HomeMy WebLinkAbout07-07-09 r~
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NOTICE OF CLAIM -. -
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(Filed Pursuant to 20 Pa. C. S. § 3532)
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^ COURT OF COMMON PLEAS OF
(~Q~'lhP.rlCt/lG( COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE OF ~ ~l~ ~ ~ ~ ~lUu< ,DECEASED
No. r~l-~~'- 0~5~
To the Clerk of the Orphans' Court Division:
Enter the claim of ~~S'ln ~S-iGc-k~ ~S~~~t,i ~~~~~ ~ C-
(Claimant)
amount of $ ~ t~ ~`"a .~~ ,against the above entitled Estate.
~~
in the
The Decedent, who resided at ~~~~ ~~`~~~t~ ~~. ~Jhl~'~~.~.~~w. ~A
,~ _ ~r (Street Address) "
l~~ ~ ,died on ~ U ~~_~ ~.~ ~OQ~' .Written notice of
~., (b to of Death)
said claim was given to
(Pers al Representative or hu/her counsel)
~ ~' 3.5~ ~'l o,><G~rJlr ~S~,D ~ ~~, ~,~ Cc~l is ~ P/k ! 7r
on ,~ Il!!1cl ~~ ,~ )(1 CZ -
~ (Date)
(Claimant's Counsel)
(Address)
(Supreme Court LD. No.)
(Telephone)
~U~n J~l~~ t-tC(~h~u, 11,1.1r~1iCi~l C~~-kr
( aimant)
C~i~nfi ~nGnG~,I ~~'~~r;~z~ ~o- ~'~~~ ~.
(St et Address)
~~~,~, ~~ I ~ 03~
(City, State, Zip)
Form OC-07 rev. 10.13.06
MS HERSHEY MEDICAL CENTER PAGE: 1
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 06/18/09 at 02:34 P M
Guarantor: HOCK AARON M
406 RIDGE RD
SHIPPENSBURG, PA 17257-0000
Patient: HOCK AARON M
Visit #: 10081417
----------
Date --------------
~ Svc Code I -----------------------
Description I ---------
Unitsl --------------
Debits ~ ----------
Credits
----------
07/10/08 --- -----------
711107 -----------------------
AIR AMBULANCE TRANSPO -------
1 -- -----------
11839.00 --- ----------
07/10/08 711108 AIR AMBULANCE MILEAGE 42 5124.00
08/12/08 902040 AUTO/WORK COMP PAYMEN -1 5000.00-
12/02/08 902005 COMMERCIAL PAY HOSP -1 11027.07-
01/22/09 920107 HMO DISCOUNT -1 88.90-
------------------------
* - Not posted ---------------------- ----------
I
-- --------------
Balance: I
-------------- ----------
847.03
----------
STATEMENT OF PHYSICIAN SERVICES
PENNSTATE AARON M HOCK $ of
406 RIDGE RD
The Milton S. HerSheX Medical Center SHIPPENSBURG PA 17257-9795 STATEIHIENT
The Cattege of Medicine u~l-TE: 06/18/09
LAST STATEMENT
ACCOUNT # 8005685 ~TE~ 05/25/09
IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035
DATE PROCELIURE DtAG .QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTtjR
CODE CQDE ADJUSTMENT BALANCE
THANK YDU FOR USINF lLSFlIC PHYSICIANS GROUP FOR YIXJR PHYSICIAN
SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE
CONTACT US AT 7I7-531-5069 OR 800-254-2b19, BETi~IEEN B:00AM AND
5:30PM MAY THRa1GH I~DNESDAY OR BETiIEEN 8:OOAM AND 4:30PM
THURSDAY AND FRIDAY.
BALANCE SUFMARY RESPpLSIBLE PARTY POLICY S TOTAL
jeeE GUARANTOR RESPONSIBILITY S 678.34
.______~______________________ IMPORTANTYP~E¢„SF,_DETACH AIYO RETURN 80ITOAf PORTION CF STAT~M,ENT ~'[H YOUR PAYIY~Ef~T______________________ ~_
BF6
MSHMC PHYSICIANS GROUP
BILLING SERVICES
P O BOX 854
HERSHEY PA 17033-0854
1...11.1.1~~~1~1~11~~~1~~1~~11~~~11~~~~11~~11~~~~11~~11~1~~1~1
etatr MSHMC PHYSICIANS GROUP
ro.
