365 6 . METOPROLOL ORAL SUSP 1 5 10.55 7.65 05/16/07 21043 670722 I V SODIUM CHLORIDE 0 FEEDING BG ENTERAL 10 1 6.00 05/17/07 05/17/07 10223 P PRIVATE MED/SURG RM 1 1 4.00 1240.00 D5/17/07 17772 56619 SPEECH/LANG TX IND 30 1 200.00 D5/17/07 56627 THER EXERCISE 15 MIN FUNCT THERAPY ACT 15M 1 53.00 )5/17/07 79557 LYME DNA PCR 1 1 53.00 )5/17/07 100346 CMV IGM AB BY EIA 1 479.00 )5/17/07 102019 GRAM STAIN 1 97.00 )5/17/07 )5/17/07 102100 10 CULTURE, BACTERIAL 1 26.00 66.00 )5/17/07 2118 1 SMEAR, FLUOR/ACID FAS 1 36.00 )5/17/07 02303 104014 CULTURE, FUNGUS OTHER ALKALINE PHOSPHATASE 1 40.00 )5/17/07 104016 BILIRUBIN TOTAL 1 1 14.00 )5/17/07 104064 GLUCOSE, FLUID 1 14.00 )5/17/07 104092 LACTIC ACID 1 22.00 15/17/07 104106 MAGNESIUM 1 61.00 15/17/07 104156 SGPT (ALT) 1 16.00 15 00 ----------------------------------------------- I ) I --------------------------------- - Continue - A -aI MS HERSHEY MEDICAL CENTER PAGE: 30 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ---Date---- ? - Svc Code -------- Description --- ? - Units---- Debits ------------ Credits 05/17/07 104378 ------------------------------------ 05/17/07 104438 PROTEIN, MISC BODY FL RENAL FUNCTION PANEL 1 23.00 05/17/07 105656 CBC W/PLT AUTO 1 1 44.00 05/17/07 05/17/07 106036 CELL COUNT & DIFF, BO 1 30.00 128.00 05/17/07 109182 109789 HSV BY PCR CYTOMEGALOV IGG AB CS 1 1 100.00 05/17/07 05/17/07 111001 1 , GLUCOSE BEDSIDE MONIT 5 197.00 140.00 05/17/07 92070 2 SMEARS,CONCENTR,INTER 1 36.00 05/17/07 45652 245900 FERROUS SULFATE 300 M ACETAMINOPHEN 650 MG/ 3 1 9.00 05/17/07 05/17/07 249184 24 LACTOBACILLUS ACIDOPH 3 3.00 9.00 05/17/07 9819 250057 CIPROFLOXACIN 500MG 2 6.00 05/17/07 272406 MAGNESIUM OXIDE 400MG NIACIN 50MG UD 1 3.00 05/17/07 05/17/07 272811 27 DALTEPARIN 2500U/0.2M 1 2 3.00 64.80 05/17/07 2987 273600 CEFAZOLIN 1 GM PRE-MI RISPERIDOL 5MG TAB 6 35.85 05/17/07 05/17/07 274365 . METOPROLOL ORAL SUSP 1 10 10.55 15.30 05/17/07 541213 622023 EEG AWAKE & DROWSY IRRIGATION SOD CHL 0 1 263.00 05/17/07 05/17/07 661645 6 . TRAY LUMBAR PUNCTURE 1 1 6.00 18.00 05/17/07 70722 703322 FEEDING BG ENTERAL 10 IP NUTR 15 MIN ORL/TB 1 1 4.00 05/17/07 9990211 , , MS PROF ALBUMIN 1 79.00 05/17/07 05/17/07 9990212 9 MS PROF NEPHELOMETRY 1 15.00 27.00 D5/17/07 990213 9990214 MS PROF GAMMAGLOBULIN MS PROF 2 41.00 05/17/07 9990215 MBP CSF MS PROF OLIGOCLON BAN 1 1 38.00 35/18/07 )5/18/07 10223 P PRIVATE MED/SURG RM 1 42.00 1240.00 )5/18/07 111001 24 GLUCOSE BEDSIDE MONIT 3 84.00 )5/18/07 5652 249184 FERROUS SULFATE 300 M LACTOBACILLUS ACIDOPH 3 9.00 )5/18/07 249819 CIPROFLOXACIN 500MG 3 2 9.00 )5/18/07 )5/18/07 250057 2 MAGNESIUM OXIDE 400MG 1 6.00 3.00 )5/18/07 72406 272811 NIACIN 50MG UD DALTEPARIN 2500U/0 2M 1 2 3.00 )5/18/07 )5/18/07 272987 . CEFAZOLIN 1 GM PRE-MI 6 64.80 35.85 15/18/07 273600 274365 RISPERIDOL .5MG TAB METOPROLOL ORAL SUSP 1 10.55 15/18/07 15/18/07 621054 67 IV LACTATED RINGERS 1 10 l 15.30 .00 6 ,5/19/07 0722 10223 FEEDING BG ENTERAL 10 1 400 . P PRIVATE MED/SURG RM 1 1240 00 ------------------------------------------------------------------) I -------------- - Continue - 4-3b MS HERSHEY MEDICAL CENTER PAGE: 31 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 - --- ---- - ------ ---Date----?-Svc Code -------- Description- --?-Units----Debits----------------- Credits 05/19/07 111001---GL --------------------------------------- 05/19/07 245652 FERROUS SULFATE 300IM 05/19/07 245900 ACETAMINOPHEN 650 MG/ 3 3 05/19/07 246703 LORAZEPAM 2 MG 1 05/19/07 249184 LACTOBACILLUS ACIDOPH 3 05/19/07 250057 05/19/07 2 MAGNESIUM OXIDE 400MG 1 72406 05/19/07 2 NIACIN 50MG U) 1 72811 05/19/07 2 DALTEPARIN 2500U/0.2M 2 72987 05/19/07 2 CEFAZOLIN 1 GM PRE-MI 6 73600 05/19/07 RISPERIDOL .5MG TAB 1 274365 05/19/07 6 METOPROLOL ORAL SUSP 10 70722 05/20/07 FEEDING BG ENTERAL 10 2 10223 05/20/07 1 P PRIVATE MED/SURG RM 1 11001 05/20/07 2 GLUCOSE BEDSIDE MONIT 4 45652 05/20/07 2 FERROUS SULFATE 300 M 3 45900 05/20/07 2 ACETAMINOPHEN 650 MG/ 2 49184 05/20/07 25 LACTOBACILLUS ACIDOPH 3 0057 05/20/07 2 MAGNESIUM OXIDE 400MG 1 72406 05/20/07 2 NIACIN 50MG UD 72811 05/20/07 27 DALTEPARIN 2500U/0.2M 2 3600 05/20/07 2 RISPERIDOL .5MG TAB 1 74365 05/20/07 6 METOPROLOL ORAL SUSP 10 70722 05/21/07 1 FEEDING BG ENTERAL 10 1 0223 05/21/07 P PRIVATE MED/SURG RM 1 16691 05/21/07 THER EXERCISES 15 MIN 1 16694 05/21/07 GAIT TRAINING 15 MIN 1 17776 05/21/07 SWALLOWING ORAL FUNC 1 111001 05/21/07 2 GLUCOSE BEDSIDE MONIT 4 45652 05/21/07 2 FERROUS SULFATE 300 M 3 45900 05/21/07 ACETAMINOPHEN 650 MG/ 3 249184 05/21/07 LACTOBACILLUS ACIDOPH 3 250057 05/21/07 MAGNESIUM OXIDE 400MG 1 272406 05/21/07 NIACIN 50MG UD 1 272811 )5/21/07 DALTEPARIN 2500U/0.2M 2 273399 )5/21/07 ISOSOURCE 250ML CAN 75 273600 )5/21/07 RISPERIDOL .5MG TAB 1 274365 )5/21/07 6 METOPROLOL ORAL SUSP 10 70722 )5/21/07 6 FEEDING BG ENTERAL 10 1 70742 )5/22/07 CONTAINER FEEDING GRA -1 10223 )5/22/07 P PRIVATE MED/SURG RM 1 17772 15/22/07 SPEECH/LANG TX IND 30 1 17775 DYSPHAGIA TX 60 ST 1 112.00 9.00 9.00 3.90 9.00 3.00 3.00 64.80 35.85 10.55 15.30 8.00 1240.00 112.00 9.00 6.00 9.00 3.00 3.00 64.80 10.55 15.30 4.00 1240.00 53.00 53.00 365.00 112.00 9.00 9.00 9.00 3.00 3.00 64.80 378.01 10.55 15.30 4.00 1240.00 200.00 200 00 5.00- ----------------------------------------------------- - 1 I --------------- - Continue - A -31 MS HERSHEY MEDICAL CENTER PAGE: 32 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ------------------------------- I ------- e Svc Code - - - - - - - -- --------- Dat--- Description- - -I-Units -Debits I Credits--I ----------------------------------------- 05/22/07 111001 GLU ---- 05/22/07 245652 FERROUS SULFATE 300IM 140 .00 05/22/07 245900 ACETAMINOPHEN 650 MG/ 3 4 9.00 05/22/07 249184 05/22/07 LACTOBACILLUS ACIDOPH 3 12.00 9.00 250057 05/22/07 272406 MAGNESIUM OXIDE 400MG NIACIN 1 3.00 05/22/07 272811 50MG UD DALTEPARIN 2500U/0 2M 2 3.00 05/22/07 273600 . RISPERIDOL .5MG TAB 1 64.80 05/22/07 274365 05/22/07 67 METOPROLOL ORAL SUSP 10 10.55 1 5.30 0722 05/23/07 FEEDING BG ENTERAL 10 1 4.00 10223 05/23/07 17772 P PRIVATE MED/SURG RM SPEECH/LANG TX I 1 1240.00 05/23/07 111001 ND 30 GLUCOSE BEDSIDE MONIT 1 3 200.00 05/23/07 245652 FERROUS SULFATE 300 M 3 84.00 05/23/07 245900 ACETAMINOPHEN 650 MG 4 9.00 05/23/07 249184 LACTOBACILLUS ACIDOPH 3 12.00 05/23/07 250057 05/23/07 MAGNESIUM OXIDE 400MG 1 9.00 272406 05/23/07 272811 NIACIN 50MG UD DALTEPARIN 2500U/0 2M 3.00 00 05/23/07 273600 . RISPERIDOL .5MG TAB 2 1 64.80 05/23/07 274365 05/23/07 METOPROLOL ORAL SUSP 10 10.55 15 30 703322 05/24/07 10223 IP NUTR,15 MIN,ORL/TB P 1 . 