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HomeMy WebLinkAbout11-21-08NOTICE OF CLAIM COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF AVROM BAILYNSON, DECEASED No. 21-07-0731 To the Clerk of the Orphans' Court Division: Kindly enter the claim of Claremont Nursing and Rehabilitation Center in the amount of $21,540.78 against the above-captioned Estate in accordance with the at~:ached invoices. This claim is a priority claim under 20 Pa.C.S. § 3392(3) for the value of nursing services performed for the Decedent within six months of the date of death. The Decedent, who resided at 1000 Claremont Road, Carlisle, PA 17013 died on June 9, 2007. Written notice of said claim was given to Eugene Bailynson, 34 Melrose Place, Mont Clair, NJ 07042 on November 21, 2008. Claimant: Claremont Nursing and Rel•~abilitation Center 1000 Claremont Road Carlisle, PA 17013 Date: ~~• o~ (• aOCJ ,'~' N ~ ~ r , cr; ._ _ c~ ti -~ r- __ ~, ' _ N U i . _ ~ C~ U N 127245 Steven M. Montresor Attorney No. 74244 Latsha Davis Yohe r~ McKenna, P.C. 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 (717) 620-2424 G 1, aremont 1'~tt1~S i ng & Rehab 2 3 PAnE>rT~NrRDLNO. 10@@ Clarem ~ Drive _ 4893 a ~ 6 FED. TAX N0. ~ i ~'~' '' 7 COV D. 8 N-C D. 9 GI D. 10 L•R D. 11 Carlisl.. PA 7@13 _ '= :~:~~ 717 243-2@31 23-6@@3119 @414@7 @43@@7 @17 12PAnENTNAFIE 13 PAnENTADDRESS Bail nson Avrom .. 14 BIRTHDATE 15 SEX 16 MS 21 D HR 22 SiAT 23 MEDICAL RECORD N0. @8191932 M 'W @414@7 - 3 4 3@ 4893 _ ___ Avrom Bailynson Howard Bailynson 7612 Aynlee iday Harrisburg] Pa ].7112 ~ 142 REV. CD. 143 DESCRIPiiON & B NURSING C 31 44 HCPCS /RATES 45 SERV. DATE 46 SERV. UNRS 47 TOTAL CHARGES 48 NON~OVERED CHARGES - SEM 225.00 17 3825.1@ - .I. 50 PAYER 51 PROVIDER N0. ~ 54 PRIOR PAYMENTS 56 EST. AMOUNT DUE 58 . ' I PRIVATE PAY CLAREMONT . •~ ~ "~€ ~..: s7 ~ -0 -~ 58 INSURED'S NAME 59 P.HEL 60 CERT. - SSN - HIC. - ID N0. 