PO BOX 643313
PITTSBURGH PA 15264-3313
OFFICE USE ONLY
HC: FBBO
TYP : DMND
STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT
06/18/09 $ 678.34 $ 678.34
00008005665 UP OODOOOOOOD067834061809
AARON M HOCK
406 RIDGE RD
SHIPPENSBURG PA 17257-9745
FDR CREDR CARD PAYMENT, PLEASE FlLL IN INFORMATION BELOW
CHECKONE
_M/C L~ I N I M ~ E I L I I I I I I I I I I ExP DATE
-VISA
-DISC CARDHOLDER NAME (PRINT)
CREDIT CARD SIGNATURE
678.34
8005665
MSHMC PHYSICIANS GROUP
^CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
STATEMENT OF PHYSICIAN SERVICES
PENNSTATE AARON M HOCK
The Milton S. Hershey Medical Center HIPPENSBURG PA 17257-9795
The College of Medicine
STATEMENT
DATE: OG/18/O9
LAST STATEIAENT
6~ 8
AccouNT # 8005885 DATE: a5~2s~os
-'~- IF ANY QUESTIONS, PLEASE coNracT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID #257857035
DATE PROCEDURE QtAG QTY DESCRIPTION INS CHARGE PAYMENT/ Gt1ARAL+tTOR
CODE CODE AQJUSTMENT BALANCE
10/24/08 INSURAWCE PAYMENT 70.8b-
1D/24/08 YOUR INSURANCE ALLOWANCE 447.27-
10/24/08 BALANCE AFTER INS 7.87
07/1L0a 933252b 8b1.D1 DOPPLER COLOR FL VEL MAP 251.OD
Q6118/06 MAXIl~1 BENEFITS PAID 0.00
10124/06 INSURANCE PAYMENT 5.62-
1Q/24/06 YOUR INSURANCE ALLOWANCE 244.75-
10124/0~6 BALANCE AFTER INS* 0.63
O7/11/O!j 933202b 8b1.01 DOPPLERS t~MP 353.00
08/18/08 MAXIMUM BENEFITS PAID 0.00
1D/24108 INSURANCE PAYMENT 29.L5-
1O124/08 YOUR INSURANCE ALLOWANCE 320.b1-
1D124/08 BALANCE AFl'ER INS* 3.24
PERFORMED BY: .SIN STENE MD DIV RESP & INTENSIVE CARE
O7/1L08 99291 518.5 CRITICAL CARE FIRST HR 611.00
08/18/08 MAXIMA BENEFITS PAID 0.00
10/24/08 INSURANCE PAYMENT 31b.39-
10/24/08 YtRNI INSURANCE ALLOWANCE 254.45-
10/24/08 BALANCE AFTER INS 35.1b
PERFORMED BY; RANDY M NAUCK MD DIV PLASTIC RECONST SURE
O7/11/08 99251 802.8 INITIAL INPT CONSULTATION 13b.D0
08/18/08 MAXIMUl7 BENEFITS PAID O.DD
10124JOKE INSURANCE PAYMENT b9.52-
~ 10/24/08 YOUR INStN1ANCE ALLOiIAt+ICE 58.76-
w 10/24/08 BALANCE AFTER INSa 7.72
c~
PERFORMED BY: SORAYA M SAMII M01 ELECTROPHYSIOLO6'Y
07!11108 93010 427.84 EC6 ELECTROCARD INTERP 80.00
