HomeMy WebLinkAbout08-4964MAJOR CASE/NON-JURY
ASSESSMENT OF DAMAGES HEARING NOT REQUIRED
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER, ESQUIRE
Attorney for Plaintiff
Attorney I.D. #60267
1601 Market Street, Suite 2300
Philadelphia, PA 19103
(215) 569-5050
MILTON S. HERSHEY MEDICAL CENTER IN THE COURT OF COMMON PLEAS OF
P.O. Box 853 CUMBERLAND COUNTY, PENNSYLVANIA
Hershey, PA 17033 :
NO. ' b8 - q9(4q 0'wi(Texo'
VS : CIVIL ACTION
DOUGLAS WISER &
BARBARA WISER, h/w
1838 Ritner Highway
Shippensburg, PA 17257
COMPLAINT - CIVIL ACTION
NOTICE
You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within
twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in
writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case
may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the
complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT
AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL
HELP.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH
INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE
OR NO FEE.
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, Pennsylvania 17013
(717)249-3166 or(800)990-9108
COMPLAINT - CIVIL ACTION
COUNT I
THE MILTON S. HERSHEY MEDICAL CENTER
VS. DOUGLAS WISER
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 May 19, 2006
thru August 10, 2006.
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.
I I
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
"An.
WHEREFORE, plaintiff demands judgment against Count I
defendant for the sum of $146,144.97 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. BARBARA WISER
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 May 19, 2006 thru August 10, 2006.
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 $146,144.97 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.
LEWIS C. T UFFER, ESQUIRE
Attorney for Plaintiff
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
PAGE:
Patient: WISER DOUGLAS E
Visit #: 7152927
Date
05/19/06
05/19/06
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Svc Code Description Units Debits I Credits
10469 T ADULT MONITOR CARE 1 1485.00
102019 GRAM STAIN 1 25.00
102100 CULTURE, BACTERIAL 1 63.00
102105 CULTURE, BLOOD 2 166.00
102214 CULTURE, URINE QUANT 1 38.00
104106 MAGNESIUM 1 15.00
104438 RENAL FUNCTION PANEL 1 42.00
105052 PARTIAL THROMBOPLAS T 1 36.00
105059 PROTHROMBIN TIME 1 22.00
105657 CBC W/PLT/DIFF AUTO 1 46.00
106011 URINALYSIS-BASIC & MI 1 36.00
245483 DEXTROSE 5% 50ML 1 35.40
246357 PENICILLIN G POTASSIU 40 111.60
272176 ZOLIPIDEM 5MG TAB 1 10.20
273022 GENTRAMICIN 80MG PREM 3 25.20
273741 METOPROLOL 25 MG TAB 1 3.00
307101 CHEST 1 VIEW 1 114.00
521211 12 LEAD ELECTROCARDIO 1 111.00
600510 PULSE OXIMETER SNSR A 1 11.00
621034 I V DEXTROSE 5%-.45 S 1 6.00
621100 CANISTER SUCT HARDSHE 1 5.00
621105 YANKAUER SUCT TB W/O 1 5.00
670330 IV INFUSION SET, UNIV 1 16.00
670334 IV INFUSION SET, UNIV 1 8.00
10469 T ADULT MONITOR CARE 1 1485.00
102002 SENSI, AGAR DIFF/ANTI 1 30.00
102003 SENSI, DISK METHOD/PL 1 39.00
102006 SENSI, MT MIC ANY # A ' 1 43.00
102105 CULTURE, BLOOD 2 166.00
102189 ID DEFIN AEROB ISOL E 1 39.00
102192 MICRO ID BY GLC 1 61.00
104106 MAGNESIUM 1 15.00
104438 RENAL FUNCTION PANEL 1 42.00
104585 GENTAMICIN LEVEL 2 68.00
105656 CDC W/PLT AUTO 1 29.00
245483 DEXTROSE 5% 50ML 1 35.40
246357 PENICILLIN G POTASSIU 40 111.60
247831 ACETAMINOPHEN 325 MG 2 3.00
250539 BUPROPION 100MG 3 9.00
273022 GENTRAMICIN 80MG PREM 1 8.40
273741 METOPROLOL 25 MG TAB 2 6.00
274019 ALTEPLASE CATH 2MG VI 2 184.55
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MS HERSHEY MEDICAL CENTER PAGE: 2
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 7152927
I ---------------------------------P-----------------------------------------
----Date------Svc-Code----------Descri ption----Unitsl-- Debits Credits
------------------------
05/20/06 310503 CT HEAD UNENH & ENH S 1 1529.00
05/20/06 310516 CT THORAX ENHANCED 1 1490.00
05/20/06 310519 CT ABDOMEN ENHANCED 1 1029.00
05/20/06 310567 CT PELVIS ENHANCED 1 1169.00
05/20/06 310703 OMNIPAQUE 300MG/ML 10 1 53.00
05/20/06 670334 IV INFUSION SET, UNIV 1 8.00
05/21/06 10469 T ADULT MONITOR CARE 1 1485.00
05/21/06 105657 CBC W/PLT/DIFF AUTO 1 46.00
05/21/06 245475 GENTAMICIN 40MG/ML 4 36.20
05/21/06 245483 DEXTROSE 5% 50ML 3 94.10
05/21/06 246357 PENICILLIN G POTASSIU 40 111.60
05/21/06 247831 ACETAMINOPHEN 325 MG 2 3.00
05/21/06 250539 BUPROPION 100MG 3 9.00
05/21/06 273022 GENTRAMICIN 80MG PREM 1 8.40
05/21/06 273741 METOPROLOL 25 MG TAB 2 6.00
05/22/06 10469 T ADULT MONITOR CARE 1 1485.00
05/22/06 105656 CBC W/PLT AUTO 1 29.00
05/22/06 245475 GENTAMICIN 40MG/ML 3 27.15
05/22/06 245483 DEXTROSE 5% 50ML 2 88.20
05/22/06 245555 LIDOCAINE 1 ML 1 3.00
05/22/06 246357 PENICILLIN G POTASSIU 40 111.60
05/22/06 246836 FENTANYL CITRATE 2 ML 1 3.00
05/22/06 250539 BUPROPION 100MG 3 9.00
05/22/06 272425 MIDAZOLAM 1MG/ML 2ML 4 6.00
05/22/06 273741 METOPROLOL 25 MG TAB 2 6.00
05/22/06 531233 INJ PROC CATH-SEL COR 1 329.00
05/22/06 531412 S&I IMAGE/INJ PUL,AO, 1 288.00
05/22/06 531431 CARDIAC CATH PLACEMEN 1 597.00
05/22/06 627070 IV EXT SET 90" W/FLAS 1 17.00
05/22/06 670334 IV INFUSION SET, UNIV 2 16.00
05/22/06 680004 ADULT CATHETER CHARGE 2 122.00
05/22/06 680014 HEMAQUET SHEATH/DILAT 1 147.00
05/22/06 680050 NON-IONIC CONTRAST 20 1 356.00
05/22/06 680066 CCL S & D SUPPLIES 1 320.00
05/23/06 10469 T ADULT MONITOR CARE 1 1485.00
05/23/06 102100 CULTURE, BACTERIAL 1 63.00
05/23/06 102105 CULTURE, BLOOD 3 249.00
05/23/06 102118 SMEAR, FLUOR/ACID FAS 1 34.00
05/23/06 102303 CULTURE, FUNGUS OTHER 1 38.00
05/23/06 104585 GENTAMICIN LEVEL 2 68.00
05/23/06 105656 CBC W/PLT AUTO 1 29.00
05/23/06 245475 GENTAMICIN 40MG/ML 3 27.15
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? -°L.'