61 GROUP NAME 62 INSURANCE GROUP N0. Bailynson Avrom @1 @62263366 ~ ~ `6 E '°` ~ ~ TREATMENiAUiHORIZAnONCODES - 66ESC 66 EMPLOYER NAME 7 PRIN. DIAG. T5419 i R.C. ~ 66 EMPLOYERLOCAnON A .. _ - ~ - E C ~°'~ -" ~' `~~ ~~ ``~° '' 76 ADM. DIAG. CD. 77 E-CODE 78 '~.. 7 c - - ,~ 2449 Er a ~ ~: "'anti' a ~. ~ _ ~ 1 b REbUVAi(S r;larerriont IvTursing tSC Rehab 2 3PATIENTCONiROLNO. 1000 Clar~>aiont. Road 4893 213 Car 1 1 5 l e PA ~~ @ 13 5 PED. TAX NO. ' ` `nom G; gP~~ `` y _ 7 COV D. 8 N-C D. 9 C•I D. 10 L•R D. 11 717 24@-19GI8 23-60@3119 030107 033107 31 31 12PAT1ENTNAME 13 PATIENTADDRESS Bail-nson Avrom 10@0 CLAREMONT ROAD CARL~CSLE PA 17@13 14 BIRTHDAIE 15 SIX 16 MS i4 r ~ ~ 21 D HR 22 STAT 23 MEDICAL RECORD N0. S ' ~ '. ~3 31 08191932 M W 013@07 @1 3 4 30 4893 09 1 _ x s t a6 •.. CE s ~' r ' 37 7~ t~123@7 01300 ,' `sl`_.~.._~ ~ ;~_l~T.~~~~;t--;_ i a 09 3844.00: -jTCY 42 REV. CD. 43 DESCRIPTION 44 HCPCS! RATES 45 SERV. DATE 46 SERV. UNfTS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 10022 PPS ROOM AND BOARD CHARG RHC02 022807 30 .ADO .'i'''.~= ~ fSid^2~i~'z1' -.Yo ,_ _. - ~ ..-.E.r.... ~• -_~L 2~.u7....+_..'i-_ n1 ~a,v~tY .ti~~ "~ilF cam.. G_ 10120 SEM R & B NURSING CARE - 225.00 31 &975.x@ 1 '~;~1~~1.: ~ F x~~ ~~ ~`; ~f ~7 1 1 '~ ~ ti - + r ~ 't ~~~ 1 0@01 TOTAL CHAP.GES , _ r h ~ ~ 5 • ~"~ J ,kT C F; ~.. ~ ~ `} ta,~h 1, "11' i+ ~ .t ... ~,~. t, rt`... y5i~ ._F Cr '] f ~ 'r`~- 1 S fT~ ~ 1 t 5C .3 ~ _ ~ 'w 'L.. G _~ (. ~ I ~; p d "3~-~~: ~ ~~~~~~~ Y ~~ ~~~ ~ A g` :~ ' . ° -.~'y,! i -T.n--- ,f ~,~ T,~ .r. 1 u n ; '? ti ~ ~ ~'; y,^ ~~ ~ + te, .. , . ~ . ._. .. :. ~ _ ~ t ,~., ~ ., „~ .,~ i I n s~ „v~.L _~ __ .. ~ .>,.~ ~6.~ z.....:~.-'~ ~ Fr.~..~~~__. .3~_L,s~._....~_ mow- .~i:. _ :~_._ . ~.~~ ~~ 'S. Si~. ii'~~ "~-_ ~iA•"ryr c_,1~ Tif~ s ~-~ .~ , i~v .~ ~' - t _ ~ 4 i :, t ., .,, "E _ ~ - 1. Y,F y~ S. Ts""it j-V'>. ~'~ V+* /~ ~:,. !!~1. ~'ty '~~ F ~~,~ ;'~~ ;~ _ ,~ .Y':J _X 'l' r~ .,~ .. :. '.n .~ 7 i 50 PAYER 51 PROVIDER NO. _ 54 PRIOR PAYMENTS ~ 5i EST. AMOUNT DUE 56 _ 95660 Medicare Part A 3 ; Y Y ~ ~;; w ' '~~ ; _ - "' ~ - ,: , ~_ .~ 57 ~ -• -• 56 INSURED'S NAME 59PAEL 60 CERT. - SSN- HIC. - ID N0. 