08/21/08 MAXIMUI4 BENEFITS PAID 0.00
10/24/08 INSURANCE PAYMENT 12.55-
10/24/08 YOUR INSURANCE ALLOWANCE bb.05-
10124/OB BALANCE AFTER INS* 1.40
PERFORMED BY: DAVID B CAMPBELL MD CT SURI6ERY
07!11/08 32110 860.2 TIDRACOT'OMY CONTROL NEMDR 7490.00
10129/08 MAXIMA BENEFITS PAID O.OD
12!10106 INSURANCE PAYMENT 2282.30-
12/10106 YOUR IMlSlR1ANCE ALLd~IANCE 5207.70- 0.00
PERFORMED BY: KOICHIRO MANDATE MD DIY OF ANESTNESIA
O711L08 Q054f1.QK 8b0.2 25 AMJES/TIDRACOTOMY PROC W/L 2725.00
10/31/08 MAXIMA BENEFITS PAID O.DO
12/10/06 INSURANCE PAYFIENT 1425.00-
01/30/09 YOUR INSURANCE ALLOWANCE 1300.00- 0.00
07/11/08 99140 860.2 EMER6EWCY SERVICE 204.00
10/31/OS MAXIMLBI BENEFITS PAID 0.00
PENNSTATE AARON M HOCK
40B RIDGE RD
The Milton S. Hershey Medical Center SHIPPENSBURG PA 17257-8795
The College of Medicine
ACCOUNT # 8005665
~- iF ANY QUESTIONS, t+LEASE coNTACr: M3HMC PATIENT FINANCIAL SERVICES
DATE FROGERURE
GouE DIA6
coDE 'QTY DESCRIPTION
1D124/08 YOUR INSURANCE ALLOWANCE
124/08 YOUR IMIS<JRANCE ALLOWANCE
10/24/08 INSURANCE PAYMENT
10/24/08 YOUR INSURANCE ALLQ~ANCE
11/03/08 SMALL BALANCE AD.AJSTI9ENT
D7/1L08 73D002b 81D.00 CLAVICLE
08/18108 MAXIMUM BENEFITS PAID
10/24/08 INSURANCE PAYMENT
10/24/013 YOUR INSURANCE ALLOWANCE
10/24/08 BALANCE AFTER INS*
O7/1L08 730902b 813.43 FOREAIiIrI ANTEROPOS LATERAL
06!].8/08 MAXIMIII BENEFITS PAID
10/24/OB INSURANCE PAYMENT
10/24/08 YOUR INSURANCE ALLOWANCE
1D/24/08 BALANCE AFTER INS
D7/1L06 7313026 813.44 NAND >3 YIENS
08118!08 MAXIMlIlI BENEFITS PAID
1D124/08 INStAtANCE PAYMENT
10/24!08 YOUR INSURANCE ALLOWANCE
10/24/Q8 BALANCE AFTER INS*
07/11/08 7301D26 811.09 SCAPULA
08/18/DB MAXIMUM BENEFITS PAID
10/24/0~6 INSURANCE PAYMENT
r 10/24/08 YOUR INSURANCE ALLOWANCE
10/24/08 BALANCE AFTER INS
O7/1L08 730702b X4.3 ELBd~I ANTEItDPOSTE LAT
08/18/08 MAXIMUM BENEFITS PAID
1D/24/08 INSURANCE PAYMENT
10/24/05 YOUR INSURANCE ALLOWANCE
10/24/Oa BALANCE AFTER INS
07/11/08 731102b 813.43 WRIST COMPLETE >3 VIEWS
08/18/OV3 MAXIMA BENEFITS PAID
10/24/08 INSURANCE PAYMENT
10/24/08 YOIAt INSURANCE ALLOWANCE
1D/24/08 BALANCE AFl'ER INS
5 of $
