HomeMy WebLinkAbout04-5238
TAB AS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER
I.D.I/60267
22nd Fl.,1845 Walnut Street
Phi1a., PA 19103
(215) 569.,.5050'
Plain/iff(s)
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. Box 853
Hershey, PA 17033
ATTORNEY FOR Plaintiff
vs
D~rendants(s)
GERNEY I. HESS
200 A Marion Avenue
Carlisle, PA 17013
COURT OF COMMON PLEAS
DIVISION
CUMBERLAND COUNTY
TERM.
>
No. 04 - .r~l>
CL~LL/~
NOTICE
COMPLAINT - CIVIL ACTION
AVISO
You have been sued in court. If you wish to
defend against the claims set forth in the following
pages, you must take action within twenty (20) days
after this complaint and notice are served, by
entering a written appearance personally or by
attorney and fi ling in wr;ting with the court your
defenses or objections to the claims set forth
against you. You are warned that if you fail to do
so the case may proceed without you and a judgment
may be entered against you by the court without
further notice for any money claimed in the complaint
or for any other claim or rel ief requested by the
plaintiff. You may lose money or property or other
rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT
ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR
TELEPHONE THE OFFICE SET FORTH BELOII. THIS OFFICE
CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A
LAWYER.
I F YOU CANNOT AFFORD TO HIRE A LAWYER, THIS
OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION
ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO
ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
Le han demandado a usted en La corte. 5i
usted qui ere defenderse de estas demandas expuestas
en las paginas siguientes, usted tiene veinte (20)
dias de plaza aL partir de La fecha de la demandanda
y la notlficacion. Hace faLta asentar una
comparencia escrita 0 en persona 0 con un abogado y
entregar a la corte en for escrita sus defensas 0 sus
objeciones alas demandas en contra de su persona.
Sea avisado que si usted no se defiende, la corte
tamara medidas y puede continuar la demandanda en
contra suva sin previa aviso 0 notificacion. Ademas,
la corte puede decidir a favor del demandante y
requiere que usted cumpLa con todas las provisiones
de esta demanda. Usted puede perder dinero 0 sus
propiedades u otros derechos importantes para usted.
LLEVE EST A DEMANDA A UN ABOGADO
INMEDIATAMENTE. SI USTED NO T1ENE ABOGADO, VAYA
PERSONALMENTE 0 LLAME POR TELEFONO A LA OFICINA
MENCIONADA A CONTI NUACION. ESTA OFICINA LE PUEDE
PROVEER LA INFORMACION NECESARIA PARA CONTRATAR A UN
ABOGADO.
SI USTED CARECE DE LOS MEDIOS NECESARIOS PARA
CONTRATAR A UN ABOGAOO, DICHA OFICINA LE PUEDE
SUMINISTRAR LA INFORMACION NECESARIA ACERCA DE
AQUELLAS AGENCIAS QUE OFRECEN SERVICIOS LEGALES A LAS
PERSONAS QUE T1ENEN DERECHO A RECIBIR TAL AYUDA
GRATIS 0 A UNA CUOTA REDUCIDA.
CUMBERLAND COUNTY BAR ASSOCIATION
2 LIBERTY AVENUE
CARLISLE, PA 17013
(717)249-3166 (800)990-9108
.
COMPLAINT - CIVIL ACTION
THE MILTON S. HERSHEY MEDICAL CENTER
VS. GERNEY I. HESS
1. Plaintiff is a non-profit corporation located at the
address indicated in the caption hereof.
2. Defendant is an individual who resides at the address
indicated in the caption hereof.
3. As the result of a certain medical condition, defendant
was treated by the plaintiff on Nov. 30, 2003 thru Jan. 14, 2004.
4. The amounts, quantities and nature of said medical care,
the dates on which said medical care was rendered, and the
charges therefore are set forth in Exhibit "A" which is incor-
porated herein as if set forth at length.