61 GROUP NAME 62 INSURANCE GROUP N0. Bailynson Avrom 18 062263366A ~ Ba 1 n s o~ P,~roir~ -~-- ~ ~' 8~ ~ r,~.~'`,.,F ~ ~ '- - - ~, ~ 1 '~ 63 7AEATMENTAUTHORIZATION CODES 61 ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION 1 - ~~ w .€., f 67 PRIN. DIAL. CD. _~ 3~ , ~' `' "~'' '~''~' ' _ ~' - ~ Ci''~e 76 ADM. DIAL. CD. 77 E1'ADE 78 V5419 2449 ; 2449 SO PRINCIPAL PROCEDURE ti CiTHEAPR '9 P C OCEDURE ~ -'"'t ~ - E2 4TTENDINGPIxYS t€i ~ . . CODE DATE ~.QEt. _.""k'~ ,~-:.;Z~%'=MTC ~ f =OTHERPR ,.C(~E OE~DtJRE '.` - t ...t ._i1AF ~_.~. b r ' ~ .~ OJDE i.:~: DATE-:: &S OTt~,9PHYS.IQ? - i C } ~Y _ 6a REMARics oT~1:pyrsla P~arroER rtr<aRF~rrrA~tvt ' @5/m ,:- ~ 1 aremont Ntif"S 1 ng & Rehab 2 3 PATIENTC0IVTROLNO. 1000 Claremont Road 4893 213 Carlisle PA 17013 5 FED. TAX N0. - `"~'1"' f ~° ` ~ - ~-`- 7 COV D. ~M - `~4_~~, 6 N-0 D. 9 GI D. 10 L•R D, 11 ~~ - - ~3-60 0 0107 022807 28 28 12PATiENT E 13 PATIENT ADDRESS NT ROAD CARL:L S L E PA 17 013 _ 14 SIRTHDA7E 15 SEX 16 MS ~ ~ 21 D HR ~ ~` ~ I~r ~ `'` 22 STAT 23 MEDICAL RECORD N0 31 ~. _- ~ ~-i :;=ti . `p _ ~' ~ ~ 0 9 : t• , 34:~ r~JFP ti..E - ~ +~ ~~' 36 - C~~`FJRt#~W _ AAA ?7 ~ "~, .~ ~ ~.a~ iC~i-_ =fit- ':riN-a,+ ~+ . ~ Q -7 -.-~. ' ~ i 7~ u1~?©7 r, ~,~ y ©1300 7 - - _ ..- .. , 3 I VA~~.~' cS'_ i ~ _~, E a1'-?arc At17i'ti~a ~.> k i)~7. - ~ Z {~, :' -~1A~kJE ~1~.:$ ,,qa~-; ~ :r ~1k7~FlT_ ,.5._:~ a09 3472.00 c _ 42 REV. CD. 43DESCRIPRON 44HCPCS/RATES 45SERV.DATE 46SERV.UNITS a, iCr-l CHARGES a~r;~~J-..CVE~-~~CFLaRGES ,~ X00 2 S ROOM AND B ARD CHARG RUC07 021107 . 1G 0D ' ~ ` f/~ t- ~( i~ "' ' ~ ~ r _f ~r C .i - ~~~~ -- -:~.'`-.V~ .L . 7~ .. ~ tJ /~ i .`_~= .~ ... te. lia!:i ~ .~ S 0 0 R & B PIURSING CARE BEM ~~ ~ OD 'S ~~ ~~0 ~~ t~ ~ ".U ~ +c-t _. H ~ _ ~` ~ .,,. r nj ' F' ~ - it f. : s r. ~ lZ: 0001 TOTAL CHARGES ~ ~OG~ Q0 ~ ~~ ~ ~ ~ ~~~ ~~s ~ ~ ~ ~~ r ~ ~' f -:r i k ~ *~*'.. r ''u :. ~ "x. _fi1 _~, $ 1 ~~ _~. .... ~,r"'f ~ ~_'~_ , . s _... ,., ' . . ' _ ~ _ k i _ , ,., _ T F y .r__~y ~..W R'~,rw ytJ-2 NS. ~~ f j ~ ~~ L rl~ L. Spy-~`~ {---I- ~ ~3, # ~' t ~ 9 .1.