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HomeMy WebLinkAbout09-4549MAJOR 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 THE MILTON S. HERSHEY MEDICAL CENTER P.O. Box 853 Hershey, PA 17033 VS IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. CA- y549 l?iv?tTirm : CIVIL ACTION TROY BEAM & DEBBIE BEAM, h/w 401 Shippensburg Road 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 I J COMPLAINT - CIVIL ACTION THE MILTON S. HERSHEY MEDICAL CENTER VS. TROY BEAM and DEBBIE BEAM 1. Plaintiff is a non-profit corporation located at the address indicated in the caption hereof. 2. Defendants are individuals who reside at the addresses indicated in the caption hereof. 3. At all times material hereto, defendants were the parents of Trevor A. Beam, a minor. 4. As the result of a certain medical condition, said child was treated at the plaintiff hospital on Jain. 10, 2008 through March 4, 2008 and Jan. 20, 2009 thru March 12, 2009. 5. The amounts, quantities and nature of the medical care rendered, the dates 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. 6. Said medical care was commensurate with the condition of defendants' child and was necessary for the health and wel- fare of defendants' child. 7. At or about the time of defendants' child's admission to the plaintiff hospital, implied, constructive and oral con- tracts arose between defendants and plaintiff by the terms of which, defendants became obligated to pay plaintiff's charges for the medical care rendered by plaintiff to defendants' child. 8. Defendants' child is indigent. I I 9. Defendants are financially able to pay for the medical care of their child. 10. By virtue of the Act of 1937, June 24, P.L. 2045, §3, as amended, 23 Pa. Cons. Stat. Ann. §4603 and all other appli- cable statutes, laws, and ordinances, defendants have a duty to support their child. 11. Defendants have been unjustly enriched by plaintiff's discharge of defendants' duty to support defendants' child, which duty, defendants failed to perform. 12. Defendants refuse to pay the balance due although plaintiff has made demand that defendants do so. 13. As a result of the foregoing, there is due and owing from defendants to plaintiff the sum indicated in Exhibit "A" WHEREFORE, plaintiff demands judgment against defendants, jointly and severally, for the sum of $296,846.81 plus six percent (60) interest per annum from the date of discharge to the date of judgment, record costs and non-record costs. TABAS & ROSEN, P.C. LEWInC. T UFFER, ESQUIRE Atto ey for Plaintiff MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit ##: 9381369 ------------ Date Svc Code -------- ------ Description ------ Unitsl Debits I Credits 01 10/08 711107 ------- AIR AMBULANCE TRANSPO 1 -------------- 1 1384 00 01/10/08 711108 AIR AMBULANCE MILEAGE 47 . 5170 00 09/30/08 09/30/08 980090 98 HOSPITAL BAD DEBT W/0 -1 . 16554.00- 0091 HOSPITAL BAD DEBT PLA ---- 1 1.6554.00 * - Not posted ------------------ ------ I - Balance: I 16554.00 ------------------------- P-1 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/1,0/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 10502398 ---- ------------------- Date - - - - - Svc - Code I Description -1 Unitsl Debits I- - -Credits- - -------------------------------------- 01/10/08 01/10/08 10295 5 PEDS INTENS CARE UN 1 3550.00 01/10/08 16503 PEDS LEVEL I TRAUMA C 1 1953.00 01/10/08 39104 3 I STAT GASES (PICU) 2 176.00 01/10/08 9105 3 I STAT NA (PICU) 2 36.00 01/10/08 9106 I STAT K (PICU) 2 36.00 01/10/08 39107 3 I STAT ION CA (PICU) 2 64.00 01/10/08 9108 4 I STAT HCT (PICU) 2 38.00 01/10/08 6121 URINALYSIS DIPSTIX PR 1 7.00 01/10/08 46473 4 ER,CRITICL CARE,30-75 1 1243.00 01/1 0/08 6717 4 NONINVAS PULSE OX, MU 1 101.00 . 01/10/08 6843 BLADDER CATH, SIMPLE 1 147.00 01/10/08 101003 1 ABO BLOOD GROUP 1 37.00 , 01/10/08 01004 ANTIBODY SCREEN 1 74.00 01/10/08 101005 101021 RH TYPE COMPAT IMMED SPIN 1 14 37.00 01/10/08 101213 , RED BLD CELLS EA U 5 1036.00 1695 00 01/10/08 01/10/08 104009 1 AMYLASE, BLOOD 1 . 47.00 01/10/08 04028 1 IONIZED CALCIUM 4 420.00 01/10/08 04042 CREATININE, BLOOD 1 15.00 01/10/08 104048 1 MYOGLOBIN 1 87.00 01/10/08 04060 1 GLUCOSE, BLOOD 5 70.00 01/10/08 04092 1 LACTIC ACID 1 65.00 01/10/08 04110 10 BLOOD GAS PANEL 4 544.00 01/10/08 4129 10 PHOSPHORUS, BLOOD 1 15.00 01/10/08 4131 1 POTASSIUM (K), BLOOD 5 75.00 01/10/08 04145 1 SODIUM (NA), BLOOD 5 75.00 01/10/08 04156 104435 SGPT (ALT) COMP METABOLIC PANEL 1 1 16.00 01/10/08 105029 FIBRINOGEN 1 63.00 01/10/08 105036 HEMATOCRIT 1 36.00 01/10/08 01/10/08 105052 10 PARTIAL THROMBOPLAS T 3 19.00 120.00 01/10/08 5054 PLATELET COUNT AUTO 1 18.00 01/10/08 105059 105657 PROTHROMBIN TIME CBC W/PLT/DIFF AU 4 96.00 01/10/08 106011 TO URINALYSIS-BASIC & MI 6 1 306.00 01/10/08 01/10/08 111001 2 GLUCOSE BEDSIDE MONIT 2 40.00 60.00 01/10/08 45477 GENTAMICIN 40 MG/1 ML 1 2.03 01/10/08 245525 2 HEPARIN SODIUM 1000 U 10 5.20 11/10/08 45553 246020 LIDOCAINE 1 ML BACITRACIN 50000 U 2 3.60 11/10/08 246021 BACITRACIN 15 GM 2 1 53.40 11/10/08 246049 CALCIUM CHLORIDE 10 M 1 6.75 4 40 -------------------------------------- I - Continue - MS HERSHEY MEDICAL CENTER PAGE: 2 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 1.0502398 ------------------------- ----------- Date Svc - Code Description - Units Debits Credits -------------------------------- 01/10/08 01/10/08 246050 246 CALCIUM CHLORIDE 10 M 1 9.55 01/10/08 057 24 CEFAZOLIN 1 GM/5 ML 2 3.60 01/10/08 6162 24 FENTANYL CITRATE 5 ML 8 28.60 01/10/08 6332 2 METHYLENE BLUE 10 ML 1 9.60 01/10/08 46475 24 SODIUM BICARBONATE 50 1 8.85 01/10/08 6584 246 DOBUTAMINE 250 MG 1 8.30 01/10/08 831 2 FENTANYL CITRATE 20 M 10 5.45 01/10/08 46836 24 FENTANYL CITRATE 2 ML 2 6.00 01/10/08 7889 24 VECURONIUM BROMIDE 2 17.75 01/10/08 9220 2 MIDAZOLAM 5MGL ML 10M 50 30.45 01/10/08 49982 25 RANITIDINE 2.5MG/ML 3 40.95 01/10/08 0577 25087 PROPOFOL 20ML 2 11.50 01/10/08 9 2 KETAMINE 100MG/ML 1 22.55 72121 DIPRIVAN INJ 10MG/ML 1 14 30 01/10/08 272129 ROCURONIUM BROMIDE 5M 2 . 74 70 01/10/08 272136 PEN G K 5MU VIAL 9 . 21 70 01/10/08 272473 PAPAVERINE 30MG 2ML A 4 . 22 52 01/10/08 273019 NAFCILLIN 1 G PREMIX 1 . 22 10 01/10/08 273023 GENTAMICIN 100MG PREM 2 . 5 10 01/10/08 273532 PROPOFOL 10MG/ML 100M 1 . 28 55 01/10/08 274218 CEFAZOLIN SODIUM BAG 4 . 28 40 01/10/08 274385 HEPARIN/NS FLUSH 1U/1 1 . 25 45 01/10/08 274989 DT PEDIATRIC 0.5ML VI 1 . 30 55 01/10/08 01/10/08 305607 305 ELBOW 1-2 VIEWS RIGHT 1 . 117.00 01/10/08 621 30 KNEE 1-2 VIEWS RIGHT 1 148.00 01/10/08 5625 305 TIBIA & FIBULA AP&LAT 2 290.00 01/10/08 630 30 FOOT 1-2 VIEWS RIGHT 1 117.00 01/10/08 7101 307 CHEST 1 VIEW 2 254.00 01/10/08 205 307 C-SPINE 2-3 VIEWS 1 163.00 01/10/08 220 3 PELVIS 1-2 VIEWS 1 167.00 01/10/08 07308 30 FEMUR AP&LAT VIEWS LE 3 528.00 01/10/08 7551 3 FLUORO MORE THAN ONE 1 319.00 01/10/08 90510 3 DRAIN,BLAKE,15 MM,ROU 1 77.00 01/10/08 91101 3 OR TIME<=lHR EACH 15M 4 2420.00 01/10/08 91102 3 OR TIME>1HR EACH 15MI 35 9695.00 01/10/08 94855 398218 FIXATOR STD MICROGRID SILICONE 1 6668.00 01/10/08 01/10/08 398230 3 SUTURE, SINGLE ARM 1 26 22.00 234.00 01/10/08 98231 39 SUTURE, DOUBLE ARM 9 153.00 01/10/08 8232 39 SUTURE, MULTIPACK 1 32.00 01/10/08 8666 PBDS MINOR ORTHO PACK 1 86.00 464147 CANCELLOUS SCREWS 2 632 00 ------ I ------------------------------------------------ I Continue - / -3 MS HERSHEY MEDICAL CENTER PAGE 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit $#: 1-0502398 ----------------------------------- _ Date - - - Svc Code I- -- -DescriPtion --- -Units- Debits Credits--I ---- _ 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/O8 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 01/10/08 J1/10/08 01/10/08 X1/10/08 464593 464920 464987 465337 466632 466638 466683 466935 469016 469277 502000 503036 503124 503129 503153 503165 503166 503167 503168 503169 511201 511202 511803 511812 600504 600511 600514 600516 621044 621100 621105 621106 621110 621203 622023 622024 622026 625011 626079 626081 627069 627070 SURGILAV SET MULTI-OR BANDAGE ACE STRUT, HYBRID BLOCK, SILICONE SCREW, BONE BIT, DRILL DRILL BIT ARM,8CM,LEFT OR RIGHT CATHETER THORACIC CLIP APPLIER ANESTHESIA TIME-HOSP DOUBLE TRANSDUCER SET PEDIATRIC A-LINE KIT BAIR HUGGER LOWER BOD COAGULATION TIME;ACTI I STAT K I STAT ION CA I STAT NA I STAT GASES I STAT HCT STERILE WATER UP TO 5 VENTILATOR DAY INITIA VENTILATOR CIRCUIT END TIDAL C02 DISP CU AMBUBAG ADULT W/MASK PULSE OXIMETER SNSR P PULSE OXIMETER SNSR I PULSE OXIMETER SNSR N I V SODIUM CHLORIDE 0 CANISTER SUCT HARDSHE YANKAUER SUCT TB W/O YANKAUER SUCT TB W10 STAPLER SKIN D ISP SS I V RHEOMACRODEX 100 IRRIGATION SOD CHL 0. IRRIGATION SOD CHL 0. IRRIGATION NACL 0.9°; IV ADMIN SET BLOOD FI IV DILUENT DEX 5a 100 IV DILUENT NML SALINE ST EXT MICRO 60" IML IV EXT SET 90" W/FLAS 1 1 1 2 2 1 2 1 1 1 39 1 1 1 3 2 2 2 2 2 400 1 1 1 2 1 -1 1 3 4 3 2 6 3 6 14 1 2 2 4 6 10 100.00 22.00 67.00 306.00 374.00 366.00 732.00 2585.00 31.00 154.00 2946.00 262.00 27.00 45.00 60.00 34.00 60.00 34.00 166.00 36.00 5.00 541.00 24.00 32.00 50.00 18.00 24.00 18.00 20.00 15.00 10.00 492.00 129.00 36.00 84.00 34.00 98.00 16.00 32.00 42.00 220 00 24.00- -------------------------- I - Cont_nue - +-q MS HERSHEY MEDICAL CENTER PAGE: 4 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 10502398 --------------------------- ---------- -------- Date Svc Code Description I Unit s Debits 1---Credits--l ----------------------------------------- 01/10/08 01/10/08 627085 63 SET ADMIN-BIFUSE MEDE 1 13.00 01/10/08 0827 6 FOLEY CATH 14 FR W/ME 1 20.00 01/10/08 30828 63 FOLEY OATH 16 FR W/ME 1 34.00 01/10/08 6903 6 CATHETER FOLEY SILIC 1 8.00 01/10/08 61516 6671 SYSTEM,CHEST DRAIN AD 1 58.00 01/10/08 27 6 SET HEAT EXCHANGE DIS 1 94.00 01/10/08 70334 6 IV INFUSION SET, UNIV 1 9.00 01/1C/08 70829 67 COLLAR ASPEN CERV CHI 1 74.00 01/10/08 0830 46 COLLAR ASPEN CERV CHL 1 74.00 01/11/08 82212 10 STERILE CARDIAC BLANK 1 72.00 01/11/08 295 39104 5 PEDS INTENS CARE UN I 1 3550.00 01/11/08 39105 STAT GASES (PICU) I STAT NA (PICU) 15 1320.00 01/11/08 39106 I STAT K (PICU) 15 15 270.00 270 00 01/11/08 01/11/08 39107 3 I STAT ION CA (PICU) 15 . 