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HomeMy WebLinkAbout04-25-12~Cca~rn,~ ~ ~~~~aioaa ~~~ ~0~3~/ate ~ ~I -11- ~9N In the Estate//~~of: \ / Estate No. .r~ 1 ~~ t~`" y Y ~ `J ~~ /~ S Date O~ ~ '~ oZ CLAIM AGAINST DECEDENT'S ESTATE , The claimant certifies that there is due and owing by the decedent in accordance with the attached statement of account or other basis for the claim the sum of ~o ^~ ~,; ~ b. -~, ~, ~- _~, ~~. Cri ~ ~ ~ ~r7 C7 1 solemn) affirm under the enalties of er'u that the contents of the fore Icy ' ` ~`'' Y P P J ry~ 9~ ~., ~a - ri ~C `t• -. c{aim are true to the best of my knowledge, information, and be{ief. v ~ '~ ~ ~ r /~hN ~ AX~aS DSs~~A ~ ame of Claimant Sig ure claimant or person authorized to make verifications on behalf of claimant _-7 Name and Title of Person 5' ning Claim Address %~~~ ,~~~~r~ - ~G~ ; ~~ ~,~` m a z ~ Yin ~ a is e/ yy3- ~ 9~- aryl Telephone Numtier CERTIFICATE OF SERVICE I herby certify that on this ~dday of (month), ~ (year), I [] delivered or ailed, first class postage prepaid a copy of the foregoing Claim to the personal representative, ~~~ r~~.e~t/ Signature Cla mant Instructions: 1. This form may be filed with the Register of Wlls upon payment of the filing fee of $3.00 provided by law. A copy must also be sent to the personal representative by the claimant. 2. If a claim is not yet due, indicate the date when it will become due. If a claim is contingent, indicate the nature of the contingency. If a claim is secured, describe the security. RW 1128 `~ zoos Patient Financial Services The Johns Hopkins Hospital Johns Hopkins Bayview Medical Center Howard County General Hospital Johns HopkinsQKeswick 3910 Keswick Road, Suite 5-5100 Baltimore, Maryland 21211 09/14/10 JOHNS HOPKINS M E D i C I N E JOHNS HOPKINS HEALTH SYSTEM MYERS, PEGGY 208021022 F 056 10/19/53 09/08/10 09/09/10 001 FINAL ESTATE OF PEGGY MYERS AETNA MEDICARE HMO MEBFFTPN 1100 GRANDON WAY APT 426 MECHANICSBURG, PA 17050 09/08/10 ADULT ICU 99078910 1 4013.00 ROOM AND BOARD SUS-TOTAL 1 4013.00 09/08/10 ADMISSION CHARGE 40600010 1 390.57 ADM CHG SUB-TOTAL 1 390.57 09/08/10 GENT SULF/PRED. 34518770 1 34 68 09/08/10 GLYCOPYRROLATE 34518980 1 . 0 52 09/08/10 HYDROXYETHYL CELLULOSE 34519580 1 . 9 66 09/08/10 PRAMIPEXOLE 34525330 1 . 5 17 09/08/10 PREDNIS ACE/SULFACET SOD 34525400 1 . 74 70 09/08/10 PROPARACAINE HCL ~ ~- 34525660 1 . 2 98 09/08/10 09/08/10 PROPOFOL Moxifloxacin 0.5~ Ophth Soln 34525690 34534010 1 1 . 12.17 09/08/10 Sod. Chloride Flush 6m1 34561030 1 118.66 0 37 09/09/10 Sod. Chloride Flush 6m1 34561030 1 . 0 37 09/08/10 PANTOPRAZOLE SODIUM, IV 40MG 34580980 1 . 