~ t I I .4~~,. c~ Y~fX Y -:.r ~2"is ~'f Y ''':~~ 24-,. :; ~ `;f ~-ia`~ ~. _b'£ S~: ~w ~ ~ ' - t, i5!'t, a t :~r r E~~ /, ~_. y r .~ - ... L-.. t..~e ,1^.'...it~y.... Lrs S S~.x. .at~..c~.iLr.~;'1 .. ._..,~ i~ ._...L~.a~_r.. ~ y.~L....,a.~ ,~.. ~. _ T~_ -._ ,_....,w ...~ .. _ _.. _ a ~ ~ .._ T .~: r 'f. ~: ~.~ s ' ~.-,c "r~ - ~ ~ - x ~y , ~rt ~~,t~ .,st ' I° x+~,r~--ter ^7' T. ?a ,r'^ * s- sue' R ~ 'x3~,t~ r ~ -r r 4 ~" ~ ` ~ d s ~ ~_ >~'.S. .~i~9rra. ~ ~f ~ ~1 ~ 4 rt z~ Y r Y ~7" ~ ~~ 4'.~ ~ "`~. ~ l 8's ~ v ~ ~ - 1 ~ e -` ~[ _ .'~''_; .. .~'.. .. .Y.:. 2 .ri .. .;i ? ~. a., ~_ iR_ ...._~ .~ a _ ~.._.., _...• ..,; ~..... ' am. ~.~.. „~ , ,~_ .. .. . _. u ,. , .. ; sj- --r r ~ fc -^'~ ~,~^,~ z ,-' ~..[ -.'fix ~ ~ ~L ~ ~ f t } 3 Y - - c - tm 1 Y '}~Y `l J ~ - i 1 _.. ,. x. w ..... .. Y.. ~ _ , ~.~:i _. .. .. .... fi .~ . 11;. _..t. 1 ~_. ...-~ _. cr .,~~ .. .. a .... .. _ .. ., ~.~.a~e- . - C ~ T _ ~ ___ -.v. 1.~u-~a._ _ .,._~. [ _. .._..__ ~ - ~~ ~~ _ -.ar .r. a i- i._.1.~. ,__~. .v. _ ~ _-_~ .. .. y.., .. I 50 PAYER ~ 51 PROVIDER N0. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE c& Medicare Part A 395660 Y Y SR .. ~ Y ~ V `L !.-e~`y S•b .. .r...~ - .__ .... - ..Pu ~ ~_J i~ O Yn~. a+u .. l . _ .:..Ed.> -. - ... 57 > ~ ~ ~ . 58 INSURED'SNAME 59P.REL 60 CERT.-SSN-HIC.-ID NO. 61 GROUP NAME 62 INSURANCEGROUPNO. Bail nson Avrom 18 062263366A ~ ~ ' ~' s ~ - ` @6335 'x _ ~ - j'^ . ~".~: ..,...:,.~,,_ r ~ I~ns:or~ ::~ • ~ _ ` , . ~ E ,. 63 TREATMENT AUTHORIZATION CODES 64FSC 65 EMPLOYER NAME 66 EMPLOYER LOCATION A C CD .x '~` ~'"=';` 67 PRIN DWG ''`: ~` `' OAS ~ -: ~* ~ ``z` '' ~' 7 ~~ ~ 76 ADM DWG CD 77 ELODE . . ~ 64 co[iE" _8 ni n _ , ~~~' ~ a ^~~'~- 1 _, rd Ctx~ . . . 78 V5419 2449 2449 '9 P.C. ~ PRINCIPAL P ROCEDURE ~~ ..~~,'~'; + -•+ s - ` - ~ ATTFNDBrG ~~ ~ CODE DATE ._•. ?~=DAT2'§ . ~ ~ a ~ -- ~ ~ . G88041 1~TELLM0N II DO BAXTER D k 34 REMARKS rr~t+vwtR+nr~rr~~=rv~ftFtvt - -B&gATE @5!08!2007 Claremont Ntlr' i rig « Rehab 2 13 PATIENTCONTAOLNO. o 10@0 Claremont Road 214 i ~ 5 FED. TAX N0. 5 S' ".