480.00 01/11/08 9108 101 I STAT HCT (PICU) 15 285.00 120 THAW FROZ PLASMA/U 1 22 00 01/11/08 101213 RED BLD CELLS EA U 6 . 2034 00 01/11/08 101214 PLT LR PHER EA U 2 . 3234 00 01/11/08 01/11/08 101220 102 FFP SINGLE DONOR EA U 1 . 172.00 01/11/08 019 102100 GRAM STAIN CULTURE BACTERIAL 1 1 28.00 01/11/08 102104 , CULTURE, ANAEROBES ON 1 70.00 63 00 01/11/08 01/11/08 102118 102 SMEAR, FLUOR/ACID FAS 1 . 38.00 01/11/08 147 10 HOMOGENIZATION, TISSU 1 38.00 01/11/08 2303 104 CULTURE, FUNGUS OTHER 1 42.00 01/11/08 028 10 IONIZED CALCIUM 1 105.00 01/11/08 4040 104048 CPK MYOGLOBIN 1 17.00 01/11/08 104060 GLUCOSE, BLOOD 2 1 174.00 14 00 01/11/08 104106 MAGNESIUM 2 . 34 00 01/11/08 01/11/08 104111 1 BLOOD GAS PANEL W/02 2 . 322.00 01/11/08 04129 104131 PHOSPHORUS, BLOOD 1 15.00 01/11/08 104145 POTASSIUM (K), BLOOD SODIUM (NA) BLOOD 1 15.00 01/11/08 01/11/08 104433 1 , BASIC METABOLIC PANEL 3 2 45.00 90.00 01/11/08 04438 1 RENAL FUNCTION PANEL 1 47.00 01/11/08 04585 1 GENTAMICIN LEVEL 3 114.00 )1/11/08 05029 105052 FIBRINOGEN PARTIAL THROMB OPLAS T 4 144.00 )1/11/08 )1/11/08 105054 10 PLATELET COUNT AUTO 5 1 200.00 18.00 5059 PROTHROMBIN TIME 5 120 00 ----------------------------------------I ------------------•---------------------- - Continue - MS HERSHEY MEDICAL CENTER PAGE: 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit ##: 10502398 ---------------------- I---Date ----I_Svc Code -------- Description ption I Units Debits I Credits ----- ---------------------------------- 01/11/08 105656 CBC W/PLT AUTO 4 128 00 01/11/08 105657 CBC W/PLT/DIFF AUTO 1 . 51 00 01/11/08 106011 URINALYSIS-BASIC & MI 4 . 160 00 01/11/08 01/11/08 111001 2 GLUCOSE BEDSIDE MONIT 16 . 480.00 01/11/08 45202 24 ATROPINE SULFATE 0.4 2 3.00 01/11/08 5472 24 CEFAZOLIN 10 GM/50 ML 5 40.40 01/11/08 5491 2 SALINE 0.450 1000 ML 1 3.00 01/11/08 45507 245 ALBUMIN 50 3 989.70 01/11/08 733 2460 PANCURONIUM BROMIDE 1 1 5.20 21 BACTTRACIN 15 GM 1 6 75 01/11/08 246049 CALCIUM CHLORIDE 10 M 1 . 4 40 01/11/08 246162 FENTANYL CITRATE 5 ML 5 . 19 05 01_/11/08 246176 FUROSEMIDE 10 MG/ML 1 . 3 00 01/11/08 246584 DOBUTAMINE 250 MG 1 . 8 30 01/11/08 246737 ACETAMINOPHEN 325 MG 3 . 9 00 01/11/08 246831 FENTANYL CITRATE 20 M 10 . 5 45 01/11/08 246836 FENTANYL CITRATE 2 ML 1 . 3 00 01/11/08 246841 SODIUM BICARBONATE 50 1 . 9 55 01/11/08 247842 CAL GLUCONATE 10ML 1 . 12 65 01/11/08 247889 VECURONIUM BROMIDE 7 . 62 15 01/11/08 248352 AMINOPHYLLINE 250MG . 3 00 01/11/08 249220 MIDAZOLAM 5MGL ML 10M 50 . 30 45 01/11/08 249982 RANITIDINE 2.5MG/ML 2 . 27 30 01/11/08 250084 VANCOMYCIN 1GM 6 . 54 75 01/11/08 250577 PROPOFOL 20ML 1 . 5 75 01/11/08 250986 WHITE PETROLATUM CPD 1 . 5 65 01/11/08 251846 VERSED 5MG/5ML 20 . 14 20 01/11/08 272129 ROCURONIUM BROMIDE 5M 1 . 37 35 01/11/08 01/11/08 273686 2 PENICILLIN GK 2MU PRE 24 . 54.95 01/11/08 74180 274 GENTAMICTN PED INJ 10 5 74.90 01/11/08 654 305 ALBUTEROL 90MCG/PUFF 2 117.08 01/11/08 621 3 KNEE 1-2 VIEWS RIGHT 1 148.00 01/11/08 05625 3 TIBIA & FIBULA AP&LAT 1 145.00 01/11/08 07101 307 CHEST 1 VIEW 1 127.00 01/11/08 308 3 FEMUR AP&LAT VIEWS LE 1 176.00 01/11/08 10501 3 CT HEAD UNENHANCED i 800.00 01/11/08 10516 3 CT THORAX ENHANCED 1 1659.00 01/11/08 10519 3 CT ABDOMEN ENHANCED i 1145.00 01/11/08 10560 310 CT C-SPINE UNENHANCED 1 887.00 01/11/08 562 31 CT T-SPINE UNENHANCED 1 827.00 01/11/08 0564 310 CT L-SPINE UNENHANCED 1 835.00 567 CT PELVIS ENHANCED 1 1301.00 ------------ - 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MS HERSHEY MEDICAL CENTER PAGE 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 10502398 ----------------? -- ------ --------------------- ------ Date -I-Svc Code Description --- Units Debits --- --- Credits--I 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/11/08 01/12/08 01/12/08 01/12/08 01/12/08 01/12/08 01/12/08 01/12/08 01/12/08 01/12/08 01/12/08 01/12/08 310701 391101 391102 398230 398233 398632 465337 469277 502000 503128 503156 511203 511354 511807 621044 621099 621101 621104 622023 622024 625009 625011 626079 626081 627069 627070 627085 636505 636903 661516 667220 10295 39104 39105 39106 39107 39108 104013 104040 104048 104106 104110 OMNIPAQUE 300MG/ML 50 OR TIME<=lHR EACH 15M OR TIME>lHR EACH 15MI SUTURE, SINGLE ARM CT/SPECIALTIES PBDS PLASTIC HAND PAC BLOCK, SILICONE CLIP APPLIER ANESTHESIA TIME-HOSP BAIR HUGGER UPPER BOD BIS SENSOR VENTILATOR DAY SUBSEQ MDT TREATMENT MDT SYSTEM SPACER I V SODIUM CHLORIDE 0 SUCT CATH KT 12F NLTX SUCT CATH KT 14F NLTX SUCT CATH KT 10F NLTX IRRIGATION SOD CHL 0. IRRIGATION SOD CHL 0. SET,BLOOD COMPONENT A IV ADMIN SET BLOOD FI IV DILUENT DEX 50 100 IV DILUENT NML SALINE ST EXT MICRO 60" IML IV EXT SET 90" W/FLAS SET ADMIN-BIFUSE MEDE STOPCOCK MANIFOLD FOU CATHETER FOLEY SILIC SYSTEM,CHEST DRAIN AD UNDERPAD, DRIFLO 23" 5 PEDS INTENS CARE UN I STAT GASES (PICU) I STAT NA (PICU) I STAT K (PICU) I STAT ION CA (PICU) I STAT HCT (PICU) ALBUMIN CPK MYOGLOBIN MAGNESIUM BLOOD GAS PANEL Continue 1 4 5 11 2 1 1 2 9 1 1 1 5 1 2 3 -2 -1 2 2 1 11 1 5 4 1 4 1 -1 1 2 1 1 1 1 1 1 1 2 2 2 4 29.00 2420.00 1385.00 99.00 34.00 168.00 153.00 308.00 756.00 45.00 49.00 541.00 280.00 25.00 12.00 15.00 10.00- 5.00- 12.00 12.00 36.00 539.00 8.00 40.00 28.00 22.00 52.00 10.00 58.00 22.00 3550.00 88.00 18.00 18.00 32.00 19.00 15.00 34.00 174.00 34.00 544_on 8.00- A - I MS HERSHEY MEDICAL CENTER PAGE: 7 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 10502398 ---------------------------- ------------------------------------- l---Date----I-Svc Code Description I Unitsl Debits I Credits I -------------------------------------------------- 01/12/08 104129 PHOSPHORUS, BLOOD 1 15 00 01/12/08 104433 BASIC METABOLIC PANEL 2 . 90 00 01/12/08 104585 GENTAMICIN LEVEL 2 . 76 00 01/12/08 105029 FIBRINOGEN 2 . 72 00 01/12/08 105052 PARTIAL THROMBOPLAS T 2 . 80 00 01/12/08 105059 PROTHROMBIN TIME 2 . 48 00 01/12/08 105656 CBC W/PLT AUTO 2 . 64 00 01/12/08 105657 CBC W/PLT/DIFF AUTO 1 . 51 00 01/12/08 106011 URINALYSIS-BASIC & MI 1 . 40 00 01/12/08 111001 GLUCOSE BEDSIDE MONIT 5 . 150 00 01/12/08 245461 NORMAL SERUM ALBUMIN 1 . 103 70 01/12/08 245733 PANCURONIUM BROMIDE 1 4 . 20 80 01/7.2/08 246162 FENTANYL CITRATE 5 ML 5 . 19 05 01/12/08 246176 FUROSEMIDE 10 MG/ML 1 . 3 00 01/12/08 246737 ACETAMINOPHEN 325 MG 3 . 9 00 01/12/08 246831 FENTANYL CITRATE 20 M 30 . 16 35 01/12/08 247842 CAL GLUCONATE 10ML 1 . 12 65 01/12/08 249220 MIDAZOLAM SMGL ML 10M 50 . 30 45 01/12/08 249982 RANITIDINE 2.5MG/ML 3 . 40 95 01/12/08 251846 VERSED 5MG/5ML 10 . 7 10 01/12/08 272425 MIDAZOLAM 1MG/ML 2ML 4 . 00 3 01/12/08 273686 PENICILLIN GK 2MU PRE 10 . 23 55 01/12/08 274053 ALBUMIN 25% 20 ML VIA 12 . 308 55 01/12/08 274180 GENTAMICIN PED INJ 10 3 . 48 90 01/12/08 274385 HEPARIN/NS FLUSH 1U/1 1 . 25 45 01/12/08 307101 CHEST 1 VIEW 1 . 127 00 01/12/08 307331 ABDOMEN 1 VIEW AP 1 . 176 00 01/12/08 511203 VENTILATOR DAY SUBSEQ 1 . 541 00 01/12/08 511354 MDI TREATMENT 6 . 336 00 01/12/08 01/12/08 621044 63 I V SODIUM CHLORIDE 0 2 . 12.00 01/12/08 3008 6 SUCTION CATH, 10FR 24 2 30.00 01/13/08 70722 1 FEEDING BG ENTERAL 10 2 8.00 01/13/08 0295 1 5 PEDS INTENS CARE UN 1 3550.00 01/13/08 01003 10 ABO BLOOD GROUP 1 37.00 01/13/08 1004 1 ANTIBODY SCREEN 1 74.00 01/13/08 01005 101021 RH TYPE COMPAT IMMED SPIN 1 4 37.00 01/13/08 101213 , RED BLD CELLS EA U 1 296.00 339 00 01/13/08 102105 CULTURE, BLOOD 1 . 92 00 01/13/08 01/13/08 102214 1 CULTURE, URINE QUANT 1 . 42.00 01/13/08 04013 104040 ALBUMIN CPK 1 15.00 1 17.00 Continue ? - 9 MS HERSHEY MEDICAL CENTER PAGE 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit ##: 1.0502398 ---------------------- ----------- - ------ ------ - ------- Date-- ---Svc Code Description Units Debits I _ _ Credits-- - - ------------------------------------------------------------------------- 01/13/08 104048 MYOGLOBIN 1 87 00 01/13/08 104106 MAGNESIUM 2 . 34 00 01/13/08 104110 BLOOD GAS PANEL 5 . 680 00 01/13/08 104129 PHOSPHORUS, BLOOD 1 . 15 00 01/13/08 104433 BASIC METABOLIC PANEL 2 . 90 00 01/13/08 104585 GENTAMICIN LEVEL 1 . 38 00 01/13/08 105029 FIBRINOGEN 1 . 36 00 01/13/08 105052 PARTIAL THROMBOPLAS T 1 . 40 00 01/13/08 105059 PROTHROMBIN TIME 1 . 24 00 01/13/08 105657 CBC W/PLT/DIFF AUTO 1 . 51 00 01/13/08 111001 GLUCOSE BEDSIDE MONIT 4 . 120 00 01/13/08 245202 ATROPINE SULFATE 0.4 2 . 3 00 01/13/08 245552 EPHEDRINE SULFATE 50 1 . 3 00 01/13/08 245733 PANCURONIUM BROMIDE 1 2 . 10 35 01/13/08 245960 EPINEPHRINE 1 ML 1 . 3 00 01/13/08 246182 GLYCOPYRROLATE 0.2 MG 1 . 3 00 01/13/08 246487 SUCCINYL CHOLINE 200 10 . 5 95 01/13/08 246831 FENTANYL CITRATE 20 M 20 . 10 90 01/13/08 246836 FENTANYL CITRATE 2 ML 1 . 