79.00 05/24/07 16694 PRIVATE MED/SURG RM GAIT TRAINING 15 MIN 1 1240.00 05/24/07 17772 SPEECH/LANG TX IND 30 2 1 106.00 05/24/07 56631 05/24/07 INSTR ADAPT EQUIP 15 3 200.00 159.00 105052 05/24/07 PARTIAL THROMBOPLAS T 1 38.00 105059 05/24/07 111001 PROTHROMBIN TIME GLUCOSE BEDSIDE M 1 23.00 05/24/07 245652 ONIT FERROUS SULFATE 300 M 2 3 56.00 05/24/07 245900 05/24/07 2 ACETAMINOPHEN 650 MG 4 9.00 12.00 49184 05/24/07 250057 LACTOBACILLUS ACIDOPH 3 9.00 05/24/07 272406 MAGNESIUM OXIDE 400MG NIACIN 50MG UD 1 3.00 05/24/07 272811 DALTEPARIN 2500U/0 2M 2 3.00 05/24/07 273600 05/24/07 . RISPERIDOL .5MG TAB 1 64.80 10.55 274365 05/24/07 670722 METOPROLOL ORAL SUSP FEEDING BG ENTERAL 10 15.30 05/25/07 10223 10 P PRIVATE MED/SURG RM 2 1 8.00 05/25/07 16694 05/25/07 GAIT TRAINING 15 MIN 2 1240 .00 106.00 17772 05/25/07 111001 SPEECH/LANG TX IND 30 GLUCOSE BEDSIDE MONIT 1 1 200.00 2 ------------------------------------- ---------------------8-00 ------------ - Continue - A -3)-,- MS HERSHEY MEDICAL CENTER PAGE: 33 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ----------- - --- Date---- ?-Svc-Code --------Description --- I - Units----Debits----------------- Credits ------------------------------------- 05 25/07 245207 05/25/07 245652 LIDOCAINE 1 ML FERROUS SULFATE 300-M 2 1 3.00 05/25/07 245900 ACETAMINOPHEN 650 MG/ 4 3.00 05/25/07 05/25/07 246836 2 FENTANYL CITRATE 2 ML 1 12.00 3.00 05/25/07 49184 250057 LACTOBACILLUS ACIDOPH 3 9.00 05/25/07 272406 MAGNESIUM OXIDE 400MG NIACIN 50MG UD 1 3.00 05/25/07 272425 MIDAZOLAM 1MG/ML 2ML 2 3.00 05/25/07 272811 DALTEPARIN 2500U 0 2M 2 3.00 05/25/07 273600 . RISPERIDOL .5MG TAB 1 64.80 05/25/07 05/25/07 274365 2 METOPROLOL ORAL SUSP 10 10.55 15-30 05/25/07 74609 3 AMPICIL/SULBACTAM 3G/ 2 3 8.25 05/25/07 06834 306854 ABCS,FIST,SINUS TRACT MOD SED 1 183.00 05/25/07 307590 >5YRS 1ST 30 PERCUT CATH CHANGE S& 1 1 1 00.00 05/25/07 05/25/07 307852 3 EXCHANGE DRAINAGE CAT 1 359.00 1345.00 05/25/07 07853 737009 CONTRAST INJ VIA CATH SHEATH 1 313.00 05/25/07 05/25/07 737046 7 AMPLATZ EX STIFF GUID 1 1 48.00 123.00 05/25/07 37070 737146 NON IONIC CONTRAST CVIR ANGIO TRAY 1 224.00 05/25/07 737148 MULITPURPOSE DRAIN CA 1 1 89.00 05/26/07 05/26/07 10223 P PRIVATE MED/SURG RM 1 222.00 1240.00 05/26/07 111001 245900 GLUCOSE BEDSIDE MONIT ACETAMINOPHEN 650 MG/ 1 2 2.00 05/26/07 249184 LACTOBACILLUS ACIDOPH 3 6 6.00 05/26/07 05/26/07 250057 MAGNESIUM OXIDE 400MG 1 9.00 3.00 05/26/07 272406 272811 NIACIN 50MG UD DALTEPARIN 2500U/0 2M 2 3.00 05/26/07 273600 . RISPERIDOL .5MG TAB 1 64.80 05/26/07 05/26/07 274365 6 METOPROLOL ORAL SUSP 10 10.55 15.30 05/26/07 00520 670722 SPIRO INCENTIVE ADULT' FEEDING BG ENTERAL 1 1 7.00 )5/27/07 )5/27/07 10223 2 0 P PRIVATE MED/SURG RM 2 1 8.00 1240.00 )5/27/07 45900 ACETAMINOPHEN 650 MG/ 4 12.00 )5/27/07 249184 2 LACTOBACILLUS ACIDOPH 3 9.00 )5/27/07 50057 272406 MAGNESIUM OXIDE 400MG NIACIN 50MG UD 1 3.00 )5/27/07 272811 DALTEPARIN 2500U/0 2M 2 3.00 )5/27/07 )5/27/07 273600 . RISPERIDOL .5MG TAB 1 64.80 10.55 15/28/07 274365 10223 METOPROLOL ORAL SUSP P PRIVATE MED/SURG RM 10 1 124 30 ----------------- .00 I ----------------------- - Continue - A J-3 MS HERSHEY MEDICAL CENTER PAGE: 34 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 06/14/07 at 02:00 PM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8289451 ----------- - ---Date- ---?-Svc-Code--------Description ---I_Units__--Debits-------Credit-------s--- __-_---_-___ 05/28/07 245900 AC ----------------------------------------- 05/28/07 249184 ETAMINOPHEN 650 MG/ LACTOBACILLUS ACIDOPH 4 12.00 05/28/07 05/28/07 250057 MAGNESIUM OXIDE 400MG 2 1 6.00 3.00 05/28/07 272406 272811 NIACIN 50MG UD DALTEPARIN 2500U/0 2M 2 3.00 05/28/07 273600 . RISPERIDOL .5MG TAB 1 64.80 05/28/07 05/28/07 274365 METOPROLOL ORAL SUSP 10 10.55 15.30 05/29/07 670722 16694 FEEDING BG ENTERAL 10 GAIT TRAINING 1 1 4.00 05/29/07 17772 5 MIN SPEECH/LANG TX IND 30 1 1 53.00 05/29/07 245900 ACETAMINOPHEN 650 MG/ 2 20 .00 05/29/07 05/29/07 249184 LACTOBACILLUS ACIDOPH 3 6 6.00 9.00 05/29/07 250057 272406 MAGNESIUM OXIDE 400MG NIACIN 5 1 3.00 05/29/07 272811 0MG UD DALTEPARIN 2500U 0 2M 1 3.00 05/29/07 05/29/07 273399 60 . ISOSOURCE 250ML CAN 42 32.40 211.69 0520 SPIRO INCENTIVE ADULT 1 ---------- ------------------------- 7.00 * - Not posted - ---- --Balance:--I--296920_53-) 3 4 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 07/27/07 at 10:20 AM Guarantor: LOGAN PATRICIA 1316 ZIMMERMAN RD CARLISLE, PA 17015-0000 Patient: LOGAN PATRICIA Visit #: 8494240 ------------------------------------------ ------------------ ----------------_ Date -------------- Svc-Code---------Description Units Debits Credits ---- ---------------- 106/07/07 245207 ----------------------------- 06/07/07 246836 LIDOCAINE 1 ML FENTANYL CITRATE 2 ML 2 1 3.00 06/07/07 272425 MIDAZOLAM 1MG/ML 2ML 2 3.00 06/07/07 274609 AMPICIL/SULBACTAM 3G/ 2 3.00 06/07/07 06/07/07 306559 3 CHANGE PERC BILIARY D 1 38 .25 506.00 06/07/07 06854 307590 MOD SED >5YRS 1ST 30 PERCUT CATH CHANGE S& 1 100.00 06/07/07 06/07/07 307616 307 CHOLANGIOGRAM T TUBE 1 1 359.00 183.00 06/07/07 855 737009 CHOLANG THRU EXISTING SHEATH 1 313.00 06/07/07 06/07/07 737046 7 AMPLATZ EX STIFF GUID 1 1 48.00 123.00 06/07/07 37070 737146 NON IONIC CONTRAST CVIR ANGIO 1 224.00 TRAY 1 89 00 ---------- ------------------------------ _ _ _1 * - Not posted -------- I- Balance: -?