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Home My WebLink About02-23-10~' UC1F",~~:'! ~~flCi: ~~; iy n Zoio~EB 23 ars ii= ~~ _ NOTICE OF CLAIM (Filed Pursuant to 20 Pa.C.S. § 3532) (~, , ,- , C URT OF COMMON PLEAS OF UMW, COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION CLERK OF ORPHAN'S COURT CU~,PREI?;.;~~;U CO., PA. ESTATE OF _ ~ I~ • ~ W~ DECEASED No. P 2~ ~a - ~~ 7~ To the Clerk of the Orphans' Court Division: Enter the claim of y~~,S ~1~~Y1s ~/lYl~1 CGt~ I~'A(,~1( amount of $ ~ ~ 7 ~ Z rclalmonr) • ,against the above entitled Estate. The Decedent, who resided at said claim was given at '/V 1 ~V 1MiY 1~{'1Y fi't' - on (Dau) N ~ (Cklmmet~s oeaare/) (Styrreme Cowt l.D. Na.J ~A~!'eJJJ ~B~BdWml~ FormOC-07 rev. !0.(1.06 died on _~ ~ ~ 0 (AddresrJ . Ca,v~; in the Written notice of N a~~ o n iNi~1.L G-~-i-~-~YP~NCC (ClmmantJ ~~3 G1'I.eVO~ ,A~i~ (3rreer AdalseJ.~ .A~x av~~~, ~.~ 22~i 2 cry, sm~e, ~~ C ~~~~-2 - ~~o e~~O JHU CLINICAL PRACTICE ASSOC C/0 Nationwide Credit Corporation PO BOX 9156 ALEXANDRIA, VA 22309 52-0595110(21)N Patient Name: KUHN KIM L 7 EASTWICK COURT COURT Guarantor Name: KUHN,KIM L 7 EASTWICK CARLISLE PA 17015 CARLISLE, PA 000017015 717-291-0700 Med Rec Num: 9367995 Invoice Num: 95131239 DOB: 19691112 Sex: F Rltn to Patnt: 2 Primary Insur Code: Cert#: Group#: Subscriber: Auth #: ance 22 GMB840629467 017117 FOSSELMAN,KIPP L Referring Physician: JACOBS MD, LISA KAY UPIN: H21963 From Thru Loc Div Units Procedure Charge Amount Payment Amount 082208 082208 IND 1602 1 88321 $225.00 $0.00 112108 IND 1602 1 S99.81 011209 IND 1602 1 $82.49 Secondary Insurance Code: Cert#: Group#: Subscriber: Description CHARGES VISA PAYMENT MASTERCARD PAYMENT $0.00 $0.00 Total Charges: $225.00 Contractual Adjustment: $0.00 Payments Adjustments: $182.30 Balance Due: $92.70 This communication is from a debt collector attempting to collect a debt and any information obtained will be used for that purpose. JHU CLINICAL PRACTICE ASSOC C/0 Nationwide Credit Corporation PO BOX 9156 ALEXANDRIA, VA 22309 52-0595110(29)Q Patient Name: KUHN KIM L 7 EASTWICK COURT COURT Guarantor Name: KUHN, KIM L 7 EASTWICK CARLISLE PA 17015 CARLISLE, PA 000017015 717-241-0700 Med Rec Num: 9367995 Invoice Num: 95149996 DOB: 19691112 Sex: F Rltn to Patnt: 2 Primary Insur Code: Cert#: Group#: Subscriber: Auth #: ance 22 GMB840629467 017117 FOSSELMAN,KIPP L Secondary Insurance Code: Cert#: Group#: Subscriber: Referring Physician: JACOBS MD, LISA KAY UPIN: H21963 From Thru Charge Amount 082808 08280 $213.00 100308 $48.80 Loc Div Units Procedure Payment Amount 3 OUT 501 1 78306 $0.00 OUT 501 1 Description CHARGES BLUE SHIELD PAYMENT $0.00 Total Charges: $213.00 Contractual Adjustment: $0.00 Payments Adjustments: $200.80 Balance Due: $12.20 This communication is from a debt collector attempting to collect a debt and any information obtained will be used for that purpose. JHU CLINICAL PRACTICE ASSOC C/0 Nationwide Credit Corporation PO BOX 9156 ALEXANDRIA, VA 22309 52-0595110(40)A Patient