3 00 01/13/08 246849 FUROSEMIDE 10 MG/ML 4 . 6 00 01/13/08 01/13/08 249982 25 RANITIDINE 2.5MG/ML 3 . 40.95 1846 VERSED 5MG/5ML 10 7 10 01/13/08 272425 MIDAZOLAM 1MG/ML 2ML 8 . 6 00 01/13/08 273686 PENICILLIN GK 2MU PRE 14 . 31 40 01/13/08 274061 MAGNESIUM SULFATE 1GM 1500 . 3 00 01/13/08 274180 GENTAMICIN PED INJ 10 3 . 48 90 01/13/08 307101 CHEST 1 VIEW 1 . 127 00 01/13/08 307308 FEMUR AP&LAT VIEWS LE 1 . 176 00 01/13/08 307550 FLUOROSCOPY UP TO 1 H 1 . 254 00 01/13/08 3911.01 OR. TIME<=1HR EACH 15M 4 . 2420 00 01/13/08 391102 OR TIME>1HR EACH 15MI 4 . 1108 00 01/13/08 398230 SUTURE, SINGLE ARM 3 . 27 00 01/13/08 398231 SUTURE, DOUBLE ARM 1 . 17 00 01/13/08 398666 PBDS MINOR ORTHO PACK 1 . 86 00 01/13/08 464593 SURGILAV SET MULTI-OR 1 . 100 00 01/13/08 502000 ANESTHESIA TIME-HOSP 8 . 683 00 01/13/08 503130 BAIR HUGGER CUB BLANK 1 . 54 00 01/13/08 503136 HOT LINE TUBING 1 . 42 00 01/13/08 511203 VENTILATOR DAY SUBSEQ 1 . 541 00 01/13/08 511354 MDI TREATMENT 3 . 168 00 01/13/08 600519 SPIRO INCENTIVE PEDS 1 . 13 00 01/13/08 621099 SUCT CATH KT 12F NLTX 10 . 50.00 Continue Iq -9 MS HERSHEY MEDICAL CENTER PAGE: 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit ##: 10502398 ----------------------- Date - - - - Svc - Code - ------------------ Descri--- - Units Debits_ _ _ Credits- ------------------------------- 01/13/08 01/13/08 621105 YANKAUER SUCT TB W/O 1 5.00 01/13/08 621274 IV DEXTROSE 50-0.9 SO 1 6.00 01/13/08 622024 IRRIGATION SOD CHL 0. 1 6 .00 01/13/08 625011 6 IV ADMIN SET BLOOD FI 1 49.00 01/13/08 26081 6 IV DILUENT NML SALINE 1 8.00 01/13/08 27069 627070 ST EXT MICRO 60" IML 3 21.00 01/14/08 10295 IV EXT SET 90" W/FLAS 5 P 1 22.00 01/14/08 104013 EDS INTENS CARE UN ALBUMIN 1 3550.00 01/14/08 104040 CPK 1 15.00 01/14/08 104048 MYOGLOBIN 1 1 17.00 01/14/08 104129 PHOSPHORUS BLOOD 1 87.00 01/14/08 104161 , PREALBUMIN 1 15.00 01/14/08 01/14/08 104433 1 BASIC METABOLIC PANEL 1 57.00 45.00 01/14/08 04585 10 GENTAMICIN LEVEL 1 38.00 01/14/08 5029 1 5 FIBRINOGEN 1 36.00 01/14/08 0 052 1 PARTIAL THROMBOPLAS T 1 40.00 01/14/08 05059 1 PROTHROMBIN TIME 1 24.00 01/14/08 05656 1 CBC W/PLT AUTO 1 32.00 01/14/08 05657 1 CBC W/PLT/DIFF AUTO 1 51.00 01/14/08 11001 2 GLUCOSE BEDSIDE MONIT 1 30.00 01/14/08 46176 2 FUROSEMIDE 10 MG/ML 1 3.00 01/14/08 46304 2 NALOXONE 400 MCG/ML 1 3.80 01/14/08 46556 246836 ASPIRIN 81 MG FENTANYL CITRATE 2 ML 1 3.00 01/14/08 246849 FUROSEMIDE 10 MG/ML 1 2 3.00 01/14/08 01/14/08 249982 RANITIDINE 2.5MG/ML 3 3.00 40.95 01/14/08 250701 27 ACETAMINOPHEN 320MG/1 1 3.00 01/14/08 2199 2 ONDANSETRON 2MG/ML 2M 3 3.00 01/14/08 72628 2 MORPHINE 1MG/ML BAG 10 30.80 01/14/08 73686 2 PENICILLIN GK 2MU PRE 14 31.40 01/14/08 74104 2 GABAPENTIN ORAL SOLN 2 3.00 01/14/08 74180 2 GENTAMICIN PED INJ 10 6 69.40 01/14/08 74385 2 HEPARIN/NS FLUSH lU/1 1 25.45 01/14/08 74651 3 ALBUTEROL 2.5MG/0.5ML 16 12.00 01/14/08 07101 307331 CHEST 1 VIEW ABDOMEN 1 VIEW AP 1 127.00 01/14/08 01/14/08 511351 AEROSOL TREATMENT 1 4 176.00 224.00 01/14/08 511371 511372 ADD ON KIT STARTER KIT 1 70.00 )1/14/08 )1/14/08 621203 I V RHEOMACRODEX 100 1 2 70.00 86.00 621274 IV DEXTROSE 5a-0.9 SO 1 6 00 ----------------------------- I - Continue - -10 MS HERSHEY MEDICAL CENTER PAGE: 10 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 101110/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 1_0502398 - ------------ Date - Svc - Code - Description - - - -Units Debits Credits ----------------------------------------- 01/14/08 01/14/08 670722 67 FEEDING BG ENTERAL 10 1 01/14/08 0727 670830 PCA ST INTEGRAL NOSIP 1 24.00 01/15/08 10295 COLLAR ASPEN CERV CHL 1 74.00 01/15/08 102019 5 PEDS INTENS CARE UN GRAM STAIN 1 3550.00 01/15/08 102100 CULTURE, BACTERIAL 1 1 28,00 70 00 01/15/08 01/15/08 102104 1 CULTURE, ANAEROBES ON 1 . 63.00 01/15/08 02147 104 HOMOGENIZATION, TISSU 1 38.00 01/15/08 013 104028 ALBUMIN IONIZED CALCIUM 1 15.00 01/15/08 104060 GLUCOSE BLOOD 1 1 105.00 01/15/08 104129 , PHOSPHORUS, BLOOD 1 14.00 15 00 01/15/08 01/15/08 1.04131 1041 POTASSIUM (K), BLOOD 1 . 15.00 01/15/08 45 104 SODIUM (NA), BLOOD 1 15.00 01/15/08 433 10 BASIC METABOLIC PANEL 2 90.00 01/15/08 4585 10 GENTAMICIN LEVEL 2 76.00 01/15/08 5029 105052 FIBRINOGEN PARTIAL THROMBOPLAS T 2 2 72.00 01/15/08 105059 PROTHROMBIN TIME 2 80.00 48 00 01/15/08 01/15/08 105657 2 CBC W/PLT/DIFF AUTO 2 . 102.00 01/15/08 45202 24 ATROPINE SULFATE 0.4 2 3.00 01/15/08 5207 245 LIDOCAINE 1 ML 2 3.00 01/15/08 477 245 GENTAMICIN 40 MG/1 ML 2 6.00 01/15/08 712 24 BUPIVACAINE 30 ML 1 3.50 01/15/08 5960 24 EPINEPHRINE 1 ML 2 3.00 01/15/08 6044 24 BUPIVACAINE 0.50 50ML 1 4.35 01/15/08 6487 2 SUCCINYL CHOLINE 200 10 5.95 01/15/08 46556 246706 ASPIRIN 81 MG MORPHINE SULFATE 2 MG 1 1 3.00 01/15/08 246708 MEPERIDINE HCL 25 MG 1 3.00 3 05 01/15/08 01/15/08 246836 2468 FENTANYL CITRATE 2 ML 2 . 6.00 01/15/08 49 2 FUROSEMIDE 10 MG/ML 2 3.00 01/15/08 48225 249982 SENNA SYRUP 1ML RANITIDINE 2 5MG/ML 1 3 5.90 01/15/08 250577 . PROPOFOL 20ML 1 40.95 01/15/08 251179 DOCUSTATE 100MG/10ML 1 5.75 3 00 D1/15/08 01/15/08 272129 2 ROCURONIUM BROMIDE 5M 1 . 37.35 D1/15/08 72199 2 ONDANSETRON 2MG/ML 2M 3 3.00 D1/15/08 72601 27 BUPIVACAINE 1/10o BAG 1 54.65 )1/15/08 3686 2 PENICILLIN GK 2MU PRE 7 15.70 )1/15/08 74180 2 GENTAMICIN PED INJ 10 4 52.05 ------------ 74651 --- ALBUTEROL 2.5MG/0.5ML 25 1 15. 00 Continue 4.00 P-11 MS HERSHEY MEDICAL CENTER PAGE: 11 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 10502398 ------------------------------------- Date Svc Code I Description Uni.tsl Debits Credits ----------------------- 01/15/08 01/15/08 274741 27 BUPIVACAINE DRIP 250M 1 85.95 01/15/08 5078 3 NEOSTIGMINE 1:1000 IN 3 3.00 01/15/08 07101 30 CHEST 1 VIEW 2 254.00 01/15/08 7308 30 FEMUR AP&LAT VIEWS LE 1 176.00 01/15/08 7551 3 FLUORO MORE THAN ONE 1 319.00 01/15/08 91101 3 OR TIMES=IHR EACH 15M 4 2420.00 01/15/08 91102 39 OR TIME>1HR EACH 15MI 17 4709.00 01/15/08 2131 398230 PLATE SUTURE SINGLE ARM 1 12 979.00 01/15/08 398652 , PBDS BASIC PACK 1 108.00 94 00 01/15/08 01/15/08 398654 39 PBDS MAJOR ORTHO PACK 1 . 360.00 01/15/08 8779 42 MESHGRAFT II 1 62.00 01/15/08 2004 46 1/2 TO 1 HOUR-RECOVER 1 771.00 01/15/08 2231 46 PRONE POSITIONING PIL 1 23.00 01/15/08 4145 4 DRILL BITS 1 142.00 01/15/08 64281 4 CORTEX SCREW SELF-TAP 5 232.00 64856 BLADE DISPOSABLE 1 31 00 01/15/08 464920 BANDAGE ACE 2 . 44 00 01/15/08 464987 STRUT, HYBRID 1 . 67 00 01/15/08 465337 BLOCK, SILICONE 1 . 153 00 01/15/08 469277 CLIP APPLIER 1 . 154 00 01/15/08 01/15/08 502000 5 ANESTHESIA TIME-HOSP 20 . 1559.00 01/15/08 03100 50 EPIDURAL TRAY 1 57.00 01/15/08 3157 5 UNDERBODY BLANKET 1 43.00 01/15/08 11351 6 AEROSOL TREATMENT 4 224.00 01/15/08 21100 62 CANISTER SUCT HARDSHE 1 5.00 01/15/08 1110 62 STAPLER SKIN DISP SS 2 164.00 01/15/08 1274 62 IV DEXTROSE 50-0.9 SO 2 12.00 01/15/08 2023 622 IRRIGATION SOD CHL 0. 3 18.00 01/15/08 024 62 IRRIGATION SOD CHL 0. 5 30.00 01/15/08 6081 62 IV DILUENT NML SALINE 1 8.00 01/15/08 7069 6 ST EXT MICRO 60" IML 1 7.00 01/15/08 40322 66 CONTAINER,ANAEROBIC S 1 9.00 01/15/08 7220 6 UNDERPAD, DRIFLO 23" 1 11.00 01/15/08 69206 VAC DRESSING LG FOR V 1 85.00 01/15/08 669209 67 CANISTER FOR VAC UNIT 1 60.00 01/16/08 0722 FEEDING BG ENTERAL 10 1 4.00 01/16/08 11679 102105 4 PEDS IMC CULTURE BLOOD 1 :?100.00 01/16/08 01/16/08 102214 1 , CULTURE, URINE QUANT 1 1 92.00 42.00 D1/16/08 04013 1 ALBUMIN 1 15.00 04129 PHOSPHORUS, BLOOD 1 is nn Continue MS HERSHEY MEDICAL CENTER PAGE: 12 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit ##: 10502398 ------------ --------------------------- --------- Date - - ( Svc - -Code - -- -------- -----Descri Ption - - - ( - Units Debits 1---credits--l ------------------------------------------------------------------------ 0111GIOB 104433 BASIC METABOLIC PANEL 1 45 00 01/16/08 105029 FIBRINOGEN 1 , 36 00 01/16/08 105052 PARTIAL THROMBOPLAS T 1 . 40 00 01/16/08 105059 PROTHROMBIN TIME 1 . 24 00 01/16/08 105656 CBC W/PLT AUTO 1 . 32 00 01/16/08 105657 CBC W/PLT/DIFF AUTO 1 . 51 00 01/16/08 245490 SODIUM CHLORIDE 0.90 1 . 25 00 01/16/08 246021 BACITRACIN 15 GM 1 . 6 75 01/16/08 246130 DIPHENHYDRAMINE 50 MG 1 . 3 00 01/16/08 246176 FUROSEMIDE 10 MG/MT 1 . 3 00 01/16/08 246556 ASPIRIN 81 MG 1 . 3 00 01/16/08 246706 MORPHINE SULFATE 2 MG 4 . 12 00 01/16/08 249156 INTRAVENOUS FAT EMULS 150 . 11 90 01/16/08 249982 RANITIDINE 2.5MG/ML 3 . 40 95 01/16/08 250701 ACETAMINOPHEN 320MG/1 2 . 6.00 01/16/08 251179 DOCUSTATE 100MG/10ML 2 6 00 01/16/08 252015 PEDIATRIC TPN 840 . 372 55 01/16/08 272199 ONDANSETRON 2MG/ML 2M 6 . 6 00 01/16/08 274376 AMP/SULFBACTAM PED DR 4 . 91.60 01/16/08 274651 ALBUTEROL 2.5MG/0.5ML 20 12.00 01/16/08 274654 ALBUTEROL 90MCG/PUFF 1 58 54 01/16/08 305621 KNEE 1-2 VIEWS RIGHT 1 . 148 00 01/16/08 305625 TIBIA & FIBULA AP&LAT 1 . 145 00 01/16/08 307308 FEMUR AP&LAT VIEWS LE 1 . 176 00 01/16/08 511351 AEROSOL TREATMENT 5 . 280 00 01/16/08 600518 OPTICHAMBER 1 . 10 00 01/16/08 621100 CANISTER SUCT HARDSHE 2 . 10 00 01/16/08 623078 SET FILTER .22 MICRON 1 . 1 1 00 01/16/08 626081 IV DILUENT NML SALINE 1 . . 8 00 01/16/08 627070 IV EXT SET 90" W/FLAS 2 . 44 00 01/16/08 627085 SET ADMIN-BIFUSE MEDE 1 . 13 00 01/16/08 661128 TRACTION CART ADD-ON 1 . 32 00 01/16/08 669209 CANISTER FOR VAC UNIT 1 . 60 00 01/17/08 11679 4 PEDS IMC 1 . 2100 00 01/17/08 101003 ABO BLOOD GROUP 1 . 37 00 01/17/08 101004 ANTIBODY SCREEN 1 . 74 00 01/17/08 101005 RH TYPE 1 . 