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
PAGE:
Patient: WISER DOUGLAS E
Visit #: 7152927
Date
05/23/06
05/23/06
05/23/06
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05/26/06
)5/26/06
)5/26/06
---------------------------------------------
Svc Code Description Units Debits I Credits
245483 DEXTROSE 5* 50ML 2 88.20
246357 PENICILLIN G POTASSIU 40 111.60
250539 BUPROPION 100MG 1 3.00
273741 METOPROLOL 25 MG TAB 2 6.00
307101 CHEST 1 VIEW 1 114.00
621042 I V SODIUM CHLORIDE 0 1 6.00
621043 I V SODIUM CHLORIDE 0 1 6.00
712011 CV CATH PLACE,PERC,> 1 428.00
712075 CATHETER INSERTION KI 1 63.00
10469 T ADULT MONITOR CARE 1 1485.00
105078 WBC AUTO 1 18.00
245475 GENTAMICIN 40MG/ML 4 36.20
245483 DEXTROSE 5% 50ML 3 94.10
245484 DEXTROSE 5% 100ML 2 36.00
246357 PENICILLIN G POTASSIU 40 111.60
246639 GUAIFENESIN 10 ML 5 15.00
246849 FUROSEMIDE 10 MG/ML 2 3.75
247831 ACETAMINOPHEN 325 MG 4 6.00
272136 PEN G K 5MU VIAL 100 211.80
273741 METOPROLOL 25 MG TAB 2 6.00
307102 CHEST 2 VIEW A/P LAT 1 138.00
703322 IP NUTR,15 MIN,ORL/TB 1 75.00
10469 T ADULT MONITOR CARE 1 1485.00
245475 GENTAMICIN 40MG/ML 5 45.25
245483 DEXTROSE 5% 50ML 3 29.50
245484 DEXTROSE 5% 100ML 1 18.00
246639 GUAIFENESIN 10 ML 5 15.00
247831 ACETAMINOPHEN 325 MG 4 6.00
272136 PEN G K 5MU VIAL 50 105.90
273359 BUPROPION 50MG SR TAB 2 6.70
273741 METOPROLOL 25 MG TAB 2 6.00
621043 I V SODIUM CHLORIDE 0 1 6.00
10469 T ADULT MONITOR CARE 1 1485.00
48229 DUPLEX SCAN EV-COMPLE 1 441.00
104433 BASIC METABOLIC PANEL 1 40.00
245475 GENTAMICIN 40MG/ML 3 27.15
245483 DEXTROSE 5% 50ML 1 17.70
245484 DEXTROSE 5% 100ML 1 18.00
246639 GUAIFENESIN 10 ML 6 18.00
247831 ACETAMINOPHEN 325 MG 10 15.00
251019 CIPROFLOXACIN 400MG 2 27.80
272136 PEN G K 5MU VIAL 50 105.90
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Iq J
MS HERSHEY MEDICAL CENTER PAGE:
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 7152927
--------------------------------------------------------------------------------
Date I Svc Code I Description Units Debits Credits
--------------------------------------------------------------------------------
05/26/06 273359 BUPROPION 50MG SR TAB 2 6.70
05/26/06 273741 METOPROLOL 25 MG TAB 2 6.00
05/26/06 274274 VANCOMYCIN HCL INJ 6 74.85
05126106 621043 I V SODIUM CHLORIDE 0 1 6.00
05/26/06 627070 IV EXT SET 90" W/FLAS 2 34.00
05/26/06 670334 IV INFUSION SET, UNIV 1 8.00
05/27/06 10469 T ADULT MONITOR CARE 1 1485.00
05/27/06 104591 VANCOMYCIN LEVEL 2 68.00
05/27/06 105656 CBC W/PLT AUTO 1 29.00
05/27/06 105657 CBC W/PLT/DIFF AUTO 1 46.00
05/27/06 245429 HYDROCORTISONE 30 GM 1 3.05
05/27/06 245475 GENTAMICIN 40MG/ML 3 27.15
05/27/06 245483 DEXTROSE 5% 50ML 1 17.70
05/27/06 246127 DIPHENHYDRAMINE 25 MG 1 3.00
05/27/06 246130 DIPHENHYDRAMINE 50 MG 1 3.00
05/27/06 246639 GUAIFENESIN 10 ML 6 18.00
05/27/06 247831 ACETAMINOPHEN 325 MG 4 6.00
05/27/06 251019 CIPROFLOXACIN 400MG 2 27.80
05/27/06 273359 BUPROPION 50MG SR TAB 2 6.70
05/27/06 273741 METOPROLOL 25 MG TAB 2 6.00
05/27/06 274274 VANCOMYCIN HCL INJ 4 49.90
05/28/06 10469 T ADULT MONITOR CARE 1 1485.00
05/28/06 245429 HYDROCORTISONE 30 GM 1 3.05
05/28/06 245475 GENTAMICIN 40MG/ML 3 27.15
05/28/06 245483 DEXTROSE 5% 50ML 1 17.70
05/28/06 246127 DIPHENHYDRAMINE 25 MG 4 12.00
05/28/06 246639 GUAIFENESIN 10 ML 5 15.00
05/28/06 273359 BUPROPION 50MG SR TAB 2 6.70
05/28/06 273741 METOPROLOL 25 MG TAB 2 6.00
X5/28/06 274274 VANCOMYCIN HCL INJ 6 74.85
)5/28/06 600520 SPIRO INCENTIVE ADULT 1 7.00
)5/28/06 621042 I V SODIUM CHLORIDE 0 1 6.00
)5/29/06 10469 T ADULT MONITOR CARE 1 1485.00
)5/29/06 101003 ABO BLOOD GROUP 2 40.00
35/29/06 101004 ANTIBODY SCREEN 2 90.00
)5/29/06 101005 RH TYPE 2 38.00
)5/29/06 101021 COMPAT, IMMED SPIN 4 268.00
)5/29/06 102118 SMEAR, FLUOR/ACID FAS 1 34.00
)5/29/06 102195 MICRO ID, YEAST EA 1 49.00
)5/29/06 102214 CULTURE, URINE QUANT 1 38.00
15/29/06 102303 CULTURE, FUNGUS OTHER 1 38.00
5/29/06 104014 ALKALINE PHOSPHATASE 1 13.00
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fi -y
MS HERSHEY MEDICAL CENTER PAGE: 5
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 7152927
- ----------------------------P-----------------------------------------
----Date------Svc-Code-------- - -Descri ption Units Debits Credits
------- ----------------------
05/29/06 104016 BILIRUBIN TOTAL 1 13.00
05/29/06 104106 MAGNESIUM 1 15.00
05/29/06 104156 SGPT (ALT) 1 14.00
05/29/06 104438 RENAL FUNCTION PANEL 1 42.00
05/29/06 105656 CBC W/PLT AUTO 1 29.00
05/29/06 106011 URINALYSIS-BASIC & MI 1 36.00
05/29/06 245475 GENTAMICIN 40MG/ML 3 27.15
05/29/06 245483 DEXTROSE 5% 50ML 1 17.70
05/29/06 246127 DIPHENHYDRAMINE 25 MG 3 9.00
05/29/06 246639 GUAIFENESIN 10 ML 4 12.00
05/29/06 247831 ACETAMINOPHEN 325 MG 2 3.00
05/29/06 273741 METOPROLOL 25 MG TAB 2 6.00
05/29/06 274274 VANCOMYCIN HCL INJ 4 49.90
05/29/06 307102 CHEST 2 VIEW A/P LAT 1 138.00
05/29/06 521211 12 LEAD ELECTROCARDIO 1 111.00
05/29/06 621042 I V SODIUM CHLORIDE 0 1 6.00
05/29/06 670334 IV INFUSION SET, UNIV 1 8.00
05/30/06 10469 T ADULT MONITOR CARE 1 1485.00
05/30/06 104049 TROPONIN 1 57.00
05/30/06 104433 BASIC METABOLIC PANEL 1 40.00
05/30/06 104585 GENTAMICIN LEVEL 3 102.00
05/30/06 104591 VANCOMYCIN LEVEL 2 68.00
05/30/06 105067 SEDIMENTATION RATE (E 1 20.00
05/30/06 105657 CBC W/PLT/DIFF AUTO 1 46.00
05/30/06 245202 ATROPINE SULFATE 0.4 2 3.00
05/30/06 245475 GENTAMICIN 40MG/ML 5 45.25
05/30/06 245483 DEXTROSE 5% 50ML 2 29.50
05/30/06 245552 EPHEDRINE SULFATE 50 1 3.00
05/30/06 246127 DIPHENHYDRAMINE 25 MG 2 6.00
05/30/06 246130 DIPHENHYDRAMINE 50 MG 1 3.00
05/30/06 246487 SUCCINYL CHOLINE 200 10 6.40
05/30/06 246639 GUAIFENESIN 10 ML 2 6.00
05/30/06 246703 LORAZEPAM 2 MG 1 3.85
05/30/06 246831 FENTANYL CITRATE 20 M 10 4.90
05/30/06 247831 ACETAMINOPHEN 325 MG 4 6.00
05/30/06 247889 VECURONIUM BROMIDE 2 15.10
05/30/06 250577 PROPOFOL 20ML 1 13.25
05/30/06 251846 VERSED 5MG/5ML 10 6.10
05/30/06 272425 MIDAZOLAM 1MG/ML 2ML 2 3.00
05/30/06 272979 FAMOTIDINE 20MG PRE-M 1 9.80
05/30/06 273359 BUPROPION 50MG SR TAB 1 3.35
05/30/06 273741 METOPROLOL 25 MG TAB 2 6.00
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MS HERSHEY MEDICAL CENTER PAGE:
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 7152927
--------------------------------------------------------------------------------
Date I Svc Code I Description I Units) Debits I Credits
--------------------------------------------------------------------------------
05/30/06 274274 VANCOMYCIN HCL INJ 4 49.90
05/30/06 274886 HEPARIN 30ML VIAL BUL 30 4.89
05/30/06 500900 ECHO 2D+M MODE 1 501.00
05/30/06 500904 CARDIAC DOPPLER 1 309.00
05/30/06 500905 COLOR FLOW DOPPLER 1 309.00
05/31/06 10469 T ADULT MONITOR CARE 1 1485.00
05/31/06 245475 GENTAMICIN 40MG/ML 2 18.10
05/31/06 245482 DEXTROSE 5% IN WATER 1 3.00
05/31/06 245483 DEXTROSE 5% 50ML 1 11.80
05/31/06 246522 VANCOMYCIN 500 MG/10 3 30.70
05/31/06 246639 GUAIFENESIN 10 ML 3 9.00
05/31/06 246849 FUROSEMIDE 10 MG/ML 2 3.75
05/31/06 272347 MYLANTA GAS 80MG UD 1 3.00
05/31/06 273741 METOPROLOL 25 MG TAB 2 6.00
05/31/06 307101 CHEST 1 VIEW 1 114.00
05/31/06 620148 STATLOCK PICC PLUS FI 1 8.00
05/31/06 623014 ULTRASITE INJ CAP BRA 2 20.00
05/31/06 627070 IV EXT SET 90" W/FLAS 1 17.00
06/01/06 10469 T ADULT MONITOR CARE 1 1485.00
06101106 102105 CULTURE, BLOOD 2 166.00
06/01/06 104433 BASIC METABOLIC PANEL 1 40.00
06101106 104585 GENTAMICIN LEVEL 3 102.00
06101106 105657 CBC W/PLT/DIFF AUTO 1 46.00
06/01/06 245475 GENTAMICIN 40MG/ML 2 18.10
06/01/06 245482 DEXTROSE 5% IN WATER 1 3.00