~`' f `"' ~ ~ 7 COV D. 6 h-0 D. 9 C-t D. 10 L•R D. 11 Carlisle PA _,013 f t~ 7 LG - '1 1 PATIENT E 13 PATIENTADDAESS fl .. T, Tt.a.. ,-. ~.. 1 (71:a (71 f~T nTJ L*~~TlITTR'I D11T Tl P+TDT l'CT L' nT '! 7~1 '] 14 BIRTHRATE ti SEX 16 MS - , . e 21 D HR 22 STAT 23 M c c D1CAL A CORD N0 ~ ~ »..~ ~~~. ~~ `-' 'rl @ 3~` 31 _ .. . , ~, ~ ~ °~ , _: ,; c'Xt ~. - ~ t 7Q 1~~,~~I~~ 1'' 00~ ~ - I 38`: , ~y4LUECCY?ES'~`y tt~... ~4Pwa"~.--~ 7LY.ALU .. S' - ~~~ •-A a 09 744 . Om C i 7..-t C 7 s . > ..__. 42 REV. CD. 43 DESCRIPTION 44 HCPCSIRATES 45 SERV.DATE 46 SERV.Urlrs 4~ ~~~??~ CHARGES ~ 48 Merl-Ce',~R2~CC'~AFGES 49 ~ 0 S ~ D B©ARD CHARG RVA@7 01© c~7 1~ . 00 ~ y'~~H ~~4 ~ 1~~ ~ ~`:~ 7 ~ Q QC ~ R ~~~C~?~R • ~~ ~a ~ ;~ ' _ r- „ ~ ~ . ~ , _.. _~~ . 1 _ -`~-- 'Y ~ ~' ~ ~1C~ O :` ~'f ?`ItAI~: CHARU~~` ~ E~~ ~ ~ ` ~ ~ : ~ ~? ~_ -. _.~ -,~. . : . . ..._... , . zz ..~z~ .. ~ . .. ~ ,k .~.~E{ ~.~,...~.. __~ ~. _ .. „ ~ _ ~~ 't ~ ~ , I - -~ ~ ~-- ~ ~ ~- ~ ~ ram ' ' ~ :+~ " ,.k i~ . r-~+~ x `; } 7 ~o.,~ ~ f , i ~ ~ ~t i~ - '-s ~ r s F~ ~3 5~. t" T ~ ~ -s cu--c ~ ~ - "-..' ~ r~ ~ ~` ~ i '` , 'L r' ~~ r 4 r i ' s. -.~. ,.. .~., . ... ,.~. ~ _.r..Y.:f, ~st.t~.-a:.. . iii ~, ..-_r _ ~_., ,.u. t .,:5. ~ _., ., -;. ...,. ~ _.x~: .~~:~~;.. .. ~ - ~ .. .. . _ - I . .. _.'w :- ~ 1 ' ~ .i ~~ _"' - - ~= ~rF ._ h _,~ ~,riT r" _h~ .£ ~Z4T~~ ~" ~. ~Cj. df 17 I _ _ _ 3r "` ..~ ~ 4 h_ _ 4- ~. C. 1 ~ l s: Y : .1 ~~1 w2 ir - ` ~. ' v ^. ri ~ " ~ ~ f - Lv _ . . .. r : :. , . . . : .. . ~:.'QC:... .h-.,.-_... _,._...,~_~r ~ c._..5,_ ~.._.G~[.al_-__..._.,._.,.. . r. -,Y.~..vs. ~._..., __. ,._ ~_ u~..... y ._,, a_..__.....~~-1~,..,. .._,_~...~t. _... ...1~,: _ d a ...,,~~ ._L _,.~. .. ~.,. ,~uti`- ~ r__ ~ r' F ~. _ '. ~.~ t ~ eY j ..r J~ __ - _ _ _ I _ _ - 1 _ -. ~ - -- 1 50 PAYER 51 PROVIDER NO. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 Medicare Part A 395660 ~ ~ k -- " ~ ~ ~ P~_~za -~Ra~y.~ _~~~ _ s~.L _._ ~,. 5~0"_ ~ _ ~ ._._- __ ~_ - - - _ ;. `~~ ~: : ~ _ _ a -• •. 58 INSURER'S NAME 59 P.flEL 60 CERT. - SSN • HIC. - ID N0. 