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HomeMy WebLinkAbout06-16-09Commonwealth of Pennsylvania County of Cumberland STATE OF PENNSYLVANIA Estate of: Estate of David W. Russell In the Cumberland County Probate Court Case# 21-08-0594 1 Courthouse Square 1 s` floor Carlisle, PA 17013-3387 STATEMENT OF CLAIM 1. Milton S. Hershey Medical CenterBureau of Account Management hereby presents for filing against the above estate this statement of claim in the amount of $1248.96 2. The basis for the claim is Milton S. Hershey Medical Center Account # 9652344 for the various dates of services within. 3. The tax identification number of the claimant is 251857035 4. The name and address of the claimant is Milton S. Hershey Medical Center/13~eau of Account Management 3607 Rosemont Avenue Suite 502 Camp Hill, PA 17001,,E _-~~ ~",,, ~:~::~ a 5. This claim is not contingent. ;13 ~ ~ ~ r _ r , 7~`-n 'v c::~ `--~~ 6. This claim is not secured. ,~~~ ~ : _~~ I under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are .~, true, to the best of my knowledge and belief. . Executed this day of~~1rn 0 , , 20~q V thony V. ugliese Ph# 7-214-3017 Bureau of Account Management Claimant State of Pennsylvania, County of Cumberland IN WITNESS WHEREOF. I have set my hand and notarial seal this ~ ]~.tIYIX. , 20~q My Commission Expires: day of / ~ ~ Notary Public TH Heather M. Thom, PJotary Public lower Allen Twp., Cumberland County My Commission Expires April 8, 2012 vN '`~ ~ ~ ~ ~'; STATEMENT'rOF PHYSICIAN SERVICES r'~~~FI~ ~ti~~'~ `y DAVID W RUSSELL 644 W LOOTER 5T ~~'' 1+~~1flt+fr. 4 Ili r4 =cry ?~~1ef(ic81 (:enter CARLISLE PA 17013-2214 ACCOUNT # 1593797 . ,~,. Y~',CNY QUES~1'iDN'S, ~.-L -ASQi ta;IMT Re;.'T Ct1R.Tli PROCEDURE D9Atm C4~DIr CLf DE Q15~'lc./08 D1~r25/06 a~,~'1~,'08 D~~'2~~'06 ~EI~6; `ED 906"1 BBAM COLLECTIONSJP 0 BDfi 8875/CAMP HILL PA 17001 M:aHMC PATIENT FINANCIAL SERVICES Q't^1! DESCRIPTION BLUE SHIELD PAYMENT* BLUE SHIELD PAYMENT PERIT PRO N SING PHY EVAL BLUE SHIELD PAYMENT* BLUE SHIELD PAYMENT o.oo D.00 2i4tD.00 PERFORMED BY: DEBORAH L IOLBRETTE MD ELECTR~HYSIOLOGY alt,='li~'D8 93il1r3 16 r ~ ECS ELECTROCARD INTERP 75.00 05,' 2.~ /D8 BLUE SHIELD PAYMENTS 12.18- 05,''2,Ai06 B SHIELD CONTRACTUAL ADJ9~ 62.82- 0.00 __ BALANCE ; DA~r`I1 !r RI.E'aSELt ._._.__ ____..___._..___.__.__ _.._~__. _. 51248.% :! ~I~. NAVE ANY @I~STIONS ABOUT THE AMOUNT YOUR INSURANCE rOMPfWl1' PAID, CONTACT THEM DIRECTLY. FOR ANY OTIER QUESTIONS I~EGARDIN6 YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMEM I~IA.S BEEN MADE, THANK YQ1 AND DISREGARD TNIS BILL. "19pPAt; YDU EilR USING MSH'C PHYSICIANS GROUP FDR YOUR PHYSICIAN '~ER4':LCES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE 4~1NI~4CT US AT 717-531-5069 OR 800-254-2614, BETiIEEN 8:OOAM AND !~;;tlPh1 MONDAY THROUGH NEDNESDAY OR BETMEEN B:DOAM AND 4:30PM "r~HUR.SDAY A9JD FRIDAY. BALAI!I~E SUMMdR.Y __ ~ESPCI~SIBL.E PARR r' POLICY # TOTAL ~x _ BIt~E CROs. CK6"' OF 5?" ATXAN07154r73~00332530D 5 150.00 fA:ARAN?'0~", RESPONSIBILITY 5 1248.% ..~._,._._ _.._______ ........... .... 1V'!a~r%7Aap~; PLEASE DETA~,~il„~-D RETURI~I $OTTON PORTION OF STATEMENT WfTH YOUR PAYMIFNT STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT: al ~ 05/29/09 ; 1248.96 ; 1248.96 M3HMC tIHYSI~•AN5 IC i9f'Ut''~ BILLINt; SERV`CE'=; P 'D BOX 854 HI.RSHEY p,~ ?~os:6,r3R!~M OODDb593797 UP DOOOOOOOOOb24896052909 IIIIIIII~1Ip11I-Iillli+Iallifllir.plltlltllfl'.IIIIIIIIIIIIIIItIIi iff~ff' MSHMt; ~t-0~'~YC; [AXIS GF~DUP DAYID W RUSSELL Tar. 644 W LOOTER ST PC E~tl.it 64'.5 :' 1. S CARL ISLE PA 17013-2214 PIT1"`}111.J~C~9~ F~';a 1~2~4-3313 OliClC! 