----1992 25 -------------------------- A 3? PENNSTATE 1 st Statement Milton S T4-11-Y ® Medical Center MSHMC PHYSICIANS GROUP BILLING SERVICES PO Box 843313, Plitsburgh, PA 15264.3313 PATRICIA LOGAN P=15 1316 ZIMMERMAN RD CARLISLE PA 17015-9246 r?rlllrrrlllrr?rrrilrlrLlJrrrd?61??LILrr?dLlLr6?61 IENVWWAEKQ? Patient Name PATRICIA LOGAN Statement Date 07/20107 Account Number 1649402 Total Charges $ 41,673.00 Insurance Payments/Adjustments $ 0.00 Patient Payments $ 0.00 Pending with Insurance $ 0.00 Amount You Owe $ 41,673.00 This new statement has been specially designed with you in mind. Let us know what other improvements we should make. Please e-mail your ideas to: Statementideas hmc- s or write to us at: Penn State Milton S. Hershey Medical Center Statement Ideas, PO Box 854, MC A410 Hershey, PA 17033 Page 1 of 20 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. To make payments,+biltigg-questions or insurance dhanges: Para Preguntas acerca de su facture, o cambios do seguro contamos con representatues disponibles pars asistir a la comunidad hispana. Phone: (717) 531-5069 or (800) 254-2619 In Person: Financial counselors are available in theAcademic 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 Boa 854, Mail Code A410 Hershey, PA 17033-0834 • Department-offpublicWelfare 1-800-692-7462 • Children's fleelthilnswrance?Program (CHIP) 1-800-543-7101 (Uninsured children and adolescents under age 19) • AdultBasic1Program 1-800-543-7101 (Uninsured adults between the ages of 19 and 64) RNM3 i? Tlris statement is for your plrysiclart services only. The hospital may bill separately for their services. PENNSTATE Milton S. Hershey Medical Center MSHMC PHYSICIANS GROUP BILLING SERVICES Po Box 643313 Pataburgh, PA 15264-3813 Statement Date: 07120/07 CHECKS SHOULD BE MADE PAYABLEAND SENT TO: MSHMC PHYSICIANS GROUP PO BOX 643313 PITTSBURGH, PA 15264-3313 1 111 111 1 1 1111 1111 11111 111 111 11111 11 1111 1111 111111 1111 111 111 111 HERSHPHYSTI-01 .................. ?® ? ?i7a Account No. Expiration Date CW Code Signature X 00001649402 UP 3? 0000000004167300072007 I? Check here if your address or Insurance information has changed ',•1 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. Page 2 of 20 ?? i 0ll?r?rrw ?r " (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL ................... PLEASE COMPLETE IF YOUR ADDRESS OR INSURANCE HAS CHANGED filial NAME RELATIONSHIP TO PATIENT HOME TELEPHONE W'ORKTELEPHONE ADDRESS CITY STATE ZIP POLICYHOLDER'S NAME POLICYHOLDER'S IDENTIFICATION NUMBER POLICYHOLDER'S DATE OF BIRTH RELATIONSHIP TO PATIENT POLICYHOLDER'S EMPLOYER NAME (Workers Compensation aAuto Insurance Claims Only) Adjuster's Name: Clalm #: INSURANCE COMPANY NAME GR UP LICY/PLAN NUMBER CLAIM MAILIN DRESS CITY STATE ZIP INSURANCE COMPANY TELEPHONE DATES OF COVERAGE EFFECTIVE FROM: EFFECTIVE TO: a_ 3 Data Code Diagnosis Description Payments/ Pending Patient 04/11/07 72125 959.8 CT CERVICAL SPINE UNENHAN Ch- am Adjustments Insurance Balance $ 377.00 $ 377.00 TOTAL: $ 377.00 S 0.00 it n nn __ Date Code Di_ agnasis Description Payments/ Pending Patient 04/11/07 72192 959.8 CT PELVIS UNENHANCED Ch_ arses Adjustments Insurance Balance 04/11/07 74150 959.12 C T ABDOMEN UNENHANCED $ 354.00 $ 354.00 04/11/07 71250 959.19 CT THORAX UNENHANCED $ 387.00 $ 387.00 $ 377.00 $ 377.00 TOTAL: $1,118.00 $ 0.00 S n nn 7 . ..e .,., Date Code Dia nosis Description Payments/ Pending Patient 04/11/07 72170 959.8 PELVIS ANTERPOSTER Char es Ad ustments Insurance Balance 04/11/07 71010 959.19 CHEST 1 VIEW $ 5700 $ 57.00 $ 60.00 $ 60.00 TOTAL: $117.00 $ 0.00 S e_nn c ?.? ,, Date Code Dia nosis Description Payments/ Pending Patient 04/11/07 99?42 959.8 OFFICE CONSULTATION Charges Adjustments Insurance Balance 04/11/07 31500 786.09 INTUBATION ENDOTRACHEAL $127.00 $ 127.00 $ 643.00 $643.00 TOTAL: $ 770.00 $ 0.00 $ 0.00 $ 770.00 Page 3 of 20 CPT Date Code Diagnosis scr on 04/11/07 99245 959.8 TRAUMA TEAM DIAG EVAL INT TOTAL: CPT Date Code Diagnosls Description 04/11/07 99233 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Diagnosis Description 04/11/07 99285 518.1 EMERGENCY VISIT TOTAL: CPT Date Code Diagnosis Description 04/12/07 71010 518.1 CHEST 1 VIEW 04/12/07 71010 518.0 CHEST 1 VIEW TOTAL: CPT DA2 D242 Diagnosis Descriptlo 04/12/07 71010 518.0 CHEST 1 VIEW Payments/ Pending Patient Charges Adiustments Insurance Bolan te $ 3,283.00 $ 3,283.00 $ 3,283.00 $ 0.00 $ 0.00 $ 3,283.00 Payments/ Pending Patient Charges Adiustments insurance Balance $ 23040 $ 230.00 $ 230.00 $ 0.00 $ 0.00 $ 230.00 Payments/ Pending Patient Charges Adiustments Insurance Balance $ 361.00 $ 361.00 $ 361.00 $ 0.00 $ 0.00 $ 361.00 F 4 W-W Payments/ Pending Patient I? Changes Adiustments Insurance B $ 60.00 $ 00 $ 60.00 $60.00 $120.00 $ 0.00 $ 0.00 $120.00 A , "ll Payments) Pending Patient Charges Adiustments Insurance Balance $ 60.00 $ 60.00 -TOTAL: .................. $-80:00 .... ............. 40. 00 $0.00 $80.00 l4Ti?QR' ,' ,RICIA 1`i??!rir :., .?, V n r.3rif?*,° r,:•,*h5:-..4 ..a'G? ?'Rn T' .Jano i`. gt Jp .-ii E gt>'.:.:., , 1/f31.. !* 828, e3}r ?OG``I' ;;.?R ? ? ? M Ct ! ?i ?? $1 ? ?? ' ? ?r ` `" '' ' ' ? , , , a ,;. ? . • t ; ?: < " ?6s`,? , . .LO ?CONF I?1?!??'?11=1?F?:• . ?"i ? ?$M?.., ;,'- ?