STATEMENT
DATE: 06/1$/09
LAST STATEMENT
DATE: 05/25/09
FED TAX ID # 251857035
INS GHAitGE PAYMENYJ GUARANTOR
ADJUSTMENT BALANCE
53.3D-
52.05-
12.55
52.Q5
1.27- 0.00
61.00
0.00
11.43-
48.3D-
1.27
61.D0
0.00
11.43-
48.30-
1.27
6b.00
0.00
12.55-
52.05-
1.40
b6.D0
0.00
12.55-
52.05-
1.40
58.DD
0.00
10.84-
45. %-
1.2D
bb.00
O.DO
12.55-
52.05-
1.40
07/1L08 7303D26 811.09 SIIQILDER COMP ~2VIEWS 68,OD
08/18108 MAXIMUM BENEFITS PAID 0,00
10/24/08 INSURANCE PAYMENT 13.15-
10/24/08 YOUR INSURANCE ALLOWANCE 53.39-
10/24/08 BALANCE AFTER INS* 1.46
PERFORMED BY: WILLIAM R DAVIDSDN MD IMA6IN6
07/11/08 9330726 861.01 2DJM-FODE ECID3 COMP 52b.D0
08/18/08 MAXIMA BENEFITS PAID 0.00
^ CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
AARON M HOCK
Medical Center HIPPENSEIURG PA 17257-9T95
ACCOUNT ## 8005665
-~- IF ANY QUESTIONS, pt.EASE CONTACT: MSHMC PATIENT FINANCIAL. SERVICES
DATE PROCEDUI~"E DIAL
'CODE CODE QTY [?ESCRIFTK?N
06/18/08 MAXIMIlfI BENEFITS PAID
10/24/0~6 INSURAI~E PAYFO:NT
10/24/08 YOUR INSURANCE ALLtIrIANCE
10/24/06 IFl~NtANCE PAYMENT
10/24/08 YOUR INSURANCE ALLOWANCE
05/19/09 INSURANCE PAYMENT
STATEMENT
[u-rE: 06/18/09
tJ1ST STATEMENT
aATE: 05/25/09
FED TAX ID #257857035
lNS CHARGE PAYMENTf 6UARANT+DR
ADJUSTMENT BALANCE
D.00
25.70-
34.44-
25.70
39.44
68.DO- a.oo
PERFORMED BY: DAVID M VAN HODK MD DIY OF DIA6 RADIOLOGY
D7/1L06 7101026.77 807.09 CI~ST 1 VIEN 68,00
08!18/08 MAXIM~i BENEFITS PAID 0.00
10/24/08 INSURANCE PAYMENT 13.15-
10/24/08 YOUR INSURANCE ALLOWANCE 53.39-
10/24/08 BALANCE AFTER INS* 1.46
D7/1L08 74D0026 V58.82 ABDOMEN SINGLE VIEN 68.00
08!18/08 MAXIMI~i BENEFITS PAID 0.00
10/24/08 INSURANCE PAYMENT 13.15-
10/24/08 YDUR INSURANCE ALLOWANCE 53.39-
10/24/08 BALANCE AFTER INS 1.46
O7/1L08 7101026.77 860.0 CHEST 1 VIEN 68,0Q
08/18/08 MAXIFdBI BENEFITS PAID 0.00
10/24/08 INSURANCE PAYMENT 13.15-
10/24/t18 YOUR INSURANCE ALLOWANCE 53.34-
10/24/06 BALANCE AFTER INS* 1.46
PERFORMED BY: CLAUDIA J KASALES MD DIV OF DIAL RADIDLOGY
~ 07/1L08 7101026.77 511.4 CHEST 1 VIEW 68.00
DB/18/08 MAX1~1 BENEFITS PAID 0
00
w 10/24/06 INSURANCE PAYMENT .