1:176E C-NLY ~C iiplC M YJ1 F tot. 9:: HC:: F6B0 ~~ ._ TYP : DMAND iY H x: 3~enrr cA.f#D PAYMENT, PLEASE FlLL IN INFORMATION BELOM L_..,_ I I 1 1 1 1 1 1 1 1 1 1 1 1 1 C:P~;C N~J1UFiER IXP DATE Cls R. !HOLCI~4~R NAIdE (PRINT) CIS"r~D17 CAIR~iDSIGNATURE 240.OD 06/19/09 1 MSHMC PHYSICIANS GROUP ~ I tll I I I II WI' I I tl'll€tNt'iltN: iI ~I:~ C I~N EC K BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK nIlrl~arzrr ~klllu~r111+i+w~ra STATEMENT DATE: 05/29/09 LAST STATEMENT DATE: 12/24/08 8 of $ FED TAX ID # 251857035 INS CHARGE PAYM6EN'i7 Gt1ARAN1'bR ADJUS"~YFENT BAt,AIWC9 ; D.00 0.00 506.00 593797 ;j'! iF THERE ARE ANY MISSPELLINGS OR ERRURS, PLEASE PRINT CORRE~T!(~NS. Guarantor"s Name Guaran#or's Address PRIMARY ' Patient's Relationship to 0nsured j ~RELF LjSPOUSE iNSURAN~E CQVERAGE ~ ^ CHIIQ ^ oTHER . _ --- ._-_-- -._.-._ tnsurance Gompany Name ---- .__ Phone # ~i 3 insurance Gompany Address Policy Holder`s Name -----~-`- --~Birthdate ---------- i Policy & Group # - y ______ - ~..,- )Policy Effective [date I ------- ---____ -_- ' -- --- -- ---- _ . ---- - Phone # s Name Employee 4 Employer's Address ---- ;phone # I City ~ State ~ Zip Goda I __._...__ .____,__-_.__.-------_-~_-. ~___~_~_ ' ----1-__- _._._.. __._.----- __-----_--- ~~ ~ Patient's Relationship to Insured ~ iNSURAIVCE CQYERAC.,E C,sE~F r]SPOUSE. I []CHILD (~ OTFlER -- I, Insurance Gompany Name ~~ --~ Phone # _ _ __ Insurance Gompany Address ------------- jI _ `--- ~ `L___------------------------ --___~__ ~ ~ Policy Hoidens Name I ~ .-- ~------ - -- -- Bin#hdate I ;~ i----------._.__--- -----...-__. ._..._.._..-__- ~ I Policy & Group # I ------~---._~-. _._.~_-----.._ Policy Effective t3ate j I ~ Employee's Name I Phone # I I j-Employer's Address------- --------- -- ' ~ `YI~ ~ ~ r~~~~ `~~ i ~ ~ ' T ~, ; ~ ~ STATEMENT OF PHYSICIAN SERVICES j'~ 1~!h ~ ~;p;j° _: DAVID W RUSSELL 644 W LOOTER ST 17~~~'~9lba , 1{:'s•>?~c,~~~ci9icalCenter CARLISLE PA 17013.2214 Ac:couNr # 1593797 7~ 8 STATEMENT L~J1TE: 05/29/9 LAST STATEMENT oArE: 12/2MD8 ' ;~~- I~' {,NY c~ilE&'°IC~N=, ~t :A ~i_',;CYplTAC'i ' MSHMC PATIENT FINANCIAL SERVICES FED TAX ID #251851035 DA:TI F'ROCEU~ftl:: ~U&~E" DIAL: G~a~DE QTY dESCRIPTION INS CHARGE PAYIII~E~iTf GUARJ114II~~L ~U$'1'M~IT'' BAI,AN+~ PERFORMED BY: ROBERT L VENDER MD DIV OF PULMONARY MEDICINE 04,'lk~ll~ 49~?x i~„ ti~;~ B DAILY HOSPITAL CARE 254.00 0~5,'1`°!D8 BLUE SHIELD PAYMENT* 100,x_ 05,'1`•!t~ B SHIELD CONTRACTUAL ADJ~ 154.00- 0.00 PERFINHIED BY: DEBORAH L NDLBRETTE MD ELECTRDPHYSIDL06if D4,'1t/DE; 93f~~fl ;'~< , is EC6 ELECTROCARD INTERP 75.00 D5~'2E/DB BLUE SHIELD PAYMENTS 12.18- 05,'21/Ob B SHIELD CONTRACTUAL ADJ~ 62.82- 0.00 PERFORMED BY: EDWARD 6 LISaCA !~ IMAGING D4~'1i'/08 ~i08<:b~ ~*~'~« . ~a ?.D/M-MODE ECHD3 LIMIT 1%.DO 04~'3t'/Og BLUE SHIELD PAYMENT~L 24.62- D4i'3L~08 B SHIELD CONTRACTUAL ADJ~ 166.38- O.OD 04a li/08 43:325:::F {-s''c...a DOPPLER COLOR FL VEL MAP 235.00 04~~?l~/p8 BLUE SHIELD PAYMENTS 4.17- 04a30/06 B SHIELD CONTRACTUAL ADJ~ 230.83- 0.00 PERFORMED BY: CHRISTOPHER JOHNNIDES MD VASCULAR SURGERY 04ia 17 /06 43'a75~:.''r ~4I':~ ~ DUPLEX SCIN VAV- CD}~LETE 2%.00 04~3q/08 BLUE SHIELD PAYMENT~L 41.00- 04J3gfDl1 B SHIELD CONTRACTUAL ADJtI 205.00- 0.00 PERFORMED BY: RICKHESVAR MAHRAJ MD DIV OF DIA6 RADIOLOGY q-~/1'1~08I 741IQ0?fi wSN. Bi: ABDOMEN SINGLE VIEp 64.00 ~/~~~ BLUE SHIELD PAYMENTS 14.00_ 04/3Di08 B SHIELD CONTRACTUAL ADJ~ 50.00- 0.00 PERFORMED BY: BRENT J NAGNER MD DIV OF DIAL RADIOLOGY 04! 1;~ X08 71I110~:ki , 5 c 5 ~ I, =a CHEST 1 VIEp 64.00 qY+/30~OB BLUE SHIELD PAYMENI~ 0.~ Ol'~'1a~08 BLUE SHIELD PAYMENTS 12.D0- OQ/13/D8 B SHIELD CONTRACTUAL AD,bI 52.00- D.00 PERFORMED BY: JOIN F MCGURRIN MD DIV DF DIAG RADIOLOGY D4lL7,~08 711k10~'.dy,:19 5l.1 ,A CI~ST 1 VIEp b4.00 04f5Q'08 BLUE SHIELD PAYMENi~I 12.00- , 04kl:~0,'D8 B SHIELD CONTRACTUAL ADJ~ 52.00- D.OD D4~/;L7,'08 71g1D;!