5. Said medical care was commensurate with the condition of
defendant and was necessary for the health and welfare of
defendant.
6. At or about the time of defendant's treatment by plain-
tiff, implied, constructive and oral contracts arose
between defendant and plaintiff by the terms of which defendant
became obligated to pay plaintiff the charges for the medical
care rendered by plaintiff to defendant.
7. Defendant refuses to pay the balance due although
plaintiff has made demand that defendant do so.
THIS DOCUMENT IS BEING USED IN CONNECTION WITH THE COLLECTION OF
A DEBT; ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
8. As a result of the foregoing, there is due and owing
from defendant to plaintiff the sum indicated in Exhibit "A".
WHEREFORE, plaintiff demands judgment against defendant for
the sum of $155,080.97 plus six percent (6%) interest per annum
from the date of discharge to the date of judgment, record costs
and non-record costs.
TABAS & ROSEN, p.e.
LE~~FER' E~E
Attorney for Plaintiff
THIS DOCUMENT IS BEING USED IN CONNECTION WITH THE COLLECTION OF
A DEBT; ANY INFORMATION OBTAINED MAY BE USED FOR THAT PURPOSE.
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
11/30/03
11/30/03
11/30/03
11/30/03
11/30/03
11/30/03
11/30/03
11/30/03
11/30/03
11/30/03
11/30/03
U/30/03
11/30/03
U/30/03
U/30/03
U/30/03
11/30/03
U/30/03
U/30/03
U/30/03
U/30/03
U/30/03
11/30/03
U/30/03
11/30/03
U/30/03
11/30/03
U/30/03
U/30/03
11/30/03
U/30/03
U/30/03
U/30/03
11/30/03
11/30/03
11/30/03
11/30/03
'11/30/03
11/30/03
11/30/03
11/30/03
U/30/03
I Sve Code I
10144
101003
101004
101005
102019
102100
102214
104005
104040
104049
104068
104102
104106
104129
104131
104158
104433
104544
104546
105052
105059
105065
105657
106011
1111J01
246465
246703
246B31
249~;17
251846
272979
310,;01
347001
347192
347195
521211
621043
621044
621054
622014
661432
667765
Description
I CRITICAL CARE UNIT
ABO BLOOD GROUP
ANTIBODY SCREEN
RH TYPE
GRAM STAIN
CULTURE, BACTERIAL
CULTURE, URINE QUANT
HOMOCYSTEINE
CPK
TROPONIN
GLYCOHEMOGLOBIN
LIPID PROFILE
MAGNESIUM
PHOSPHORUS, BLOOD
POTASSIUM (K), BLOOD
TRANSFERRIN
BASIC METABOLIC PANEL
VITAMIN B-12
IRON (FE), BLOOD
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
RETICULOCYTE COUNT, A
CBC W/PLT/DIFF AUTO
URINALYSIS-BASIC & MI
GLUCOSE BEDSIDE MONIT
ASPIRIN 300 MG
LORAZEPAM 2 MG
FENTANYL CITRATE 20 M
FAMOTIDINE 40MG/5M/
VERSED 5MG/5ML
FAMOTIDINE 2IJMG PRE-M
CT HEAD UNENHANCED
MRI BRAIN UNENHANCED
MRA HEAD UNENHANCED
MRA NECK UNENHANCED
12 LEAD ELECTROCARDIO
I V SODIUM CHLORIDE 0
I V SODIUM CHLORIDE 0