13.15-
10/24/08 YOUR INSURANCE ALLOWANCE 53.39-
10124l08 BALANCE AFTER INS* 1.46
PERF~IMED BY: JDIN F MC6URRIN MD DIV OF DIAL RADIOLOGY
07/1LD8 7101026 511.4 CHEST 1 VIEW 68.00
08/18/08 MAXIMIBI BENEFITS PAID O.OD
1D/24/08 INSURMICE PAYMENT 13.15-
10/24/08 YOUR INSURANCE ALLOWANCE 53.39-
1D/24/08 BALANCE AFTER INS 1.46
O7/11/D8 7025026 784.94 SKULL a4 YIEWS 91.00
08/18/08 MAXI14~1 BENEFITS PAID D.DO
10/24/08 INSURANCE PAYMENT 17.77-
10/24/08 YOUR INSURANCE ALLOWANCE 71.26-
10/24/08 BALANCE AFTER II~L4~ 1.97
PERFORMED BY: MEERA RAGHAVAN MD DIV OF DIAL RADIOLOGY
07/11108 7310026.54 813.43 WRIST ANTEROPOSTE LATERAL 66.D0
08/18/il8 MAXIFRAtiI BENEFITS PAID D.00
10/24!08 INSURANCE PAYMENT 11.43-
10/24/06 Ii+LSURANCE PAYMENT 12.55-
^CHECK BOX AND ENTER ANY ADDRESS OR I NSURANCE CORRECTIONS ON BACK
PENNSTATE AARON M HOCK ~ ~"- g ~ g
The Milton 406 RIDGE RD
S. Hershey Medical Center SHIPPENSBURG PA 17257-8795
STATEIIAENT
The College of Medicine DATE: 06/18!09
ACCOUNT # 8005665 LAST STATEIIIENT
DATE: 05/25/09
,},
~r IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES
RE
~~ FED TAX ID #251857035
DATE
~~ ~~ QTY DESCRIPTit'IN INS CHARGE PAYMEHTI GUARANTOR
ALIJUSTMENT BALANCE
04/30V09 INSURANCE PAYMENT %4.D0-
04/30/D4 YOUR IMISt1RANCE ALLOWANCE 241D.OD- 0.00
07/10/08 94140 852.20 EMERGENCY SERVICE 204.00
08118/08 MAXIMI~1 BENEFITS PAID 0,00
08/25/08 NEED 1ST INSURANCE 0,D0
11/1LD8 NEED >1 REMROC CODE 0.~
83/06/04 INVALID/MQSSING CD 0,00
04/30/04 INSURANCE PAYMENT 114.00-
04/30/09 YOUR INSWRANCE ALLOWANCE 95.OD- 0.00
PERFORMED BY: ROBERT A CHERRY MD TRAUMA SURGERY DIV
D7/1L~ 99233.24 954.8 DAILY HOSPITAL CARE 272,00
08/18/08 MAXIMS BENEFITS PAID D.00
1L2b108 INCIDENTAL/INTEGRA 0.00
~ 06/04/04 INSURANCE PAYMENT lir3,yg_
~ O61Q4/D4 YOUR INSURANCE ALLOWMICE 113.47-
~ 06/04109 BALANCE AFTER INS 4,95
PERFORMED BY: EDWARD J VRESILOVIC MD ORTHOPAEDICS DIVISION
O7/1L0~8 94252.57 S1D.00 INITIAL INPT CaLStILTATION 203,00
08/18/08 MAXIl~1 BENEFITS PAID 0,00
1D/24/08 INSURiB1CE PAYMENT 11D.86-
10/24/D8 YOUR INSURANCE ALLOWANCE 74.82-
1DI24/08 BALANCE AFTER INS 12.32
D7/11/08 23570 $11.DD FX-SCAPULA CLD ND MIWIPUL %7.00
~ 08/18/08 MAKIMUM BENEFIT'S PAID 0.00
10/24/08 INSURANCE PAYMENT 2%.56-
N 1OJ24/08 YOUR IN6URANCE ALLOWANCE 637.49-
10/24/08 BALANCE AFTER IMF 32.45
O7/1L08 235D0 810.D0 FRACT CLAVICULAR NJO MAFIP 402,00
08/18/08 MAXIMIJ}1 BENEFITS PAID 0~0D
10/24'/08 INSURANCE PAYMENT 139.01-
10/24/08 YOUR INSURANCE ALLOWANCE 7ei7,r,~_
ld/24/08 BALANCE AFTER INS* lir,,t~