~~ 5:k ~ ,, awrsa'a~ aa~rsga'as q~l:u~,~os 4az~~ ~~~. 5z~.~a. 05/: 4.'08 Di5/a4i'08 CHEST 1 VIEp 64.00 BLUE SHIELD PAYMENT~t 12.00- B SHIELD CONTRACTUAL ADJ~ 52.00- 0.00 PERFORMED BY: ROBERT L VENDER MD DIV OF PULMONARY MEDICINE DAILY IbSPITAL CARE mgr ,,DO BLUE SHIELD PAYMENT9 100.00_ B SHIELD CONTRACTUAL ADJ~ ~r,,00_ PERFORMED BY: RONALD P MILLER !® DIYISIDN DF NEPHRDLOGY 04/]~7r'OB 44255 ~ t!3 514 . ~ INITIAL IF~T COI~LSULTATION 508.D0 ~~~~ ~C, I I I~ ~ .] CI~iECK 817.X. AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK D.00 IF THERE ARE ANY MISSPELLINGS OR ERRORS, PLEASE PRINT CORRECTIONS. Guarantor's Name Guaran#or's Address PRIMARY Patien#'s Rela#[anship to Insured SELF ~SSPOUSE INSURANCE COVERAGE ! [CHILD J13THER --_--_ Insurance Company Name -_-_- I Phone t~ Insurance Company Address Policy Holder's Name ~---~~-a ---~- ~girthdaie --~ --~---- _ _ __ _ _ Policy 8 Group # ~ ~ - ~-- v}.__-------------_ --__ Policy Effective Date -------_-~'- ' _--._~Fhone I#------ s Name Employee 4 ~ _ ~~______---- Emplayer's Address ~_.-._ ~._---- -_. _~.-_-_ ;Phone # I I ---a ------- City i ___. _.._.-____ ~ state ---~T----------------., _ ~ zip Code -1 SECC)N©ARY iPatient'sRelationship#ainsured l INSURANCE C®VERAGE I ~~ SELF ^ SPOUSE ~ r~CHELD LJ OTHER ~nsurance Company Name ~-~- .-- ~ ---___. .-Phone # ~~ ) ~ i Insurance Company Address I~ Policy Holder's Name -- ---- Birthdate - ~ I _ ------- --- ---__ p --~- _ G 1 - ---- Policy Elfec#ive Date _ roup , Policy $~ , i ~ ~, --j {----------------------------_._.__-.._.._-_._-- Employee's Name i -- ------ _____._..--- Phone fi i i ~ Empioyer's Address i f i STATEMENT OF PHYSICIA_ N SERVICES ~ ~~.a~~j`i ~~~.~.~ ._ DAVtD W RUSSELL --- G44 W I_OUTER ST }'~~ ik1~lt~~.~~~ }{ F~st,evPk4ec.yrcalCenter CARLISLE PA 17013-2214 i'~^ (r~lli ; ~~ ~f ~ i°t9pc.in~~ STATEMENT DATE: 05/29/09 LAST STATEMENT 6~ 8 ACCOUNT # 1593797 DATE: 12124!08 ~r_ ~=:~~t~r~~iE~'roH` r~+. :asr: ~:ot~7p~r hA!~HMC PATIENT FINANCIAL SERVICES FED TAX ID #251857035 [Il~."~1_ f'FgCEt>uRC (•4~E DkAt~ Cq~~E QT1r t3ESCRIPTION IHS> CHARGE ~ ~ RilYl{Ilt~i'T1 +q#IA,RI13~tkDR ADJI>;ST#41~T Bi1lL;IS PERFORMED BY: RICKHESVAR MAHRAJ MD DIV OF DIA6 RADIDL06Y D4.'l~i,'t18 ~'1J:.g2ti,:i4 5a. 4 CHEST 1 VIEN b4.D0 04.'3~I4'A~ BLUE SHIELD PAYMENT* q,90_ D4.'3IL'IIC~ B SHIELD CONTRACTUAL AD.!* 52,00- O~i~'3t1,'patr BALANCE TRANSFERS 2.10 D4~'l~ye'~tIB i1~~,112~i 5:1..1 4 CHEST 1 VIEW ~,~ Dli~'3t1,'tpp8 BLUE SHIELD PAYMENi~ 12,00_ D4~'3tL'i~E? B SHIELD CONTRACTUAL AD.AE 52.00- 0.00 D~ii.~'14v'k19 i 117 t12h , }-;~~ 5~ 1 9 ;:HEST 1 VIEN 64.00 D~f~.r'3IU'1~ BLUE SHIELD PAYFIENTX 12.00- D~~,r'3tV'198 B SHIELD CONTRACTUAL AD.~ 52,00- 0.00 hERFDRMED BY: R~ERT L VENDER FD DIV OF PULI~IARY IfDICIbE 04,r'I4i'UQ4 ~''i:3::.i~: si1r9 7iI DAILY IDSPITAL CARE 2r~.00 OS,''14r'fIO BLUE SHIELD PAYMEMX lOD.00- 05,r'14/1l8 B SHIELD CONTRACTUAL AD.~ 154,.00- 0.00 PERFORMED BY: RICKHESVAR MAIRAJ !b DIV DF DII~ RADIOL06Y 04,~'15~'ll8 P1!~1L~2~ tiX.l '3 ~~HEST 1 VIEN ~,OD 04.r30~'It8 BLUE SHIELD PAYlIENi* 12.00- 04.~30ft16 B SHIELD CONTRACTUAL AD.1~ 52.00- 0.00 iaERF011MED BY: EDNARD 6 LISZICA MD INA6INI; 04feL5rl>B 43:w202A *~=F Ir ~DDPPLER3 C191P 330.00 04030~tIB BLUE SIQELD PAYMENTIE 16.95- 04f~'30/t18 B SHIELD CONTRACTUAL AD.AE 308.81- 04f~r30/tIB BALANCE TRANSFER 4.24 04015/[18 '~3=072b M2ca It ;?D/M-FDDE ECtD9 COIF 492.00 ~~'~~~ BLIP SHIELD PAYMIENiX 40.47- 04030/08 B SHIELD CONTRACTUAL AD.~ 440.79- D4030rp~ BALANCE TRANSFERS 10.24 04l15r~"1 '~:S?>2.S2ti ~r2~ li }IOPPLER COLAR FL VEL MAP 2~r,~ 04i'S4~U~1 BLUE SHIELD PAYlIENT~ 3.34- 04~'34~Od B SHIELD CONTRACTUAL AD.~ 230.83- 04r'54~~~ BALANCE TRANSFER* 0.83 PERFORMED BY: ROBERT L VENDER FD DIV OF PULlgdARY l~DICINE 0'FI"L5,'i~8 ~p~'3'~.