_ CPT Date Code Diagnosis Description 04/12/07 31622 862.29 BRONCHOSCOPY DIAG FLEX/R 1 Ch_ arses Payments/ Adiustments Pending Insurance Patient Balance 04/12/07 43200 862.29 ESOPHAGOSCOPY DIAGNOSTIC $ 769.00 $ 439 00 $769.00 . $ 439.00 TOTAL: $1,208.00 $ 0.00 $ O00 $ 1,208,00 " W800ding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL 4 3 -? HERSHPHYM-03 Page 4 of 20 CPT Date Cog Qlaanosl Descriotlo 04/12/07 71010 V58.81 CHEST I VIEW 04/12/07 71010 518.0 CHEST 1 VIEW TOTAL: Payments/ Charges Adjustments $ 60.00 $ 60.00 $120.00 $ 0.00 $ 0.00 $120.00 CPT Date Code Diagnosis Description 04/12107 21501 519.2 DRAIN ABSCESS THORAX DEEP 04/12107 99233 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Diagnosis Description 04/12/07 93010 794.31 ECG ELECTROCARD INTERP TOTAL: CPT Date S'e d Diagnosis Description 04/12/07 00520 862.29 ANES FOR CLSD CHEST PROC TOTAL: I CPT Date Code Diagnosis Description 04/13/07 75989 575.8 RAD GUID/PERC DRAIN INTER 04113/07 47490 575.8 PERC'C'HOLECYSTOSTOMY TOTAL: CPT Date Code Diagnosis Description 04113/07 76705 571.8 ABDOMEN LIMITED FOLLOW-UP TOTAL: Payments/ Charges Adiustments $1,404.00 $ 230.00 Pending Patient Insurance Balance $ 60.00 $ 60.00 Pending Patient Insurance Balance $1,404.00 $ 230.00 $1,634.00 $ 0.00 $ 0.00 $1,634.00 Payments/ Pending Patient Charges Adiustmenis Insurance Balance $ 68.00 $ 68.00 $ 68.00 $ 0.00 $ 0.00 $ 68.00 Payments/ Pending Patient Charges Adiustments Insurance Balanos $1,656.00 $ 1,656.00 $1,656.00 $ 0.00 $ 0.00 $ 1,656.00 Payments/ Pending Patient Charges Adiustments Insurance Balance $ 387.00 $ 387.00 $1,997.00 ................ $1;997:00 ....... $ 2,384.00 $ 0.00 $ 0.00 $ 2,384.00 Payments/ Pending Patient Charges Adiustments Insurance Balance $193.00 $193.00 $193.00 $ 0.00 $ 0.00 $193.00 " (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL R 2 HERSHPHYVN.03 Page 6 of 20 CPT Date Code Diagnosis Description 04/13/07 70450 959.01 CT HEAD LINENHANCED TOTAL: CPT Date Code Diagnosis De cr 'on 04/13/07 71010 492.8 CHEST 1 VIEW TOTAL: CPT P-0 L2k Diagnosis Description 04113107 99233 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date code Diagnosis Description 04/14/07 71010 518.89 CHEST 1 VIEW TOTAL: CPT Date Code Diagnosis Description 04/14/07 99233 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Diagnosis Description 04/15/07 71010 518.1 CHEST 1 VIEW 04/15/07 71010 511.9 CHEST 1 VIEW 04/15/07 71250 518.1 CT THORAX UNENHANCED TOTAL: Payments/ Pending Patient Charges Ad ustments Insurance Balance $ 278.00 $ 278.00 $ 278.00 $ 0.00 $ 0.00 $ 278.00 Payments/ Pending Patient Charges Adjustments Insurance Bala De4 $180.00 $180.00 $180.00 $ 0.00 $ 0.00 $180.00 Payments/ Pending Patient Charles Adiustmenh Insurance Balance $ 230.00 $ 230.00 $ 230.00 $ 0.00 $ 0.00 $ 230.00 Payments/ Pending Patient Charges Adiustmerrta Insurance Bala nce $ 60.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 Payments/ Pending Patient Chame Adfustme Insurance Balance _ $ 230.00 $ 230.00 $ 230.00 $ 0.00 .............. $ 0.00 $ 230.00 w1`7. IW?f ?'? .{r 1$?."t?l(1?!(? i IIf ...................... ..'7' `h?.;.}' ..................... •kan ':1 Payments/ Pending Patient Charges Adiustments Insurance Ba a oe $ 60.00 $ 80.00 $ 60.00 $ 60.00 $ 377.00 $ 377.00 $ 497.00 $ 0.00 $ 0.00 $ 497.00 "(preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL P.0 v HERSNPHYSTI-03 Surjinnr? I n? o-l-We's and C'hcrr.01PIcs (61ntinnoL..) CPT Date Code Diagnosis Description Payments/ Pending Charles Adiustments Insurance Patient Balance 04116/07 71010 518.82 CHEST 1 VIEW ' $ 60.00 $ 60 00 04/16/07 71010 518.82 CHEST 1 VIEW $ 60.00 . $ 60 00 04/16/07 71010 786.09 CHEST 1 VIEW $ 60.00 . $ 60.00 TOTAL: $180.00 $ 0.00 $ 0.00 $180.00 CPT Date Code Diagnosis Description 04/16/07 43246 519.2 ESOPHAGOGA DIR PLACE GAST 04/16/07 17999 519.2 WASH OUT CERVICOMEDIATIN . TOTAL: CPT Date Code Diagnosis Description 04/16/07 00740 519.2 ANE UPR GASTRO ENDO PROC TOTAL: CPT Data Code i n is Descriptio 04/16107 99254 519.2 INITIAL INPT CONSULTATION TOTAL: CPT Date Code Diagnosis Descftbon 04/16/07 99232 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Diagnosis Description 04/17/07 71010 511.9 CHEST 1 VIEW TOTAL: Payments/ Charges Ad ustmen s $1,195.00 $ 2,896.00 Pending Patient Insurance B la ante $1,195.00 $ 2,896.00 $ 4,091.00 $ 0.00 $ 0.00 $ 4,091.00 Payments/ Pending Patient Charges Adiustments Insurance Balance $ 1,012.00 $1,012.00 $ 1,012.00 $ 0.00 $ 0.00 $1,012.00 . Payments/ Pending Patient Charges Adjustments Insurance 8 la ance $ 378.00 $ 378.00 $ 378.00 $ 0.00 $ 0.00 $ 378.00 Payments/ Pending Patient Charnel Adiustments Insurance Bal_ ance .. ............. .....$180:00 . $ 160.00 $160.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patient Charges Adiustments insurance Balance $ 60.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL /4-y/ HERSHPWSTI-0S Page 7 of 20 CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurence Balance 04/17/07 71260 518.1 CT THORAX W/CONTRAST ENH $ 401.00 $ 401.00 04/17/07 71010 514 CHEST 1 VIEW $ 60.00 $ 60.00 TOTAL: CPT Date Cr Diagnosis Descriptio 04/17/07 99233 519.2 HOSP VISIT EXTEN CC TOTAL: CPT Date Code Diagnosis Description 04/17/07 99232 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Diaonosis Description 04/18/07 71010 518.82 CHEST 1 VIEW TOTAL: CPT DAll -Q? Diagnosis Dosmiption 04/18/07 99233 519.2 HOSP VISIT EXTEN CC .. ... TOTAL: .... CPT Date Code Diagnosis Description 04/18/07 99232 959.8 DAILY HOSPITAL CARE TOTAL: $ 461.00 $ 0.00 $ 0.00 $ 461.00 Payments/ Pending Patient Charges Adiustments Insurance $ Balanc 230.00 $ 20 $ 230.00 $ 0.00 $ 0.00 $ 230.00 Payments/ Pending Patient Charges Adjustments Insurance Balance $ 180.00 $ 160.00 $160.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patient Charges Adjustments Insurance Balance $ 80.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 6000 P ayments/ Pending Patient Charge A stments Insurance Balance $ 230.00 $ 230.00 $ 230.00 $0.00 $0.00 $230.-00- Payments/ Pending Patient Charges Adiustments Insurance Balance $160.00 $ 160.00 $ 160.00 $ 0.00 $ 0.00 $160.00 " (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL fi ?? HMHPW$TI-0a Page 8 of 20 CPT Date Code Diagnosis Description 04/19/07 71010 511.9 CHEST 1 VIEW TOTAL: CPT Date Code Diagnosis Description 04/19/07 99232 519.2 HOSP VISIT INTER CC TOTAL: CPT Date Code is nosi s i 04/19/07 99232 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Coe Dia nosis Description 04120/07 17999 519.2 WASHOUT CERVICOMEDIASTINA TOTAL: Payments/ Pending Patient Charges Adiustments Insurance Balance $ 60.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 Payments/ Pending Patient Chames Ad ustments Insurance Balance $ 160.00 $160.00 $160. 