HomeMy WebLinkAbout08-13-12NOTICE OF CLAIM
(Filed Pursuant to 20 Pa.C.S. § 3532)
COURT OF COMMON PLEAS OF
C.- u ,~,~-j..~? ~' ~ ~ ~u `7 COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
~ ~ ,~{
ESTATE OF ~ ~ ~ ~ O U l `, ~ ~~
DECEASED
To the Clerk of the Orphans' Court Division: S ~ (~ ~.~ ~ { ~ r'c:c.
~- 1~~: /
~~' -b E. l1 ~ ~~ Co +r.
Enter the claim of ~ l1 ~'`~~-° ~-' ~ ~`~ ~~~ ~f~~~e.ci~rnC-'1~' ~-~-' w~pv ~~"-~ '°'~' in the
(Claimant)
amount of $ ~~ ~ ~ ~ ~ ,against the above entitled Estate.
The Decedent who resided at ~ ~ ~ Leh u S ~~ ~ ~ '~' s _ ~ `~ ' ~~"~~ ~ f -'v'LC .S ~c.
' ) (Street Address)
died on t ~ S/ ~ ~ .Written notice of
(Date of Deathj
said claim was given to ~~'~' « ~"~ ~ ~~~~~"
(Persona-~presentntive or his/her counsel)
at ~ ~ ~ • ~h v ,~z.% ~ ~ ~u ,~- ! ~ ~ t ~ - (''JCS., 1-7 4 1
(Address)
on "/ r~ t ~
(Date) (~
(Claiman -7 }~ C
(Street Address)
(City, State, Zip)
(Claimant's Counsel) (Supreme Court 1. D. No.)
(Address)
(Telephaze)
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Form OC-07 rev. 10.13.06
3a PAT. 476 0013381-01
'SSH CAMP HILL 2SSH CAMP HILL GNTL~
111
R ~ ° 5047
5 0 3 NORTH 21ST STREET PO BOX 6 4 2 3 6 9 6 STATEMENT GONERS PERIQD 7
CAMP HILL PA 17 0112 2 8 PITTSBURGH PA 152 6 5 FED TAX N° FROM THROUGH
251885943 122011 010912
717-972-1100
8 PATIENT NAME x 2 0 4 2 6 8 4 0 7A 9 PATIENT A°DRESS x 2 2 6 7 RITNER HIGHWAY
b BOUDER GAIL L b CARLISLE PA d 17015 e
CONDITION CODES 29 ACDT 30
ADMISSION
10 BIRTHDATE 11 SEX 16 DHR 17 STAT 18 19 20 21 22 23 24 25 26 27 2S STATE
12 DATE 13 HR 14 TYPE 15 SRG
17 03
10151932 F
31 OCCURRENCE • 122__01 1 8 3 4
33 OCCURRENCE
• _
~•
35 OCCURRENCE SPAN
CODE FROM THROUGH
36 OCCURRENCE SPAN
CODE FROM THROUGH
37
CODE DATE •~ ~' CODE DATE •~ a
'
~ •. 41 VA n
LUE CODES
3 39
CODE VALUE CODES
AMOUNT •~ • CODE AMOUNT
~ OUDE R GAIL L 37
5 10 39 00
2267 RITNER HIGHWAY a O1 0
128
CARLISLE PA 17015 b 80 200
PHONE (717) 243-4634 G
d
1-1 tiCPCS RATE - HIPPS CODE 45 SERV. DATE :6 SERV. UNITS ~7 TOTAL CHARGES ~}8 NON-COVERED CHARGE'S d9
42 REV. CD. 43 DESCRIPTION
00
1166
12
1399200
'
' 0120 ROOM & BOARD . g 1028000 2
2 0120 ROOM & BOARD 1285.00
586
344400
3
3 0250 PHARMACY GENERAL 570 1687975
0258 PHARMACY IV SOLUTIONS 117 712125 5
5 0270 MED/SUR SUPPLIES GENERA 105 1177967 6
6 0300 LABORATORY GENERAL 2 96996 '
0320 RADIOLOGY DIAGNOSTIC GE E 1 54216 e
e 0381 BLOOD PACKED RED CELLS I 1 102414 9
9 0386 BLOOD-OTHER COMPONENTS 586 1066130 I '°
'° 0410 RESPIRATORY SERVICES GE E 5 44980 "
" 0420 PHYSICAL THERAPY 5 43560 12
12 0430 OCCUPATIONAL THERAPY GE E 5 79900 t3
" 0440 SPEECH PATHLOGOY GENERA 1 106949 '°
" 0480 CARDIOLOGY GENERAL 21 481800 75
15 0 7 31 HOLTER MONITOR g 18'710 16
16 0942
,7
18
19
20
21 EDUCATION/TRAINING/DIET R
I ~ ,~
,e
19
20
21
22
22
29 0 0 01 PAGE _1 OF __l, CREATI ON DAT
F
G E
011912 • ~ 8 4
AMOUNT DUE 4 5
56 NPI 3 2 2 23
13 4 6 2 4 8 3 3 3
50 PAYER NAME 51 HEALTH PLAN ID s"vc~~ eErv 54 PRIOR PAYMENTS 55 EST. 57 251885943 A
A ENCOMPASS 251885943 Y Y
OTHER B
16 5 7
a HIGHMARK FREEDOM BLUE HMO Y Y PRV ID 3 92 03 9
MCR SHADOW HM 392039
' Y Y
61 GROUP
NAME
62 INSU
RANCE GROUP NO.
58 INSURED'S NAME S UNIQUE ID
59 P.REL 60 INSURED
a
A BOUDER GAIL L 18 20193037 a
1998215
B BOUDER GAIL L 18 FER104842777001
BOUDER GAIL L 18 204268407A
65 EMPLOYER NAME
64 DOCUMENT CONTROL NUMBER
a
63 TREATMENT AUTHORIZATION CODES
p e
a 6008107
3 276.0 V54.19 428.0 496 585.9 298.9 443.9 ,8
16 276
coX V54
.
.
715.8 9 71 PPS %~ 73 5 6 0
69 ADMIT 70 PATIENT CODE 5 6 0 ECI
DX V54.16 REASON DX 136640716 UAL 1 C33423
OTHER PROCEDURE 75 76 ATTENDING NPI
"• . b
.
7q PRINCIPAL PROCEDURE •
CODE DATE • ~ ^ • CODE DATE
LAST CUNNINGS FIRST III
9 9. 0 4 010 712 - -. .- 77 OPERATING NPI 13 6 6 4 0 716 UAL 1 C 3 3 4 2 3
OTHER PROCEDURE
..
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•
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•~ .. CODE DATE •~
LAST CUNNINGS FIRST III
80 REMARI(S MCR SHADOW HM 81CC
a B 2 8 2 E 0 0 0 0 0 780THER NPI QUAL
FIRST
b LAST
PO BOX 8 9 012 2
c 79 OTHER NPI QUAL
('~Z~Mp T~TT ~T ~ t'1-i 1 7 0 8 J - 0 12
d LAST FIRST
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS B~ AN8/~F~h~FT-/~6~T H~EOF
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