(w~ 5l~l.9], k:tAILY HOSPITAL CARE 254.00 061".14,+08 BLUE SHIELD PAYlI£NT* 100.00- t16/°L4,'08 B SHIELD CONTRACTUAL AD.A>E ~,OD_ 0.00 ~'ERFORMED BY: DdVID M VAN FDOIC ItD DIV OF DIA6 RADIDLD&Y D40:16~-D8 rna >.uc~b x.~ 1. , ~ c:HESr 1 vIEN 64.00 040:iW'l18 BLUE SHIELD PAYl~NT* 12.00- t14/?IOr't18 B SHIELD CtSITRACTUAL AD.~ 52.00- 0.00 I~~~II~ ~11~I ~~ 11I I ~C1 ` j l CIS ~G ~ BOX Ar~ID ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK i~ THERE ARE ANY MISSPELLINGS OR ERRURS, PLEASE PRINT CfJRRECTlCiNS. Guarantor's Name Guarantor's Address PRIMARY INSURANCECgVERAGE Insurance Company Name ~Ty Insurance Company Address Policy Holder's Name -_-~-- --~- Palley Bc GrOUp ft __.__.-._~.~~._~~___ Employee's Name ------ ------- ----- Employer's Address Phone # City State i Zip Code Patient's Relationship to Insured SEGON©ARY i~ SELF [j SPS?U3E ^cWiia ^bTHER ~ INSURANCE GQVERAGE ~ Phone # {Insurance Company Name Insurance Company Address Birthdate Policy Effective Date Phone # } Pa#ien#`s Relationship to Insured ~~; see-F ^ s~ause I ~ CHSi.a ~~ 41_liER.-_---.-- -__-i_~ _.-_? _____..--- _.._ __ Policy Holder's Name Policy & Group ri ^-__ Employee's Name 6lrthdate Policy Effective Date Phone ff f i Employer's Address ~~ i . r ~ STATEM I-NT I:1F PHYSICIAN SERVICE S~ _ j ( ~Y* PENNSTATE [)AVID W RUSSELL Tl~ IVLlte~r, ;` t'~ 'ti ~ - 644 W I_OUTER ST ; "~,9~ 'eat (~nier CARLISLE PA 17013-2274 STATEMENT TI7e Colle}~~ ~ ~ F h~ ~,'r ( 18'.~ DATE: 05/29/09 AC:CULINT # 1593797 LAST STATEMENT DATE: 1y24/08 ~- IF ANr QuESTiaNS, p~. :,e ~; ¢ ,: are F n~. ,~;;HMC PATIENT FINANCIAL SERVICES FED TAX ID #251857035 DATE; 1~11EOC1G~RE: CODE 61~-G ~~tai~E ~.~~ Q DE$CRIPTIf)N INS CHARGE PAYMENT! ` GUARANTOR . ADJUSTMENT BAL,A#~NCf ~~~ BLUE SHIELD PAYMENT* 61.60- ~~~ B SHIELD CONTRACTUAL ADJ* ~r7~00_ 04/30f06 BALANCE TRANSFER* ~.q~ 04t/1LOB 741602b C-~;4~, a; " T ABDOMEN EI~IANCED gr~T.~ 04'/30/06 BLUE SHIELD PAYMENT* b1.b0- ~~~ B SHIELD CONTRACTUAL ADJ~ 370,x_ ~~~ BALANCE TRANSFER* ~~q~ 04/1LOS 7219326 '~~~~, ~ rT PELVIS ENHANCED gf06~p0 ~+~~ BLUE SHIELD PAYMENT* b1.60- ~~~ B SHIELD CONTRACTUAL ADJ~ 329.D0- ~~~ BALANCE TRANSFER* ~.,q~ PERFORMED BY: HASSAN M HAL Md DIV OF DIA6 RADIOL06Y D4/11/OB 710352b +a'~,,~ CHEST SPECIAL VIENS y~,QO ~~~ BLUE SHIELD PAYMENT* 21.00- ~~~ B SHIELD CONTRACTUAL ADJ~ 43.00- 0.00 PERFORMED BY: SHDAIB ALAM MO DIV OF PULMONARY FEDICINE D4~/1L08 44233.60 1~E ,H1 €3AILY HOSPITAL CARE r~~00 06/14/06 BLUE SHIELD PAYMENTS 100,00_ 06/14/06 B SHIELD CONTRACTUAL ADJ~ 154.00- O.DO PERFORMED BY: SUSANN E SCHETTER 00 DIV OF DIA6 RADIOL06Y D4/12/OQ 710102b ~~~'4 ~[6 i~HEST 1 VIEW yL,00 ~~~ BLUE SHIELO PAYMENT* I2.00- 04/30/06 B SHIELD CONTRACTUAL AD,AE 52.00- O.DO i~ERFORMED BY: JAVIER E BANCHS MD ELEC1'RDPHYSIOL06Y 04/12/06 49233 ~~~4 !f I~IOSP VISIT EXTEN CC 254.00 06/07/06 BLUE SHIELD PAYMENf* 1DD.00- 06/O7/OB B SHIELD CONTRACTUAL AD.hE r~,~_ 0.00 +~ERFORMED BY: REBECCA BASCOl1 MD DIY OF PULMONARY MEDICINE 04/12/06 94233.60 !•t8„~3:1 IaAILY HOSPITAL CARE 2r~.O0 06/14/06 BLUE SHIELD PAYMENTS lOD.DO- 06/14/D6 B SHIELD CONTRACTUAL AD.AE 154.00- 0.00 ~'ERFOR~D BY: JANET A NEUTZE F~ DIV OF DIA6 RADIOL06Y 04/13/06 7101026 ;~36„G[I ::HEST 1 VIEW 64.00 ~~~ BLUE SHIELD PAYMENT* 9.60- 04/30/06 B SHIELD CONTRACTUAL ADJ~ 52.00- ~~/~ BALANCE TRANSFERS 2.40 ~~ERFDRMEO BY: REBECCA BASCOM MD DIY OF PULMONARY MEDICIFR: 04/13/06 49233.60 c::.~l . E:I. ~:oAILY HOSPITAL CARE 254.00 05/14/OB BLUE SHIELD PAYMENTS 100.00- 05/14/06 B SHIELD CONTRACTUAL ADJ~ 154.00- 0.00 I i u~ n ~ i i r-~ir~iirrrrr~rrlirir ~~I l ~ °~I~pER:'c i EIC~~ +~ND ENTER ANYADDRESS OR INSURANCE CORRECTIONS ON BJ1CK i ai n i i irrrrrrn~rr~rrrrr~ iairrrrririrr i~ THERE ARE ANY MISSPELLINGS OR ERRORS, PLEASE PRINT CORF~ECTlONS. Guarantor's Name Guarantor's Address Q R I MARY i Patient's Relationship to insured INSURANCE COVERAGE 1 ^SELF [a5POU5E [,' CHlL[? tJ tS7tiER Insurance Company Names ---__~-~^ 'Phone # ------------_____-___-----------______ _ ~!