0 $ 0.00 $ 0.00 $180.00 Payments/ Pending Patient Charoes Adiustments Insurance Ba ance $ 160.00 $160.00 $ 160.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patient Charges Adiustments Insurance Balance $ 2,896.00 $ 2,896.00 $2,896.00 . $ 0.00 $ 0.00 $ 2,896.00 Date 04/20/ CPT Code Dia nos s Description 07 71010 511.9 CHEST 1 VIEW Charges Payments/ Adjustments Pending Insurance 'Patient Balance $ 60.00 $ 60.00 TOTAL: ......... .... $ 60.00 $ 0.00 $ 0.00 $ 60.00 } r low ... ......... .... ........... .. _..... ....... . Date 04/20/0 CPT Code is n si 7 00400 519.2 Qe3cdptIo ANE/PROC/ANTER INTEG SYS Chames Payments/ Adiustments Pending Insurance Patient Balance $ 644.00 $ 644.00 TOTAL: $ 644.00 $ 0.00 $ o.oo $ 644.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL 4I HERMPHYST I i-w Page 9 of 20 CPT Date Code Diagnosis Description 04120/07 99232 519.2 HOSP VISIT INTER CC TOTAL: CPT D92 Sr.Qd§ Diagnosis Description 04/21/07 71010 511.9 CHEST 1 VIEW TOTAL: CPT Date Code Diagnosis Description 04/21107 99232 519.2 HOSP VISIT INTER CC TOTAL: CPT Date Code Diagnosis Description 04/21/07 99232 959.8 DAILY HOSPITAL CARE TOTAL: CPT - Code Diagnosis Description 04/22/07 71010 514 CHEST 1 VIEW TOTAL: ....................................... . CPT Date Code Diagnosis Description 04/22/07 99232 519.2 HOSP VISIT INTER CC TOTAL: Payments/ Pending Patient Charges Adjustments Insurance Balance $160.00 . $ 160.00 $160.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patient Charges Adiustments Insurance Balance $ 60.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 Payments/ Pending Patient Charges Adiustments Insurance ce Bolan $160.00 $ 160.00 $160.00 $ 0.00 $ 0.00 $ 160.00 Payments/ Pending Patient Charges Adjustments Insurance Balance $160.00 $ 160.00 $160.00 $ 0.00 $ 0.00 $150.00 iii L \\\ 7.? Payments/ Pending Patient Charges Adiustments Insurance Bolan ce $ 60,00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 ?Ml "" WWI , Payments/ Pending Patient Charges Adiustments Insurance Balance $160.00 $ 160.00 $160.00 $ 0.00 $ 0.00 $160.00 (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL h ll 7 HERSHPHYSTI-08 10 of 20 CPT Date Code Dia nosis Description 04/22107 99232 959.8 DAILY HOSPITAL CARE TOTAL: Payments/ Pending Patient Charges Adjustments Insurance Balance $160.00 $ 160.00 $160.00 $ 0.00 $ 0.00 $160.00 CPT Payments/ Pending Patient Date Code Diaonosis Description Charges Adiustments Insurance Balance 04/23/07 71260 518.0 CT THORAX W/CONTRAST ENH $ 401.00 $ 401.00 TOTAL: $ 401.00 $ 0.00 $ 0.00 $ 401.00 CPT Date Code Diagnosis Description 04/23/07 71010 511.9 CHEST 1 VIEW TOTAL: CPT Date Code Diagnosis Description 04/23107 99232 519.2 HOSP VISIT INTER CC TOTAL: CPT Date Codes i osis Description 04/23/07 99232 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Diaonosis Description 04/24/07 71010 518.89 CHEST 1 VIEW TOTAL: Payments/ Pending Patient Charges Adiustments Insurance Balance $ 60.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 Payments/ Pending Patient Charges Adiustments insurances Balance $ 160.00 $ 160.00 $160.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patient Charges Adiustments Insuranoe Balance $ 160.00 $160.00 $160.00 $ 0.00 $ 0.00 $ 160.00 ........ .......................... Payments/ Pending Patient Charges Adiustments Insurance B I nc $ 60.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYSTI-M Page II of 20 CPT Date Code Diagnosis Description 04/24/07 99232 519.2 HOSP VISIT INTER CC TOTAL: Payments/ Pending Patient Charges Adjustments Insurance B la ance $160.00 $ 160.00 $160.00 $ 0.00 $ 0.00 $160.00 CPT Date Code Diagnosis Description 04/24/07 99232 959.8 DAILY HOSPITAL CARE TOTAL: CPT Q& Qg&la Qlagnosi Description 04/25107 71010 518.89 CHEST 1 VIEW TOTAL: CPT Date Code Diagnosis Description 04/25/07 99232 519.2 HOSP VISIT INTER CC TOTAL: CPT Date Code Diagnosis Description 04/25/07 99232 959.8 DAILY HOSPITAL CARE TOTAL: CPT _DOtg Code i i Description 04/26/07 71010 518.89 CHEST 1 VIEW TOTAL: Payments/ Pending Patient Charges Adjustments Insurance Balance $160.00 $ 160.00 $160.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patient Charges Adjustments Insurance Balance $ 60.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 y Payments/ Pending Patient Charges Adjustments Insurance Balance $160.00 $160.00 $160.00 $ 0.00 $ 0.00 $160.00 M Payments/ Pending Patient Charges Adjustments Insurance Balance _ $160.00 $160.00 $160.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patient Charges Adjustments Insurance 8 lance $ 60.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL ?? HERSHPWST1433 Page 12 of 20 CPT Date Code Diagnosis Description 04/26107 99232 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Diagnosis Description 04/26!07 99232 519.2 HOSP VISIT INTER CC TOTAL: CPT Code Diagnosis Description 04/27/07 71010 518.89 CHEST 1 VIEW TOTAL: CPT Date Code Diagnosis Description 04/27/07 99232 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Diagnosis Description 04/27/07 99233 519.2 HOSP VISIT EXTEN CC TOTAL: CPT Date Code i osi Description 04/28107 71010 511.9 CHEST 1 VIEW TOTAL: Payments/ Pending Patient Charge s Adjustments Insurance Balance $ 160.00 $ 180.00 $160.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patient Changes Adjustments Insurance Balance $ 160.00 $ 160.00 $160.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patient Charges Adjustments Insurance Balance $ 60.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 Payments/ Pending Patient Charges Adjustments Insurance Balance .$160.00 $ 180.00 $160.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patient Charges Adjustments Insurance Balance $ 230.00 $ 230.00 $ 230.00 $ 0.00 $ 0.00 $ 230.00 Payments/ Pending Patient C a e Adiustments Insurance Balance $ 60.