PERFORMED BY: ROBERT A CHERRY MD TRAUMA SURGERY DIV
O7/1L08 38100 865.04 SPLENECTOFtY TOTAL 4724,00
08/18/06 MAXIIAJ}I BENEFITS RAID 0.00
1L'2b/D8 Ii~LSURANCE PAYIR:NT 1b28.88-
1L26/08 YOUR INSURANCE ALLOMIMICE 3095.12- D.DO
07/11/08 32551.LT 8b0.D THDRACOSTOMY TUBE HEMOTH 1073.00
08/18/08 MAXIMA BENEFITS PAID 0,00
11/26/08 INSURANCE PAYMENT 141.03-
1L26/08 YOWL INSURANCE ALLOWANCE 431.47- 0.00
PERFORMED BY; GINA M CREUf2$URG MD DIV OF DIAL RADIOLOGY
O7/1LD8 7101026.77 Sb1.21 CHEST 1 VIEM (x,00
'[]CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
The Milton S. Hershey N
® The College of Medicine
AARON M HOCK
~~' SH PPENSBURG PA 77257-5795
ACCOUNT # 8005685
IF ANY QUESTIONS, PLEASE CONTACT: MSHiVIC PATIENT FINANCIAL SERVICES
DATE PROCEDURE QtA6 Q~ DESCRIPTION
CODE CODE
1D/24/D8 YOUR INSURANCE ALLONANCE
1L17/OB TNANC YOU FOR PAYMENT
STATEWIENT
DATE: 06/18/09
LAST STATEWIENT
DATE: 05/25/09
FED TAX ID # 251857035
INS CHARGE PAYMENT/ GUARANTOR
ADJUSTMENT BALANCE
341.02-
4.30- D.00
O7/10/06 7212826 959.8 CT TIDRACIC SPINE UNENHAN 434.00
~~~ MAXIMA BENEFITS PAID 0,00
1~~/~ It~LSURANCE PAYMENT 83.68-
10/24/08 YOUR IFlSIJRANCE ALLOMIANCE 341.02-
1L17/OB THMK YOU FOR PAYMENT 4.30- 0.00
PERFORMED BY: ROBERT A CNERRY MD TRAUMA SURGERY DIY
PLACE OF SYC: EMERGENCY RODfI
07/10/08 44245.57 954.8 TRAUMA TEAM DIAL EVAL INT 3872,00
~~/~ MAXIMA BENEFITS PAID O.OD
11/2b/08 INSURANCE PAYMENT 369.37-
1L26/08 YOUR INSURANCE ALLOMANCE 3502.63- O.DD
PERFORMED BY: PNILIP A VILLANUEVA MID DIVISION OF NEUAOSURG
PLACE OF SVC: INPATIENT
07/10/08 b1312.52 852.20 CRIWI EVAL HEM SUPRAT EPI 10670.DD
~~~ MAXIMA BENEFITS PAID O,OD
1D/22/08 DUPLICATE PREVIOUS D.OD
1~~/~ I16StAtAMCE PAYMENT 2710.13-
10/24/08 YOUR IMLSURMICE ALLONANCE 7658.74-
1L17/08 THANK YOU FOR PAYMENT 21.65- 274.48
PERFORMED BY: MARK KIMAK MD DIV OF EMER6 ROOM
PLACE OF SVC: EMERGENCY ROOM
~ 07/10/08 99285 459.8 EMERGENCY VISIT 42T
D0
W ~~/~ .
MAXIl~I BENEFITS PAID 0,00
~ 10/24/08 INSURANCE PAYMENT 71.16-
10/24/08 YOUR IMIS<JRANCE ALLp~IANCE 147.93-
10l24108 BALANCE AFTER INS* 207.91
PERFORMED BY: FRANCESCA M RU6GIERD MD DIV OF ANATOMIC PATH
PLACE OF SVC: INPATIENT
D7/1D/08 8830526 865.04 TISSUE EXAM LEVEL 4 144,00
~~~ MAXIM~I BENEFITS PAID 0,00
11/19/08 INSURANCE PAYf~NT lb.b4-
1L14/08 YOUR INSURANCE ALLONANCE 169.12-
1L19/08 BALANCE AFTER INS 8.14
D7/10/06 8830426 852.2D TISSUE EXAM LEVEL 3 57.00
~~/~ MAXIMA BENEFITS PAID O.DO
11!14/D8 INSINtANCE PAYMENT 57.00- O.DO
PERFt>RFiED BY: RAMESH KODAVATI6ANTI MD DIV OF ANESTHESIA