_--- -1------ ---- -- Insurance Company Address Policy Holder's Name -_.__._._-- -----. lgirthdate ~_~-- i Poticy 8 Group # Policy Effective Da#e Employee's Name ----------- __ .__-----__._-- PPhone # Employer's Address Phone #~ -----___ ~.-_.r_ I City ---~,_-~__~- State I i Zip Gode L______..__..._-___.__.-____-_.._-_____-_-..-__i____~---_ __~__1~-_.- -----__-.. _._.._-_---.-_-- SECONDARY lPat~erst>~ ~iei~teon5n~p ca t~,s~,rca INSURANCE COVERAGE ~ ;J SELF ^SPCYUSE I ^CFiILD ^OTHER - jinsurance Company Name -------J--- -__ Phone # -------~---- _ -_--- ----L---) -_- - ---- -- --__- -___ ~~ Insurance Company Address L------------__---.- -----_. ~--____- i Policy Holder's Name ---- - -__ Bir#hdate l-_---------______--___-_---- ----- f Policy & Group # :i I - ----1--------~.__.,- ~Palicy EffeatRUe [Sate ~ Employee s Name i Fhone # ~ ~_-.- --1 ~- _._~~.._------ -- _______~ ~ i Employer's Address it _-___._-_ -_~._1 ~ __._ _ j~ I ~ ~ ~ ; , ~' , STATEMENT OF PHYSICIAN SERVICES 1,~ ~, I g ~ air ? 'I ~~ ~1 ~:1~ f ;.a,; ~NN~~aT~_ DAVID W RUSSELL q olf g T1k.~I~f:1 a "~~ Tlx; (.cai a r'~ - 644 W I_OUTER ST ~`~ 1 r ~r s tti ~ +,'lerl~~:al: C:c:n:er CARLISLE PA 170132214 ' ~ f ' ~ vt c it .~ STATEMENT DATE: 05/29/09 ACCOLINT # 1593797 LAST STATEMENT DATE: ~2/~/Os ~- IF ANY QUESTIt)N8 WI_ : a ~ r: : t~rr cp w r ~a1SHMC PATIENT FIIVANC IAL SERVICES FED TAX ID # 251857035 PItOGEplaRla 13117E CtgC-N 17iC~+'~ t'as ~~ Q~-~,r ' DESCRIPTION INS CHARGE PAYMENTI GUAll/11R ' Au.1usT1a~ENr BALAI+~E 04/23/06 BLUE SHIELD PAYMENT* b7.02- 04/23/06 B SHIELD C~ITRACTUAL ADJ~ 83,7g_ d4/23/O6 B SHIELD CONTRACTUAL ADJ~ 571.44- 04/23/OB BALANCE TRANSFER 16.76 04/1Q/06 7582.526.1 ~~9, ~'t~ , "_ yEN)6RAM IVC SUP & IM'ERP 403.00 D4/23/06 BLUE SHIELD PAYMENTS 62.40- 04/23/O6 B SHIELD CONTRACTUAL ADJ* ~,DO_ 04/23lDB BALANCE TRANSFER 20.60 PERFORMED BY: RICKHESVAR MAHRAJ MD DIV OF DIA6 RADIOL06Y 04t/10/OD 71D10~2& ~~.# , CHEST I VIEMI 6,4,00 D4/23/OB BLUE SHIELD PAYMENTS q,6,0_ D4/23/O6 B SHIELD CONTRACTUAL ADJ* 5200_ 04/23/O6 BALANCE TRANSFER 2.q~p o4nao6 75!~n;o6.~.c ;c. , 04/23/06 D4/23/OB 04/23/08 04/10/06 49?:i3,k t, , r 74 , "+ 06/07/06 05/07/06 o4/lao6 44;-=c3,c t, i~i11!: , ~~I 05/14/06 06/14/06 o4i11ro6 nolaR:6.~ ~~ !~~, 11~ 04/3o/a6 04/30/06 04/30/06 04/1L06 721252.6 04/30/06 04/30/06 04/30/06 04/1L06 7045026 04/30/06 04!30/06 04/30/06 PERFORMED BY: FRANC C LYNCH !~ INTERVEMIDNAL PERC PLCM~II'/IVC FILT IM'E 145.00 BLUE SHIELD PAYMENT* ~,OD_ B SHIELD CONTRACTUAL ADU~ I„50~D0_ BALANCE TRANSFER 4.~ PERFORMED BY: JAVIER E BANCHS MD ELECTROPHYSIOL06Y HOSP VISIT EXTEN CC r~~00 BLUE SHIELD PAYMENi~ 100.x_ B SHTELD CONTRACTUAL AD,A+E r~,00_ 000 PERFORMED BY: SHDAIB ALAM !0I DIV OF PULMONARY MEDICIirE DAILY HOSPITAL CARE ~r ,DD BLUE SHIELD PAYMENTS 100.D0- B SHIELD CONTRACTUAL AD,1N 154.00- 0.00 PERFORMED BY: JOHN F l~JRRIN MD DIV OF DIA6 RADIOL06Y CHEST 1 vIEN 64.00 BLUE SHIELD PAYMENTS 4.6p_ B SHIELD CONTRACTUAL AD.~ 52.00- 9ALANCE TRANSFER 2.40 PERFORMED BY: KEVIN P MCNAMARA MD DIV OF DIA6 RADIOL06Y "~~~~' ;T CERVICAL SPINE UNENHAN 406.00 BLUE SHIELD PAYMENTS 53.6D- B SHIELD CONTRACTUAL ADJ* 334.00- BALANCE TRANSFER 13.4D c~ysa Il: :T HEAD UNMIANCED 296.00 BLUE SHIELD PAYMENTS 46.60- E SHIELD tXBtTRACTUAL AD.BE 237.00- BALANCE TRANSFER 12.2D aERFORMIFO BY: BRENf J NA6NER MD DIV OF DIA6 RADIOL06Y 04/1L06 7126026 cr~i~R ~$ r;:T THORAX N/CONTRAST EMI 434.00 ~~~~~I f~~~„I f III I I I F -, :I fI It8^ ~) 1-~I C h~ E~C)X 1'LND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK r~ ~ r ~ ~i ~ r ~" i, ,~ i u "u~rwrr~rr iF THERE ARE ANY MISSPELLINGS OR ERR®RS, PLEASE PRINT GGIRRECTlC1NS. Guarantor's Name Guarantor's Address PRIMARY INSURANCE COVERAGE Insurance Company Name ~' insurance Company Address Policy Holder's Name -----'---------- Policy & Group # - -^---^----~ Employee's Name ---- ------------ Employer's Address ~ - i Phone # I I CSty iState I ~ Zip Cade ______.