Name: KUHN KIM L 7 EASTWICK COURT COURT CARLISLE, PA DOB: Sex: Rltn to Patnt: Primary Insur Code: Cert#: Group#: Subscriber: Auth #: CARLISLE PA 17015 000017015 717-241-0700 Med Rec Num: 9367995 19641112 F 2 ance 22 GMB840624467 017117 FOSSELMAN,KIPP L Referring Physician: JACOBS MD, LISA KAY UPIN: H21963 Guarantor Name: KUHN,KIM L 7 EASTWICK Invoice Num: 45157289 Secondary Insurance Code: Cert#: Group#: Subscriber: From Thru Loc Div Units Procedure Description Charge Amount Payment Amount 082808 082808 OF 901 1 99209 CHARGES $315.12 $0.00 100608 OF 901 1 BLUE SHIELD PAYMENT $0.00 $199.00 Total Charges: $315.12 Contractual Adjustment: $0.00 Payments Adjustments: $295.12 Balance Due: $20.00 This communication is from a debt collector attempting to collect a debt and any information obtained will be used for that purpose. JHU CLINICAL PRACTICE ASSOC C/0 Nationwide Credit Corporation PO BOX 9156 ALEXANDRIA, VA 22309 52-0595110(29)Q Patient Name: KUHN KIM L 7 EASTWICK COURT COURT CARLISLE, PA DOB: Sex: Rltn to Patnt: Primary Insur Code: Cert#: Group#: Subscriber: Auth #: CARLISLE PA 17015 000017015 717-241-0700 Med Rec Num: 9367995 19691112 F 2 ance 22 GMB840629467 017117 FOSSELMAN,KIPP L Referring Physician: JACOBS MD, LISA KAY UPIN: H21963 From Thru Charge Amount OB2808 08280 $303.00 100308 $62.40 Loc Div Units Procedure Payment Amount 3 OUT 501 1 71260 $0.00 OUT 501 1 Total Charges: $303.00 Payments Adjustments: $287.40 Guarantor Name: KUHN,KIM L 7 EASTWICK Invoice Num: 45169830 Secondary Insurance Code: Cert#: Group#: Subscriber: Description CHARGES BLUE SHIELD PAYMENT $0.00 Contractual Adjustment: $0.00 Balance Due: $15.60 This communication is from a debt collector attempting to collect a debt and any information obtained will be used for that purpose. JHU CLINICAL PRACTICE ASSOC C/0 Nationwide Credit Corporation PO BOX 9156 ALEXANDRIA, VA 22309 52-0595110(24)Q Patient Name: KUHN KIM L Guarantor Name: KUHN,KIM L 7 EASTWICK COURT 7 EASTWICK COURT CARLISLE , PA 17015 CARLISLE, PA 000017015 717-241-0700 Med Rec Num: 9367995 Invoice Num: 95169831 DOB: 19691112 Sex: F Rltn to Patnt: 2 Primary Insurance Secondary Insurance Code: 22 Code: Cert#: GMB840629467 Cert#: Group#: 017117 Group#: Subscriber: FOSSELMAN,KIPP L Subscriber: Auth #: Referring Physician: JACOBS MD, LISA KAY UPIN: H21963 From Thru Loc Div Units Procedure Description Charge Amount Payment Amount 082808 082808 OUT 501 1 79160 CHARGES $311.00 $0.00 082808 082808 OUT 501 1 72193 CHARGES $263.00 $0.00 100308 OUT 501 1 BLUE SHIELD PAYMENT $0.00 $108.00 Total Charges: $599.00 Contractual Adjustment: $0.00 Payments Adjustments: $567.00 Balance Due: $27.00 This communication is from a debt collector attempting to collect a debt and any information obtained will be used for that purpose. JHU CLINICAL PRACTICE ASSOC C/0 Nationwide Credit Corporation PO BOX 9156 ALEXANDRIA, VA 22309 52-0595110(02)B Patient Name: KUHN KIM L Guarantor Name: KUHN,KIM L 7 EASTWICK COURT 7 EASTWICK COURT CARLISLE PA 17015 CARLISLE, PA 