06101106 245483 DEXTROSE 5% 50ML 1 11.80
06101106 246127 DIPHENHYDRAMINE 25 MG 1 3.00
06101106 246522 VANCOMYCIN 500 MG/10 3 30.70
06/01/06 246639 GUAIFENESIN 10 ML 3 9.00
06/01/06 247831 ACETAMINOPHEN 325 MG 4 6.00
06101106 273359 BUPROPION 50MG SR TAB 2 6.70
06101106 273741 METOPROLOL 25 MG TAB 2 6.00
)6/02/06 10469 T ADULT MONITOR CARE 1 1485.00
)6/02/06 104433 BASIC METABOLIC PANEL 2 80.00
)6/02/06 104591 VANCOMYCIN LEVEL 2 68.00
)6/02/06 105656 CBC W/PLT AUTO 1 29.00
)6/02/06 245475 GENTAMICIN 40MG/ML 1 9.05
)6/02/06 245483 DEXTROSE 5% 50ML 0 5.90
)6/02/06 245490 SODIUM CHLORIDE 0.9% 3 53.10
)6/02/06 246639 GUAIFENESIN 10 ML 4 12.00
)6/02/06 246836 FENTANYL CITRATE 2 ML 1 3.00
)6/02/06 247831 ACETAMINOPHEN 325 MG 4 6.00
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MS HERSHEY MEDICAL CENTER PAGE: 7
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 7152927
--------------------------------------------------------------------------------
Date I Svc Code Description I Units Debits I Credits
--------------------------------------------------------------------------------
06/02/06 249241 MIDAZOLAM 10MG/2ML 10 3.00
06/02/06 272136 PEN G K 5MU VIAL 76 158.85
06102106 273359 BUPROPION 50MG SR TAB 2 6.70
06/02/06 273741 METOPROLOL 25 MG TAB 2 6.00
06/02/06 274019 ALTEPLASE CATH 2MG VI 2 184.55
06/02/06 500905 COLOR FLOW DOPPLER 1 309.00
06/02/06 500908 TRANSESOPHAGEAL ECHO 1 847.00
06/02/06 500910 DOPPLER FOLLOW-UP LIM 1 226.00
06/02/06 621042 I V SODIUM CHLORIDE 0 1 6.00
06/02/06 627070 IV EXT SET 90" W/FLAS 1 17.00
06/02/06 670334 IV INFUSION SET, UNIV 1 8.00
06/03/06 245490 SODIUM CHLORIDE 0.9% 1 35.40
06/03/06 246639 GUAIFENESIN 10 ML 2 6.00
06/03/06 272136 PEN G K 5MU VIAL 50 105.90
06/03/06 273741 METOPROLOL 25 MG TAB 1 3.00
--------------------------------------------------------------------------------
* - Not posted I Balance: 41545.34
--------------------------
A-7
MS HERSHEY MEDICAL CENTER PAGE:
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 7216350
--------------------------------------------------------------------------------
Date I Svc Code Description units Debits I Credits
------------------------------------------------------------------------------
06/08/06 104585 I I GENTAMICIN LEVEL
06/08/06 105657 CBC W/PLT/DIFF AUTO
34.00
46.00
--------------------------------------------------------------------------------
* - Not posted Balance: 80.00
--------------------------
?q-z
MS HERSHEY MEDICAL CENTER PAGE:
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 9083071
--------------------------------------------------------------------------------
Date Svc Code Description I Unitsl Debits Credits
--------------------------------------------------------------------------------
06/08/06 46472 EMERGENCY VISIT, LEVE 1 559.00
06/08/06 46712 12 LEAD EKG-TRACING O 1 111.00
06/08/06 102105 CULTURE, BLOOD 2 166.00
06/08/06 104022 B TYPE NATRIURETIC PE 1 168.00
06/08/06 104049 TROPONIN 1 57.00
06108106 104433 BASIC METABOLIC PANEL 1 40.00
06/08/06 105656 CBC W/PLT AUTO 1 29.00
06/08/06 245490 SODIUM CHLORIDE 0.9% 1 35.40
06/08/06 246176 FUROSEMIDE 10 MG/ML 2 4.65
06/08/06 272136 PEN G K 5MU VIAL 50 105.90
06/08/06 273022 GENTRAMICIN 80MG PREM 1 8.40
06108106 307102 CHEST 2 VIEW A/P LAT 1 138.00
06/08/06 600516 PULSE OXIMETER SNSR N 1 22.00
06108106 621043 I V SODIUM CHLORIDE 0 1 6.00
06108106 627070 IV EXT SET 90" W/FLAS 3 51.00
06109106 10243 I CRITICAL CARE UNIT 1 2795.00
06109106 46061 IV SOLUTION 1 13.00
06109106 46620 ROUTINE VENIPUNCTURE 1 16.00
06/09/06 46699 THERA/DIAG INJECTION 1 53.00
06/09/06 46794 IV PUMP, SINGLE LINE 1 3.00
06109106 46843 BLADDER CATH, SIMPLE 1 132.00
06/09/06 46932 IV INF,HYDRAT,UP TO 8 1 122.00
06/09/06 70211 XD OBS EMERGENCY DEPT 8 704.00
06/09/06 102100 CULTURE, BACTERIAL 1 63.00
06109106 102215 CULTURE TYPE IMM/ANTI 2 52.00
06/09/06 104049 TROPONIN 3 171.00
06/09/06 104433 BASIC METABOLIC PANEL 1 40.00
06/09/06 105067 SEDIMENTATION RATE (E 1 20.00
06/09/06 105657 CBC W/PLT/DIFF AUTO 1 46.00
06/09/06 106011 URINALYSIS-BASIC & MI 1 36.00
06109106 245475 GENTAMICIN 40MG/ML 4 36.20
06109106 245483 DEXTROSE 5% 50ML 2 23.60
06/09/06 245490 SODIUM CHLORIDE 0.9* 1 35.40
06/09/06 245524 FUROSEMIDE 10 MG/ML 5 6.00
06/09/06 246836 FENTANYL CITRATE 2 ML 1 3.00
06/09/06 249241 MIDAZOLAM 10MG/2ML 10 3.00
D6/09/06 250539 BUPROPION 100MG 2 3.00
D6/09/06 251251 KDUR 20MEG UD 1 3.00
36109106 251365 DILTIAZEM 25MG 5 17.55
)6/09/06 272136 PEN G K 5MU VIAL 50 105.90
)6/09/06 273023 GENTAMICIN 100MG PREM 2 4.85
)6/09/06 273359 BUPROPION 50MG SR TAB 4 13.40
--------------------------------------------------------------------------------
- Continue -
Iq _?
MS HERSHEY MEDICAL CENTER PAGE:
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 9083071
--------------------------------------------------------------------------------
Date Svc Code Description Unitsl Debits Credits
--------------------------------------------------------------------------------
06/09/06 273737 PANTOPRAZOLE 40 MG TA 1 3.00
06/09/06 310516 CT THORAX ENHANCED 1 1490.00
06/09/06 310695 VISIPAQUE 320MG/ML 10 1 139.00
06/09/06 500905 COLOR FLOW DOPPLER 1 309.00
06109106 500908 TRANSESOPHAGEAL ECHO 1 847.00
06109106 500910 DOPPLER FOLLOW-UP LIM 1 226.00
06/09/06 521211 12 LEAD ELECTROCARDIO 1 111.00
06/09/06 600510 PULSE OXIMETER SNSR A 1 11.00
06/09/06 621042 I V SODIUM CHLORIDE 0 1 6.00
06109106 621043 I V SODIUM CHLORIDE 0 1 6.00
06109106 626081 IV DILUENT NML SALINE 1 8.00
06109106 627069 ST EXT MICRO 60" IML 1 7.00
06109106 627070 IV EXT SET 90" W/FLAS 2 34.00
06/09/06 630831 FOLEY CATH 16 FR W/BA 1 11.00
06/09/06 661432 BAG URINE DRAINAGE 1 13.00
06109106 667765 SCD SLEEVES, KNEE LEN 1 75.00
06109106 670330 IV INFUSION SET, UNIV 4 64.00
06109106 670334 IV INFUSION SET, UNIV 3 24.00
06/10/06 10243 I CRITICAL CARE UNIT 1 2795.00
06/10/06 101003 ABO BLOOD GROUP 1 20.00
06110106 101004 ANTIBODY SCREEN 1 45.00
06110106 101005 RH TYPE 1 19.00
06110106 101021 COMPAT, IMMED SPIN 2 134.00
06110106 101213 RED BLD CELLS EA U 1 273.00
06/10/06 104433 BASIC METABOLIC PANEL 1 40.00
06/10/06 105036 HEMATOCRIT 1 17.00
06110106 105657 CBC W/PLT/DIFF AUTO 1 46.00
06/10/06 245475 GENTAMICIN 40MG/ML 2 18.10
06/10/06 245483 DEXTROSE 5% 50ML 1 11.80
06/10/06 245490 SODIUM CHLORIDE 0.9% 1 35.40
06110106 246176 FUROSEMIDE 10 MG/ML 1 3.00
06/10/06 246849 FUROSEMIDE 10 MG/ML 4 7.50
06/10/06 251251 KDUR 20MEG UD 1 3.00
06110106 272136 PEN G K 5MU VIAL 50 105.90
06/10/06 273359 BUPROPION 50MG SR TAB 2 6.70
06/10/06 273737 PANTOPRAZOLE 40 MG TA 1 3.00
06/10/06 274789 DILTIAZEM 125MG/125ML 3 97.80
06/10/06 307101 CHEST 1 VIEW 1 114.00
06/10/06 600510 PULSE OXIMETER SNSR A 1 11.00
36110106 600520 SPIRO INCENTIVE ADULT 1 7.00
)6/10/06 627069 ST EXT MICRO 60" IML 2 14.00
)6111106 10243 I CRITICAL CARE UNIT 1 2795.00
--------------------------------------------------------------------------------
- Continue -
fi -i0
MS HERSHEY MEDICAL CENTER PAGE
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 9083071
--------------------------------------------------------------------------------
Date Svc Code Description Units Debits I Credits
--------------------------------------------------------------------------------
06/11/06 102214 CULTURE, URINE QUANT 1 38.00
06111106 104433 BASIC METABOLIC PANEL 1 40.00
06111106 105059 PROTHROMBIN TIME 1 22.00
06/11/06 105656 CBC W/PLT AUTO 1 29.00
06/11/06 111001 GLUCOSE BEDSIDE MONIT 3 81.00
06/11/06 245475 GENTAMICIN 40MG/ML 2 18.10
06/11/06 245483 DEXTROSE 5% 50ML 1 11.80
06/11/06 245490 SODIUM CHLORIDE 0.9% 1 35.40