-.-_--------------- -1-----------------------._._L_~_-~_ 1 -- ~------------__-_-- PatienYs Relationship to Insured i SEC©NDARY ;Patient's Relationship to Insured [,]sEIF [_jSPJ4YSE ~- n eHILD J oTHEa ~ i INSURANCE CQVERAGE , ; J sE~r- ^ SPOUSE ~ racHSLa i_~orHE~ _ . ~Phone # ' f Insurance Company Name - ~~ -------- ~- Phone # ( 3 1Insurance Company Address It ) ~Birthdate s ~ Policy Holder's Name Birthdate i __-----~-_-~._.-_,__..------.~_ ~ ~.~ ~_____.~_-~----__.~.`-.--- _._-__------ f._- _..----_. --._--- Pollc Effective Date y Policy Effective Date y tip Grou # i Polk p ' ~ ~ hony # " ~, ~_.-.-.--- ~ ;Employee's Name I ! _ i Phone i ) ---~--------------- - ~ ~ 1 __...-.._ - r-~__---------.-_~_ er's Address Em lo ' ~ i a..r.._~_.._._...__...- p y i l ~ ~ ~ K ~, ;~, j `~ ,. STATEMENT OF PHYSICIAN SERVICES ~. ~.. }~j~;~,~~r;'~..j;q"( DAVID W RUSSELL $ of $ - - I3~E. 44+Ituk~ I`It . $ c-i!rt° .`~ >-! rsx~e v til ' +~4 ~'lwsirtrie. 644 W LOOTER S7 edical Center CARLISLE PA 17013-2214 STATEWIEPIT DATE: OS/29/O9 ACCOUNT # 1593797 LAST STATEIIIENT DATE: ~ ~f24~~$ • ~ r i 4ax +:~.+F:~r c~~:>, p+ Iasi: ~:;aN~.acr: M;;H~ PATIENT FINANCIAL SERVICES FED TAX ID # 259857035 I~~ Tt : ~Po onr: ~~ cc~ E QT1f DESCRIPTION Ifi+AS CHARGE ~~ 6tlAi~t,Ai~fFDR t'A ' ~ t'M$t~i'[' BALI~IWL~ ~+, `.;, ,q~ ' B SHIELD CONTRACTUAL ADJ* 52.D0- +~-'~: "'~ BALANCE TRANSFERAL 2.40 PERFORMED BY: SNDAIB ALAM MD DIV DF PULMONARY MEDICINE g4,'DFh~'Gl,? ~p:~i,,l~: 5~i4.6:; DAILY HOSPITAL CARE 254.00 q5.']`-, ~ BLUE SHIELD PAYMENi~ 100.00- q5~']r ~ pP~ B SHIELD CONTRACTUAL AD.1* 154.OD- 0.00 PERFORMED BY: DEBORAH L IOLBRETTE MD ELECTR~HYSIOL06Y g4.~'OF:a qE ~_i(I:;'?I v'8:! . ,? EC6 ELECTROCARD INTERP BSO 75.00 g5,~'7l a ~ BLUE SHIELD PAYMENT* D.00 O.OD PERFORMED BY: STEVE M E1TIN6ER MD IHTERVENTIOAIAL q4~'O~`~ ~ 93~i5fir"..ti,.4;t: ~~2a . t1 INTERP - AN6I0 521.00 ~+~ ~2'- ~ ~ BLUE SHIELD PAYMENTS gigF.BO_ Q4; '2? r q8 B SHIELD CONTRACTUAL ADJL[ ~. ~- D4r'2? r OA BALANCE TRANSFERLE 11.20 a'1'+,~'O9 r 09 -3~~.p2,6, ~~; ,F4r„ . q LEFT HRT- PERC 1288.00 ~,~'2? a qA BLUE SHIELD PAYMENTLE ,q~.DO- ~,~ 2i r qS B SHIELD t21h1'TRACTUAL ADJLf 788.00- ~'23r~ BALANCE TRANSFERS 1D0.00 q4,~ 09 + D6 +~?. , [a: ~~ 2~+ . Cs AN6I0 - CORONARY 8B7. DO ~+~' 2.i r ~ BLUE SHIELD PAYMENT~L 45.43- ~+~' 2~ ° ~ B SHIELD CONTRACTUAL ADJ~L 830.21- q'+~' 2.3 r ~ BALANCE TRANSFERlt 11.36 IsERFDRMED BY: LOUIS S IIIIMIER MD DIV DF DIA6 RADIOL06Y g4r'O4r(~ :':1#~]+7i':h I~~t8.69 CHEST 1 VIEW 64.00 fir' 23' BLUE SHIELD PAYMENi~ 4.60- 114r' 23 r ' B SHIELD CONTRACTUAL ADJ~ 52.00- q4~ 23 r ~1 BALANCE TRANSFER z.40 PERFORMED BY: JAVIER E BANCHS MD ELECTROPIIYSIOL06Y q#/'O9.''lQ3 <^4"~'.> 4~4 , ~ ][NITIAL IMAPT CONSULTATId~I 288.E q~~~7''~ ' BLUE SHIELD PAYMENTAL 120.00- D-x/ '17 `~ B SHIELD CONTRACTUAL AD.i>E 168.00- 0.00 PERF~IIfD BY: SIDAIB ALAM MD DIV DF PULMONARY MEDICIMR; 04/'~~-,'kt g92s1 X16 Bk OAILY H0.SPITAL CARE 254.00 gIS/ 4,':jK BLUE SHIELD PAYMENT~L 100 00- 0!S/:14,'r18 B SHQELD CONTRACTUAL ADJil . ]54.00- O.OD PERFORMED BY: FRANK C LYNCH MO1 INTERVENTIONAL ~/;10~'!~ :i~5~tq.1~l: "v'I~7,H A'EV MAJOR VEIN CAVAL FILT 3215.OD ~+/"3~'f1PI BLUE SHIELD PAYMENTAL q4/~!3r'!'