I V LACTATED RINGERS
IRRIGATION WATER 1000
RAG URINE DRAINAGE
SCD SLEEVES, KNEE LEN
- Continue -
A ~I
PAGE:
1
Patient: HESS GERNEY I
Visit #: 3971157
I Units I
1
1
1
1
1
1
2
1
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
2
3
1
3
20
3
1
2
1
1
1
1
1
2
3
1
1
1
1
Debits
2535.00
18.00
32.00
17.00
23.00
57.00
6B.00
27.00
39.01J
153.00
53.00
55.00
42.00
U.OO
11.00
58.00
36.00
78.00
22.00
32.00
20.00
20.00
32.00
3B.00
75.00
2.10
26.10
B.60
38.85
4.25
8.50
649.00
1409.00
953.00
953.00
101.00
12.00
18.00
6.00
6.00
13.00
75.00
Credits
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
11/30/03
11/30/03
11/30/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/01/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
I Svc Code I
670330
670334
67C520
308
502
601
10144
102105
102215
104049
104106
104438
105017
105656
111001
245985
246176
246465
247842
249517
272979
273298
274061
621044
621054
626081
6271169
670330
~)l 0
674
680
10144
102002
102019
102100
102105
104106
104110
104129
104131
104433
106011
Description
IV INFUSION SET, UNIV
IV INFUSION SET, UNIV
TRACH CARE SYSTEM 14
INITIAL EVALUATION-OT
SPEECH/HEARING EVAL-S
INITIAL EVALUATION-PT
I CRITICAL CARE UNIT
CULTURE, BLOOD
CULTURE TYPE IMM/ANTI
TROPONIN
MAGNESIUM
RENAL FUNCTION PANEL
PERIPHERAL SMEAR
CBC W/PLT AUTO
GLUCOSE BEDSIDE MONIT
ACETAMINOPHEN 600 MG
FUROSEMIDE 10 MG/ML
ASPIRIN 300 MG
CAL GLUCONATE 10ML
FAMOTIDINE 40MG/5M/
FAMOTIDINE 20MG PRE-M
COMBIVENT INHALER 14.
MAGNESIUM SULFATE IGM
I V SODIUM CHLORIDE 0
I V LACTATED RINGERS
IV DILUENT NML SALINE
ST EXT MICRO 60" IML
IV INFUSION SET, UNIV
ORAL/PHARYNG SWALLOW
THER EXERCISE 15 MIN
THERAPEUTIC EXERCISE
I CRITICAL CARE UNIT
SENSI, AGAR DIFF/ANTI
GRAM STAIN
CULTURE, BACTERIAL
CULTURE, BLOOD
MAGNESIUM
BLOOD GAS PANEL
PHOS PHORUS, BLOOD
POTASSIUM (K), BLOOD
BASIC METABOLIC PANEL
URINALYSIS-BASIC & MI
- Continue -
ft-~
PAGE:
2
Patient: HESS GERNEY I
Visit #: 3971157
I Units I
4
1
1
1
1
1
1
2
1
2
1
1
1
1
3
1
10
1
1
2
2
1
4
3
1
1
1
1
1
1
1
1
2
1
1
2
2
1
1
1
1
1
Debits
Credits
64.00
8.00
20.00
137.00
268.00
137.00
2535.00
150.00
24.00
102.00
42.00
38.00
10.00
27.00
75.00
2.10
0.50
2.10
2.10
25.90
8.50
146.10
6.40
18.00
6.00
8.00
7.00
16.00
315.00
46.00
46.00
2535.00
56.00
23.00
57.00
150.00
84.00
110.00
11.00
11.00
36.00
19.00
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12/02/03
12 / 02 /03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/03/03
12/04/03
12/04/03
12/04/03
12/04/03
12/04/03
I Sve Code I
111001
24':,524
245985
246176
246465
249517
250620
251130
272205
272979
273498
274061