5 99 09/09/10 PANTOPRAZOLE SODIUM, IV 40MG 34580980 1 . 5 99 09/08/10 Succinylcholine 20mg IV 34534830 10 . 2 40 09/08/10 DEXAMETHASONE 1MG IM, IV 34501790 4 . 0 80 09/09/10 HEPARIN SOD. 1000 UNITS IV, SC 34503460 5 . 3 15 09/08/10 FUROSEMIDE 20MG IM, IV 34502900 1 . 0 01 09/08/10 Lidocaine 2~ lOmg IV 34534800 10 . 0 40 09/08/10 MIDAZOLAM HCL 1MG IM, IV 34505150 4 . 1.12 09/08/10 09/08/10 MIDAZOLAM 1MG IM,IV Phenylephrine lml IV 34531220 100 63.00 09/08/10 ONDANSETRON 1MG IV 34534820 .34505590 10 4 0.40 0 52 09/08/10 FENTANYL CITRATE O.1MG INJ 34502700 25 . 27.00 208021022 09/14/10 Patient Financial Services The Johns Hopkins Hospital Johns Hopkins Bayview Medical Center Howard County General Hospital Johns Hopkins~Keswlck 3910 Keswick Road, Suite 5.5100 Baltimore, Maryland 21211 09/14/10 JOHNS HOPKINS M E D I C I N E 1ONNS NOPKINS NEA LTH SYSTEM MYERS, PEGGY 208021022 F 056 10/19/53 09/08/10 09/09/10 001 FINAL ESTATE OF PEGGY MYERS AETNA MEDICARE HMO MEBFFTPN 1100 GRANDON WAY APT 426 _, MECHANICSBURG, PA 17050 09/08/10 FENTANYL CITRATE O.1MG INJ 34502720 1 0 43 09/08/10 FENTANYL CITRATE O.1MG INJ VAR 34530870 2 . 2.15 PHARMACY SUB-TOTAL 188 372.64 09/08/10 SODIUM CHLORIDE INF 100ML IV2 34506780 1 1 06 09/08/10 SODIUM CHLORIDE INF 1000ML IV 34506850 1 . 0 75 09/08/10 SODIUM CHLORIDE INF 500ML IV 34506890 1 . 0.75 PHARMACY-IV SOLUTIONS SUB-TOTAL 3 2.56 09/08/10 FILTER EXHILATION DX 800 43101070 1 24 62 09/08/10 METER HOURLY URINE LATEX FREE .43103190 1 . 11 71 09/08/10 , OXISENSOR ADULT DIGIT DISP *" 43103710 1 . 16 52 09/08/10 BAG RESUSITATION ADULT W/PEEP 43103840 1 . 31 54 09/08/10 Sens adult single use LNOP-ADT 43109500 1 . 16 80 09/08/10 KIT TRIFURACATED TRANSDUCER 43303310 1 . 14 00 09/08/10 KIT SUCTION CATH 14FR 24HR 43303700 1 . 12 00 09/08/10 DRAPE, INCISE 1060 46510460 1 . 8 00 09/08/10 SUTURE,6-0 VICRYL 5-28 2562G-' 46516010 2 . 80 00 09/08/10 SUTURE, 6-0 SURGIDAC SS-14 46521500 3 . 36 00 09/08/10 Extraocular custom pack 46523650 1 . 91 00 09/08/10 SOLN. BAL. SALT, BSS 47883010 1 . 9.00 MEDICAL-SURGICAL SUPPLISUB-TOTAL 15 351.19 09/08/10 GUIDEWIRE .015 * 15CM/ 09/08/10 CATH RADIAL ARTERY 20FR 09/08/10 AIRWAY LARYNGEAL MASK #4 ADULT 41007420 41090490 41090630 1 1 1 25.00 11.00 19.00 208021022 09/14/10 ~' , Patient Financial Services The Johns Hopkins Hospital Johns Hopkins Bayview Medical Center Howard County General Hospital Johns Hopkins~Keswick 3910 Keswick Road, Suite 5-5100 Baltimore, Maryland 21211 09/14/10 JOHNS HOPKINS M E D I C I N E JOHNS HOPKINS HEALTH SYSTEM MYERS, PEGGY 208021022 F 056 10/19/53 09/08/10 09/09/10 001 FINAL ESTATE OF PEGGY MYERS AETNA MEDICARE HMO MEBFFTPN 1100 GRANDON WAY APT 426 MECHANICSBURG, PA 17050 09/08/10 KIT, INVASIVE ARTERIAL MONITOR 41091110 2 40 00 09/08/10 KIT, ANESTHESIA SET-UP 41Q91130 1 . 