61 GROUP NAME 62 INSURANCE GROUP N0. Bai~ly nsan Avrom 18 062263366A p ~ _ : ' _ ...~..1. ~~ C 63 TREATMENiAUTHORIZATION CODES 6d ESC 65 EMPLOYER NAME 66 EMPLOYEA LOCAl10N A ~$ x~ 4 P `tae' ~2i w'. ~}~.,--.:.. _ 'aaZS~stt?E;~~^" C 67 PRIN. DIAG. CD. ~ Lv~ '~~""¢'`~ ' ~` - ~ ~ ;. -R,~ ~~; _4 ~~ it 76 ADM. DIAG. CD. T7 E•CODE 78 X96 78052 2 25000 CODE DATE x.-:,.- ti(:DDEk.' ~~.: CYIEE - ~ FHYS.B}?. ~ a ~~ ` G880 41 NiELLMON II DO BAXTER D 6 - > orHERPAOC ~- • ~. a~• - _caE~ ~,+.. s~=~ . DAr~ R cp~.~.~..e. s~-E s3"t2TT~iPHYS.i6~ - - 8 ~ ~ ~ wREMARKS3900@4 - 12/9/06 TO 12/20/06 -'oTHEePtiY's:~ii= ~~ a 395660 - 12/20/06 - ADMIT •-- b ~ AEPAE._TJTAT14g _ ' . , 88 RA .. -: _-: . ?~_~ ~ 05~~'08 ~ 2.QQ I~~ - - [~_.. _._~..___- OCR/ORIGINAL ICc-HTIFY THE CEiti'.HCAitONS(IN 1HE ReYeRSE AP?LY TO THLS Hits 1N01RE ~unEl Pear N:aenc C i. aremont Nur ~ i ng & Rehab 2 3 PATIcMCONTA0LN0. 0 1@@@ Clarer~o~-~t Road 4893 212 Carlisle PA ~;@13 5 FED. TAX N0. ~ ~^~~ ~ '~`~~~ ~ 7 CfJV D. ~~ -~ 8 N-0 D. 9 GI D. 10 L-R C. 11 717 24@-19G~t3 23-60@3119 @13@07 @131@7 2 2 12 PATIENT ihAFl:E 13 PATIENT ADDRESS Sail nson Avrom 1@@@ CLAREMONT ROAD CARLISLE PA 17@13 t4 BIRTHDATE 15 SEX 16 MS ~~ ~ ~~~`: 21 DHR 225TAT „. 23 MEDICAL RECORD NO. i:,:' fi`" Vii, -.,~ ~, - {, = 31 @8191932 M W 013@07 @1 3 ~4 3@ 4893 ~ 09 .~: .. s .. ~' ,' .. i ~ 7~ X123@7 013@07 ~ : :_ ~~ ~ ~ ~ _.__ . ~ .x _ . ~_. ~..~ ~~ ~_,, 3 1~SLfl IX}c~S ~ . ~ ~r~ ~lf_ ~JA<~~CC~E3~- ~ I GaiE% ~- -L A 1k'"a trl: ;~~ _ .6G'r,~ - - AWJlPIT' i`,. - a 09 248.00 :;. I ~'~'.:- C ~ d }'T4 Sig ~ x t x. l - ~ t 1 ~ ~ ^~ ...I~ ~ -1 ~.~~?: i ~ ~. i~ 1 .~ _. .. ~~ . f -. K . ~.41 42 REV. CD. 43 DESCRIPTION 44 HCPCS /RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON~'AVERED CHARGES 49 i0@22 PP5 ROOM AND BOARD CHARG RVL11 @205@7 2 .~JO ,.,..sue ~. ~tl -~> ~~~~- , ~- ~ ~ . -~~; ( F '~~@,~zs 4~~r~~'~; ~>Kr~RG~?._,. y~~.~c~'"t~ _. ~_{~ ... .`~:'.~ ~.,; ~, ... ._._ ~. ~ _ .~'f;~~ ~~'I~~ .:: V _}{~r.. i ~ ` ~ 3 e r~i ~ T u ~ ,. ~ ~ .. ,.._ -. ~ :3r: . .