~ B SHIELD CONTRACTUAL ADJ~ D4/23r1~k BALANCE TRANSFERLE Iq4/:Arf~4 3~ 11qlI ~I I!Ii:.11 V"17. ~ INTR OATH SUP/INF VENACAV 739.E f I ~ f ~ ~~~ + ~~ !I ~ 1' l I iI I ~il [7 chi Ci: ~# BOI)C AN D ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK 604.b8- 2459.15- 151.17 6F THERE ARE ANY MISSPELLINGS OR ERRORS, PLEASE PRINT CORRECTIC3NS. Guarantor's Name Guarantor's Address PRIMARY INSURANCE COVERAGE Insurance Company Name insurance Company Address ~- Policy Holder's Name ~ - ---__-__-- Poiiey & Group y~ -~-_`~-- Employee's Name ^-----------__.__.~. Employer"s Address-~_____ ~-- Phone # Patient's Relationship to Insumd fiELF ^ SPOUSE CHILD `tJ tJTHER ---- ~ Phone # _.__..--._--- ~I I t3irthdate Policy Effective Bate Phone # ~ } City State ~ Zip Coda SECONDARY INSURANCE CQVERAGE Insurance Company Nams Insurance Company Address Paliay Halder's Name -~-_---_____._-- Policy ;~ Group t4 Employees Name Employer's Address ~----- Patient's Relationship to Insured ,]SELF (_~SPCSUSE [~ CHILD ^ ATHER _--(P h o ne ~ --------- -- ~{ ) Birthdate Policy Effective t3ate Phone tt ( 7 ~ STATEMENT' IDF PHYSICIAN SERVICES 4 x ~~k ~y~+3EL F } I r r'' ,.Iv ttRplOe +~ F r ~NN.~ 1/~~ DAVID w RussELL 2 of 8 - 644 W I_OUTER ST The Nfilton S. Hershey P~Zee::>31 Center CARLISLE PA 1~TQ13-2214 STATEMENT ®The College of Medir,~n~~ DATE: 05/29/09 LAST STATEMENT ACCOUNT #~ 1593797 ~aTE: 12/24/08 '~- iF ANY QUESTIONS, PLEASE coN-rAC'r::~!~HMC PATIENT FIWANCIAL SERVICES FED TAX ID # 2518571035 DATI: PR0~1=PURE D4AG D'1-'i' DESCRIPTION _ PAY1w1ENT/ GUARAT~'T~R CQI~ ODE INS CHARGE ADJUSTItilEN7 BALAl~ICE PERFORMED BY: DAVID C HMI MD VASCULAR SURGERY 04/07/08 934T02b 4x53.42 DUPLEX SCAN EY - (XRiPLETE 267. D0 04!23/08 BLUE SHIELD PAYMENT* 30.80_ 04/23/08 B SHIELD COhITRAC1UAl ADJ~ 228.~r0_ 04/23/08 BALANCE TRANSFERS 7.70 PERFORMED BY: JOHN F MC6URRIN MD DIV OF DIAG RADTOLOGIf 04/07/08 710102b 511.9 CHEST 1 VIEW by.OD 04/23J08 BLUE SHIELD PAYMENT* g~~_ 04/23/08 B SHIELD CONTRACTUAL ADJ* 52.00- 04/23/08 BALANCE TRI~FERs~ 2.,4,0 ¢ERFORMED BY: SHDAIB ALAM MD DIV OF PULMONARY MEDICINE 04/07/08 99233.60 518.81 LtAILY HOSPITAL CARE r~,p0 06/14/08 BLUE SHIELD PAYMENTIE 100.D0- 06/14/08 B SHIELD CONTRACTUAL ADJ* r~.00_ D.00 I~ERFDRMED BY: JENNIFER GRANDOTING MD TMA6IN6 04/08/06 933122b.6C 424.0 'rEE3 COMP 994.00 04/23/08 BUR: SHIELD PAYMENT* 9b ~ ~_ ~/~~ B SHIELD CONTRACTUAL ADJ~x 873.04- ~~~ BALANCE TRANSFERI~ ~,~ 04/08/08 433202b.7b 424.0 IX~PLERS COIOi 330.DD D4/23/08 BLUE SHIELD PAYMENT* 1b.95- 04/23/OB B SHIELD CONTRACTUAL ADJ~x 308.81- 04/23/06 BALANCE TRANSFER* 4.24 04/08/08 9332526.76 424.D DOPPLER COLOR FL VEL MAP 2~Ir,pO 04/23/08 SLUE SHIELD PAYMENTS 3.34- 04/23/06 B SHIELD CONTRACTUAL A0~ 230.83- D4/23/08 BALANCE TRMISFER~ 0.83 04/OQ/08 933072b 424.0 ~D/N-~FO~ ECFIDf COMP 492.00 04/23/08 BLUE SHIELD PAYMENT* 40.47- 04/23/08 B SHIELD CONTRACTUAL AD~AI 44x0 79- 04/23/08 BALANCE TRANSFERS . 1D.24 04/08/O8 933202b 424.0 OPPLER3 COMP 330.OD 04/23/08 BLUE SHIELD PAYMENI'~ Ib.95- 04/23/06 B SHIELD 00NtTRACTUAL ADJI~ 3D8.81- 04/23/08 BALANCE TRAN.SFER=ix 4.24 04/08/08 933262b 424.D tOPPLER COLOR FL YEL MAP 235.00 04/23/08 BLUE SHIELD PAYMENTS 3 ~_ 04/23/08 B SNIELD CONTRACTUAL ADJ~ , 230 83- 04/23/08 BALANCE TRANSFER'S . 0.83 '°ERFORI~D BY: JOIN F MCGURRIN MD DI'V OF DIA6 RADTOLO6Y 04/08/08 710102b 518.89 HEST 1 VIEW b4.00 04/23/08 BLUE SHIELD PAYMENT O~~IIIt~INI?itl II% NIIt~gl~•I INS IIIY1t~tN11I~~I~LLrf~ ^CHECK. BOX' .ptVD ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK ~Wli~llllflll A9 .urNacurwn.~.~.:,..~.~~.,.~..y....~..-.. _.. .. _............__ .............. 4.60- EF THERE ARE ANY MiSSPELLlNGS OR ERRf3RS, PLEASE PRINT G®RRECTl4NS. Guarantor°s Name Guarantor's Address City Phone # PR (MARY ~ Patient's Relationship to Insured L~$ELF C_JSP4USE INSURANCE COVERAGE ~ ~,OH9kD ^OTFiEK ~~ -'-----_-_..___._ 1 ---- ---- .___ insurance Company Name ._....._- ~.._.-'---'- -- ~ Phone C D Bnsurance Company Address Rolicy Holder's Name ~_~~~~ ~-~~irthdate ---- _ ~_--___.