30 00 09/08/10 09/08/10 KIT, IV TRAY CATH FOLEY 18FR lOCC LUSR 41091140 43330160 2 2 . 24.00 26.00 STERILE SUPPLY SUB-TOTAL 10 175.00 09/08/10 BASIC METABOLIC PANEL, EMER 49005650 1 20 35 09/08/10 BASIC METABOLIC PANEL, EMER 49005650 1 . 20 35 09/08/10 ANTIBODY SCREEN SALINE+AHG 48340500 1 . 22 20 09/08/10 ABO CELL GROUPING 48340150 1 . 7 40 09/08/10 RHO(D)TYPE 4834-0170 1 . 7.40 LABORATORY SUB-TOTAL 5 77.70 09/08/10 BLOOD GASES, EMERGENCY 49D41860 1 57 36 09/09/10 09/08/10 BLOOD GASES, EMERGENCY BLOOD 49001860 1 . 57.36 09/09/10 GASES, EMERGENCY BLOOD GASES 49001860 1 57.36 09/08/10 , EMERGENCY GLUCOSE WH 49001860 1 57.36 09/08/10 , OLE BLOOD GLUCOSE, WHOLE BLOOD 49001490 49001490 1 1 7.40 09/08/10 POTASSIUM, WHOLE BLOOD, EM 49001040 1 7.40 7 40 09/08/10 POTASSIUM, WHOLE BLOOD, EM 49001040 1 . 7 40 09/08/10 SODIUM, WHOLE BLOOD, EMERG 49001030 1 . 3 70 09/08/10 SODIUM, WHOLE BLOOD, EMERG 49001030 1 . 3.70 LABORATORY/CHEMISTRY SUB-TOTAL 10 266.44 09/08/10 HEMOGLOBIN,TOTAL,WHOLE BLOOD', ~900~8Y0 1 7.40 208021022 09/14/10 Patient Financial Services The Johns Hopkins Hospital Johns Hopkins Bayview Medical Center Howard County General Hospital Johns Hopkins~Keswick 3910 Keswick Road, Suite 5-5100 Baltimore, Maryland 21211 JOHNS HOPKINS M E D I C I N E JOHNS HOPKINS HEALTH SYSTEM 09/14/10 MYERS, PEGGY 208021022 F 056 10/19/53 09/08/10 09/09/10 001 FINAL ESTATE OF PEGGY MYERS AETNA MEDICARE HMO MEBFFTPN 1100 GRANDON WAY APT 426 MECHANICSBURG, PA 17050 09/08/10 HEMOGLOBIN,TOTAL,WHOLE BLOOD 49001820 1 7 40 09/08/10 HEME-S,EMERGENCY 49030220 1 . 14 80 09/08/10 HEME-B,EMERGENCY 49030220 1 . 14 80 09/08/10 PROTHROMBIN TIME, EMER 47633320 1 . 14 80 09/08/10 APTT, EMER 47633420 1 . 14.80 LABORATORY/HEMATOLOGY SUB-TOTAL 6 74.00 09/08/10 MRSA SURVEILLANCE CULTURE 47270290 1 37 01 09/08/10 VRE STOOL SURVEILLANCE CULTURE 47270320 1 . 37.01 LABORATORY/BACT-MICRO SUB.-TOTAL 2 74.02 09/08/10 CHEST AP 44810300 1 109 65 09/08/10 CHEST AP PORTABLE 44810310 1 . 109.65 RADIOLOGY DX CHEST SUB-TOTAL 2 219.30 09/08/10 SDS-Moderate 1-4hr RR 41429130 1 1545 00 09/08/10 WILMER O R PRICE PER MINUTE 42400020 305 . 5425.95 OR SERVICES SUB-TOTAL 306 6970.95 09/08/10 ANESTHESIA MINUTES OF CARE.. 332p,0020 305 1436.55 ANESTHESIOLOGY GENERAL SUB-TOTAL 305 1436.55 208021022 09/14/10 Patient Financial Services The Johns Hopkins Hospital Johns Hopkins Bayview Medical Center Howard County General Hospital Johns Hopkins~Keswick 3910 Keswick Road, Suite 5-5100 Baltimore. Maryland 21211 09/14/10 JOHNS HOPKINS M E D I C I N E JOHNS HOPKINS HEA LTN SYSTEM MYERS, PEGGY 208021022 F '056 10/19/53 09/08/10 09/09/10 001 FINAL ESTATE OF PEGGY MYERS AETNA MEDICARE HMO MEBFFTPN 1100 GRANDON WAY APT 426 MECHANICSBURG, PA 17050 09/08/10 Mech. Vent Initial <12 hours 45811500 1 340 79 09/08/10 Bi-Phasic/Non. Inv. Ventilatio 45811100 1 . 