Loading...
HomeMy WebLinkAbout09-13-10 (2)NOTICE OF CLAIM (Filed Pursuant to 20 Pa.C.S. § 3532) COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF ROBIN GERHOLD ,DECEASED No. 21-10-527 To the Clerk of the Orphans' Court Division: Enter the claim of Cancer Treatment Centers of America -Professional Corporation of PA in the (Claimant) amount of $ 5,197.50 ,against the above entitled Estate. The Decedent, who resided at 10 Annette Dr.; Enola, PA 17025-1801 (Street Address) died on May 8, 2010 .Written notice of (Date of Death) said claim was given to Donald & Linda Morgan c/o attorney, Murrel R. Walters, III (Persona! Representative or his/her counsel) at 54 E Main Street Mechanicsburg PA 17055 _ (Address) on September 9, 2010 (Date) ERMC c/o Patient Accounts (Claimant's Counsel) (Supreme Courf I.D. No.) (Address) (Telephone) Form OC-07 rev. 10.13.06 (Claimant) 2610 Sheridan Road, 1st Floor (Street Address) Zion, IL 60099-2615 (City, Stale, Zip) N e O ~ y 1 ~° ~ ~ {~ t'ri ... f*1 ' ( ~ :. L7 ~ '~ C.J -~1 n=~~-fi ~a ~j ~ vs ~ ` Z ~ -~-~ ~ - '' C~ .~ -, «:_ rn i •~ ' to ~ ~ - ~ _ '7 V~ ' Cancer Treatment t: SM AB :f~~ CTCA PROFE66IONAL CORP PATIENT ACOVNT LIST SDIM7ARY AMB Printed on: 09/09/10 at 15:09 PAGE: 1 PT NAME: GERHOLD ROHIN MRN: 00424323 ENTITY: CP PRIME: CIGNA SHC: SELF PAY TER: Account AS Vieit AR Period Total Total Total Number Code Type Date Range Charges Adjust Payments Balance 527115 B PROFESSIONA 04/12/10-04/12/10 2055. 00 -513. 75 -1233. 00 3De. z5 529364 B pROFBSSIONA 04/13/10-04/13/10 438. 00 -109. 50 -262. 80 65. 70 539965 H PROFSS5IONA 04/12/10-04/12/10 68. 00 -17. 00 -40. 80 10. 20 535210 H PROPBSSIONA 04/13/10-04/13/10 846. 00 -211. 50 -507. 60 126. 90 535213 B PROFESSIONA 04/13/10-04/13/10 874. 00 -218. 50 -524. 40 131. 10 538664 B PROPHSSIONA 04/14/10-04/14/10 1313. 00 -328. 25 -787. 80 196. 95 539223 B PROPSSSIONA 04/12/10-04/12/10 56. 00 -14. 00 -33. 60 8. 40 539421 P PROFESSZONA 04/12/10-04/12/10 0. 00 0. 00 0. 00 0. 00 539422 P PROF89SIONA 04/12/10-04/12/10 0. 00 0. 00 0. 00 0. 00 541046 B PROFESSIONA 04/12/10-09/12/10 384. 00 -96. 00 -230. 40 57. 60 543005 B PROPESSIONA 04/12/10-04/12/10 369. 00 -92. 25 -221. 90 55. 35 543026 B PROFESSIONA 04/12/10-04/12/10 654. 00 -163. 50 -392. 40 98. 10 543045 B PROFESSIONA 04/12/10-04/12/10 712. 00 -178. 00 -427. 20 106. 80 545430 Z PAOFESSIONA 04/27/10-04/27/10 2854. 00 -713. 50 -1701. 00 939 .50 545432 P PROPESSIONA 09/27/10-04/27/10 0. 00 0. 00 0. 00 0 .00 545456 B PROFESSIONA 04/27/10-04/27/10 673. 00 -168. 25 -252. 38 252 .37 545724 Z PROPE35IONA 04/16/10-04/16/10 166. 00 -41. 50 -124. 50 0 .00 547046 B PROFESSIONA 04/20/10-04/20/10 402. 00 -100 .50 -241. 20 60 .30 547796 H PROPESSIONA 04/21/10-04/21/10 195. 00 -48 .75 -117. 00 29 .25 547798 8 PROPBSSIONA 04/21/10-04/21/10 68. D0 -17 .00 -40. 80 10 .20 547800 B PROPESSIONA OS/OL/10-OS/O1/10 56. 00 -14 .00 -33. 60 8 .40 548151 B PROFESSIONA 05/04/10-05/04/10 56. 00 -14 .00 -33. 60 8 .40 548770 H PROFESSIONA 04/19/10-09/19/10 227. 00 -56 .75 -136. 20 34 .05 550428 H PROFESSZONA 04/18/10-04/18/10 454. 00 -113 .50 -272. 