„v..Y_ iC .,._ i~ ~Y.L.._".u V1.LL~ ~. .w..u.. _.L.J. ~,.: x.. ~..r~x t, ~r ~. _ M1 __ ~. ... ? ..._ ,. ~'S.. ~ .__ ~. ....- ~i .,t....l. xa-T j.~ v'ii 1 yr F s • ? ~ ~ j~ ~ \ i i M1 '[.'. fi~ in r.~u .~. .i_.__;.-.,_. ~ LJ..} .~,.~ c ~Gi_~~.~.Y, u ..ii F~_.. Z ~r:: ;~ ~:~... '~:r t.[v~~~!'; l 1~.,~ ~ '~;~, `~'.~~ "~$"..~~ .. ~ _..^-~ .2`~ }4~~i~T ~-:'~. _ ._~.. ~ t°'- .~... `e r s _ _ _ .., .._. .., .- a .. ~ ''~, ..,.-. '_~ ~' _,.. ___ . ,.s..~Cra .,o.o.o,.. l f'7~..: ~~.. ~.~il..:tiwi ,. _ .. ~ ~ .~~~ ~. ~~ :' yv ~: a 'r --- :mot ~~ ~s ~ - - ~~ .. .,.~ -,,... ._....ti.. ,..st ice. _ _ .. ..R. .. .. ._~ ., - ..~. _ .__ .... ~...~..... r I ~ 1 i - - - - ~ 50 PAYER 51 PROVIDER N0. 54 PRIOR PAYMENTS 56 EST. AMOUNT DUE , . 56 Medicare Part A 395660 Y Y ~"~~ ~ -'~`~ ~.~ .- ~vate:~ p3~TLL Pr -,~566Q: ~ 1 _. z__ ~ _ . .~ _ _ . 57 ~ ~ -I • . 58 INSURER'S NAME 59 P.AEL 60 CERT. - SSN - HIC. - ID N0. 61 GROUP NAME 62 INSURANCE GROUP N0. Bailynson Avrom 18 062263366A A ~lynson3A rrom ~ Ba ~ 1°b'~ G?h~-6~36~- ""~' i v ~ . E C 63 TP,EATMENiAUTHORIZATION CODES 6i ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION A -. ~, _ B ~ 7 PRIN. DWG. CO. _ ~ ~ ''"`~= ~,~ 76 ADM. DIAG. CD. -- - ~. 7BG~hx. -_ -.~~c- la wt~c-.: - - 77 E-CODE 73 U5419 2449 ::2449 9 P.C. ~ PRINCIPAL PROCEDURE ~iHHi,PROCFDt~riE~- as cooE oATe ~ ~~.•~~z -.._ ~ :u 5Z~ATTENDt77GPHYS. t0' 8 ~~ ~ ~ G88 41 ~ ~ h ~ sisn .....OTHER,PAJRE: ,... _ i ~ ... 6 N~i'1 -i ~ _ ....,. , z. CODE'fi HATE .~.;+ ~: ; . G1'l0E " nti OA7F 63 0 / HER PtfYS; IDr 8 - _ ~,., ~ ~_, , b ~_:~ 4 REMARKS &S r^?AViDeR RE?f?ESETe RTt~ - B6DATE = - @5/@8/2@m7 COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF AVROM BAILYNSON, DECEASED No. 21-07-0731 CERTIFICATE OF SERVICE The undersigned hereby certifies that on this date a true and corrf;ct copy of the foregoing Notice of Claim was served via Certified Mail, Return Receipt Requeste~3 and First-Class United States mail, postage prepaid, upon the following: Eugene Bailynson 34 Melrose Place Mont Clair, NJ 07042 Dated: l~o~~• ~~_ ._ Steven M. Montresor 127245