267 76 09/08/10 ETC02 Monitor (Initial day) 45815900 1 . 116.84 RESPIRATORY SERVICES SUB-TOTAL 3 725.39 09/08/10 ADULT MEDICAL SCREENING EXAM - 41491000 1 76.86 EMTALA SCREENING SUB-TOTAL 1 76.86 09/08/10 *Adult ER LVL IV - ADMITTED 41495090 1 845.49 ER BEYOND EMTALA SCREENSUB-TOTAL 1 845.49 09/08/10 ELECTROCARDIAGRAM (EKG) 45199120 1 69.68 EKG/ECG SUB-TOTAL 1 69.68 09/23/10 AETNA PMT I/P L095 -15172 87 CK/EFT # 160920100001443,. . 09/23/10 HMO ALLOWANCE(NO JHHP I1? W161 - -968 47 10/12/11 AETNA PMT I/P L095 . 0 00 CK/EFT # 161006110001522 . 10/12/11 AETNA PMT I/P L095 15172 87 CK/EFT # 161006110001522 . 10/12/11 HMO ALLOWANCE (NO JHHP IP W161 968 47 10/12/11 NOT A COVERED SERVICE Y307 . 0.00 208021022 09/14/10 Patient Financial Services Tfie Johns Hopkins Hospital Johns Hopkins Bayview Medical Center Howard County General Hospital Johns Hopkins~IGeswick 3910 Keswick Road, Suite 5-5100 Baltimore, Maryland 21211 09/14j10 JOHNS HOPKINS M E D I C I N E JOHNS HOPKINS HEALTH SYSTEM MYERS, PEGGY 208021022 F 056 10/19/53 09/08/10 09/09/10 001 FINAL ESTATE OF PEGGY MYER5 ETNA-MEDICARE HMO MEBFFTPN 1100 GRANDON WAY APT 426 MECHANICSBURG, PA 17050 PAYMENTS & ADJUSTMENTS SUB-TOTAL 0.00 208021022 09/14J10 Patient Financial Services The Johns Hopkins Hospital Johns Hopkins Bayview Medical Center Howard County General Hospital Johns Hopkins~Keswick 3910 Keswick Road, Suite 5-5100 Baltimore, Maryland 21211 JOHNS HOPKINS M E D I C I N E JOHNS HOPKINS HEALTH SYSTEM 09/14/10 MYERS, PEGGY 208021.022 F 056 10/,i9/53.A9/08/10 09/09/10 001 FINAL ESTATE OF PEGGY MYERS AETNA MEDICARE HMO MEBFFTPN 1100 GRANDON WAY APT 426 MECHANICSBURG, PA 17050 BILLING SUMMARY 221 ADM CHG 1 390.57 250 PHARMACY 188 372.64 258 PHARMACY-IV SOLUTIONS 3 2.56 270 MEDICAL-SURGICAL SUPPLIES 15 351.19 272 STERILE SUPPLY 10 175.00 300 LABORATORY 5 77.70 301 LABORATORY/CHEMISTRY 10 266.44 305 LABORATORY/HEMATOLOGY 6 74.00 306 LABORATORY/BACT-MICRO 2 74.02 324 RADIOLOGY DX CHEST 2 219.30 360 OR SERVICES 306 6970.95 370 ANESTHESIOLOGY GENERAL 305 1436.55 410 RESPIRATORY SERVICES. 3 725.39 451 EMTALA SCREENING '~'~' '' =' 1 76.86 452 ER BEYOND EMTALA SCREENING 1 845.49 730 EKG/ECG 1 69.68 ICU SURG 1DAYS @4013.00 4013.00 TOTAL CHARGES 860 16141.34 TOTAL PAYMENTS & ADJUSTMENT 0.00 CURRENT BALANCE 16141.34 208021022 09/14/10 16141.34