37 00 01/17/08 101021 COMPAT, IMMED SPIN 1 . 74 00 01/17/08 101213 RED BLD CELLS EA U 1 . 339 00 01/17/08 104013 ALBUMIN 1 . 15 00 01/17/08 104129 PHOSPHORUS, BLOOD 1 . 15 00 01/17/08 104433 BASIC METABOLIC PANEL 1 . 45.00 Continue A -13 MS HERSHEY MEDICAL CENTER PAGE: 13 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit $#: 1.0502398 --------------------------- ___ ___ __ -------------------- Date I Svc Code Description I Units Debits I Credits ------------------------------------------------- 01/17/08 105029 FIBRINOGEN 1 36 00 01/17/08 105052 PARTIAL THROMBOPLAS T 1 . 40 00 01/17/08 105059 PROTHROMBIN TIME 1 . 24 00 01/17/08 105656 CBC W/PLT AUTO 1 . 32 00 01/17/08 105657 CBC W/PLT/DIFF AUTO 1 . 51 00 01/17/08 245490 SODIUM CHLORIDE 0.90 1 . 25 00 01/17/08 246021 BACITRACIN 15 GM 1 . 6 75 01/17/08 246556 ASPIRIN 81 MG 1 . 3 00 01/17/08 246706 MORPHINE SULFATE 2 MG 4 . 12 00 01/17/08 249156 INTRAVENOUS FAT EMULS 188 . 14 90 01/17/08 249982 RANITIDINE 2.5MG/ML 2 . 27 30 01/17/08 251174 ACETAMINOPHEN/ CODEINE 2 . 3 00 01/17/08 251179 DOCUSTATE 100MG/10ML 2 . 6 00 01/17/08 252015 PEDIATRIC TPN 1600 . 372 55 01/17/08 272199 ONDANSETRON 2MG/ML 2M 6 . 6 00 01/17/08 272601 BUPIVACAINE 1/10. BAG 1 . 54 65 01/17/08 274376 AMP/SULFBACTAM PED DR 4 . 91 60 01/17/08 600516 PULSE OXIMETER SNSR N 1 . 24 00 01/17/08 621273 IV DEXTROSE 50-0.9 SO 1 . 6 00 01/17/08 623078 SET FILTER .22 MICRON 1 . 11 00 01/17/08 626081 IV DILUENT NML SALINE 1 . 8 00 01/17/08 627070 IV EXT SET 90" W/FLAS 2 . 44 00 01/17/08 627085 SET ADMIN-BIFUSE MEDE 1 . 13 00 01/17/08 667220 UNDERPAD, DRIFLO 23" 1 . 11 00 01/17/08 667410 HEAD SUPPORT GEL; ADU 2 . 32 00 01/17/08 669209 CANISTER FOR VAC UNIT 5 . 300 00 01/17/08 670805 PUMP,BREAST,UNIVERSAL 1 . 55 00 01/18/08 10634 NON WEIGHTED NJ TUBE 1 . 17 00 01/18/08 11679 4 PEDS IMC 1 . 2100 00 01/18/08 104013 ALBUMIN 1 . 15 00 01/18/08 104129 PHOSPHORUS, BLOOD 1 . 15 00 01/18/08 104433 BASIC METABOLIC PANEL 1 . 45 00 01/18/08 105029 FIBRINOGEN 1 . 36 00 01/18/08 105052 PARTIAL THROMBOPLAS T 1 . 40 00 01/18/08 105059 PROTHROMBIN TIME 1 . 24 00 01/18/08 105657 CBC W/PLT/DIFF AUTO 1 . 51 00 01/18/08 202000 ANESTHESIA TIME-HOSPI 12 . 975 00 01/18/08 202004 1/2 TO 1 HOUR - RECOV 1 . 377 00 01/18/08 210001 OR TIME<=lHR EACH 15M 4 . 2420 00 01/18/08 01/18/08 210002 24 OR TIME>lHR EACH 15MI 8 . 2216.00 01/18/08 5439 245 I.V. FAT EMULSION 500 225 16.15 490 SODIUM CHLORIDE 0.90 1 25.00 Continue -ly MS HERSHEY MEDICAL CENTER PAGE: 14 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 1.0502398 ------------------ Date------Svc-Code -- - - - - - - Description I Units) Debits --- I --- Credits-- - - - - --------------------------------------------------------------------- 01/18/08 246130 DIPHENHYDRAMINE 50 MG 1 3 00 01/18/08 246556 ASPIRIN 81 MG 1 . 3 00 01/18/08 246706 MORPHINE SULFATE 2 MG 5 . 15 00 01/18/08 246836 FENTANYL CITRATE 2 ML 1 . 3 00 01/18/08 249982 RANITIDINE 2.5MG/ML 3 . 40 95 01/18/08 250577 PROPOFOL 20ML 1 . 5 75 01/18/08 251174 ACETAMINOPHEN/CODEINE 2 . 3 00 01/18/08 251179 DOCUSTATE 100MG/10ML 1 . 3 00 01/18/08 252015 PEDIATRIC TPN 1600 . 372 55 01/18/08 272199 ONDANSETRON 2MG/ML 2M 6 . 6 00 01/18/08 272425 MIDAZOLAM 1MG/ML 2ML 2 . 3 00 01/18/08 272601 BUPIVACAINE 1/10. BAG 2 . 109 30 01/18/08 274376 AMP/SULFBACTAM PED DR 4 . 91 60 01/18/08 274651 ALBUTEROL 2.5MG/0.5ML 3 . 3 00 01/18/08 307101 CHEST 1 VIEW 1 . 127 00 01/18/08 398652 PBDS BASIC PACK 1 . 94 00 01/18/08 464593 SURGILAV SET MULTI-OR 1 . 100 00 01/18/08 622023 IRRIGATION SOD CHL 0. 2 . 12 00 01/18/08 622026 IRRIGATION NACL 0.90 1 . 34 00 01/18/08 623078 SET FILTER .22 MICRON 1 . 11 00 01/18/08 626081 IV DILUENT NML SALINE 3 . 24 00 01/18/08 627070 IV EXT SET 90" W/FLAS 2 . 44 00 01/18/08 627085 SET ADMIN-BIFUSE MEDE 1 . 13 00 01/18/08 669206 VAC DRESSING LG FOR V 1 . 85 00 01/18/08 669207 VAC DRESSING MED FOR 1 . 85 00 01/18/08 669209 CANISTER FOR VAC UNIT 1 . 60 00 01/18/08 712011 CV CATH PLACE,PERC,> 1 . 476 00 01/19/08 11679 4 PEDS IMC 1 . 2100 00 01/19/08 102100 CULTURE, BACTERIAL 1 . 70 00 01/19/08 104433 BASIC METABOLIC PANEL 1 . 45 00 01/19/08 105656 CBC W/PLT AUTO 1 . 32 00 01/19/08 245490 SODIUM CHLORIDE 0.9s 1 . 25 00 01/19/08 246556 ASPIRIN 81 MG 1 . 3 00 01/19/08 249156 INTRAVENOUS FAT EMULS 225 . 17 85 01/19/08 249982 RANITIDINE 2.5MG/ML 3 . 40 95 01/19/08 251179 DOCUSTATE 100MG/10ML 2 . 6 00 01/19/08 252015 PEDIATRIC TPN 800 . 372 55 01/19/08 272601 BUPIVACAINE 1/10. BAG 1 . 54 65 01/19/08 274376 AMP/SULFBACTAM PED DR 4 . 91 60 01/19/08 307101 CHEST 1 VIEW 1 . 127 00 01119108 01/19/08 623078 6 SET FILTER .22 MICRON 1 . 11.00 26081 IV DILUENT NML SALINE 4 32.00 Continue MS HERSHEY MEDICAL CENTER PAGE: 15 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 10502398 --------------- -Date----I-Svc Code - - - Description Units Debits Credits -------------------------- 01/19/08 01/19/08 01/19/08 01/19/08 01/19/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/20/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 01/21/08 627069 627070 627085 669209 670722 11679 101003 101004 101005 101021 106011 245439 245490 246556 246848 249982 250701 252015 272601 274376 600516 623078 626081 627070 627085 11679 101213 104161 104438 105656 245477 245490 245555 246144 246836 249982 250701 251174 272199 272601 274376 391101 ST EXT MICRO 60" IML IV EXT SET 90" W/FLAS SET ADMIN-BIFUSE MEDE CANISTER FOR VAC UNIT FEEDING BG ENTERAL 10 4 PEDS IMC ABC BLOOD GROUP ANTIBODY SCREEN RH TYPE COMPAT, IMMED SPIN URINALYSIS-BASIC & MI I.V. FAT EMULSION 500 SODIUM CHLORIDE 0.9% ASPIRIN 81 MG LIDOCAINE 10 ML RANITIDINE 2.5MG/ML ACETAMINOPHEN 320MG/1 PEDIATRIC TPN BUPIVACAINE 1/10o BAG AMP/SULFBACTAM PED DR PULSE OXIMETER SNSR N SET FILTER .22 MICRON IV DILUENT NML SALINE IV EXT SET 90" W/FLAS SET ADMIN-BIFUSE MEDE 4 PEDS IMC RED BLD CELLS EA U PREALBUMIN RENAL FUNCTION PANEL CBC W/PLT AUTO GENTAMICIN 40 MG/1 ML SODIUM CHLORIDE 0.90 LIDOCAINE 1 ML EPINEPHRINE HCL 1 MG/ FENTANYL CITRATE 2 ML RANITIDINE 2.5MG/ML ACETAMINOPHEN 320MG/1 ACETAMINOPHEN/CODEINE ONDANSE`i'RON 2MG/ML 2M BUPIVACAINE 1/10o BAG AMP/SULFBACTAM PED DR OR TIME<=1HR EACH 15M Continue -2 3 1 1 2 1 1 1 1 2 1 225 1 1 1 2 2 1800 1 4 1 1 5 2 1 1 1 1 1 1 2 1 5 10 1 1 1 2 52 1 4 4 66.00 13.00 60.00 8.00 2100.00 37.00 74.00 37.00 148.00 40.00 16.15 25.00 3.00 3.23 27.30 6.00 372.55 54.65 91.60 24.00 11.00 40.00 44.00 13.00 2100.00 339.00 57.00 47.00 32.00 4.05 25.00 3.00 7.95 3.00 13.65 3.00 3.00 30.60 54.65 91.60 2420.00 14.00- /A 'l(?o MS HERSHEY MEDICAL CENTER PAGE: 16 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 1.0502398 ---------- -------------------- ------------------------------------ --Date I Svc Code Description I Unitsl Debits I Credits ----------------------------------------------------------- 01/21/08 391102 OR TIME>1HR EACH 15MI 8 2216 00 01/21/08 398230 SUTURE, SINGLE ARM 2 . 18.00 01/21/08 398434 BAG URINE 1 16 00 01/21/08 398521 CAUTERY PENCIL 1 . 15.00 01/21/08 398779 MESHGRAFT II 4 248.00 01/21/08 422004 1/2 TO 1 HOUR-RECOVER 1 771.00 01/21/08 462231 PRONE POSITIONING PIL 1 23.00 01/21/08 464856 BLADE DISPOSABLE 1 31.00 01/21/08 464920 BANDAGE ACE 2 44.00 01/21/08 464987 STRUT, HYBRID 3 201.00 01/21/08 502000 ANESTHESIA TIME-HOSP 12 975.00 01/21/08 503128 BAIR HUGGER UPPER BOD 1 45.00 01/21/08 503136 HOT LINE TUBING 1 42.00 01/21/08 600004 RTL VAC WOUND CLOSURE 7 665.00 01/21/08 621106 YANKAUER SUCT TB W/O 1 5.00 01/21/08 621110 STAPLER SKIN DISP SS 4 328.00 01/21/08 622024 IRRIGATION SOD CHL 0. 2 12.00 01/21/08 626081 IV DILUENT NML SALINE 3 24.00 01/21/08 1 627070 IV EXT SET 90" W/FLAS 1 22.00 01/21/08 630833 URETHRAL CATH PREP TR 1 4 00 01/21/08 631008 FOLEY CATH, SILIC PED 1 . 10.00 01/21/08 670722 FEEDING BG ENTERAL 10 1 4.00 01/22/08 10277 7 PEDS PRIVATE RM 1 1485.00 01/22/08 104438 RENAL FUNCTION PANEL 1 47.00 01/22/08 105656 CBC W/PLT AUTO 1 32.00 01/22/08 245490 SODIUM CHLORIDE 0.9% 1 25 00 01/22/08 245960 EPINEPHRINE 1 ML 2 . 6.00 01/22/08 246556 ASPIRIN 81 MG 1 3.00 01/22/08 246706 MORPHINE SULFATE 2 MG 1 3.00 01/22/08 246841 SODIUM BICARBONATE 50 1 9 55 01/22/08 248402 SILVER SULFAD IAZINE 5 1 . 10 48 01/22/08 249982 RANITIDINE 2.5MG/ML 3 . 40 95 01/22/08 250701 ACETAMINOPHEN 320MG/1 3 . 9 00 01/22/08 251174 ACETAMINOPHEN/CODEINE 2 . 3 00 01/22/08 273436 ZOSYN 2.25GM PREMIX B 2 . 50 90 01/22/08 273872 RANITIDINE 75 MG SYR 1 . 10 85 01/22/08 274376 AMP/SULFBACTANI PED DR 4 . 91 60 01/22/08 600511 PULSE OXIMETER SNSR P 1 . 18 00 01/22/08 626081 IV DILUENT NML SALINE 3 . 24 00 01/22/08 627069 ST EXT MICRO 60" IML 1 . 7 00 01/22/08 627070 IV EXT SET 90" W/FLAS 1 . 22 00 01/22/08 670722 FEEDING BG ENTERAL 10 1 . 4.00 Continue /q ' [7 MS HERSHEY MEDICAL CENTER PAGE: 17 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit ##: 10502398 ----------------------- - - - ---------------------------------- Date Svc Code Description --- I - Unitsl- - -Debits --- I --- Credits--I ---------------------------------------------- 01/23/08 01/23/08 10277 24 7 PEDS PRIVATE RM 1 1485.00 01/23/08 5472 24 CEFAZOLIN 10 GM/50 ML 2 11.20 01/23/08 5490 246 SODIUM CHLORIDE 0.90 0 12.50 01/23/08 556 2 ASPIRIN 81 MG 1 3.00 01/23/08 46706 25 MORPHINE SULFATE 2 MG 4 12.00 1174 ACETAMINOPHEN/CODEINE 12 18 00 01/23/08 272601 BUPIVACAINE 1/10% BAG 1 . 54 65 01/23/08 273872 RANITIDINE 75 MG SYR 1 . 10 85 01/23/08 274036 D5 1/2 NS + 5MEQ KCL 1 . 16 95 01/23/08 274376 AMP/SULFBACTAM PED DR 2 . 