06/11/06 245524 FUROSEMIDE 10 MG/ML 3 6.00
06111106 245814 DILTIAZEM 60 MG 3 9.00
06111106 246344 NYSTATIN 15 GM 1 15.01
06/11/06 246849 FUROSEMIDE 10 MG/ML 2 3.75
06/11/06 247684 OCEAN NASAL SPRAY 45 1 4.00
06/11/06 251251 KDUR 20MEG UD 2 3.00
06/11/06 272136 PEN G K 5MU VIAL 50 105.90
06/11/06 273359 BUPROPION 50MG SR TAB 2 6.70
06111106 273737 PANTOPRAZOLE 40 MG TA 1 3.00
06111106 274324 HUMULIN R 200 20.75
06111106 310528 CT SINUS MAXILLOFAC U 1 917.00
06/11/06 621042 I V SODIUM CHLORIDE 0 1 6.00
06111106 621044 I V SODIUM CHLORIDE 0 1 6.00
06112106 10243 I CRITICAL CARE UNIT 1 2795.00
06/12/06 101003 ABO BLOOD GROUP 2 40.00
06/12/06 101004 ANTIBODY SCREEN 2 90.00
06/12/06 101005 RH TYPE 2 38.00
06/12/06 101021 COMPAT, IMMED SPIN 6 402.00
06/12/06 104433 BASIC METABOLIC PANEL 2 80.00
06/12/06 105656 CBC W/PLT AUTO 1 29.00
06/12/06 245472 CEFAZOLIN 10 GM/50 ML 8 69.60
06/12/06 245475 GENTAMICIN 40MG/ML 2 18.10
06/12/06 245483 DEXTROSE 5% 50ML 1 11.80
06/12/06 245484 DEXTROSE 5% 100ML 1 6.00
06/12/06 245490 SODIUM CHLORIDE 0.9% 1 35.40
06112106 245524 FUROSEMIDE 10 MG/ML 8 12.00
06/12/06 245814 DILTIAZEM 60 MG 4 12.00
06/12/06 246127 DIPHENHYDRAMINE 25 MG 1 3.00
06/12/06 246176 FUROSEMIDE 10 MG/ML 1 3.00
06/12/06 246344 NYSTATIN 15 GM 1 15.01
36/12/06 246849 FUROSEMIDE 10 MG/ML 3 7.50
)6/12/06 251251 KDUR 20MEG UD 2 3.00
)6/12/06 272136 PEN G K 5MU VIAL 50 105.90
)6/12/06 273359 BUPROPION 50MG SR TAB 2 6.70
--------------------------------------------------------------------------------
- Continue -
MS HERSHEY MEDICAL CENTER PAGE:
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 9083071
-------------------------------------------------------------------------
Date I Svc Code Description I Unitsl Debits Credits
06/12/06 273737 PANTOPRAZOLE 40 MG TA 1 3.00
06/12/06 274019 ALTEPLASE CATH 2MG VI 1 184.55
06/12/06 274244 POLYETHYLENE GLYCOL-E 1 3.25
06/12/06 307101 CHEST 1 VIEW 1 114.00
06/12/06 600510 PULSE OXIMETER SNSR A 1 11.00
06/12/06 621042 I V SODIUM CHLORIDE 0 1 6.00
06/12/06 623014 ULTRASITE INJ CAP BRA 1 10.00
06/13/06 10144 I CRITICAL CARE UNIT 1 2795.00
06/13/06 101120 THAW FROZ PLASMA/U 2 40.00
06/13/06 101213 RED BLD CELLS EA U 3 819.00
06/13/06 101220 FFP SINGLE DONOR EA U 2 308.00
06/13/06 104028 IONIZED CALCIUM 5 415.00
06113106 104060 GLUCOSE, BLOOD 4 48.00
06/13/06 104106 MAGNESIUM 1 15.00
06/13/06 104110 BLOOD GAS PANEL 3 366.00
06/13/06 104111 BLOOD GAS PANEL W/02 4 580.00
06113106 104131 POTASSIUM (K), BLOOD 6 78.00
06/13/06 104145 SODIUM (NA), BLOOD 4 52.00
06/13/06 104433 BASIC METABOLIC PANEL 1 40.00
06/13/06 104438 RENAL FUNCTION PANEL 1 42.00
06/13/06 104585 GENTAMICIN LEVEL 2 68.00
06/13/06 105036 HEMATOCRIT 1 17.00
06/13/06 105052 PARTIAL THROMBOPLAS T 2 72.00
06/13/06 105059 PROTHROMBIN TIME 2 44.00
06/13/06 105656 CBC W/PLT AUTO 1 29.00
06/13/06 105657 CBC W/PLT/DIFF AUTO 1 46.00
06/13/06 191023 LVL4 SURGICAL PATHOLO 1 82.00
06/13/06 191090 GRP1 STAIN-MICRO 1 67.00
06/13/06 245202 ATROPINE SULFATE 0.4 2 3.00
06/13/06 245475 GENTAMICIN 40MG/ML 2 18.10
06/13/06 245483 DEXTROSE 5% 50ML 1 11.80
06/13/06 245490 SODIUM CHLORIDE 0.9% 1 35.40
06/13/06 245524 FUROSEMIDE 10 MG/ML 5 6.00
06/13/06 245540 ETOMIDATE 2 MG/ML 1 23.90
06/13/06 245552 EPHEDRINE SULFATE 50 1 3.00
06/13/06 245626 NORMAL SERUM ALBUMIN 4 247.80
06/13/06 245994 AMINOCAPROIC ACID 5 G 4 27.95
06/13/06 246130 DIPHENHYDRAMINE 50 MG 1 3.00
06/13/06 246162 FENTANYL CITRATE 5 ML 3 9.00
06/13/06 246185 HEPARIN SODIUM 1000 U 10 9.35
06/13/06 246340 NITROPRUSSIDE 50 MG 2 35.10
06113106
------------- 246487
----------- SUCCINYL CHOLINE 200
----------------------- 10
------- 6.40
-------------
-------------
- Continue -
A -iz'
MS HERSHEY MEDICAL CENTER PAGE: 5
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 9083071
--------------------------------------------------------------------------------
Date Svc Code ( Description Unitsl Debits I Credits
--------------------------------------------------------------------------------
06/13/06 246643 PHENYLEPHRINE 10 MG/M 2 6.20
06/13/06 246706 MORPHINE SULFATE 2 MG 1 3.00
06/13/06 246831 FENTANYL CITRATE 20 M 20 9.80
06/13/06 247842 CAL GLUCONATE 10ML 1 10.85
06/13/06 247889 VECURONIUM BROMIDE 1 7.55
06/13/06 248474 NITROGLYCERIN INF 200 1 18.70
06/13/06 248787 PROTAMINE SULFATE 250 50 57.40
06/13/06 250084 VANCOMYCIN 1GM 2 16.60
06/13/06 250092 OXYCODONE APAP 1TAB 2 3.00
06113106 250577 PROPOFOL 20ML 2 26.50
06/13/06 251129 POTASSIUM CHLORIDE 10 5 5.25
06/13/06 251130 POTASSIUM CHLORIDE 50 20 10.15
06/13/06 251846 VERSED 5MG/5ML 20 12.20
06/13/06 272129 ROCURONIUM BROMIDE 5M 2 64.85
06/13/06 272136 PEN G K 5MU VIAL 50 105.90
06/13/06 272199 -ONDANSETRON 2MG/ML 2M 4 54.45
06/13/06 272979 FAMOTIDINE 20MG PRE-M 1 9.80
06/13/06 273298 COMBIVENT INHALER 14. 1 241.00
06/13/06 273954 DOPAMINE 400 MG BAG 10 38.30
06113106 274886 HEPARIN 30ML VIAL BUL 30 4.89
06/13/06 307101 CHEST 1 VIEW 1 114.00
06/13/06 391101 OR TIME<=lHR EACH 15M 4 2176.00
06113106 391102 OR TIME>lHR EACH 15MI 15 3735.00
06/13/06 391492 VALVE, HEART, MITRAL, 1 9746.00
06/13/06 398230 SUTURE, SINGLE ARM 8 72.00
06/13/06 398231 SUTURE, DOUBLE ARM 16 272.00
06/13/06 398232 SUTURE, MULTIPACK 3 96.00
06/13/06 398233 CT/SPECIALTIES 5 85.00
06/13/06 459055 DRAPE SURGICAL SLUSH 1 101.00
06/13/06 461244 LEAD MYOCARDIAL TEMPO 1 108.00
06/13/06 461381 ROUND BLAKE DRAIN, 19 2 136.00
06/13/06 480024 HEMOCONCENTRATOR 1 459.00
06/13/06 480027 CARDIOPULMONARY BYPAS 1 8693.00
06/13/06 480043 CARDIOPLEG CLD INDUCT 1 314.00
06/13/06 480044 CARDIOPLEG MAINT SOLN 1 314.00
)6/13/06 500905 COLOR FLOW DOPPLER 1 309.00
)6/13/06 500908 TRANSESOPHAGEAL ECHO 1 847.00
)6/13/06 500910 DOPPLER FOLLOW-UP LIM 1 226.00
)6/13/06 502000 ANESTHESIA TIME-HOSP 19 1344.00
)6/13/06 503038 QUAD TRANSDUCER SET U 1 469.00
)6/13/06 503106 VIP SWAN 1 120.00
)6/13/06 503123 ADULT A-LINE KIT 1 32.00
--------------------------------------------------------------------------------
- Continue -
9-d
MS HERSHEY MEDICAL CENTER PAGE: 7
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 9083071
--------------------------------------------------------------------------------
Date I Svc Code I Description I Unitsl Debits I Credits
--------------------------------------------------------------------------------
06/14/06 272987 CEFAZOLIN 1 GM PRE-MI 2 10.95
06/14/06 273741 METOPROLOL 25 MG TAB 2 6.00
06/14/06 307101 CHEST 1 VIEW 1 114.00
06/14/06 620148 STATLOCK PICC PLUS FI 1 8.00
06/14/06 621105 YANKAUER SUCT TB W/O 5 25.00
06/14/06 623014 ULTRASITE INJ CAP BRA 2 20.00
06/14/06 670334 IV INFUSION SET, UNIV 1 8.00
06/14/06 670722 FEEDING BG ENTERAL 10 1 4.00
06/15/06 10469 T ADULT MONITOR CARE 1 1485.00
06/15/06 101003 ABO BLOOD GROUP 1 20.00
06/15/06 101004 ANTIBODY SCREEN 1 45.00
06/15/06 101005 RH TYPE 1 19.00
06/15/06 101021 COMPAT, IMMED SPIN 4 268.00
06/15/06 101213 RED BLD CELLS EA U 2 546.00
06/15/06 104106 MAGNESIUM 3 45.00
06/15/06 104131 POTASSIUM (K), BLOOD 3 39.00
06/15/06 104438 RENAL FUNCTION PANEL 3 126.00
06/15/06 104585 GENTAMICIN LEVEL 2 68.00
06115106 105052 PARTIAL THROMBOPLAS T 1 36.00
06/15/06 105059 PROTHROMBIN TIME 1 22.00
06/15/06 105656 CBC W/PLT AUTO 2 58.00
06/15/06 245204 DEXTROSE 50 ML 1 6.40
06115106 245475 GENTAMICIN 40MG/ML 2 18.10
06/15/06 245483 DEXTROSE 5% 50ML 1 11.80
06/15/06 245490 SODIUM CHLORIDE 0.9% 1 35.40
06115106 246175 FUROSEMIDE 40 MG 1 3.00
06/15/06 246176 FUROSEMIDE 10 MG/ML 1 3.00
06/15/06 246400 PROMETHAZINE 25 MG/ML 1 3.00
06115106 246449 PSYLLIUM,HYDROPH MUC. 1 3.00
06/15/06 246517 WARFARIN SODIUM 5 MG 1 3.00