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 • (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL A-q? HERSHPHYSTI-M Page 13 of 20 CPT Date Code Diagnosis Descl on 04128/07 99231 959.8 DAILY HOSPITAL CARE TOTAL: CPT -QQ-d@ Diagnosis Description 04128/07 99233 519.2 HOSP VISIT EXTEN CC TOTAL: CPT Date Code Diagnosis Description 04/29/07 71010 486 CHEST 1 VIEW TOTAL: CPT Date Coe D nosis Description 04/29/07 99231 959.8 DAILY HOSPITAL CARE TOTAL: CPT Dj* 4 Diaonos! Description 04/29/07 99233 519.2 HOSP VISIT EXTEN CC TOTAL: ..................................... CPT Date Code Diagnosis Description 04/30/07 71035 511.9 CHEST SPECIAL VIEWS 04/30/07 71035 511.9 CHEST SPECIAL VIEWS TOTAL: Payments/ Pending Patient Charges Ad ustmen Insurance Balance $ 87.00 $ 87.00 $ 87.00 $ 0.00 $ 0.00 $ 87.00 Payments/ Pending Patient Charoes Adjustments Insurance $ Bala 230.00 $230.00 $ 230.00 $ 0.00 $ 0.00 $ 230.00 Payments/ Pending Patient Charoes Adiustments Insurance Balance $ 60.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 ?. Payments/ Pending Patient Charges Adiustmerrts Insurance Bala n $ 87.00 $ 87.00 $ 87.00 $ 0.00 $ 0.00 $81.70 0 Payments/ Pending Patient Charoes Adjustments Insurance $ 230.00 $ 23000 $ 230.00 $ 0.00 $ 0.00 $ 230.00 Payments/ Pending Patient Charges Adjustments Insurance Balance $ 60.00 $ 60.00 $ 60.00 $ 60.00 $120.00 $ 0.00 $ 0.00 $ 120.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL I ?? HERSHPHYSTI-03 Page 14 of 20 Date Code Dia nosis Description 05/01/07 99232 519.2 HOSP VISIT INTER CC TOTAL: Payments/ Pending Patient Charges Adiustments insurance Balanca $160.00 $ 160.00 $160.00 $0.00 $ n 0 ..._. __ (Preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL ! / MFGRNONHCT?Jw Date Code Diagnosis Des ution Payments/ Pending Patient 04/30/07 99232 959.8 DAILY HOSPITAL CARE Char a Adiustments Insurac;e Balance $160.00 $180.00 TOTAL: $160.00 soon Date Code Dia nosis Description Payments/ Pending Patient 04/30/07 99232 519,2 HOSP VISIT INTER CC $Char160ges Adiustments Insurance Balance .00 $180.00 TOTAL: $ 160.00 S n_nn Date Code Diagnosis Description Payments/ Pending Patient 05/01/07 71010 486 CHEST 1 VIEW ar es Adiustments Insurance Balance $ 60.00 $ 60.00 TOTAL: $60.00 Snnn cam,... ?____ Date Code Din nosis Description Payments! Pending Patient 05/01/07 99232 959.8 DAILY HOSPITAL CARE Charges s t Insurance Balance $ 160.00 $ 160.00 TOTAL: $160.00 S o_oe ? n ?„ ..__ __ Date COdQ Diagnosis Description Payments/ Pending Patient 05/02/07 71010 786.09 CHEST 1 VIEW Char es Adjustments Insurance Balance $ 60.00 $ 60.00 TOTAL: $ 60.00 $ 0.00 $ 0.00 $ 60.00 Page 15 of 20 CPT Date L2do Dlaonosl Description 05/02/07 99232 959.8 DAILY HOSPITAL CARE TOTAL: Payments/ Pending Patient Ch_ arses Adjustments Insurance Balance $ 160.00 $180,00 $160.00 $ 0.00 $ 0.00 $160.00 CPT Date Code Diagnosis Description 05/02/07 99232 519.2 HOSP VISIT INTER CC TOTAL: CPT Date Code Diagnosis Description 05/02/07 93010 427.89 ECG ELECTROCARD INTERP TOTAL: CPT Date Code Diagnosis Description 05/03/07 99232 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Diagnosis Description 05/04/07 71010 518.0 CHEST 1 VIEW TOTAL: ............................................ Payments/ Pending Patient Changes Adjustments Insurance Balance $ 160.00 $160.00 $160.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patent Charges Adiustmer?ts Insurance Balance $ 68.00 $ 68.00 $ 68.00 $ 0.00 $ 0.00 $ 68.00 Payments/ Pending Patient M Charges Adjustments Insurance Balance Q $ 160.00 $160.00 $180.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patient Charges Adjustments Insurance Balance $ 60.00 $ 80.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 CPT Payments/ Pending Patient Date Code i i Description hC arses Adjustments Insurance Bolence 05/04/07 74160 518.1 C T ABDOMEN ENHANCED $ 413.00 $ 413.00 05/04/07 71260 518.89 CT THORAX W/CONTRAST ENH $ 401.00 $ 401.00 TOTAL: $814.00 $0.00 $0.00 $814.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL P 67) HERSHPHYBT7-03 I Page 16 of 20 CPT Date Code Diagnosis Descri • n 05104/07 70491 862.29 CT NECK ENHANCED TOTAL: Payments/ Pending Patient Charge s Adjustments Insurance Balance $ 447.00 $ 447.00 $ 447.00 $ 0.00 $ 0.00 $ 447.00 CPT Date Code Diagnosis Description 05105107 99233 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Coe Diaonosls es 'o 05106/07 99232 959.8 DAILY HOSPITAL CARE TOTAL: Payments/ Pending Patient Chames Adjustments Insurance Balance $ 230.00 $ 230.00 $ 230.00 $ 0.00 $ 0.00 $ 230.00 Payments/ Pending Patient Charges Adjustments Insuranc Beiance $ 160.00 $160.00 $160.00 $ 0.00 $ 0.00 $160.00 CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 05/07/07 99233 959.8 DAILY HOSPITAL CARE $ 230.00 $ 230.00 TOTAL: $ 230.00 $ 0.00 $ 0.00 $ 230.00 RIMM '' CPT Payments/ Pending Patient Date Code Diagnosis Description Charg Adjustments Insurance Balance 05/07/07 71010 518.89 CHEST 1 VIEW $ 60.00 $ 60.00 TOTAL: $ 60.00 $ 0.00 $ 0.00 $ 60.00 CPT Payments/ Pending Patient Date Code Diaonosis Description Chames Adjustments Insurance Balance 05108/07 99231 293.1 DAILY HOSPITAL CARE $ 87.00 $ 87.00 TOTAL: $ 87.00 $ 0.00 $ 0.00 $ 87.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL D7 `51 HERSHPHYETI.03 Page 17 of 20 CPT Date Code is nosis Description 05/08/07 99253 709.9 INITIAL INPT CONSULTATION Payments/ Pending Patient Charges Adiustments Insurance Balance $ 261.00 $ 261.00 TOTAL: CPT Date Code Diagnosis Description 05/09107 71010 786.09 CHEST 1 VIEW TOTAL: $ 261.00 $ 0.00 $ 0.00 $ 261.00 Payments/ Pending Patient Charges Adjustments Insurance Balance $ 60.00 $ 60.00 $ 60.00 $ 0.00 $ 0.00 $ 60.00 CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adjustments Insurance Balance 05/10/07 71010 518.89 CHEST 1 VIEW $ 60.00 $ 60.00 05/10/07 72170 959.8 PELVIS ANTERPOSTER $ 57.00 $ 57.00 05/10/07 73500 959.6 HIP UNILATERAL 1 VIEW $ 57.00 $ 57.00 TOTAL: CPT Date Code Diaanosl Description 05/10/07 99254 348.30 INITIAL INPT CONSULTATION TOTAL: $174.00 $ 0.00 $ 0.00 $174.00 Payments/ Pending Patient Charges $ 378.00 