45 80 01/23/08 621042 I V SODIUM CHLORIDE 0 2 . 12 00 01/23/08 627070 IV EXT SET 90" W/FLAS 1 . 22 00 01/23/08 670334 IV INFUSION SET, UNIV 1 . 9 00 01/24/08 10277 7 PEDS PRIVATE RM 1 . 1485 00 01/24/08 104161 PREALBUMIN 1 . 57 00 01/24/08 245208 LIDOCAINE 1 ML 1 . 3 00 01/24/08 245477 GENTAMICIN 40 MG/1 ML 2 . 4 05 01/24/08 245708 BUPIVACAINE 10 ML 1 . 4 20 01/24/08 246556 ASPIRIN 81 MG 1 . 3 00 01/24/08 246706 MORPHINE SULFATE 2 MG 3 . 9 00 01/24/08 246836 FENTANYL CITRATE 2 ML 1 . 3 00 01/24/08 248402 SILVER SULFADIAZINE 5 1 . 10 48 01/24/08 250577 PROPOFOL 20ML 1 . 5 75 01/24/08 251174 ACETAMINOPHEN/CODEINE 6 . 9 00 01/24/08 272425 MIDAZOLAM 1MG/ML 2ML 2 . 3 00 01/24/08 273872 RANITIDINE 75 MG SYR 1 . 10 85 01/24/08 01/24/08 391101 39 OR TIMES=IHR EACH 15M 4 . 2420.00 01/24/08 8652 422008 PBDS BASIC PACK 2-1/2 TO 3 HOURS 1 94.00 01/24/08 502000 -RECD ANESTHESIA TIME-HOSP 1 4 1271.00 391 00 01/24/08 503141 LARYNGEAL MASKS 1 . 51 00 01/24/08 621384 IV KCL 10MEQ+D5 NACL 1 . 8 00 01/24/08 01/24/08 622024 622 IRRIGATION SOD CHL 0. 2 . 12.00 01/25/08 026 IRRIGATION NACL 0.90 2 68.00 01/25/08 10277 16742 7 PEDS PRIVATE RM 1 1485.00 01/25/08 246556 P INITIAL EVALUATION- ASPIRIN 81 MG 1 169.00 01/25/08 246706 MORPHINE SULFATE 2 MG 1 3 3.00 9 00 01/25/08 251174 ACETAMINOPHEN/CODEINE 6 . 9 00 01/25/08 01/25/08 273872 621 RANITIDINE 75 MG SYR 1 . 10.85 01/26/08 384 1 IV KCL IOMEQ+D5 NACL 1 8.00 0277 7 PEDS PRIVATE RM 1 1485.00 Continue 6-1g MS HERSHEY MEDICAL CENTER PAGE: 18 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 1.0502398 ----------- -------------------------- Date I Svc Code Description --- I - UnitsI - Debits Credits ? ----------- -------------- 001/1/2266//08 08 01/26/08 01/26/08 01/26/08 01/26/08 01/27/08 01/27/08 01/27/08 01/27/08 01/27/08 01/27/08 01/27/08 01/28/08 01/28/08 01/28/08 01/28/08 01/28/08 01/28/08 01/29/08 01/29/08 01/29/08 01/29/08 01/29/08 01/29/08 01/29/08 01/30/08 01/30/08 09/30/08 09/30/08 56679 246556 246705 251174 273872 627069 10277 246556 246705 251174 273872 274019 307101 10277 16746 16755 56694 246556 273872 10277 56694 246556 246705 273872 307308 600032 246556 273872 980090 960091 P INITIAL EVALUATION- ASPIRIN 81 MG MORPHINE SULFATE 4 MG ACETAMINOPHEN/CODEINE RANITIDINE 75 MG SYR ST EXT MICRO 60" IML 7 PEDS PRIVATE RM ASPIRIN 81 MG MORPHINE SULFATE 4 MG ACETAMINOPHEN/CODEINE RANITIDINE 75 MG SYR ALTEPLASE CATH 2MG VI CHEST 1 VIEW 7 PEDS PRIVATE RM P THER EXCERCISES 15M P THERAPEUTIC ACTIV 1 P INSTR ADAPT EQUIP 1 ASPIRIN 81 MG RANITIDINE 75 MG SYR 7 PEDS PRIVATE RM P INSTR ADAPT EQUIP 1 ASPIRIN 81 MG MORPHINE SULFATE 4 MG RANITIDINE 75 MG SYR FEMUR AP&LAT VIEWS LE FIRST STEP SELECT OVE ASPIRIN 81 MG RANITIDINE 75 MG SYR HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 1 2 1 1 1 2 1 2 1 1 19 2 1 -1 1 169.00 3.00 3.00 3.00 10.85 7.00 1485.00 3.00 3.00 3.00 10.85 216.10 127.00 1485.00 56.00 56.00 112.00 3.00 10.85 1485.00 112.00 3.00 6.00 10.85 176.00 722.00 6.00 10.85 173792.61 173792.61- --------------- ----------------- -------------------------------- ------- * - Not posted Balance: -- I -- 173792 61 -------------------------- 1#' I `I MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:51 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 9360073 Date -------------- Svc - Code -------- ------- ----- Description - - - ------ ------ -Units - -------------------- -Debits I --- Credits--I 1 15/08 09/30/08 04111 9 ------------ ---- BLOOD GAS PANEL W/02 -------- 1 --------- ----------------- 161.00 09/30/08 80090 98 HOSPITAL BAD DEBT W/O -1 161.00- 0091 - HOSPITAL BAD DEBT PLA ------- 1 161.00 * - Not posted ------------- -------------------------- - Balance: 161.00 ------------------------- 11 - a o MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 10/10/08 at 11:52 AM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit ##: 9554075 Date ------------ -I Svc Code ------- -------------- Description I ---- Units Debits Credits 03/04/08 184132 ------------------- - FOOT 1-2 VIEWS RIGHT -------- 1 ------------------------- 110 00 03/04/08 184215 FEMUR AP&LAT VIEWS LE 1 . 166 00 06/30/08 980090 HOSPITAL BAD DEBT W/O -1 . 179 40- 06/30/08 980091 HOSPITAL BAD DEBT PLA -- 1 179.40 . * - Not posted ------------------ -------- - ---------- --------------- Balance: 276.00 -------------------------- STATEMENT OF PHYSICIAN SERVIC ii PENNSTATE TROY BEAM 401 SHIPPENSBURG RD The Milton S. Hershey Medical Center SHIPPENSBURG PA 17257-8617 The Colle f M d qp 1 °r 11 STATEMENT ge o e icine DATE: 1011 O/08 ACCOUNT ## 1127881 LAST ATE STATEMENT Q9/05/0$ E?} IF ANY QUESTIONS, PLEASE CONTACT: MSHM DATE' pM DD URE DIi4G C PATIENT FINANCIAL SERVICES TAX # 251857035 F eaaE QTY DESCRIPTIONE 1NS ti CHAR PAYM D »> PATIENT: TREVOR A BEAM 1127881 ? B1ILANGE R 9426602 PERFORMED BY: ALLISTER M BOUSTRED NO DIV PLASTIC RECONST S PLACE OF SVC: OP PHYSICIAN 02/01/08 99024 894.0 POST-OP FOL-UP VISIT 0 00 . 0.00 9442448 PERFORMED BY: MOLLY D BLACK MD ORTHOPAEDICS DIVISION 03/04/08 94024 V54.89 PLACE OF SVC: OP PHYSICIAN POST-OP FOL-UP VISIT 0.00 0.00 9446480 PERFORMED BY: ALLISTER M BOUSTRED MD DIV PLASTIC RECONST S PLACE OF SVC: OP PHYSICIAN 02/08/08 99024 894.0 POST-OP FDL-UP VISIT 0 00 . 0.00 9448970 PERFORMED BY: ROBERT G ATNIP MD VASCULAR SURGERY 02/19/08 99024 959.8 PLACE OF SYC: OP PHYSICIAN POST-OP FDL-UP VISIT 0.00 0.00 BALANCE: TREVOR A BEAM W OD >>> PATIENT: TREVOR A BEAM 7502398 10502398 PERFORMED BY: DANIELLE K GOAL MD DIV OF DIAG RADIOLOGY PLACE OF SVC: INPATIENT 01/10/DB 7355026 821.00 3 FEMUR (THIGH) ONE JOINT 180 00 05/15/08 . SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 63.00- 63.00 180.00 01/10/08 7356026 959.7 KNEE LIMITED 05/15/08 64.00 SELF-PAY SETTLEMENT AOJ 05/15/08 SELF-PAY SETTLEMENT AD 22.40- 22.40 64.00 01/10/08 7359026 959.7 2 TIBIA FIBULA 1 JOINT 05/15/08 120.00 ; SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 43.00- 43.00 120.00 01/10/08 7362026 959.7 FOOT LIMITED 05/15/08 57.00 SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 19.95- 19.95 57. DD 01/10/08 7204026 959 09 K CHOUDHARY MD DIV OF DIAL RA R . N . a5/L/pg 76.00 SPINE ANT/POS L AT CERVIC 7b OD 05/15/08 SELF-PAY SETTLEMENT ADJ 26.60- SELF-PAY SETTLEMENT AD 26.60 76.00 01/10/D8 7101026 959.19 2 CHEST 1 VIEW 05/15/08 128.00 SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 44.80- 44.so 1zs.DD war CI CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK A '0),:)- STATEMENT OF PHYSICIAN SERVICES PENNSTATE TROY BEAM AO 401 SHIPPENSBURG RD The Milton S. Hershey Medical Center 2 °r 11 The College of Medicine SHIPPENSE;URG PA 77257-8677 STATEMENT DATE. 10/10/08 ACCOUNT ## 1127881 DATE.STATEMENT os/os1os {} IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES DATE Plt{)El?UiE gljtgty'° FED TAX ID # 257857035 ' Ct DE. G 1DE QTY DESCRIPTIOtJ INS ;OHr4RGE J ''- GUARt..'ftR PW' 01/10/08 7217026 954.19 ?:? PELVIS AN.nTERPOSTER ADJUSTMENT BALANCE D5/15/? 60.00 SELF-PAY SETTLEMENT ADJ D5/15/08 SELF-PAY SETTLEMENT AD 21.00- 21.00 60.0D 01/10/08 11044 $21 11 PERFORMED BY: SCOTT A LYNCH MD HERSHEY SPORTS MEDICINE 05/15/08 . DEER SKIN TIS MUS BO 1204.00 SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 421.40- 421.40 1204.Dp 01/10/DB 20690 821.11 APPL U4IPL UdI EXT FIX SY 05/15/08 1030.00 SELF-PAY SETTLEMENT ADJ 05/15/DB SELF-PAY SETTLEMENT AD 360.50- , 360.50 1030.00 01/10/08 27530 823.02 FX TIBIA PRWML SHP NO RE 05/15/08 1474.00 SELF-PAY SETTLEMENT ADJ D5/15/D8 SELF-PAY SETTLEMENT AD 515.90- 515.40 1474.00 PERFORMED BY: STEVEN A MEADOR MD DIV OF EMERG ROOM 01/10/Da 99291 959.8 PLACE OF SVC: EMERGENCY ROOM CRITICAL CARE FIRST HR 05/15/08 544.00 SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 192.15- 142.15 544.00 01/10/08 9924521 959 8 PERFORMED BY: ANDREAS H MEIER MD DIV PEDIATRIC SURGERY 05/15/08 . TRAUMA TEAM DIAL EVAL INT 3480.00 SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 1218.00- 121a.DO 3480.00 PERFORMED BY: GARY D CENEVIVA MD PEDIATRIC CRIT & TNT CARE 01/10/08 99291.25 518.5 PLACE OF SVC: INPATIENT CRIT CARE 1ST HR 05/15/08 544.00 SELF-PAY SETTLEMENT ADJ 05/15/Da SELF-PAY SETTLEMENT AD 192.15- 192.75 549.00 01/10/08 36580 518.5 REPLC NON-TUN CV CATH N/0 05/15/08 4a0.o0 SELF-PAY SETTLEMENT ADJ 05/n/08 SELF-PAY SETTLEMENT AD 168.D0- 16$.00 480.00 01110/08 32020 AT 959 11 PERFORMED BY: ANDREAS H MEIER MD DIV PEDIATRIC SURGERY 05/15/08 . THDRACOSTOMY TUBE HEMOTH 1166.00 SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 408.10- 408.10 1166.00 01/10/08 36556 959,11 05/15/08 05/15/08 01/10/08 35571 904.7 05/15/08 05/15/08 INSERT NON-TWEL CY CATH SELF-PAY SETTLEMENT ADJ SELF-PAY SETTLEMENT AD PERFORMED BY. ROBERT G ATNIP MO VASCULAR SURGERY BYP GRF VEIN POPLITEAL-TI SELF-PAY SETTLEMENT ADJ SELF-PAY SETTLEMENT AD 688.00 7042.00 240.80- 240.80 688.DO 2464.70- 2464.70 7042.00 A-a3 STATEMENT OF PHYSICIAN _..._._., 7p?i11e1'R.w,w£'"?'','?fl?xrbryd((di„°,r..,:........ aG PENN STATE TROY BEAM ? The Milton S. Hershey Medical Center 401 SHIPPENSBURG RD 3 of 11 4 0 The College of Medicie SHIPPENSBURG PA 17257-8617 STATEMENT DATE: 10110108 ACCOUNT # 1127881 4 IF ANY QUESTIONS, PLEASE CONTACT MS DATE: STATEMENT 08/0108 DA TE OROCEOURE , DIA6 HMC ATIENT FINANCIAL SERVICES FED TAX ID # 251857035 CODE'' CQ13 Q :DESCRIPTION PAYIbIEtVl'1 GUARAFFTOR INS CHARGE 01/10/08 PERFdRM1ED By. JAMES?1 GREENSMITH MD DIY OF ANESTHESIA 01444 ADJUSTIM{EHT BALANCE , 404 7 49 POPL EXC/GFT/REP OCC/ANEU 05/15/08 SELF-PAY SETTLEMENT ADJ 4802.00 05/I5/011 SELF-PAY SETTLEMENT AD 1680.7b- 1680.70 4802.OD 01/10/08 36620 404.7 ART CAM PERCUTAN 05/15/08 SELF-PAY SETTLEMENT ADJ 337.00 05/15/08 SELF-PAY SETTLEMENT AD 117.95- 117.95 337.00 01/10/08 PERF BDUSTRED MD DIY PLASTIC RECONST S 27600.RT 891 1 B A . FASCIOTOMY LEG ANTERIDR C 05/15/08 SELF-PAY SETTLEMENT ADJ 2205.00 05/15/08 SELF-PAY SETTLEMENT AD 771.75- 771.75 22D5.00 01/10/08 27658.51 891.1 REP TENDON EXTENSOR LEG S 05/15/08 SELF-PAY SETTLEMENT ADJ 1943.00 05/15/08 SELF-PAY SETTLEMENT AD 680.05- 680.05 1943.D0 01/10/08 13121.59 873.0 COM RP SCL AM LG 2 6-7 5C 05/15/08 . . SELF-PAY SETTLEMENT ADJ 1277.OD 05/15/08 SELF-PAY SETTLEMENT AD 446.95- 446.95 1277.00 01/10/08 13101.51 874.4 COMPLEX REP TRUNK 2 6-7 5 05/15/08 . . SELF-PAY SETTLEMENT ADJ 1151.00 05/15/08 SELF-PAY SETTLEMENT AD 402'85 402.85 1151.00 01/10/08 13102 879.4 4 COMP REP TRW S5CM EA ADD 05/15/08 SELF-PAY SETTLEMENT ADJ 1452. OD 05/15/08 SELF-PAY SETTLEMENT AD 508.20- 508.20 1452.00 O1/10/D8 PERFORMED BY. SCOTT A LYNCH MD HERSHEY SPORTS MEDICINE 94253.57 821 11 05/15/08 . -. INITIAL-INPT CONSULTATION 277.Qa /?/? SELF-PAY SETTLEMENT ADJ 95 96 SELF-PAY SETTLEMENT AD ' 90.45 277.00 PERFORMED BY: PATRICK M MCQUILLAN MD DIV OF ANESTHESIA 01/10/08 PLACE OF SVC: EMERGENCY ROOM 31500.54 786.09 INTIKATION ENDOTRACHEAL 05/15/08 SELF-PAY SETTLEMENT ADJ 682.00 05/15/08 SELF-PAY SETTLEMENT AD 2M"70- 238.70 082.00 PERFORMED BY: DANIELLE K BOAL MD DIV OF DIAG RADIOLOGY PLACE OF SVC: INPATIENT 01/10/D8 7307026 959.3 ELBOW ANTEROPOSTE LAT 05/15/08 SELF-PAY SETTLEMENT ADJ 51.00 05/15/08 SELF-PAY SETTLEMENT AD 17.85- 17.85 51.00 01/11/08 71 01026 954.14 CHEST I VIEW 05/15/08 SELF-PAY SETTLEMENT ADJ 64,00 05/15/08 SELF-PAY SETTLEMENT AD 22.40- 22.4a 64.00 rw???1t+„b?ar ? CNEGK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK '?` ) v STATEMENT OF PHYSICIAN SERVICES PENNSTATE _ -. ....m„ ...... TRO .... ....._ .... Y BEAM The Milton S. Hershey Medical Center HIPPENSBURG PA 17257-8617 The College of Medicitce STATEMENT 4 of 11 SATE: 10/1 0108 ACCOUNT ¢# 7127881 LASE STATEMENT 09/05/08 IF ANY QUESTIONS, PLEASE CONTACT: MS P R D ? ` HMC PATIENT FINANCIAL SERVICES QT Y DESC FED TAX ID # 251857035 COD9. RIPTION N5 C1lRE AENTf cuARAim 01/11/08 821.0(! FEMUR (THI6Ha ONE JOTFtT ALIIUSTMENT BALANCE' 05/15/08 SELF-PAY SETTLEMENT ADJ 60.00 05/15/08 SELF-PAY SETTLEMENT AD 21.OD- 21.00 60.00 D1/11/D8 7359026 959.7 TIBIA & FIBULA 1 JOINT 05/15/08 SELF-PAY SETTLEMENT' ADJ 6Q.00 05/15/08 SELF-PAY SETTLEMENT AD 21.00- 21.00 60.00 01/11/08 7356026 959.7 KNEE LIMITED 05/15/08 SELF-PAY SETTLEMENT ADJ b4.00 05/15/08 SELF-PAY SETTLEMENT AD 22.40- 22.40 64.00 01/11/08 7219326 959.19 CT PELVIS ENHANCED 05/15/08 SELF-PAY SETTLEMENT ADJ 400.00 05/15/08 SELF-SPAY SETTLEMENT AD 14D. D0- 140.00 400.00 01/11/08 7416026 959.19 C T ABDOMEN ENHANCED 05/15/08 SELF-PAY SETTLEMENT ADJ 438,00 05/15/08 SELF-PAY SETTLEMENT AD 153.30- 153.30 438.00 01/11/08 7126026 959.19 CT THORAX N/CONTRAST ENH 05/15108 SELF-PAY SETTLEMENT ADJ 425.00 05/15/08 SELF-PAY SETTLEMENT AO 148.75- 148.75 425.00 01/11/08 7212526 959 09 CHOUDHARY MD DIV O R I R Y F DIAL RADIOLD6 05/15/08 . CT CE SPINE UN ENHIW VICALL 400.00 SELF-PAY SETTLEMENT AT],I 05/15/08 SELF-PAY SETTLEMENT AD 140.00- 140.00 400.00 01/11/08 7213126 959.8 CT LUMBAR SPINE UNENHANCE 05/15/08 SELF-PAY SETTLEMENT ADJ 400.00 05/15/08 SELF-PAY SETTLEMENT AD 14Q.00- 140.00 400.00 01/11/08 7212826 959.8 CT THORACIC SPINE UNENHAN 05/15/08 SELF-PAY SETTLEMENT AOJ 400.00 05/15/08 SELF-PAY SETTLEMENT AD 140.00- 140.00 400.00 01/11/08 7045026 959.01 CT HEAD UNENHANCED 05/15/08 SELF-PAY SETTLEMENT ADJ 295.00 05/15/08 SELF-PAY SETTLEMENT AD 103.25- 103.25 295.00 01/11/08 35860 904 7 PERFORMED BY: ROBERT G ATNIP MD VASCULAR SURGERY 05/15/08 . EXPL POOP HEM/ THROM EXT 1625.00 SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 568,75- 05/15/08 SELF-PAY SETTLEMENT AD 568.75 568.75 2193.75 01/11/08 99233 24 959 8 PERFORMED BY: ROBERT E CILLEY MD DIV PEOIATRTC SURGERY . 05/15/08 . DAILY HOSPITAL CARE 244.OQ 05/15/08 SELF-PAY SETTLEMENT ADJ 85 40- SELF-PAY SETTLEMENT A0 . 85.40 244.00 /? -4, STATEMENT OF PHYSICIAN SERVIC ?*-?- :,?„rK, -•?.:.?rr?x»? xr.:..at9?nt+?pa'IllJasv.?{ ''',_..,_. PENN.] LATE TROY BEAM p 9 5 °f 11 19 The Milton S. Hershey Medical Center 401 SHIINSEENSBUPA R?57.8617 STATEMENT The College of Medicine PATE: 10/10/08 ACCOUNT # 1127887LAASTE STATEMENT 09/05/08 IF ANY Q STIONSPIx ,aEDUIZe D PLEASE !qGa°NrACr SERVICES 1 D TAX ID 2 DATE CEDE DESCRIPTION FINANCIAL QTY _ # 51857035 CdJt?I FE uE MSHMC C PEtYIUlEN7'I. GUARAN74}Z hHS,, NAHIGE ADJU$TM,EINT 6ALANCE PERFORMED BY: GARY D'CENEVIVA MD PEDIATRIC CRIT & INT CARE 01/11/06 99291 518.5 CRIT CARE 1ST HR 05/15/DB SELF-PAY SETTLEMENT ADJ 549.00 05/15/08 SELF-PAY SETTLEMENT AD 192.15- 192.15 549.00 PERFORMED BY: ROBERT F TAMBURRO MD PEDIATRIC CRIT & IN' CA 01/11/08 99292 518.5 6 CRIT CARE EA 30 MIN 05/15/D8 SELF-PAY SETTLEMENT ADJ 1650.00 05/15/08 SELF-PAY SETTLEMENT AD 577.50- 577.50 1650.00 01/11/08 01500 904 7 PERFORMED BY. VENUGOPAL S REDDY MD DIV OF ANESTHESIA . 16 ANE PRC ART LR LG/BYPS GF 05/15/08 SELF-PAY SETTLEMENT ADJ 15b8.00 05/15/08 SELF-PAY SETTLEMENT AD 548.80- 548.80 1568.00 01/11/08 11043 58 891 1 PERFORMED BY: ALLISTER M BOUSTRED MD DIV PLASTIC RECONST S . . 2 DEER SKIN TISSUE MUS 05/15/08 SELF-PAY SETTLEMENT ADJ 1782.00 05/15/08 SELF-PAY SETTLEMENT AD 623.70- 623.70 1782.00 PERFORMED BY: DANIELLE K GOAL MD DIV OF DIAL RADIOLOGY 01/12/08 71DID26 959.19 CHEST 1 VIEW OP HOSPITAL 05/15/08 SELF-PAY SETTLEMENT AIIJ 05/15/08 SELF-PAY SETTLEMENT AD 22.40- 22.40 64.00 01/12/08 7400026 V58.82 ABDOMEN SINGLE VIEW 05/115/08 SELF-PAY SETTLEMENT ADJ 64.00 05/15/08 SELF-PAY SETTLEMENT AD 22.40- 22.40 64,00 PERFORMED BY: ROBERT E CILLEY MD DIV PEDIATRIC SURGERY 01/12/08 99232.24 959.8 PLACE OF SVC: INPATIENT DAILY HOSPITAL CARE 05/15/08 SELF-PAY SETTLEMENT ADJ 170.00 05/15/08 SELF-PAY SETTLEMENT AD 59.50- 59.50 170.00 01/12/08 99291 518 5 PERFORMED BY: ROBERT F TAMBURRO MD PEDIATRIC CRIT & INT CA 05/15/08 . CRIT CARE 1ST HR 549 00 05/15/08 , SELF-PAY SETTLEMENT ADJ 192 15- SELF-PAY SETTLEMENT AD . . 142.15 544.00 01112/08 99292 518.5 2 CRIT CARE EA 30 MIN 05/15/08 SELF-PAY SETTLEMENT ADJ 550.00 05/15/08 SELF-PAY SETTLEMENT AD 192.50- 192.50 550.00 01/13/08 20693 58 821 11 PERFORMED BY: DAVID C GOODSPEED MD ORTHOPAEDICS DIVISION . 05/15/08 . ADJ/REV EXT FIX SYS W ANE 1715 00 (15/15/08 . SELF-PAY SETTLEMENT ADJ 600 25- SELF-PAY SETTLEMENT AD . bD0,25 1715.00 ... _. .. d`lKiCHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON RACK z( -....- __.:., `-- STATEMENT OF PHYSICIAN SERVICES PENN TATS 'WT P TROY BEAM 401 SHIPPENSBURG RD The Milton S. Hershey Medical Center 1 6 of 11 SHIPPENSBURG PA 17257-8617 9 The College of Medicine STATEMENT DATE: 10110108 I ACCOUNT ## 1127881 07 DATE $091051NT 09/05108 \ J IF ANY QUESTIONS, PLEASE CONTACT SFI C D%ITE POCEDURE [AAA M NT FINANCIAL. SERVICES E 251857035 F TAX ID COLE COat QTY DE C RIPTIOfV INS 4WARGE ' P YMeNT1. GUQftANV_ ' PERFORMED BY: DANIELLE K GOAL MD DIV DI f? AJUS 1MENt BALANCE OF AL RADIOLOGY 01/13/08 7101026 786.09 CHEST 1FVIEW: OP HOSPITAL 05/15/08 SELF-PAY SETTLEMENT ADJ b4.00 05/15/08 SELF-PAY SETTLEMENT AD 22.40- 22.40 64.00 01/13/08 7355026 $21.00 FEMUR (THIGH) ONE JOINT 05/15/08 SELF-PAY SETTLEMENT ADJ 60.00 05/15/08 SELF-PAY SETTLEMENT AD 21.00- 21.00 bD.DD PERFORMED BY: ROBERT F TAMBURRO MD PEDIATRIC CRIT & INT CA 01/13/08 99291 518.5 PLACE OF SVC: INPATIENT CRIT CARE 1ST HR 05!15/08 544.00 SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 192.15- 192.15 549.00 01/13/08 99292 518.5 2 CRIT CARE EA 30 MIN 05/15/08 SELF-PAY SETTLEMENT ADJ 550.00 05/15/08 SELF-PAY SETTLEMENT AD 142.50- 142.50 550.00 01/13/08 35226 78 904 3 PERFORMED BY: RANDY M HAUCK MD DIV PLASTIC RECONST SURD . . 05/15/Og REP BL YES A-Y FIST LOWER 5338. DD SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 1868.30- 05!15/08 SELF-PAY SETTLEMENT AD 1868.30 1868.30 7206.30 01/13/08 11042.58 891.1 DEER SKIN SUBC TISS 05/15/08 234.00 SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 81.90- 81.90 234.00 01/13/08 OD400 891 1 PERFORMED BY: DONALD E MARTIN MD DIV OF ANESTHESIA . 05/15/08 12 ANE/PROC/ANTER INTEG SYS 1176.00 SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 411.60- 411.60 1176.00 01/14/08 7400026 V58 82 PERFORMED BY: ARABINDA K CHOUDHARY MD DIV OF DIAL RADIOLOG . 05/15/08 ABDOMEN SINGLE VIEW 64.00 SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 22.40- 22.40 64.00 01/14/08 7101026 Y58.81 CHEST 1 VIEW 05/15/08 SELF-PAY SETTLEMENT ADJ 64.00 05/15/08 SELF-PAY SETTLEMENT AD 21.35- 21.35 64.00 D1/14/DS 44232 24 959 8 PERFORMED BY: ROBERT E CILLEY MD DIV PEDIATRIC SURGERY . . 05/15/08 DAILY HOSPITAL CARE 170.00 SELF-PAY SETTLEMENT ADJ 05/15/08 SELF-PAY SETTLEMENT AD 54.50- 54.50 170.00 01/14/08 99241 518.5 PERFORMED BY: ROBERT F TAMBURRO MD PEDIATRIC CRIT & INT CA CRIT CARE 1ST HR 549 QO CHECK BOX AND ENTER ANY ADDRES S OR INSURANCE CORRECTfONS ON BACK 1i -,k 7 STATEMENT OF PHYSICIAN SERVICES PENNSTATE TROY BEAM P o ._.. -- The Milton S. Hershey Medi 401 SHIPPENSBURG RD cal Center S 7 of 11 The College of Tilediclne HIPPENSBURG PA 17257-8617 STATEMENT DATE. 10110/08 ACCOUNT # 1127881 LAST STATEMENT DATE: 09105/O8 4 IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES n OI _.. UATL PI MR?EI?I?RE gpE " ., llbl P.'