06115106 246621 DOCUSATE SODIUM 100 M 2 6.00
06/15/06 246849 FUROSEMIDE 10 MG/ML 2 3.75
)6/15/06 248356 METOPROLOL 5MG/5ML 2 21.00
)6/15/06 250092 OXYCODONE APAP 1TAB 8 12.00
)6/15/06 251170 MORPHINE SULFATE 15MG 2 6.00
)6/15/06 251251 KDUR 20MEG UD 2 3.00
)6/15/06 251492 SODIUM POLYSTYRENE SU 4 28.17
)6/15/06 272136 PEN G K 5MU VIAL 50 105.90
)6/15/06 272611 AMIODRONE 150MG 13MC 5 6.85
)6/15/06 272911 HEPARIN 25,000U/250ML 25 16.30
)6/15/06 272968 ENTERIC COATED ASPIRI 1 3.00
)6/15/06 273741 METOPROLOL 25 MG TAB 2 6.00
Continue
MS HERSHEY MEDICAL CENTER PAGE:
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 9083071
--------------------------------------------------------------------------------
Date I Svc Code I Description Units Debits I Credits I
--------------------------------------------------------------------------------
06/15/06 274477 AMIODARONE 450MG/250M 15 49.00
06/15/06 274597 CALCIUM GLUCONATE 1G/ 10 28.40
06/15/06 521211 12 LEAD ELECTROCARDIO 2 222.00
06/15/06 600510 PULSE OXIMETER SNSR A 2 22.00
06/15/06 621042 I V SODIUM CHLORIDE 0 2 12.00
06/15/06 623078 SET FILTER .22 MICRON 1 11.00
06/15/06 625011 IV ADMIN SET BLOOD FI 1 23.00
06/15/06 626081 IV DILUENT NML SALINE 1 8.00
06/15/06 627070 IV EXT SET 90" W/FLAS 4 68.00
06116106 10469 T ADULT MONITOR CARE 1 1485.00
06116106 104106 MAGNESIUM 2 30.00
06/16/06 104438 RENAL FUNCTION PANEL 2 84.00
06116106 104585 GENTAMICIN LEVEL 2 68.00
06116106 105052 PARTIAL THROMBOPLAS T 3 108.00
06116106 105059 PROTHROMBIN TIME 1 22.00
06/16/06 105656 CBC W/PLT AUTO 1 29.00
06116106 245475 GENTAMICIN 40MG/ML 1 16.60
06116106 245483 DEXTROSE 5% 50ML 1 11.80
06116106 245490 SODIUM CHLORIDE 0.9% 1 35.40
06116106 246175 FUROSEMIDE 40 MG 1 3.00
06116106 246449 PSYLLIUM,HYDROPH MUC. 2 6.00
06116106 246517 WARFARIN SODIUM 5 MG 1 3.00
06116106 246621 DOCUSATE SODIUM 100 M 1 3.00
06116106 250092 OXYCODONE APAP 1TA13 6 9.00
06116106 251130 POTASSIUM CHLORIDE 50 20 10.20
06/16/06 251170 MORPHINE SULFATE 15MG 2 6.00
06116106 251251 KDUR 20MEG UD 2 3.00
06116106 272136 PEN G K 5MU VIAL 50 105.90
06/16/06 272967 BAZA CR 60GM TUBE 1 15.45
06/16/06 272968 ENTERIC COATED ASPIRI 1 3.00
06116106 273741 METOPROLOL 25 MG TAB 2 6.00
)6/16/06 274477 AMIODARONE 450MG/250M 45 147.00
36/17/06 10469 T ADULT MONITOR CARE 1 1485.00
)6/17/06 101213 RED BLD CELLS EA U 2 546.00
)6/17/06 104106 MAGNESIUM 1 15.00
)6/17/06 104438 RENAL FUNCTION PANEL 1 42.00
)6/17/06 105036 HEMATOCRIT 1 17.00
)6/17/06 105052 PARTIAL THROMBOPLAS T 3 108.00
)6/17/06 105059 PROTHROMBIN TIME 3 66.00
16/17/06 105656 CBC W/PLT AUTO 1 29.00
6/17/06 245475 GENTAMICIN 40MG/ML 1 16.60
6/17/06 245483 DEXTROSE 5% 50ML 1 11.80
--------------------------------------------------------------------------------
- Continue -
1? -!4
MS HERSHEY MEDICAL CENTER PAGE:
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 9083071
--------------------------------------------------------------------------------
I Date I Svc Code I Description I Units Debits I Credits I
--------------------------------------------------------------------------------
06/17/06 245490 SODIUM CHLORIDE 0.9% 1 35.40
06/17/06 246175 FUROSEMIDE 40 MG 1 3.00
06/17/06 246449 PSYLLIUM,HYDROPH MUC. 1 3.00
06/17/06 246517 WARFARIN SODIUM 5 MG 1 3.00
06/17/06 246621 DOCUSATE SODIUM 100 M 2 6.00
06/17/06 250092 OXYCODONE APAP 1TAB 8 12.00
06/17/06 250341 AMIODARONE 200MG 2 6.00
06/17/06 251251 KDUR 20MEG UD 4 6.00
06/17/06 272136 PEN G K 5MU VIAL 50 105.90
06/17/06 272911 HEPARIN 25,000U/250ML 25 16.30
06/17/06 272968 ENTERIC COATED ASPIRI 1 3.00
06/17/06 273737 PANTOPRAZOLE 40 MG TA 1 3.00
06/17/06 273741 METOPROLOL 25 MG TAB 2 6.00
06/17/06 274477 AMIODARONE 450MG/250M 15 49.00
06/17/06 307102 CHEST 2 VIEW A/P LAT 1 138.00
06/17/06 621043 I V SODIUM CHLORIDE 0 1 6.00
06/17/06 625011 IV ADMIN SET BLOOD FI 2 46.00
06118106 10469 T ADULT MONITOR CARE 1 1485.00
06/18/06 104106 MAGNESIUM 1 15.00
06/18/06 104438 RENAL FUNCTION PANEL 2 84.00
06/18/06 104585 GENTAMICIN LEVEL 2 68.00
06/18/06 105052 PARTIAL THROMBOPLAS T 1 36.00
06118106 105059 PROTHROMBIN TIME 1 22.00
06118106 105656 CBC W/PLT AUTO 1 29.00
06/18/06 245475 GENTAMICIN 40MG/ML 1 16.60
06118106 245483 DEXTROSE 5% 50ML 1 11.80
06118106 245490 SODIUM CHLORIDE 0.9% 1 35.40
06/18/06 246175 FUROSEMIDE 40 MG 1 3.00
06/18/06 246449 PSYLLIUM,HYDROPH MUC. 1 3.00
06/18/06 246517 WARFARIN SODIUM 5 MG 1 3.00
06/18/06 246621 DOCUSATE SODIUM 100 M 2 6.00
06118106 250092 OXYCODONE APAP 1TAB 8 12.00
06118106 250341 AMIODARONE 200MG 2 6.00
D6/18/06 272136 PEN G K 5MU VIAL 50 105.90
D6/18/06 272911 HEPARIN 25,000U/250ML 25 16.30
36/18/06 272967 BAZA CR 60GM TUBE 1 15.45
)6/18/06 272968 ENTERIC COATED ASPIRI 1 3.00
)6/18106 273737 PANTOPRAZOLE 40 MG TA 1 3.00
)6/18/06 273741 METOPROLOL 25 MG TAB 2 6.00
)6/18/06 521211 12 LEAD ELECTROCARDIO 2 222.00
)6/18/06 621043 I V SODIUM CHLORIDE 0 1 6.00
)6/19/06 1001 INTIAL EVALUATION-PT 1 151.00
- Continue -
MS HERSHEY MEDICAL CENTER PAGE: 10
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 9083071
--------------------------------------------------------------------------------
Date Svc Code ( Description Units Debits Credits
--------------------------------------------------------------------------------
06/19/06 104106 MAGNESIUM 1 15.00
06119106 104438 RENAL FUNCTION PANEL 1 42.00
06/19/06 105059 PROTHROMBIN TIME 1 22.00
06119106 105656 CBC W/PLT AUTO 1 29.00
06/19/06 246175 FUROSEMIDE 40 MG 1 3.00
06/19/06 250092 OXYCODONE APAP 1TAB 4 9.00
06119106 250341 AMIODARONE 200MG 1 3.00
06119106 251251 KDUR 20MEG UD 2 3.00
06/19/06 272968 ENTERIC COATED ASPIRI 1 3.00
06/19/06 273737 PANTOPRAZOLE 40 MG TA 1 3.00
06/19/06 273741 METOPROLOL 25 MG TAB 1 3.00
06/19/06 521211 12 LEAD ELECTROCARDIO 1 111.00
--------------------------------------------------------------------------------
* - Not posted Balance: 73075.63
9-a
MS HERSHEY MEDICAL CENTER PAGE: 1
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:26 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 7313896
--------------------------------------------------------------------------------
Date I Svc Code I Description I Unitsl Debits I Credits
--------------------------------------------------------------------------------
07/11/06 ( 307102 I CHEST 2 VIEW A/P LAT 1 I 145.00
--------------------------------------------------------------------------------
* - Not posted Balance: 1 145.00
? -o
MS HERSHEY MEDICAL CENTER PAGE:
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:25 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 7321906
-----------------------
Date Svc Code ------------------------
Description --------
Units -------------------------
Debits ( Credits
-----------------------
108/10/06 I 521211 ------------------------
112 LEAD ELECTROCARDIOI --------
1 I -------------------------
117.00
--
-----------------------
* - Not posted ------------------------ --------
- ------------------
-----
Balance: I 117.00
-------------------------
-"), 0
MS HERSHEY MEDICAL CENTER PAGE: 1
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/31/06 at 11:25 AM
Guarantor: WISER DOUGLAS E
1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257-0000
Patient: WISER DOUGLAS E
Visit #: 7321788
-----------------------
Date I Svc Code I -----------------------
Description ---------
I Units
----- -------------------------
Debits I Credits I
-------------------------
------------
08/10/06 ------------
500900 ----------------------
ECHO 2D+M MODE ----
1 526.00
08/10/06 500904 CARDIAC DOPPLER 1 324.00