40 68 .10 551028 H PROFSSSIONA 05/04/10-05/04/10 769. D0 -192 .25 -461. 40 115 .35 552779 B PROPESSIONA 04/26/10-04/26/10 68. 00 -17 .00 -90. 80 10 .20 553172 H PROPESSIONA 04/22/10-04/22/10 696. 00 -174 .00 -417. 60 104 .40 553177 8 PROPESSIONA 05/03/10-05/03/10 696. 00 -174 .00 -417. 60 104 .40 553408 A PROFESSIONA 04/25/10-04/25/10 454. 00 -113 .50 -272. 40 68 .10 553719 2 PROFESSIONA 04/27/10-04/27/10 56. 00 -14 .00 -42 .00 0 .00 553895 Z PROF855IONA 04/27/10-09/27/10 56. 00 -14 .00 -42 .00 0 .00 554162 A PROFESSIONA 04/27/10-04/27/10 56. 00 0 .00 0 .00 56 .00 554163 Z pROFESSIONA 04/28/10-04/28/10 56 .00 -14 .00 -42 .00 0 .00 554168 A PROF89SIONA 04/28/10-04/28/10 56 .00 0 .00 0 .00 56 .00 555094 B PROFBSSIONA 04/16/10-04/16/10 1392 .00 -348 .00 -835 .20 208 .80 556158 Z PROFBSSIONA 04/29/10-04/29/10 68 .00 -17 .00 -51 .00 0 .00 556553 B PROPESSIONA 04/27/10-04/27/10 227 .00 -56 .75 -139 .92 30 .33 557684 Z PROFESSIONA 04/25/10-04/25/10 696 .00 -174 .00 -522 .00 0 .00 559512 Z PROFESSIONA 05/03/10-05/03/10 97 .00 -24 .25 -72 .75 0 .00 560894 Z PROFESSIONA 04/27/10-04/27/10 2137 .00 -534 .25 -1602 .75 0 .00 560902 Z PROPESSIONA 04/27/10-04/27/10 1419 .00 -883 .75 -530 .25 0 .00 560905 Z PROPESSIONA 04/27/10-04/27/10 1414 .00 -883 .75 -530 .25 0 .00 561899 Z PROFE66IONA 04/29/10-04/29/10 116 .00 -116 .00 0 .00 0 .00 563972 Z PROFESSIONA OS/05/10-OS/OS/10 1044 .00 -174 .00 -522 .00 348 .00 564325 Z PROFHSSIONA OS/OS/10-OS/OS/10 56 .00 -14 .00 -42 .00 0 .00 565591 Z PROFESSIONA 05/07/10-05/07/10 56 .00 -14 .00 -42 .00 0 .00 ~It lraQ oun ~~uiuiQeye to ~no~c Ica' yaaac leaetCiea~ce a~ulceQ. BENEFITS ASSIGNED TO THE PROVIDER ' Cancer Treatment R t: SM A8 of~erica• PT NAME: GEAHOLD ROBIN PRIME: CIGNA COCA PROFESSIONAL CORP PATIENT ACOUNT LIST SUMMARY AMH Printed On: 09/09/10 at 15:09 MRN: 00924323 ENTITY: CP SEC: SELP PAY TER: PAGE: 2 AOCOUIlt AS ViBit AR P@rlOd Total Total Total Number Code Type Date Range Charges Adjust Payments Balance 569252 Z PROFRSSIONA 05/07/10-05/07/10 3481. 00 -870. 25 -2610. 75 0.00 569255 Z PROPHSSIONA OS/OS/10-OS/OS/10 348. 00 -87. 00 -261. 00 0.00 577150 Z PROFESSIONA 04/30/10-04/30/10 152. 00 -38. 00 -114. 00 0.00 590316 Z PROPESSIONA 04/12/10-04/12/10 618. 00 -154 .50 -463. 50 0.00 993803 Z PROPESSIONA 05/04/10-05/04/10 186. 00 -46 .50 -139. 50 0.00 593807 Z PROPESSIONA 04/30/10-04/30/10 282. 00 -70 .50 -211. 50 0.00 596038 Z PROFESSIONA 04/15/10-04/15/10 313. 00 -78 .25 -234. 75 0.00 596039 Z PROPESSZONA 04/27/10-04/27/10 596. 00 -149 .00 -447. 00 0.00 596041 Z PROFESSIONA Oa /27/10-04/27/10 292. 00 -73 .00 -219. 00 0.00 606858 2 PROFSSSIONA 04/25/10-04/28/10 348 .00 -87 .00 -261. 00 0.00 607659 2 PROF838IONA 05/02/10-05/02/10 696 .00 -174 .00 -522 .00 0.00 614453 P PROFESSIONA 05/04/10-05/04/10 0 .00 0 .00 0 .00 0.00 625878 A PROFESSIONA 05/04/10-09/04/10 1010 .00 0 .00 0 .00 1010.00 625886 A PROPESSIDNA 09/04/10-09/04/10 1010 .00 0 .00 0 .00 1010.00 Total for GERHOLD ROBIN 33932.00 -9010.50 -19724 .OD 5197.50 Grand Total 33932.00 -9010.50 `It lad 6ee~c oun ,~ciuiBeye to ~icde your ~ea.~tlcca~e ~u~ce4s. -19724.00 5197.50 BENEFITS ASSIGNED TO THE PROVIDER