O7/1D/08 D021D.P5 852.20 31 ANES/INTRACRANIAL PROCED 3374.00
~~~ MAXIMAJMI BENEFITS PAID 0.00
08/25/08 NEED 1ST INSURANCE 0.00
11/11/08 INVALID/MISSING CO O.DD
D3/06l09 IFNALID/MISSING CO D.00
CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
-~- LF aNY QuESrioNS, PLFJISE coNTncT: MSHMC PATIENT FINANCIAL SERVICES
DATE PROCEDURE QLAG QTY DE3C~IPTION
CODE CODE
>» PATIENT: AARpd M IDCIC 7503425
FED TAX ID # 251857035
INS CHARGE PAYMENT/ GUARANTOR
ADJUSTMENT BALANCE
1D5034?5
PERFORMED BY: SCOTT N MICHELITCH MD DIV OF DIA6 RADIOLOGY
PLACE OF SVC: INPATIENT
O7/10/08 721702b 459.19 PELVIS M(F'ERPOSTER bb.00
06/18/08 MAXIMl~1 BENEFITS PAID 0,00
10/24/08 II~SiNtANCE PAY~NT 12.55-
10/24/08 YOUR INSURANCE ALLOMIANCE 52.05-
1O124/08 BALANCE AFTER INS* 1.40
O7/lt1/D8 710102b 807.04 CREST 1 VIEi~ 68.DO
08/18/06 MAXIMA BENEFITS PAID 0,D0
10!24/08 IMfSURMICE PAYMEM 13.15-
10/24/08 YOUR IMLSVfIANCE ALLONANCE 53.34-
10/24/08 BALANCE AFTER INS* 1.46
PERFORMED BY: HASSAN M HAL MD DIV OF DIAL RADIOLOGY
07/10/08 7126026 860.0 CT THORAX N/CON1'RAST ENH 464.OD
08/18/08 MAXIMA BENEFITS PAID 0.00
10/24/08 INSURANCE PAYMENT 90.03-
10/24/08 YOUR IMIS<JRANCE ALLONANCE 363.97-
11/17/08 TNANK YOU FOR PAYMENT 10.00- O.OD
07/10/08 741b026 865.04 C t ABDOfIEN ENHANCED 478.00
08/18/08 MAXIMUM BENEFITS PAID 0.00
10/24/08 INSTANCE PAYMENT 92.21-
10l24/08 YDIRt INSURANCE ALLONANCE 375.54-
1L17/08 THANK YOU FOR PAYMR:M 1D.25- D.00
w
~ 07/10/08 721432b 865.09 CT PELVIS ENHANCED 434.OD
DBJ18I08 MAXIMUH BENEFITS PAID 0.00
10/24/08 IFfSURpNCE PAYMENT 83.68-
10/24/06 YOUR INSURANCE ALLOMIANCE 341.02-
1L17/08 THANK YOU FOR PAYMENT 9.30- 0.00
PERFORMED BY: SANGAM 6 KANEKAR MD DIY OF DIAL RADIOLOGY
O7/10!08 T04502b 801.20 CT NERD UNEbIIANCED 319.D0
06/18/08 MAXIMUM BENEFITS PAID 0.00
10/24/06 INSURANCE PAYMRrNT 61.30-
10/24/08 YOUR IMlSURANCf ALLONAMJCE 250.89-
1L17/08 THANK YOU FOR PAYMENT 6.81- 0.00
O7/10/D8 721252b 459.09 CT CERVICAL SPINE U18:IOI1W 434.00
08/18/06 MAXIMA BENEFITS PAID 0.00
10!24/08 INSURANCE PAYMENT 83.b8-
10/24/08 YOUR IMLSURAMCE ALLONANCE 341.D2-
11/17/08 THANK YOU FOR PAYMENT 4.30- 0.00
07/10/06 7213126 454.8 CT LUMBAR SPINE UNENHANCE 434.00
OB/18/0~6 MAXIMA BEMR:FTTS PAID D.00
10/24/08 INSURANCE PAYMENT 83.68-
BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
PENNSTATE AARON M HOCK ~ ~~- ~ of $
408 RIDGE RD
The Milton S. Hershey Medical Center SHIPPENSBURG PA 17257-9795 STATEMENT
The College of Medicine DATE: 06/18/09
LAST STATEMENT
ACCOUNT # 8005665 DATE: 05!25/09