08110106 500905 COLOR FLOW DOPPLER 1 324.00
---------
-------------
------------------------
* - Not posted ---------------------- ---------
I
- ---
Balance: 1174.00
-------------------------
fi -mil
STATEMENT OF PHYSICIAN SERVICES
PENNSTATE DOUGLAS E WISER 1 at 6
STATEMENT
IF The Mail = S. Hmbey Medical Center' 1838 PENSBUHIGHWAY
7257-9570
The College of Medicine DATE: 10!31!06
LAST STATEMMEMR
ACCOUNT # 1573433 DATE: 091MOS
IF ANY QUESTICUIS. PLEASE CONTACT. MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 25185703:
?7? PAUM : UULWLM C PU5tK L' /5RSS
7]52927
PERFORMED BY: MICHAEL A BRIBE MD DIV OF DIAG RADIOLOGY
PLACE OF SVC: INPATIENT
05/19/06 7101026 786.9 CHEST I VIEW 57.00
PERFORMED BY: MICHAEL J LAZAR MD CT SURBERY
05/19/06 99222 421.0 INITIAL MSP77AL CARE 274.0D
PERFORMED BY: ROBERT C ABER MD DIV OF INFECT MS & EPIDN
05/19/06 99255 421.0 INITIAL INPT CONSULTATION 469.00
PERFO1KD BY: EDWARD 6 LIMA MD IMAGING
05/19/06 93010 421.0 ECG ELECTROCARD INTERP 65.00
PERFORMED BY: TIMOTHY J MOSRER NO DIV OF DIAL RADI01.09Y
05/20/06 7047026- 437.1 CT HEAD UNENI & ENHANCED 395.001
PERFORMED BY: JANET A NEUM MD DIV OF DIAL RADICL06Y
05/20/06 7416026 785.6 C T ABDOMEN ENHANCED 393.00
05/20/06 7219326 785.6 CT PELVIS ENHANCED 359.00
05/20/06 7126026 518.89 CT THORAX N/CONiRAST ENH 382.DD
PERFORMED BY: ROBERT C ABER MD DIV OF INFECT DIS & EPIOM
05/20/06 99232 421.0 HOSP VISIT INTER-CC I37.D0
05/21/06 99231 421.0 HOSP VISIT BRIEF CC 82.00
PERFORMED BY: EDWARD 6 LISaU MD IMAGING
.__.05/21/06---99253--- ....421.0. INITIAL INPT CONWLTATIOW -234.00-
PERFORMED BY: STEVE M ETTINBER MD INTERVENTIONAL
05/22/06 9350026 V72.81 CDR OATH PLACE ONLY 921.00
05/22/06 93545 V72.81 ANGIO - CORONARY 767.00
05!22106 9355626 V72.81 INTERP - ANGIO 430.00
PERFORMED BY: JOHN J BAUD MD DIV OF INFECT DIS & EPIOM
05/22/06 99232 421.D HOSP VISIT INTER CC 137.00
PERFORMED BY: JANET A NEUTZE MD DIV OF DIAG RADIOLOGY
05/23/06 7101026 514 CHEST 1 VIEW 57.DO
PERFORMED BY: JOHN J ZURLO NO DIV OF INFECT DIS & EPIOM
05/23/06 99232 421.0 HOSP VISIT INTER M 137.00
PERFORMED BY: RITU RAJNAR MD DIV OF DIAL RADIOLOGY
05/24/06 7102026 518.0 CHEST 2 VIEWS FRONT/LAT 69.00
? CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
wn
aa?ns
enn
r
v?
-d
57.00
274.00
469.00
65.00
395.00
393.00
359.00
382. DO
137.00
82.00
234.00
921.00
767.00
450.00
137.00
57.00
137.00
69.00
„
STATEMENT OF PHYSICIAN SERVICES
PENNSTATE DOUGLAS E WISER
The Wpm S. Hershq Medical Center SH P ENSBURG PA 17257-9570
10 The College of Median
ACCOUNT ¢# 1573433
IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES
05/24/06 99232 421.0
05/25/06 99232 421.0
05/26/06 9397026 729.5
05/26/06 99232 682.4
05/27/06 99232 421.0
05/27/06 99232 682.4
05/28/06 99232 682.4
05/29/06 7102026 V72.84
05/29/06 99232 682.4
05/29/06 93010 V72.8
05/30/06 9332026 424.0
-D5/30/06.9330726-. 424.0
05/30/06 9332526 424.0
05/30/06 99232 682.4
05/30/06 99232 421.0
05/31/06 7101026 511.9
05/31106 99232 682.4
06101106 99232 682.4
06/02/06 9332126 424.0
STATEMENT
DATA 10151106
LAST STATEMENT
DATE: 09129106
FED TAX ID#2
HOSP VISIT INTER CC 137.00
WSP VISIT INTER CC 137.00
PERFORMED BY: KARLA ANDERSON NO VASCULAR SURGERY
4UPLEX SCAN EV - COMPLETE 230.00
PERFORMED BY: JOHN J ZURLO MD DIV OF INFECT DIS A EPIDM
HOSP VISIT INTER CC 137.00
PERFORMED BY: MICHAEL J LAZ'AR MO CT SURGERY
DAILY HOSPITAL CARE 137.00
PERFORMED BY: JON J ZURLO MD DIV OF INFECT DIS A EPIOM
HOSP VISIT INTER M 137.00
HOSP VISIT INTER CC 137.00
PERFORMED BY: THOMAS M DYKES MD DIV OF DIAL RADIOLOGY
CHEST 2 VIENS FRONT/LAT 69.00
PERFORMED BY: JOHN J ZURLO MD DIV OF INFECT DIS & EPIDN
HOSP VISIT INTER CC 137.00
PERFORMED BY: MIN PU MD IMAGING
ECG ELECTROCARD'INTERP 65.00
PERFORMED BY: EDMARD G LIMA NO IMAMS
DDPPLERs COMP 285.00
2D/M-FDDE ECHO) COMP 425.00
DOPPLER COLOR FL VEL MAP 203.00
PERFORMED BY: JON J ZURLD MD DIV OF INFECT DIS A EPIDN
HOSP VISIT INTER M 137.00
PERFORMED BY: JOSEPH A GASCHO FD IMAGING
IDSP VISIT INTER CC 137.00
PERFORMED BY: KAVITA B SANGHVI MD DIV OF DIAL RADIOLOGY
CHEST I VIEN 57.00
PERFORMED BY: JOHN J ZURLO MD DIY OF INFECT DIS & EPIDM
HOSP VISIT INTER CC 137.00
HOSP VISIT INTER CC 137.00
PERFORMED BY: URS A LEUEBERGER MD IMAGING
DOPPLER) LIMIT los:OD
BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
2 of 6
137.00
137.00
230.00
137.00
137.00
137.00
137.00
69.00
137.00
65.00
285.DO
425.00
203.00
137.00
137.00
57.00
137.00
137.00
108.00
I. •
STATEMENT OF PHYSICIAN SERVICES
pEN1VSTATE DOUGLAS E WISER 3 of 6
1838 Rni HIGHWAY
The 1V?. --m S. Hershey Medical Center SHIPPENSBURG PA 17257-9570 STATEMENT
The College of Medicine DATE: I W31106
LAST STATEMENT
ACCOUNT # 1573433 DATE. 0912WOO
IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID 25185705:
6/02/06 1 2 424.11 TEE) COMP P9. 0 659. 0
06/02/06 9332326 424.0 DOPPLER COLOR FL VEL MAP 203.00 203.00
PERFORMED BY: JOIN J ZIMLD MD DIV OF INFECT DIS A EPIDM
06/02/06 99232 682.4 HOSP VISIT INFER CC 137.00 137.00
W03/06 99232 682.4 HOSP VISIT INFER CC 137.00 137.00
7225167
PERFORMED BY: MICHAEL J LAZAR MD CT SURGERY
PLACE OF SVC: . OP PHYSICIAN
07/11/06 99024 V42.2 POST-011 FOL-l>P VISIT 0.00 0.00
7247623
PERFDINED BY: TWA J CROOK MD DIV OF INFECT DIS & EPIDM
PLACE OF SVC: OP HOSPITAL
07/06/06 99214 424.90 C/C OUTPATIENT VLS EST 122.00 122.00
7319%
PERFORMED BY: JANET A NEUME MD DIV OF DIAL RADIOLOGY
PLACE OF SVC: OP HOSPITAL
07/11/06 7102026 511.9 CNEST 2 VIEWS FRW/LAT 72.00 72.00
7321394
PERFORMED BY: TWA J CROOK NO DIV OF INFECT DIS B EPIOM
PLACE OF SVC: OP HOSPITAL
0647.0/06 99214 9%.61 C/C OUfPATTENf VIS EST 122.00 122.00
7321786
PERFORMED BY: ANDREW D WSER MD IMAGING
PLACE'-OF SVC: OP HOSPITAL
06/10/06 9330726 424.1 21I/M-MODE ECHO) COMP 446.00 446.00
06/10/06 9332026 424.1 DOPPLER) COMDR 299.00 299.00
06/10/06 9332526 424.1 DOPPLER COLOR FL VEL MAP 213.00 213.00
7321906
PERFORMED BY: JOSEPH A GASCHD MD IMAGING
PLACE OF SVC: OP PHYSICIAN
06/10106 99211 427.31 WPPATIENf VISIT EST 46.00 48.00
PERFORMED BY: URS A LEUEtBERGER MD IMAGING
06/10106 93010 427.31 ECG ELECTROCARD INTER,P 68.00 65.00
9053071
PERFORMED BY: KAVITA B SANGHYI MD DIV OF DIAL RADIOLOGY
PLACE OF SVC: EMERGENCY ROOM
06100/06 7102026 514 CHEST 2 VIEWS FRDNf/LAT 69.00 69.00
BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
Iq ` o 1
to s
STATEMENT OF PHYSICIAN SERVICES
PENNSTATE DOUGLAS E WISER
The N Mtn S. Hersh Medical Center SHIPPENSBURGGPA 1? 95M
10 The College of Medicine
ACCOUNT # 7573433
IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES_
4 of 6
STATEMENT
DATE: 101$1106
LAST STATEMENT
DATE: 09128106
FED TAX ID # 251857035
PERKIWD 6C: !RABIC E LUBELL FlU ULY ur uiw unuiuluwr
PLACE OF SVC: INPATIENT
06/09/06 7126026 785.6 CT THORAX N/CWRAST ENN 382.00
PERFORMED BY: MIN PU MD IMAGING
06/09/06 9332126 424.0 DOPPLER) LIMIT 108.00
06/09/06 9332526 424.0 DOPPLER COLOR FL VEL MAP 203.00
06/09/06 9331226 424.0 TEE) COMP 859.00
PERMED BY: JOHN FIELD NO GENERAL CARDIOLOGY
06/09/06 99223 426.0 INITIAL HOSPITAL CARE 384.00
06/09/06 93010 427.31 ECG ELECTROCARD IITERP 65.00
PERFORMED BY: ROBERT P STECHER NO DIV OF DIAL RADIOLOGY
06/10/06 7101026 514 CHEST 1 VIEN 57.00
PERFORMED BY: JON FIELD MD GENERAL CARDIOLOGY
06/10/06 99233 428.0 DAILY HOSPITAL CARE 194.00
PERFORMED BY: DAN T NGINEN NO DIV OF DIAS RADIOLOGY
'06/11/06 7048626 473.0 CT MXILLOFACIAL UNENH 353.00
PERFORMED BY: JOHN FIELD MD GENERAL CARDIOLOGY
06/11/06 99233 428.0 DAILY HOSPITAL CARE 194.00
PERFORMED BY: ROBERT P STECHER MD DIV OF DIAL RADIOLOGY
06/12/06 7101026 511.9 CHEST 1 VIEN 57.00
PERFORMED BY: JOHN FIELD NO GENERAL CARDIOLDGY .