000017015 717-241-0700 Med Rec Num: 9367945 Invoice Num: 45496269 DOB: 19691112 Sex: F Rltn to Patnt: 2 Primary Insur Code: Cert#: Group#: Subscriber: Auth #: ance 22 GMB890624967 017117 FOSSELMAN,KIPP L Secondary Insurance Code: Cert#: Group#: Subscriber: Referring Physician: UPIN: From Thru Loc Div Units Procedure Description Charge Amount Payment Amount 100108 100108 I 2202 21 00909 CHARGES $2,340.00 $0.00 103008 I 2202 1 BLUE SHIELD PAYMENT $0.00 5559.32 Total Charges: $2,390.00 Contractual Adjustment: $0.00 Payments Adjustments: $2,200.18 Balance Due: 5139.82 This communication is from a debt collector attempting to collect a debt and any information obtained will be used for that purpose. JHU CLINICAL PRACTICE ASSOC C/0 Nationwide Credit Corporation PO BOX 9156 ALEXANDRIA, VA 22309 52-0595110(40)A Patient Name: KUHN KIM L 7 EASTWICK COURT COURT Guarantor Name: KUHN,KIM L 7 EASTWICK CARLISLE PA 17015 CARLISLE,PA 000017015 717-241-0700 Med Rec Num: 9367995 Invoice Num: 95578112 DOB: 19641112 Sex: F Rltn to Patnt: 2 Primary Insur Code: Cert#: Group#: Subscriber: Auth #: ante 22 GMB890629467 017117 FOSSELMAN,KIPP L Referring Physician: UPIN: From Thru Loc Div Units Procedure Charge Amount Payment Amount 100108 100108 I 901 1 19357 57,663.50 $0.00 100108 100108 I 901 1 15930 $364.26 $0.00 100108 100108 I 901 1 15931 $369.26 $0.00 121008 I 901 1 $2,507.92 022409 I 901 1 $1,752.90 Secondary Insurance Code: Cert#: Group#: Subscriber: Description CHARGES CHARGES CHARGES BLUE SHIELD PAYMENT BLUE SHIELD PAYMENT $0.00 50.00 Total Charges: $8,392.02 Contractual Adjustment: $0.00 Payments Adjustments: $7,953.81 Balance Due: $938.21 This communication is from a debt collector attempting to collect a debt and any information obtained will be used for that purpose. JHU CLINICAL PRACTICE ASSOC C/0 Nationwide Credit Corporation PO BOX 9156 ALEXANDRIA, VA 22309 52-0595110127)T Patient Name: KUHN KIM L 7 EASTWICK COURT COURT Guarantor Name: KUHN, KIM L 7 EASTWICK CARLISLE PA 17015 CARLISLE,PA 000017015 717-291-0700 Med Rec Num: 4367995 Invoice Num: 45595562 DOB: 19641112 Sex: F Rltn to Patnt: 2 Primary Insur Code: Cert#: Group#: Subscriber: Auth #: once 22 GMB840624967 017117 FOSSELMAN,KIPP L Secondary Insurance Code: Cert#: Group#: Subscriber: Referring Physician: UPIN: From Thru Loc Div Units Procedure Charge Amount Payment Amount 100108 100108 1 701 1 19307 $3,106.77 $0.00 100108 100108 I 701 1 19303 $2,423.97 $0.00 111908 I 701 1 $1,781.60 012109 I 701 1 $464.32 021009 I 701 1 $1,976.50 032009 I 701 1 $1,781.60 Description CHARGES CHARGES BLUE SHIELD PAYMENT $0.00 BLUE SHIELD PAYMENT $0.00 BLUE SHIELD PAYMENT $0.00 BLUE SHIELD PAYMENT $0.00 Total Charges: $5,530.79 Contractual Adjustment: 50.00 Payments Adjustments: $5,085.34 Balance Due: 5995.90 This communication is from a debt collector attempting to collect a debt and any information obtained will be used for that purpose. JHU CLINICAL PRACTICE ASSOC C/0 Nationwide Credit Corporation PO BOX 9156 ALEXANDRIA, VA 22309 