__ _~_-. i ~_~. ~ ---I--------- ------ -- _ __~ Policy & Group # Policy Effective Date ______.___~______-__ ° _-___ - Phane # s Name Employee ~ ,_ (i~ } __L.~_______-~___w. Employer's Address State 'Zip Code SEGC3NDARY fNSURANCE CC?VERAGE Insurance Company Name Insurance Company Address Policy Holder's Name Policy & Group # Employee'5 Name ~Employer'sAddress~ Patient`s Relationship to Insurec ;J SELF [~ SPOUSE ^-FiELO I_~ OTHEF____--- III YhonC' # i( D Bir#hdate Policy Effective Date Phone # ` ~ ~ STATEMENT rJF PHYSICIAN SERVICES pE]~jNSTATE DAVID W RUSSELL f 1 644 W LOUTER ST The Milton S. Hersh~E:v I1~x[~~c~a1(:enter CARLISLE PA 1:701,3-2214 ® The College of hiedi~nne .- _.--. ACCOUNT # 1593797 S'fATErAENT DATE: 05~29/O9 UiST STATEMENT DiATE: 12~24~08 1 ~ 8 ~° IF ANY QUESTIONS, PLEASE I.ON'rAGr MSHMC PATIENT FINANCIAL. SERVICES FED TAX ID # 251857035 d~T~ P ~~ E?~"Y ' DESCRIPTION INS; CHARGE ~'AYMENT/ GUARANTOR AQJUSTMEHT BALANCE »> PATIENT: DAVID W Ii~SELL 1!54';747 9652344 ~ERFDRMED BY; BRENT J WAGNER MD DIV OF DIAH RADIOL061' PLACE OF SVC: INPATIENT 04/03/08 7101026 486 CHEST 1 VIEW x,00 ~/1~~ BLIP SHIELD PAYFIENT~ 9.60_ 04/lb/D6 B SHIELD CONTRACTUAL ADJ~ 52.00- 04/lb/06 BALANCE TRANSFER 2.40 04/04/06 7101026 486 CHEST 1 VIEW ~,Op 04/16/06 BLUE SHIELD PAYMENT* 9.60- 04/16/06 B SHIELD CDIirR1iCTUAL ADJ* 52.D0- 04/I6/06 BALANCE TRANSFER 2.40 04/04/06 7126026 415.19 CT THDRAi{ W/CONTRAST ENH 434.00 04/23/06 BLUE SHIELD PAYMENT* 61.60- 04/23/06 B SHIELD CONTRACTUAL ADJ* 3,g7~00_ 06/13/06 B/S Ti1K~ACIC 61.60 ~~~ BLUE SHIELD PAYMENT 61.60- 15.40 04/04/06 7101D26.76 466 CHEST 1 VIEW 64,Q0 04/23/06 BLUE SHIELD PAYMENT* 0,00 OQ/13/06 BLUE SHIELD PAYMENT* 12.00- 06/13/06 B SHIELD CONTRACTUAL ADJ~ 52.D0- 0.00 PERFORMED BY: ROBERT L VENDER MD OTV OF PULMONARY MEDICINE 04/04/06 49223.60 516.61 INITIAL HOSPITAL CARE 474.00 06/14/06 BLUE SHIELD PAYMENTS 146.00- O6/14/06 B SHIELD CONTRACTUAL ADJ* 264.00- 0.00 PERFORMED BY: GERALD V NACCARELLI MD ELECTR~DPHYSIOLOGY 04/04/08 93010 Y61.2 EC6 ELECTROCARD INTERP BSO 75.D0 06/21/06 SLUE SHQELD PAYMENi~ 0.00 0.00 PERFORMED BY: CLAUDIA J KASALES MD DIV OF D:IA6 RADIDLO6Y 04/05/06 7101026 511.9 :HEST 1 VIEW 6r+,DO 04/23/06 BLUE SNIELD PAYMENT* q.~_ 04/23/06 B SHIELD CONTRACTUAL ADJrI 52.00- 04/23l06 BALANCE TRANSFER 2.40 PERFOpF1ED BY: KEVIN 6LEE90N MD DIV OF PULMONARY MEDICINE 04/06/06 99291.60 518.61 t;RIT'ICAL CARE FIRST HR 571.00 06/14/06 BLUE SHIELD PAYMENTS 233.75- 05/14/08 B SHIELD CONTRACTUAL ADJ~ 337.25- 0.00 PERFORFED BY: CLAUDIA J KASALES MD DYV OF DIA6 RADIOLOGY D4/O6/06 7101026 766.00 CHEST 1 VIEW 64.00 04/23/06 BLUE SHIELD PAYM~ 9.60- 04/23/06 B SHIELD COMRACi1JAl ADJ~ 52.00- 04/23lO6 BALANCE TRANSFER 2.40 rrllrrrrrlrrrrtn>~ un t~rrua~tx Ii 7 hI1Al4~ ~ullt rrrrurr~ ~I:INI~rr~t~rl:ttNI~91 Ali I~r~ r,Eaaru~.~~rir CHECK BO:X hND ENTER ANY ADDRESS OR !9NSURANCE CORRECTIONS ON BACK rrrr~rrrri~i iu~r ~~~~„~..~„~,,.,..,~..v......~.........Y.,.._..__..._._...._ .._ . l~ Guaran#or's Name Guarantor's Address iF THERE ARE,4lVY MISSPELLINGa OR ERRORS, PLEASE PRiNI' CORRECTlOtVS. Phone n PRIMARY IN~URANCECOYERAGE Insurance Company Name -- _` Insurance Company Address T Pokey Holder's Name ~-~ Policy & Group P! `-- ---__~~.--- Employee's Name -------------- _-- Employer"s AddressT Paden#'s Relationship to Insured i~SELF [SPOUSE I j CHfLR ^ tFTHER Phone # E I ~--- - 6irthdate policy Effective Date Phase q ( ? City State ~ Zip Code SECON©ARY INSURANCE CC?VERAGE Insurance Company Name "_______-__ Insurance Company Address Policy Holder's Name Policy & Group # Employee's Name --_ _.-_--------_.~--- Employer's Address -~-- ------ Patient's Relationship to Insured SEi.F [~ SPOUSE ~;cHlf_o [~oTHE~ - Phone tt -----_--. -- I( ) Birthdate Policy Effective date Phone fi 4