06/12/06 99233 428.0 DAILY HOSPITAL CARE 194.00
PERFORMED BY: CYNTHIA J MMITENER MD DIV OF INFECT DIS & EP
06/13/06 99254 421.0 INITIAL INPT CONSULTATION 338.00
PERFORMED BY: EDMARD G LIMA MD IMAGING
06/13/06 9331426 424.0 TEE) I/R ONLY 515.00
06/13/06 9332526 424.0 DOPPLER COLOR FL VEL MAP 203.00
06/13/06 9332126 424.0 4OPPLER) LIMIT 108.00
PERFORMED BY: MARK E LOBELL MD DIV OF DIAL RADIOLOGY
06/13/06 7101026 518.89 CHEST 1 VIEN 57.00
PERFORMED BY: ASHRAF A ABOUELELLA MD DIV OF ANATOMIC PATHO
06/13/06 8830526 424.90 TISSUE EXAM LEVEL 4 156.D0
06113/06 8831226 424.90 SPECIAL STAINS-MICRO 113.00
?CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
?6
382.00
108.00
203.00
859.00
384.00
65.00
57.00
194.00
353.00
194.00
57.00
194.00
338.00
515.00
203.00
108.00
57.00
156.00
113.00
Y to f
STATEMENT OF PHYSICIAN SERVICES
PENNSTATE DOUGLAS E WISER 5 at 6
1838 RITNER HIGHWAY STATEIIEMT
41 The 1t+1?i1t0lt S. Hersh Medical Center SHIPPENSBURG PA 17257.9570
The College of Ned thine LATE: 10151106
LAST STATEUW
ACCOUNT # 1573433 DATE: 09128106
IF ANY QUESTIOU, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES _ FED TAX ID # 251857
-- - ------------
P POWD BY: HiGNAEL J LACM RIP GI MKT
06/13/06 33430 394.9 KMAL VALVE REPLACE N BY 8810.00 8610.00
PERFORMED BY: DAVID M FEHR MO DIV OF ANESTHESIA
06/13/06 ON62 394.9 42 WITH PUMP WGENATOR 3696.00 36%.00
06/13/06 93503 394.9 SWAN GANZ CATHETER 805.00 805.00
06/13/06 36620 394.9 ART OATH PERCUTAN 303.00 303.00
PERFORMED BY: KAVITA B SANGHVI ND DIV OF DIAL RADMLOGY
06/14/06 7101026 786.09 CHEST 1 VIEW 57.00 57.DD
PERFORMED BY: JOHN FIELD MD GENERAL CARDIOLOGY
06/15/06 93010 426.82 ECG ELECTRDCARD INTERP 65.00 65.00
06/15/06 93010.76 427.31 ECG ELECTROCARD INTERP 65.00 65.00
PERFORMED BY: CYNTHIA J WHITENER ND DIY OF INFECT DIS 8 EP
06/16/06 99232 421.0 HOSP VISIT INTER CC 137.00 137.00
06/17/06 99232 421.0 HASP VISIT INTER M 137.00 137.00
PERFORMED BY: RAFEL F TAPPOlNI MD DIV OF DIAL RADIOLOGY
06/17/06 7102026 511.9 CHEST 2 VIEWS FRONT/LAT 69.OD 69.00
PERFORMED BY: EDWARD G LIS IA HD IMAOM
06/18/06 93010 426.11 ECG ELECTRDCARD INTERP 65.00 65.00
06/18/06 93010.76 426.11 ECG ELECTROCARD INTERP 65.00 65.00
.06/19/06 -93010--- 426.11 ECG ELECTROCARD INTERP 65.00 65.00
BALANCE: DOUGLAS E WISER 930008.00
IF YOU HAVE ANY QUESTIONS ABOUT THE AMMINT YOUR INSURANCE
COMPANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTHER QUESTIONS
REGARDING YDUR BALANCE, PLEASE CONTACT MIR OFFICE. IF PAYMENT
HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL.
aetaERBM],?Uee
THANK YOU FOR USING MSHHMC PHYSICIANS GROUP FOR YOUR PHYSICIAN
SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE
CONTACT US AT 717-531-5069 OR 800-254-2619, BETWEEN 8:ODAM AND
5;30PM MONDAY THROUGH NEDNESDAY OR BETWEEN B:DOAM AND 4:30PH
THIIRSSDAY AND FRIDAY.
CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE
ON BACK
t• ¦
STATEMENT OF PHYSICIAN SERVICES
PENNS TATS DOUGLAS E WISER
1838 RITNER HIGHWAY
41 The W- ton S. Hershey Medical Center SHIPPENSBURG PA 17257-9570 STATEMEIIT
7be College of Medicine DATE 10/31106
LAST STATEMENT
ACCOUNT # 1573433 DATE. 09128106
IF ANY QUESTIONS, PLEASE CONTACT. MSHMC PATIENT FINANCIAL SERVICES FED TAX ID * 2511
SAME 21190Y ALE PARTY POLICY # MIX
NNE GUARMIMR RESPONSIBILITY 4 30005.00
6 Of 6
Nf?ORTANT PLEASE OETAC N AND RETURN 812TTOR Q(R IGN RF.STATE1f??ET -MURPAYifNET
STATEMENT DATE; GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT
BF6 10131106 $ 3000LOO $ 30008.00
MSHMC PHYSICIANS GROUP
BILLING SERVICES
H OERSBHEXY PA 1703M854
00001573433 UP 0000000003000800103106
11IN1111111111111111111111IIIIIt11111111INIIIIIIKill III11twill
Ma?? MSHMC PHYSICIANS GROUP DOUGLAS E WISER
Ta 1838 RITNER HIGHWAY
PO BOX 643313 SHIPPENSBURG PA 17257-9570
PITTSBURGH PA 15264-3313
OFRCE USE ONLY FOR CREDIT CARD PAYMENT, PLEASE FILL IN INFORMATIDN BELDW
1573433
CHBCKONE 11111111111111111
_M/C CARD NUMBER ECP DATE
_VISA 808.00 111211
HC: F6130 -DISC CARDHOLDER NAME (PRINT)
TYP : DMND
CREDIT CARD SIGNATURE MSHMC PHYSICIANS GROUP
CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON 13ACK
WISERpOGUGLAS #1573433 $116,136.97 (Hosp)
30,008.00 (Phys)
VERIFICATION
LINDA SCHLADER hereby states that she is the
Team Manager, Customer Service of the Milton S. Hershey
Medical Center and verifies that the statements made in the
foregoing pleading are true and correct to the best of her
knowledge, information and belief. The undersigned understands
that the statements therein are made subject to the penalties of
18 Pa. C.S. §4904 relating to unsworn falsification to
authorities.
r
LINDA SCHLADER
DATE: O7
?
p? ?' P?T
, _ 1 Z
o b -tc
? _
Z
j
? CASE NO: 2008-04964 P
SHERIFF'S RETURN - REGULAR
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
MILTON S HERSHEY MEDICAL CENTE
VS
WISER DOUGLAS ET AL
KENNETH GOSSERT , Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE was served upon
WISER DOUGLAS the
DEFENDANT , at 0907:00 HOURS, on the 23rd day of August 2008
at 1838 RITNER HIGHWAY
SHIPPENSBURG, PA 17257
BARBARA WISER, WIFE
by handing to
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
9l? 18.00
/ ?C$ 19.00
.00
10.00
So Answers:
14?
R. Thomas Kline
08/25/2008
TABAS & ROSEN
Sworn and Subscibed to By:
before me this day
of A.D.
. CASE NO: 2008-04964 P
SHERIFF'S RETURN - REGULAR
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
MILTON S HERSHEY MEDICAL CENTE
VS
WISER DOUGLAS ET AL
KENNETH GOSSERT , Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE was served upon
WISER BARBARA the
DEFENDANT , at 0907:00 HOURS, on the 23rd day of August 2008
at 1838 RITNER HTrT4WAV
SHIPPENSBURG, PA 17257
BARBARA WISER
by handing to
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
Service
9I?Dg
pwB
Affidavit
Surcharge
Sworn and Subscibed to
before me this
of
So Answers:
6.00
.00
.00
10.00 R. Thomas Kline
.00
16.00 08/25/2008
TABAS & ROSEN
By:
day
A. D.
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER, ESQUIRE ID NO.: 60267
1601 Market Street, Suite 2300
PHILADELPHIA, PA 19103
215-569-5050
The Milton S. Hershey Medical Center
P.O. Box 853
Hershey, PA 17011
VS.