52-0595110(21)N Patient Name: KUHN KIM L Guarantor Name: KUHN,KIM L 7 EASTWICK COURT 7 EASTWICK COURT CARLISLE PA 17015 CARLISLE, PA 000017015 717-241-0700 Med Rec Num: 9367995 Invoice Num: 45609157 DOB: 19641112 Sex: F Rltn to Patnt: 2 Primary Insurance Secondary Insurance Code: 22 Code: Cert#: GMB890629967 Cert#: Group#: 017117 Group#: Subscriber: FOSSELMAN,KIPP L Subscriber: Auth #: Referring Physician: FLORES MD, JAIME UPIN: I93012 From Thru Loc Div Units Procedure Description Charge Amount Payment Amount 100208 100208 I 1601 2 86309 CHARGES 5636.00 $0.00 100206 100208 I 1601 2 88305 CHARGES $292.00 $0.00 100208 100208 I 1601 9 88360 CHARGES $460.00 $0.00 110708 I 1601 1 BLUE SHIELD PAYMENT $0 00 $640.82 . Total Charges: $1,588.00 Contractual Adjustment: $0.00 Payments Adjustments: $1,427.61 Balance Due: $160.19 This communication is from a debt collector attempting to collect a debt and any information obtained will be used for that purpose. JHU CLINICAL PRACTICE ASSOC C/0 Nationwide Credit Corporation PO BOX 9156 ALEXANDRIA, VA 22304 52-0595110(02)B Patient Name: KUHN KIM L 7 EASTWICK COURT COURT Guarantor Name: KUHN,KIM L 7 EASTWICK CARLISLE PA 17015 CARLISLE,PA 000017015 717-241-0700 Med Rec Num: 9367995 Invoice Num: 45998314 DOB: 19691112 Sex: F Rltn to Patnt: 2 Primary Insurance Code: 22 Cert#: GMB890624967 Group#: 017117 Subscriber: FOSSELMAN,KIPP L Auth #: Referring Physician: UPIN: Secondary Insurance Code: Cert#: Group#: Subscriber: From Thru Loc Div Units Procedure Description Charge Amount Payment Amount 100108 100108 I 2204 21 00904 CHARGES $1,170.00 $0.00 090609 I 2204 1 BLUE SHIELD PAYMENT $0 00 $526.50 . 061209 I 2204 1 BLUE SHIELD PAYMENT $D 00 $640.64 . 061709 I 2204 1 BLUE SHIELD PAYMENT $0 00 50.00 . Total Charges: $1,170.00 Contractual Adjustment: $0.00 Payments Adjustments: $1,111.50 Balance Due: $58.50 This communication is from a debt collector attempting to collect a debt and any information obtained will be used for that purpose. JHU CLINICAL PRACTICE ASSOC C/0 Nationwide Credit Corporation PO BOX 9156 ALEXANDRIA, VA 22309 52-0595110(17)) Patient Name: KUHN KIM L 7 EASTWICK COURT COURT Guarantor Name: KUHN, KIM L 7 EASTWICK CARLISLE PA 17015 CARLISLE, PA 000017015 717-291-0700 Med Rec Num: 9367995 Invoice Num; 95699526 DOB: 19641112 Sex: F Rltn to Patnt: 2 Primary Insurance Secondary Insurance Code: 22 Code: Cert#: GMB890629967 Cert#: Group#: 017117 Group#: Subscriber: FOSSELMAN,KIPP L Subscriber: Auth #: Referring Physician: JACOBS MD,LISA KAY UPIN: H21963 From Thru Loc Div Units Procedure Description Charge Amount Payment Amount 102008 102008 OF 1101 1 99295 CHARGES $595.00 $D.00 112108 OF 1101 1 BLUE SHIELD PAYMENT $256.78 $0.00 Total Charges: $545.00 Contractual Adjustment: $0.00 Payments Adjustments: $525.00 Balance Due: $20.00 This communication is from a debt collector attempting to collect a debt and any information obtained will be used for that purpose. ~~ ti c~ ~~ a°. 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