Adjustments Insuran ??? $ 378.00 e $ 378.00 $ 0.00 $ 0.00 $ 378.00 x , y i • z CPT Date Code Diagnosis D cri ion 05/12/07 70553 348.8 MRI BRAIN UNEN ENH TOTAL: CPT Date Code Diagnosis Descrbtion 05/12107 99231 959.8 DAILY HOSPITAL CARE 05113107 99231 959.8 DAILY HOSPITAL CARE TOTAL: Payments/ Pending Patient Charges Adjustments Insurance Balance $ 887.00 $ 687.00 $ 887.00 $ 0.00 $ 0.00 $ 687.00 Payments/ Charles Adjustments $ 87.00 $ 87.00 Pending Patient Insurance Balance $ 87.00 $ 87.00 $174.00 $ 0.00 $ 0.00 $174.00 (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL ?EesHPHYM-03 1 . Page 18 of 20 CPT Date Code Diagnosis Description 05/14107 99232 959.8 DAILY HOSPITAL CARE TOTAL: Payments/ Pending Patient Charges Adiustments Insurance Balance $ 160.00 $160.00 $160.00 $ 0.00 $ 0.00 $ 160.00 CPT Date Code Diagnosis description 05/14/07 99232 348.30 HOSP VISIT INTER CC TOTAL: CPT Die Code Diagnosis Description 05/15/07 99231 959.8 DAILY HOSPITAL CARE 05/16/07 99231 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Diagnosis Description 05/17/07 95816 780.02 EEG AWAKE & DROWSY TOTAL: , CPT Date Code Diagnosis Description 05117/07 88108 793.0 CYTO CONCEN W/SMEARS TOTAL: Payments/ Pending Patient Charges Ad ustments Insurance Balance $ 160.00 $160.00 $ 160.00 $ 0.00 $ 0.00 $160.00 Payments/ Pending Patient Charges Adiustments Insurance Bala c $ 87.00 $ 87.00 $ 87.00 $ 87.00 $174.00 $ 0.00 $ 0.00 $174.00 Payments/ Pending Patient C a es Adiustments Insurance Balance $ 376.00 $ 376.00 $ 376.00 $ 0.00 $ 0.00 $ 376.00 Payments/ Pending Patient Charges Adiustments Insurance Balance $ 124.00 $124.00 $ 124.00 $'0.00 $ 0.00 ... $1'24:00 CPT Date Code Diagnosis Description Payments/ Pending Charges Adiustments Insurance Patient Balance 05/17/07 99232 959.8 DAILY HOSPITAL CARE $ 160.00 $160 00 05/18/07 99231 959.8 DAILY HOSPITAL CARE $ 87.00 . $ 87 00 05/19/07 99231 959.8 DAILY HOSPITAL CARE $ 87.00 . $ 87 00 05/20/07 99231 959.8 DAILY HOSPITAL CARE $ 87.00 . $ 87.00 TOTAL: $ 421.00 $ 0.00 $ 0.00 $ 421.00 • (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL /1 =•J HERSHPHYST1-w Page 19 of 20 CPT D Code Diaonosl Description 05/21/07 99231 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Dia osis Description 05/21/07 99232 348.30 HOSP VISIT INTER CC TOTAL: CPT Date Code Diagnosis Description 05/22/07 99231 959.8 DAILY HOSPITAL CARE TOTAL: CPT QMt Sege Diagnosis Description 05/23/07 99231 293.0 DAILY-HOSPITAL CARE TOTAL: CPT Data Code Diagnosis Description 05!23107 99231 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Dlagnosis Description 05/23/07 99232 348.30 HOSP VISIT INTER CC TOTAL: Payments/ Pending Patient Charges Adjustments Insurance Balance $ 87.00 $ 87.00 $ 87.00 $ 0.00 $ 0.00 $ 87.00 Payments/ Pending Patient Charges Adjustments Insurance Balance $160.00 $ 180.00 $180.00 $ 0.00 $ 0.00 $160.00 Paymenta/ Pending Patient Charges Adjustments I ran Balance $ 87.00 $ 87.00 $ 87.00 $ 0.00 $ 0.00 $ 87.00 Payments/ Pending Patient Charges Adjustments Insurance Ba ance $ 87.00 $ 87.00 $ 87.00 $ 0.00 $ 0.00 $ 87.00 1'7' rRV ' t(. C . Payments/ Ch A Pending , Patient arges djustments Insurance Balance $ 87.00 . $ 87.00 $ 87.00 $ 0.00 .................................. $ 0.00 $ 87.00 . ............ ............. .................. Payments/ Pending Patient Charges Adiustments I nsurance Balance $160.00 $ 160.00 $180.00 $ 0.00 $ 0.00 $160.60- * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL `I HERSHPWST1-03 •. • Su11111111ij uJSc'rr?icc'.y unrl C'hrrl?;c.? (Ct?ati1111c11:..? CPT Date Code Dianno? 05125/07 49424 V58.49 05/25/07 76080 V58.49 05/25/07 49423 V58.49 05/25/07 75984 V58.49 is Description CONTRAST INJ.ABSCESS/CYST RAD EXAM FISTU/SINS TRCT EXCH PREV PLACED CATH PERC CATH CHNG INTERP Payments/ Charges Adiustmen?s $ 210.00 $ 176.00 $ 403.00 $ 233.00 Pending Patient Insurance Balance $ 210.00 $176.00 $ 403.00 $ 233.00 TOTAL: CPT Date Code Diagnosis Description 05/25/07 99231 959.8 DAILY HOSPITAL CARE TOTAL: CPT Da a Code Diagnosis Description 0528/07 99231 959.8 DAILY HOSPITAL CARE TOTAL: CPT Date Code Diagnosis Description 05/29/07 99233 293.0 DAILY HOSPITAL CARE TOTAL: CPT Date Code Diaonosis Description 05/29/07 99238"959.8 HOSP DISC DAY LESS 30 MIN TOTAL: CPT Date Cog Diagnosis Description 06/07107 47505 V58.49 INJ PROC/CHOLAN/EXSI CATH 06/07/07 74305 V58.49 CHOLANGIOGRAPHY POST OP 06107/07 47525 V58.49 CHNG PERC BIL DRAIN CATH 06107/07 75984 V58.49 PERC CATH CHNG INTERP TOTAL: $1,022.00 $ 0.00 $ 0.00 $1,022.00 Payments/ Pending Patient Chances Adjustments Insurance Balance $ 87.00 $ 87.00 $ 87.00 $ 0.00 $ 0.00 $ 87.00 Payments/ Pending Patient Charges Adjustments Insurance Balance $ 87.00 $ 87.00 $ 87.00 $ 0.00 $ 0.00 $ 87.00 Payments/ Pending Patient Charges Adjustments Insurance alance $ 230.00 , $ 230.00 $ 230.00 $ 0.00 $ 0.00 $ 230.00 Payments/ Pending Patient Charges Adjustments Insurance Balance $147:00.. .......... $.1+47:00.... $ 147.00 $ 0.00 $ 0.00 $147.00 Payments/ Charges Adjustments $ 482.00 $ 138.00 $1,533.00 $ 233.00 Pending Patient Insurance Balance $ 482.00 $ 138.00 $1,533.00 $ 233.00 $ 2,388.00 $ 0.00 $ 0.00 $ 2,386.00 GRAND TOTAL: $ 41,673.00 $ 0.00 $ 0.00 $ 41,673.00 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL ?- 55 HERSHPHYSTI-M LOGAN, PATRICIA #1649402 $298,912.78 (Hosp) . 41,673.00 (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. Lj- 4'--' /), 44A"?- LINDA SCHLADER DATE:-0 Cd c -` Sb i ?O i , C ? am SHERIFF'S RETURN - REGULAR CASE NO: 2008-04484 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND MILTON S HERSHEY MEDICAL CENTE VS LOGAN STEPHEN ET AL STEVE BENDER , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon LOGAN PATRICIA the DEFENDANT , at 1350:00 HOURS, on the 9th day of August 2008 at 1316 ZIMMERMAN ROAD CARLISLE, PA 17015 by handing to PATRICIA LOGAN a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing 6.00 Service .00 Affidavit ,00 Surcharge 10.00 .00 4103)06 ? 