. _ QTY DESGR4PTIi?h( C FED TAX ID # 251857035 Al'?l1EC?ly'(" GUAI21aNTQfd G D5l15 Q Q,b .. ; HAi2E ,;' INS .3• v E - T L ` o. ASTN1EtT, "BALANCE 01fU 8 / . SELF-PAY SETTLEMENT ADJ 192.15- 05/15/08 SELF-PAY SETTLEMENT AD 192.15 549.00 01/14/08 99292 518.5 2 CRIT CARE EA 30 MIN 550.00 05/15/08 SELF-PAY SETTLEMENT ADJ 192.50- 05/15/08 SELF-PAY SETTLEMENT AD 192.50 550.00 PERFORMED BY: SOSAMMA T METHRATTA MD DIV OF DIAL RADIOLOGY 01/15/08 7355026 821.00 FEMUR (THIGH) ONE JOINT 60.00 05/15/08 SELF-PAY SETTLEMENT ADJ 21. OD- 05/15/08 SELF-PAY SETTLEMENT AD 21.0D 60.00 PERFORMED BY: MICHAEL A HULSE DO DIV OF DIAL RADIOLOGY 01/15/08 7101026 860.0 2 CHEST 1 VIEW 128.00 05/15/08 SELF-PAY SETTLEMENT ADJ 44.8D- 05/15/08 SELF-PAY SETTLEMENT AD 44.8D 128.00 PERFORMED BY: ROBERT E CILLEY MD DIV PEDIATRIC SURGERY 01/15/08 99232.24 959.8 DAILY HOSPITAL CARE 170.00 05/15/08 SELF-PAY SETTLEMENT ADJ 59.50- 05/15/08 SELF-PAY SETTLEMENT AD 59.50 170.00 PERFORMED BY: ROBERT F TAMBURRO MD PEDIATRIC CRIT & INT CA 01/15/08 99291 518.5 CRIT CARE 1ST HR 549.OD 05/15/08 SELF-PAY SETTLEMENT ADJ 192.15- 05/15/08 SELF-PAY SETTLEMENT AD 192.15 549.00 01/15/08 99292 518.5 2 CRIT CARE EA 30 MIN 550.00 05/15/08 SELF-PAY SETTLEMENT ADJ 192.50- 05/15/08 SELF-PAY SETTLEMENT AD 192.50 550.00 PERFORMED BY: ALLISTER M BOUSTRED MD DIV PLASTIC RECONST S 01/15/08 15100.58 891.1 GRAFT SK SPLIT TRK ARLES 2854,00 05/15/08 SELF-PAY SETTLEMENT ADJ 998 9D- 05/15/08 SELF-PAY SETTLEMENT AD . 498 90 05/15/08 SELF-PAY SETTLEMENT AD . 998.90 3852.90 01/15/08 15002.58 891.1 SURD PREP OF RECIP SITE 1067.00 05115/08 SELF-PAY SETTLEMENT ADJ 373 45- 05/15/08 SELF-PAY SETTLEMENT AD . 373.45 1067.00 01115/08 11043.58 891.1 DEER SKIN TISSUE MUS 891.00 05/15/08 SELF-PAY SETTLEMENT ADJ 311.85- 05/15/08 SELF-PAY SETTLEMENT AD 311.85 891.0D 01/15/08 15101.58 891.1 2 GRF SPLT TRK LIMB ADD 100 1992,00 05/15/08 SELF-PAY SETTLEMENT ADJ 697 20- 05/15/08 SELF-PAY SETTLEMENT AD . 697.20 1992.00 01/15/08 15003.58 891.1 2 SURG PREP EA ADD 100SQ CM 468 00 05/15/08 . SELF PAY SETTLEMENT ADJ s ?CHECK BOX AND ENTER ANV enno??ec no ?wooe.Fn? i.r.r,n.-?.?.., ?' •' STATEMENT OF PHYSICIAN SERVICES PENNSTATE TROY BEAM _._....._. PAGE 8 ae 11 401 SHIPPENSBURG RD The Milton S. Hershey Medical Center SHIPPENSBURG PA 17257-8617 STATEMENT The College of Medicine DATE: 10110108 LAST STATEMENT ACCOUNT ## 1127881 DATE: 09/05108 IF ANY QUESTIONS, PLEASE CONTACr MSHMC PATIENT FINA CIAL SERVICES PRII ED E DTAG DATE CObE GU( N LoTY DESCRIPT!(3??I INS CHARGE. r FED TAX ID #1 259857035 P/#YlI EN 7 GUA,PA" [TOR ELF-PAY SETTLEMENT AD AD?l USTNIE NT 681.ANCE 1 63.80 4 .OD PERFORMED BY: MOLLY D BLACK MD DRTHOPAEDICS DIVISION 01/15/08 27507.58 821.11 TRT THIGH FR W/PLATE,SCRW 5459.00 05/15/08 SELF-PAY SETTLEMENT AOJ 1910.65- 05/15/08 SELF-PAY SETTLEMENT AD 1910.65 5459.00 PERFORMED BY: DMITRI S BEZINDVER MD DIV OF ANESTHESIA 01/15/08 01230 821.11 27 ANE OPN PRO/UPPR 2/3 FEMU 2646.00 05/15/08 SELF-PAY SETTLEMENT ADJ 926.10- 05/15/08 SELF-PAY SETTLEMENT AD 926.10 2646.00 PERFORMED BY: DANIELLE K BOAL MD DIV OF DIAL RADIOLOGY 01/16/D8 7355026 821.00 FEMUR (THIGH) ONE JOINT 6D.DD 05/15/08 SELF-PAY SETTLEMENT AD.T 21.00- 05/15/08 SELF-PAY SETTLEMENT AD 21.00 60.00 01/16/08 7356026 719.06 KNEE LIMITED 64.00 05115/08 SELF-PAY SETTLEMENT ADJ 22.40- 05115/08 SELF-PAY SETTLEMENT AD 22.40 64.00 01/16/08 7359026 959.7 TIBIA & FIBULA 1 JDINT 60.00 15115/08 SELF-PAY SETTLEMENT ADJ 21.00- 05/15/08 SELF-PAY SETTLEMENT AD 21.0D 60.00 PERFORMED BY: ROBERT E CILLEY MD DIV PEDIATRIC SURGERY 01/16/08 99232.24 959.8 DAILY HOSPITAL CARE 170.00 05/15/08 SELF-PAY SETTLEMENT ADJ 59.50- 05/15/08 SELF-PAY SETTLEMENT AD 59.50 170.00 PERFORMED BY: NEAL J THOMAS MD PEDIATRIC CRIT & INT CARE 01/16/08 99291 518.5 CRIT CARE 1ST HR 549.DD 05/15/08 SELF-PAY SETTLEMENT ADJ 192.15- 05/15/D8 SELF-PAY SETTLEMENT AD 192.15 549.00 PERFORMED BY: ROBERT E CILLEY MD DIV PEDIATRIC SURGERY 01/17/08 99232.24 959.8 DAILY HOSPITAL CARE 17D.DD 05/15/08 SELF-PAY SETTLEMENT ADJ 59 50- 05/15/08 SELF-PAY SETTLEMENT AD . 59.50 170.00 PERFORMED BY: SOSAMMA T METHRATTA MD DIV OF DIAL RADIOLOGY 01/18/08 7101026 V58.81 CHEST 1 VIEW 64.00 05115/08 SELF-PAY SETTLEMENT ADJ 22.40- 05/15/08 SELF-PAY SETTLEMENT ADJ 22.40 64.00 PERFORMED BY: ROBERT E CILLEY MD DIV PEDIATRIC SURGERY 01/18/08 99231.24 959.8 DAILY HOSPITAL CARE 93,00 05/15/08 SELF-PAY SETTLEMENT ADJ 32.55- 05/15/08 SELF-PAY SETTLEMENT ADJ 32.55 93.DO ? GHECK BOX AND ENTER ANY ADDRESS R NSURANCE GORRECTiONS ON BACK ? ?y STATEMENT OF PHYSICIAN SERVICES PENNSTATE TROY BEAM PAGE— 9 or 11 lp 401 SHIPPENSBURG RD The Milton S. Hershey Medical Center HIPPENSBURG PA 17257-8617 STATEMENT The College of Medicine DATE: 10/10JOS LAST STATEMENT ACCOUNT ## 1127881 DATE: O9/05/O8 IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID ## 251857035 „ PROCEDURE -DIAG l1ATE QTY D SGiI"1P7tOrN INS CHARGE, Pi4YIC41`N"1'/ GUARAttT09 CODE COQ ADJUStMENT BALAW E PERFORMED BY: JOHN D PUTOCHNY MD DIV PLASTIC RECONST SURG 01/18/08 11043.58 891.1 DEER SKIN TISSUE MUS 891.00 DS/15/08 SELF-PAY SETTLEMENT ADJ 311.85- 05/15/08 SELF-PAY SETTLEMENT ADJ 311.85 891.00 01/18/08 97605 891.1 05/15/08 05/15/08 01/18/08 01470 05/15/08 05/15/08 01/19/08 7101026 05/15/08 D5/15/08 NEGATV PRIES WOUND THERAPY SELF-PAY SETTLEMENT ADJ SELF-PAY SETTLEMENT ADJ PERFORMED BY: RICHARD L BITNER MD DIV OF ANESTHESIA 891.1 15 AN PR NV,MS,TN L LG AK FT 1470.00 SELF-PAY SETTLEMENT ADJ 514.50- SELF-PAY SETTLEMENT ADJ 514.50 1470.01) V58.81 PERFORMED BY: SOSAhMMA T METHRATTA MD DIV OF DIAG RADIOLOGY 75.00 19.69- 19.69 75.00 CHEST 1 VIEW 64.00 SELF-PAY SETTLEMENT ADJ 22.40- SELF-PAY SETTLEMENT ADJ 22.40 64.00 PERFORMED BY: BRETT N ENGBRECHT MD DIV PEDIATRIC SURGERY DAILY HOSPITAL CARE 93.00 SELF-PAY SETTLEMENT AD.) 32.55- SELF-PAY SETTLEMENT ADJ 32.55 93.DD 01/19/08 99231.24 959.8 D5/15/08 05/15/08 01/20/08 99231.24 959.8 05/15/08 05/15/BB DAILY HOSPITAL CARE SELF-PAY SETTLEMENT ADJ SELF-PAY SETTLEMENT ADJ 93.00 32.35- 32.35 93.00 PERFORMED BY: ANDREAS H MEIER MD DIV PEDIATRIC SURGERY 01/21/08 99231.24 959.8 DAILY HOSPITAL CARE 93.00 05/15/08 SELF-PAY SETTLEMENT ADJ 32.55- 05/15/08 SELF-PAY SETTLEMENT AIL) 32.55 93.00 PERFORMED BY: ALLISTE R M BOUSTRED MD DIV PLASTIC RECONST S 01/21/08 15100.58 891.1 GRAFT SK SPLIT TRK ARLGS 2854,00 05/15/08 SELF-PAY SETTLEMENT ADJ 998.90- 05/15/08 SELF-PAY SETTLEMENT ADJ 998.90 2854.D0 01/21/08 15002.58 891.1 05/15/08 05/15/08 01/21/08 15101.58 891.1 05/15/08 05/15/08 01/21/08 15003.58 891.1 05/15/08 05/15/08 SURG PREP OF RECIP SITE SELF-PAY SETTLEMENT AD.) SELF-PAY SETTLEMENT ADJ 6 GRF SPLT TRK LIMB ADD 100 SELF-PAY SETTLEMENT ADJ SELF-PAY SETTLEMENT ADJ 6 SURG PREP EA ADD 100SP CM SELF-PAY SETTLEMENT ADJ SELF-PAY SETTLEMENT ADJ 1067.00 5976.00 1414.00 CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE GORREGTIONS ON BACK 3V 373.45- 373.45 1067.00 2091.60- 2091.60 5976.00 491.40- 491.40 14K. DO STATEMENT OF PHYSICIAN SERVICES FEIWIWSTATE TROY BEAM 0 .. . .. .. ....... P The Milton S. Hersh Medical Center 441 SHIPPENSBURG S 1001' 11 The College of Medicine HIPPENSBURG PA 17257-8617 STATEMENT DATE: 10110108 ACCOUNT ## 1127881 LAST STATEMENT DATE: 09105108 IF ANY QUESTIONS PLEASE CONTACT: MSHMC PATIENT FIN DATE PRC?CE6URE D?11G. ANCIAL SERVICES FED TAX ID ## 251857035 ' CODE eULl `'; QTY pBSCRIPTION tNS CHARQE PA,. , NTT,' GUARA'N OR 4DJUS`f!Nf sALANCE PERFORMED BY: LEONAROUS M POTT MD DIY OF ANESTHESIA 01/21/08 D 0400 891.1 15 ANE/PROC/ANTER INTEL SYS 1470 00 D5/15/08 . SELF-PAY SETTLEMENT ADJ 514 50- D5/15/08 SELF-PAY SETTLEMENT ADJ . 514.50 1470.00 PERFORMED BY: ANDREAS H MEIER MD DIV PEDIATRIC SURGERY 01/22/08 99231 959.8 DAILY HOSPITAL CARE 93 00 05/15/08 . SELF-PAY SETTLEMENT ADJ 32 55- 05/15/08 SELF-PAY SETTLEMENT AD . 32.55 93.00 01/23/08 99231 959.8 DAILY HOSPITAL CARE 93 00 05/15/08 . SELF-PAY SETTLEMENT ADJ 32 55- 05/15/08 SELF-PAY SETTLEMENT ADJ . 32.55 93.00 01/24/08 99231 959.8 DAILY HOSPITAL CARE 93 00 05/15/08 . SELF-PAY SETTLEMENT AOJ 32 55- 05/15/08 SELF-PAY SETTLEMENT ADJ . 32.55 93.00 PERFORMED BY: ANDRZEJ TROJANONSKI MD DIV OF ANESTHESIA 01/24/08 00400 891.1 7 ANE/PROC/ANTER INTEL SYS 686 00 D5/15/08 . SELF-PAY SETTLEMENT ADJ 240 10- 05/15/08 SELF-PAY SETTLEMENT ADJ . 240.10 686.00 PERFORMED BY: JOHN D POTOCHNY MD DIV PLASTIC RECONST SURE 01/24/08 15852.78 891.1 2 DRESS CHANGE UNDER ANES 670 00 05/15/08 . SELF-PAY SETTLEMENT ADJ 234 50- 05/15/08 SELF-PAY SETTLEMENT ADJ . 234.50 670.00 PERFORMED BY: ANDREAS H MEIER MD DIV PEDIATRIC SURGERY 01/25/08 99231 959.8 DAILY HOSPITAL CARE 93 00 05/15/08 . SELF-PAY SETTLEMENT ADJ 32 55- 05/15/08 SELF-PAY SETTLEMENT AD.) . 32.55 93.00 PERFORMED BY: PETER W DILLON MO DIV PEDIATRIC SURGERY 01/26/08 99231 959.8 DAILY HOSPITAL CARE 93 00 05/15/08 . SELF-PAY SETTLEMENT ADJ 32 55- 05/15/08 SELF-PAY SETTLEMENT ADJ . 32.55 93.DD PERFORMED BY: KATHLEEN EGGLI MD DIV OF DIAL RADIOLOGY 01/27/08 7101026 V58.81 CHEST 1 MIEN 64 00 05/15/08 . SELF-PAY SETTLEMENT ADJ 22 40- 05/15/08 SELF-PAY SETTLEMENT ADJ . 22.40 64.00 PERFORMED BY: PETER W DILLON MD DIV PEDIATRIC SURGERY 01/27/08 99231 959.8 DAILY HOSPITAL CARE 93 00 D5/15/O8 . SELF-PAY SETTLEMENT ADJ 32 55- 05/15/08 SELF-PAY SETTLEMENT ADJ . 