Douglas Wiser & Barbara Wiser, h/w
1838 Ritner Highway
Shippensburg, PA 17257
CUMBERLAND COUNTY
COURT OF COMMON PLEAS
NO.: 08-4964
ORDER FOR JUDGMENT FOR WANT OF AN ANSWER AND ASSESSMENT OF DAMAGES
TO THE PROTHONOTARY:
Kindly enter judgment in the sum of $176,346.26 in favor of the Plaintiff(s) in the
above entitled matter for failure of the Defendant(s) to file an Answer to Plaintiff(s) Complaint in
Civil Action and assess Plaintiff(s) damages as follows:
Amount of Claim:
Interest at 6% per
annum from date of
discharge 08/10/06
Total:
cp ;,
$ 146,144.97 c. =
$ 30,201.29 -
$ 176,346.26
Attorney for Plaintiff(s)
I assess damages as above
,
Pro Prothonot
I....., .............:.............hereby certify that the
10 day letter under R.C.P.R. 237.1 was forwarded to
Defendant Douglas Wiser & Barbara Wiser, h/w
Address 1838 Ritner Highway, Shippensburg, PA 17257
Date December 31, 2009
I........ ... ........ certify
that the above names are correct and
the Precise Residence Address of the
Judgment creditor is
-*14.OO.P a A-rw
Address: Same cocla5'88
Address of ASIAR3
Defendants: Same 001t? ? i_ r _ _1
The Milton S. Hershey Medical Center
P.O. Box 853
Hershey, PA 17011
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS.
Douglas Wiser & Barbara Wiser, h/w
1838 Ritner Highway
Shippensburg, PA 17257
NO.: 08-4964
AFFIDA?'O OM,,M?t I,*-A*,V--'gMV°ICE
COMMONWEALTH OF PA
COUNTY OF CUMBERLAND
LEWIS C. TRAUFFER being legally sworn, deposes and says:
(a) that the defendant (s) is/are not in the Military or Naval Service of the United States
or
or of its allies, or otherwise within the provisions of the Soldiers' and Sailors' Civil
relief action of Congress of 1940 as amended;
(b) that defendant Douglas Wiser is over 21 years of age and resides at:
1838 Ritner Highway, Shippensburg, PA 17257 and is employed in Private Business.
(c) that defendant Barbara Wiser is over 21 years of age and resides at:
1838 Ritner Highway, Shippensburg, PA 17257 and is employed in Private Business.
Affidavit has ascertained the foregoing information by inquiry and belief and makes this Affidavit
with due authority.
Sworn to and subscribed before me
on this 20 day of January, 2010.
LEWIS . TRAUFFER, ESQUIRE
Attorney for the Plaintiff
r
CommiNWEALI'NOF PENNSYLVANIA
NOTARIAL SEAL
CHLOETTE WSIAVAGE, Notary Public
Of Philadelphia, Ptah. County
?rt6ftn ission ExpI August t7, 201Q.
NOTAR4PBLIC?j
TABAS & ROSEN, P.C.
a BY: LEWIS C. TRAUFFER, ESQUIRE ID No.: 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.
Douglas Wiser &
Barbara Wiser, h/w
1838 Ritner Highway
Shippensburg, PA 17257
NOTICE OF INTENTION TO TAKE DEFAULT JUDGMENT
TO: Douglas Wiser
1838 Ritner Highway
Shippensburg, PA 17257
DATE OF NOTICE/FECHA DEL AVISO: DECEMBER 31 , 2009
Court of Common Pleas
: Cumberland County
: No.:08-4964
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY
AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU.
UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGEMENT MAY BE ENTERED AGAINST YOU
WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE
THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER.
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, PA 17013 Phone No.: (717) 249-3166 or (800) 990-9108
AVISO IMPORTANTE
USTED SE ENCUENTRA EN ESTADO DE REBELDIA POR NO HABER PRESENTADO UNA COMPARECENIA ESCRITO CON ESTE
TRIBUNAL SUS DEFENSAS U OBJECTIONES A LOS RECLAMOS FORMULADOS EN CONTRA SUYO. AL NO TOMAR LA
ACCION DEBIDA DENTRO DE DIEZ DIAS DE LA FECHA DE ESTA NOTIFICATION, EL TRIBUNAL PODRA, SIN
NECESIDAD DE COMPARECER USTED EN CORRE U OIR PREUBA ALGUNA, DICTAR SENTENCIA EN SU CONTRA Y USTED
PODRIA PERDER BIENES U OTROS DERECHOS IMPORTANTES.
USED DEBE LLEVAR ESTE AVISO A UN ABOGADO ENSEGUIDA. SI USTED NO TIENE ABOGADO, VAYA PERSONALM
0 LLAME POR TELEFONO A LA OFICINA MENCIONADA A CONTINUACTION. ESTA OFICINA LE PUEDE PROVEER LA
INFORMATION NECESARIA PARA CONTRATAR A UN ABOGADO.
SI USTED CARECE DE LOS MEDIOS NECESARIOS PARR CONTRATAR A UN ABOGADO, DICHA OFICINA LE PUEDE
SUMINISTRAR LA INFORMATION NECESSARIA ACERCA DE AQUELLAS AGENCIAS QUE OFRECEN SERVICIOS LEGALES A
LAS PERSONAS QUE TIENEN DERECHO A RECIBIR TAL AYUDA GRATIS 0 A UNA CUOTA REDUCIDA.
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, PA 17013 Phone No.: (717) 249-3166 or (800) 990-9108
LEWIS C. TRAUFFER, ESQUIRE
ATTORNEY FOR THE PLAINTIFF
THIS CORRESPONDENCE IS BEING USED TO COLLECT A DEBT AND
THE INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER, ESQUIRE ID No.: 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.
Douglas Wiser &
Barbara Wiser, h/w
1838 Ritner Highway
Shippensburg, PA 17257
NOTICE OF INTENTION TO TAKE DEFAULT JUDGMENT
TO: Barbara Wiser
1838 Ritner Highway
Shippensburg, PA 17257
DATE OF NOTICE/FECHA DEL AVISO: DECEMBER 31 , 2009
: Court of Common Pleas
: Cumberland County
: No.:08-4964
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY
AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU.
UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGEMENT MAY BE ENTERED AGAINST YOU
WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE
THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER.
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, PA 17013 Phone No.: (717) 249-3166 or (800) 990-9108
AVISO IMPORTANTE
LISTED SE ENCUENTRA EN ESTADO DE REBELDIA POR NO HABER PRESENTADO UNA COMPARECENIA ESCRITO CON ESTE
TRIBUNAL SUS DEFENSAS U OBJECTIONES A LOS RECLAMOS FORMULADOS EN CONTRA SUYO. AL NO TOMAR LA
ACCION DEBIDA DENTRO DE DIEZ DIAS DE LA FECHA DE ESTA NOTIFICATION, EL TRIBUNAL PODRA, SIN
NECESIDAD DE COMPARECER USTED EN CORTE U OIR PREUBA ALGUNA, DICTAR SENTENCIA EN SU CONTRA Y USTED
PODRIA PERDER BIENES U OTROS DERECHOS IMPORTANTES.
USED DEBE LLEVAR ESTE AVISO A UN ABOGADO ENSEGUIDA. SI USTED NO TIENE ABOGADO, VAYA PERSONALMENTE
0 LLAME POR TELEFONO A LA OFICINA MENCIONADA A CONTINUACTION. ESTA OFICINA LE PUEDE PROVEER LA
INFORMACION NECESARIA PARA CONTRATAR A UN ABOGADO.
SI USTED CARECE DE LOS MEDIOS NECESARIOS PARA CONTRATAR A UN ABOGADO, DICHA OFICINA LE PUEDE
SUMINISTRAR LA INFORMACION NECESSARIA ACERCA DE AQUELLAS AGENCIAS QUE OFRECEN SERVICIOS LEGALES A
LAS PERSONAS QUE TIENEN DERECHO A RECIBIR TAL AYUDA GRATIS 0 A UNA CUOTA REDUCIDA.
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, PA 17013 Phone No.: (717) 249-3166 or (800) 990-9108
LEWIS C. TRAUFFER, ESQUIRE
ATTORNEY FOR THE PLAINTIFF
THIS CORRESPONDENCE IS BEING USED TO COLLECT A DEBT AND
THE INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
ME
OFFICE OF THE PROTHONOTARY
CUMBERLAND COUNTY COURT HOUSE
ONE COURTHOUSE SQUARE
CARLISLE, PA 17013
TO: Douglas Wiser
1838 Ritner Highway
Shippensburg, PA 17257
0
The Milton S. Hershey Medical Center
P.O. Box 853
Hershey, PA 17011
VS.
Douglas Wiser & Barbara Wiser, h/w
CUMBERLAND COUNTY
No.: 08-4964
NOTICE
Pursuant to Rule 236 of the Supreme Court of Pennsylvania, you are hereby notified that
a Judgment has been entered against you in the above proceeding as indicated below.
3, J, A,/
PROTHONOTARY
X JUDGMENT BY DEFAULT
MONEY JUDGMENT
JUDGMENT IN REPLEVIN
JUDGMENT FOR POSSESSION
JUDGMENT ON AWARD OF ARBITRATION
TRANSFER OF JUDGMENT
IF YOU HAVE ANY QUESTIONS CONCERNING THIS NOTICE, PLEASE CALL:
ATTORNEY LEWIS C. TRAUFFER, ESQUIRE
AT THIS TELEPHONE NUMBER: 215-569-5050
1.
kA
OFFICE OF THE PROTHONOTARY
CUMBERLAND COUNTY COURT HOUSE
ONE COURTHOUSE SQUARE
CARLISLE, PA 17013
TO: Barbara Wiser
1838 Ritner Highway
Shippensburg, PA 17257
The Milton S. Hershey Medical Center
P.O. Box 853
Hershey, PA 17011
VS.
Douglas Wiser & Barbara Wiser, h/w
CUMBERLAND COUNTY
No.: 08-4964
NOTICE
Pursuant to Rule 236 of the Supreme Court of Pennsylvania, you are hereby notified that
a Judgment has been entered against you in the above proceeding as indicated below.
P40 TU TARY
JUDGMENT BY DEFAULT
MONEY JUDGMENT
JUDGMENT IN REPLEVIN
JUDGMENT FOR POSSESSION
JUDGMENT ON AWARD OF ARBITRATION
TRANSFER OF JUDGMENT
IF YOU HAVE ANY QUESTIONS CONCERNING THIS NOTICE, PLEASE CALL:
ATTORNEY LEWIS C. TRAUFFER. ESQUIRE
AT THIS TELEPHONE NUMBER: 215-569-5050