16.00 L 4- Sworn and Subscibed to before me this day of So Answers: 000, R. Thomas Kline 08/11/2008 TABAS & ROSEN By. Deputy Sheriff A. D. SHERIFF'S RETURN - NOT FOUND CASE NO: 2008-04484 P COMMONTWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND MILTON S HERSHEY MEDICAL CENTE VS LOGAN STEPHEN ET AL R. Thomas Kline Sheriff or Deputy Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named DEFENDANT LOGAN STEPHEN but was unable to locate Him in his bailiwick. He therefore returns the COMPLAINT & NOTICE , NOT FOUND , as to the within named DEFENDANT 1316 ZIMMERMAN ROAD , LOGAN STEPHEN CARLISLE, PA 17015 DEFENDANT HAS BEEN DECEASED FOR 2 YEARS. Sheriff's Costs: Docketing 18.00 Service 6.00 Not Found 5.00 Surcharge 10.00 .00 ?' 39.00 So answ R. -Thomas Kline Sheriff of Cumberland County TABAS & ROSEN 08/11/2008 Sworn and Subscribed to before me this day of A. D. r ..--,. MILTON S. HERSHEY MEDICAL CENTER P.O. Box 853 Hershey, PA 17033 VS. STEPHEN LOGAN & PATRICIA LOGAN, h/w 1316 Zimmerman Road Carlisle, PA 17015 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA yy?y NO. 08 -44$3-CIVIL TERM CIVIL ACTION PRAECIPE TO ENTER APPEARANCE TO THE PROTHONOTARY: Please enter my appearance on behalf of the Defendant, Patricia Logan, in the above- captioned matter. of ` Date. Mark F. Bayley, Esquire Bayley & Mangan 17 West South Street Carlisle, PA 17013 (717) 241-2446 Supreme Court I.D. # 87663 Attorney for Defendant .r,.-.. MILTON S. HERSHEY MEDICAL CENTER P.O. Box 853 Hershey, PA 17033 VS. STEPHEN LOGAN & PATRICIA LOGAN, h/w 1316 Zimmerman Road Carlisle, PA 17015 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 08 - 4483 CIVIL TERM : CIVIL ACTION CERTIFICATE OF SERVICE I, Mark F. Bayley, Esquire, attorney for Defendant do hereby certify that I this day served a copy of the within Praecipe upon the following by depositing same in the United States mail, postage prepaid, at Carlisle, Pennsylvania, addressed as follows: Tabas & Rosen, P.C. Attn. Lewis C. Trauffer, Esquire 1601 Market Street, Suite 2300 Philadelphia, PA 19103 Dated: t ( - Mark F. Bayley, Esqu' e Attorney for Defendant ro .... .?? M -? ?? ? ?' MILTON S. HERSHEY MEDICAL CENTER P.O. Box 853 Hershey, PA 17033 VS. STEPHEN LOGAN & PATRICIA LOGAN, h/w 1316 Zimmerman Road Carlisle, PA 17015 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Wf4l NO. 08 -448+ CIVIL TERM CIVIL ACTION ANSWER AND NOW, comes Patricia Logan, by and through her attorney, Mark F. Bayley, and answers Plaintiffs Complaint as follows: 1. Denied. By way of further answer, after reasonable investigation in the time allotted, the Defendant is in no position to verify this averment; strict proof at trial is therefore demanded. 2. Admitted. 3. Admitted. 4. The document set forth as Exhibit "A" in Plaintiffs Complaint speaks for itself and no response is necessary; to the extent that a response is deemed necessary, this averment is denied. 5. Denied. By way of further answer, after reasonable investigation in the time allotted, the Defendant is in no position to verify this averment; strict proof at trial is therefore demanded. 6. This paragraph consists of legal conclusion to which no response is necessary; to the extent that a response is deemed necessary, this averment is denied. P. A 7. Admitted in part and denied in part. It is admitted that Defendant has no way of paying a lump sum payment of $340,585.78 regardless of whether she legally owes said amount; it is denied that she owes the above amount and it is denied that she is unwilling to negotiate a reasonable payment plan to satisfy a reasonable charge. 8. This paragraph consists of legal conclusion to which no response is necessary; to the extent that a response is deemed necessary, this averment is denied. WHEREFORE, Defendant respectfully requests Count 1 of Plaintiffs Complaint to be dismissed. 9. No response necessary. 10. Denied. By way of further answer, Stephen Logan is deceased. 11. Denied. By way of further answer, Stephen Logan is deceased. 12. Admitted. 13. Denied. By way of further answer, after reasonable investigation in the time allotted, the Defendant is in no position to verify this averment; strict proof at trial is therefore demanded. 14. Denied. By way of further answer, Defendant does not know Plaintiffs definition of "indigent." 15. By way of further answer, Stephen Logan is deceased. lb. This paragraph consists of legal conclusion to which no response is necessary; to the extent that a response is deemed necessary, this averment is denied. 17. This paragraph consists of legal conclusion to which no response is necessary; to the extent that a response is deemed necessary, this averment is denied. 18. Denied. By way of further answer, Stephen Logan is deceased. 4 r 19. This paragraph consists of legal conclusion to which no response is necessary; to the extent that a response is deemed necessary, this averment is denied. WHEREFORE, Defendant respectfully requests Count 2 of Plaintiffs Complaint to be dismissed. Respectfully submitted, BAYLEY & MANGAN ? v Mark F. Bayley, Esquire 17 West South Street Carlisle, PA 17013 (717) 241-2446 Supreme Court I.D.#87663 VERIFICATION I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. Cons. Stat. § 4904 relating to unworn falsification to authorities. Aatu-? ??? Patricia Logan, Defend t - 1W . MILTON S. HERSHEY MEDICAL CENTER P.O. Box 853 Hershey, PA 17033 vs. STEPHEN LOGAN & PATRICIA LOGAN, h/w 1316 Zimmerman Road Carlisle, PA 17015 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 08 - 4483 CIVIL TERM CIVIL ACTION CERTIFICATE OF SERVICE I, Mark F. Bayley, Esquire, do hereby certify that I this day served a copy of the foregoing document upon the following by depositing same in the United States mail, postage prepaid, at Carlisle, Pennsylvania, addressed as follows: Tabas & Rosen, P.C. Attn: Lewis C. Trauffer, Esquire 1601 Market Street, Suite 2300 Philadelphia, PA 19103 Mark F. Bayley, O?? l l-o 1 ?? c ?. ..?- i?" ? ? '"" ?, '???' ""'ea ".? N