32.55 93.00 PERFORMED BY: KATHLEEN EGGLI MD DIV OF DIAS RADIOLOGY 01/29/08 7355026 821.00 FEMUR (THIGH) ONE JOINT 60 00 05/15/08 . SELF PAY SETTLEMENT ADJ 21.00- ? CHECK BOX AND ENTER ANY ADDRESS OR INStIRANGE GORREGTI ONS ON BA CK STATEMENT OF PHYSICIAN SERVICES rr+vc PENNSTATE TROY BEAM 11 at 1 1 401 SHIPPENSBURG RD IF The Milton S. Hershey Medical Center HIPPENSBURG A 17257-8617 STATEMENT The College of Medidne DATE: 10110108 LAST STATEMENT ACCOUNT ## 1127881 DATE: 09105108 ' IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES ? FED TAX ID # 251857035 A PRpC??URE Ctl4` OATE- DE Gfx CfiDE QT DESCRIPTION INS CHARGE PY14AiNl1 ENT. AB1 GUARANTOR 05/15/08 SELF-PAY SETTLEMEM'A03 _ 21.60 60. 00 PERFORMED BY: BRETT W ENGBRECHT MD DIV PEDIATRIC SURGERY 01/29/08 99231 959,8 DAILY HOSPITAL CARE 93.00 05/15/08 SELF-PAY SETTLEMENT ADJ 32.55- 05/15/08 SELF-PAY SETTLEMENT AOJ 32.55 93.00 BALANCE: TREVOR A BEAM 094608.95 IF YOU HAVE ANY QUESTIONS ABOUT THE AMOUNT YOUR INSURANCE COMPANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTHER QUESTIONS REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMENT HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL. RNM3 THANK YOU FOR USING MSHMC PHYSICIANS GROUP FOR YOUR PHYSICIAN SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE CONTACT US AT 717-531-5D69 OR 80O-254-2619, BETWEEN 8:ODAM AND 5:30PM MONDAY THROUGH WEDNESDAY OR BETWEEN 8:00AM AND 4:30PM THURSDAY AND FRIDAY. BALANCE SUMMARY RESPONSIBLE PARTY POLICY IE TOTAL *" GUARANTOR RESPONSIBILITY 94608.95 ----------------- STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT: BF6 10110108 $ 94608.95 $ 94608,95 MSHMC PHYSICIANS GROUP BILLING SERVICES P O BOX 854 HERSHEY PA 17033-0854 110001127881 UP 0000000009460895101008 L 111111MINI 1111111 Nil [I [all oil 111111111 Mail MSHMC PHYSICIANS GROUP TROY BEAM To, 401 SHIPPENSBURG RD PO BOX 643313 SHIPPENSBURG PA 17257-8617 PITTSBURGH PA 15264--3313 7FF/CE USE ONLY CHECK ONE FOR CREDIT CARD PAYMENT, PLEASE FILL IN INFORMATION BELOW - ?,;;r ^c'i ]A€RLTE'.= t:Hl 'CO.U F€?R IF:'?rH, I I I I I I I l( I [J 1127881 M/C CARD NUMBER :Ir-k"NfI7ClNT . "B.U ,VISA EXP DATE $ 94608.95 10131108 -DISC CARDHOLDER NAME (PRINT) :_q HG: F6B0 CREDIT CARD SIGNATURE MSHMC PHYSICIANS GROUP ? GHEGK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK 3 1 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 05/12/09 at 04:53 PM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 12555997 Date- ---------- -I-Svc Code ----- -------------------------- I ---- Description I -- - ------- Unitsl -------------- Debits I ---------- Credits I 01/20/09 184215 --- ------- FEMUR AP&LAT VIEWS LE ----- --- 1 ------------- 196 00 ------------ 04/30/09 980090 HOSPITAL BAD DEBT W/O -1 . 196 00- 04/30/09 980091 HOSPITAL BAD DEBT PLA 1 196 00 . 05/05/09 980092 RETURN HOSPITAL BAD D -1 . 196 00- 05/05/09 980093 RETURN FROM B/D HOSP 1 196.00 . * - Not posted ------------ -------- I - -------------- Balance: I -------------- ------------ 196.00 l ------------ <??33 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 05/12/09 at 04:53 PM Guarantor: BEAM TROY 401 SHIPPENSBURG RD SHIPPENSBURG, PA 17257-0000 Patient: BEAM TREVOR A Visit #: 12561005 ----------------------------- ----------------- ----------------------- Date Svc Code Description Units --- Debits 1---Credits--l -------------------- --------------------------------- 03/11/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 03/12/09 04/30/09 04/30/09 05/05/09 05/05/09 Not posted 246057 47133 47524 191010 246057 246493 246705 246836 250577 272199 272425 307551 390824 391101 391102 398230 398410 398666 399515 422004 460576 464610 464633 502000 765009 980090 980091 980092 980093 CEFAZOLIN 1 GM/5 ML POST OP CARE 1-2 HRS PRE-OP CARE LVL1 SURGICAL PATHOLO CEFAZOLIN 1 GM/5 ML DEXAMETHASONE 4 MG/ML MORPHINE SULFATE 4 MG FENTANYL CITRATE 2 ML PROPOFOL 20ML ONDANSETRON 2MG/ML 2M MIDAZOLAM 1MG/ML 2ML FLUORO MORE THAN ONE DRAPE OR TIME<=lHR EACH 15M OR TIME>1HR EACH 15MI SUTURE, SINGLE ARM SOLUTION DURA PREP PBDS MINOR ORTHO PACK CUFF TOURNIQUET-B 1/2 TO 1 HOUR-RECOVER. STAPLER CUFF TOURNIQUET STOCKINET ANESTHESIA TIME-HOSP MASTISOL HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA RETURN HOSPITAL BAD D RETURN FROM B/D HOSP 2 1 2 1 2 4 2 1 1 4 2 1 1 4 4 3 2 1 1 1 1 1 1 8 1 -1 1 -1 1 3.75 546.00 822.00 27.00 3.75 3.00 6.00 3.00 5.75 3.00 3.00 355.00 13.00 2692.00 1232.00 27.00 20.00 86.00 48.00 858.00 17.00 20.00 10.00 758.00 4.00 7566.25 7566.25 7566.25- 7566.25- Balance: 1 7566.25 ?-3y STATEMENT OF PHYSICIAN SERVICES PENNSTATE TROY BEAM PAGE 1 of 2 401 SHIPPE:NSBURG RD The Milton S. Hershey Medical Center SHIPPENSBURG PA 17257-8617 STATEMENT The College of Medicine DATE: 05105109 LAST STATEMENT ACCOUNT # 1127881 DATE: 05101109 11- IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES # pA x P) 4 I E , Ll(AG ?. ; s1 , ,. . .FED TAX ID 261857035 "NT RA ! k??;t z COb"' CADE...<wn_. Qt 1 pE"?i`.?TIQN t6r?f'` Eipl 1N5 CHa"3A#Ii'ADitt TISAEN7 GBALA F+IiR'. »y,. PATIENT: TREVOR A BEAM 1127881 a .. DER 12525439 PERFORMED BY: MOLLY O BLACK MD ORTHOPAEDICS DIVISION PLACE OF SVC: OP PHYSICIAN 01/20/09 99213 996.40 OUTPATIENT VISIT EST 152.00 152.00 12555997 PERFORMED BY: MICHAEL A HULSE DO DIV OF DIAG RADIOLOGY PLACE OF SVC: OP HOSPITAL 01/20/09 7355026 V54.89 FEMUR (THIGH) ONE JOINT 66.00 66.00 12561005 PERFORMED BY: MOLLY D BLACK MD ORTHOPAEDICS DIVISION PLACE OF SVC: SURGERY - SHORT STAY 03/12/09 20680 V67.4 REMOVAL IMPLANT DEEP 1924.00 1924.00 PERFORMED BY: SONIA J VAIDA MD DIV OF ANESTHESIA 03/12/09 01230 V67.4 14 ANE OPN PRO/UPPR 2/3 FEMU 1526.00 1526.00 PERFORMED BY: JOZEF MALYSZ MD DIV OF ANATOMIC PATHOLOGY PLACE OF SVC: OP HOSPITAL 03/12/09 8830026 996.40 TISSUE EXAM LEVEL 1 24.00 24.00 BALANCE: TREVOR A BEAM $3692.00 IF YOU HAVE ANY QUESTIONS ABOUT" THE AMOUNT YOUR INSURANCE COMPANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTHER QUESTIONS REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMENT HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL. RNM3 THANK YOU FOR USING MSHMC 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 8:00AM AND 5:3OPM MONDAY THROUGH WEDNESDAY OR BETWEEN 8:OOAM AND 4:30PM THURSDAY AND FRIDAY. CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK STATEMENT OF PHYSICIAN SERVICES PENNSTATE TROY BEAM The Milton S. Hershey Medical Center SH PPENS URG PA 1 257-8617 The College of Medicine ACCOUNT # 1127881 IF ANY QUESTIONS, PLEASE coNTACT: MSHMC PATIENT FINANCIAL SERVICES DA7 E PRQCEl).L E +?RIA? u ?tiy fE t 3 IW ylk ,tw , } CODSt'bDE rNr1R13ESCyIIFs?TCyN,;f+3,^,? 5 INS 2 of 2 STATEMENT DATE: 05105/09 LAST STATEMENT DATE: 05101/09 FED TAX ID ## 251857035 CHARGE E'AYME T1,?,6UARANTOR ADJUSTlGAENI° ;,,BALANCE BALANCE SUMMARY RESPONSIBLE PARTY POLICY 9 TOTAL 9** GUARANTOR RESPONSIBILITY 4 3692.00 ------_»--__ _ IMPORTANT: PLEASE DETACH AND RETURN 80TTOM PORTION OF STATEMENT W/TN YOUR P4Y1NEN7 BF6 STATEMENT DATE: GUARANTOR. RESPONSIBILITY: MINIMUM PAYMENT: MSHMC PHYSICIANS GROUP 05105109 $ 3692.00 $ 3692.00 BILLING SERVICES P 0 BOX 854 HERSHEY PA 17033-0854 00001127881 UP 0000000000369200050509 Mail MSHMC PHYSICIANS GROUP To: TROY BEAM PO BOX 643313 401 SHIPPENSBURG RD PITTSBURGH PA 15264-3313 SHIPPENSBURG PA 17257-8617 OFFICE USE ONLY CHECK ONE FOR CREDIT CARD PAYMENT, PLEASE PILL IN INFORMATION BELOW === _-- `?:= yyRlfi:E;r-H1r-_A_C_0_ M/c I I I I I i l l l l l l l l l l l 1127881 VISA ARD NUMBER EXP DATE _ ='-'=1?A "7 15=AIVIl7i11_ -DISC $ 3692.00 0 HC: F6B0 CARDFIOLDER NAME (PRINT) r'A.mRu I' N TYP : DMND NR rr?wcnsPAYI#EILE ?" CREDIT CARD SIGNATURE MSHMC PHYSICIANS GROUP HECK ? BOX AND ?ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK 11-36 BEAM, TREVOR #1127881 $190,783.61 (Hosp) 94,608.95 (Phys) 7,762.25 (Hosp) 3,692.00 (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. LINDA SCHLADER DATE: i tfi0? *'18.50 f140 AT"'{ Ck.`?? Q 15 8(?o Sheriffs Office of Cumberland County R Thomas Kline Sheriff Ronny R Anderson Chief Deputy Jody S Smith Civil Process Sergeant Edward L Schorpp Solicitor ?4??ti,fiv at ?a+rrGrrr??? 4F?:iCE "T TKE $1-:RIFF . FILED--f i-;-[CF OF THIS R117 - `NOTARY 2009 AUG 19 AM 9: 16 PENNSl,LVANA The Milton S. Hershey Medical Center I vs. Troy Beam Case Number 2009-4549 SHERIFF'S RETURN OF SERVICE 08/07/2009 R. Thomas Kline, Sheriff, who being duly sworn according to law, states that he made a diligent search and inquiry for the within named defendant to wit: Debbie Beam, but was unable to locate her in his bailiwick. He therefore returns the within Complaint and Notice as not found as to the defendant Debbie Beam. After several attempts the complaint has expired. 08/07/2009 R. Thomas Kline, Sheriff, who being duly sworn according to law, states that he made a diligent search and inquiry for the within named defendant to wit: Troy Beam, but was unable to locate him in his bailiwick. He therefore returns the within Complaint and Notice as not found as to the defendant Troy Beam. After several attempts the complaint has expired. SHERIFF COST: $108.00 August 17, 2009 SO ANSWERS, ?- r R THOMAS KLINE, SHERIFF TABAS & ROSEN, P.C. BY: LEWIS C. TRAUFFER, ESQUIRE I.D. 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 17033 VS. TROY BEAM & DEBBIE BEAM, H/W 401 SHIPPENSBURG ROAD SHIPPENSBURG, PA 17257 PRAECIPE TO THE PROTHONOTARY: : COURT OF COMMON PLEAS : CUMBERLAND COUNTY : NO.: 09-4549 Please mark the above matter settled, discontinued and ended upon payment of your costs only. LEWIS C. TRAUFFER Attorney for Plaintiff OF THE 2009 AUG 28 PVI 2: 11