274138
307101
621044
674
680
10145
104042
104065
104398
105052
105656
111001
246465
249';17
250620
272205
272911
272979
274138
307331
621044
637032
670330
670722
703322
10145
102214
104110
104398
105029
Description
GLUCOSE BEDSIDE MONIT
FUROSEMIDE 10 MG/ML
ACETAMINOPHEN 600 MG
FUROSEMIDE 10 MG/ML
ASPIRIN 300 MG
FAMOTIDINE 40MG/5M/
FLUCONAZOLE 200MG
POTASSIUM CHLORIDE 50
CLINDAMYCIN 600MG IV
FAMOTIDINE 20MG PRE-M
FLUCONAZOLE 200MG BAG
MAGNESIUM SULFATE 1GM
MOXIFLOXACIN 400MG IV
CHEST 1 VIEW
I V SODIUM CHLORIDE 0
THER EXERCISE 15 MIN
THERAPEUTIC EXERCISE
T INTERMEDIATE CARE U
CREATININE, BLOOD
UREA NITROGEN (BUN),
ELECTROLYTES
PARTIAL THROMBOPLAS T
CBC W/PLT AUTO
GLUCOSE BEDSIDE MONIT
ASPIRIN 300 MG
FAMOTIDINE 40MG/5M/
FLUCONAZOLE 200MG
CLINDAMYCIN 600MG IV
HEPARIN 25,000U/250ML
FAMOTIDINE 20MG PRE-M
MOXIFLOXACIN 400MG IV
ABDOMEN 1 VIEW AP
I V SODIUM CHLORIDE 0
TUBE FEEDING W/GUIDE
IV INFUSION SET, UNIV
FEEDING BG ENTERAL 10
IP NUTR,15 MIN,ORL/TB
T INTERMEDIATE CARE U
CULTURE, URINE QUANT
BLOOD GAS PANEL
ELECTROLYTES
FIBRINOGEN
- Continue -
A3
PAGE:
3
Patient: HESS GERNEY I
Visit #: 3971157
I Units I
4
1
1
10
1
2
1
10
4
2
1
4
1
1
2
1
1
1
1
1
1
1
1
4
1
2
1
6
1
2
1
1
2
1
1
1
1
1
1
1
1
1
Debits
Credits
100.00
2.50
2.10
0.50
2.10
25.90
241.10
5.90
52.52
8.50
269.05
6.40
44.05
104.00
12.00
46.00
46.00
1345.00
11.00
10.00
27.00
32.00
27.00
100.00
2.10
25.90
241.10
78.78
3.75
8.50
44.05
143.00
12.00
24.00
16.00
4.00
68.00
1345.00
34.00
110.00
27.00
29.00
MS HERSHEY MEDICAL CENTER
SOO UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
PAGE:
4
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Patient: HESS GERNEY I
Visit #: 39711S7
Date
I Svc Code I
Description
I Unitsl
Debits
Credits
12/04/03 10S0S2 PARTIAL THROMBOPLAS T 3 96.00
12/04/03 105054 PLATELET COUNT AUTO 1 14.00
12/04/03 10~)OS9 PROTHROMBIN TIME 1 20.00
12/04/03 105657 CBC W/PLT/DIFF AUTO 1 32.00
12/04/03 111001 GLUCOSE BEDSIDE MONIT 4 100.00
12/04/03 24S524 FUROSEMIDE 10 MG/ML 1 2.50
12/04/03 246437 POTASSIUM CHLORIDE 20 4 8.40
12/04/03 249517 FAMOTIDINE 40MG/5M/ 2 25.90
12/04/03 250620 FLUCONAZOLE 200MG 1 241.10
12/04/03 272205 CLINDAMYCIN 600MG IV 6 78.78
12/04/03 272911 HEPARIN 25,000U/250ML 1 3.75
12/04/03 272979 FAMOTIDINE 20MG PRE-M 2 8.50
12/04/03 274138 MOXIFLOXACIN 400MG IV 1 44.05
12/04/03 307101 CHEST 1 VIEW 1 104.00
12/04/03 310501 CT HEAD UNENHANCED 1 649.00
12/04/03 621044 I V SODIUM CHLORIDE 0 3 18.00
12/04/03 627069 ST EXT MICRO 60" IML 1 7.00
12/04/03 670330 IV INFUSION SET, UNIV 1 16.00
12/04/03 670334 IV INFUSION SET, UNIV 2 16.00
12/04/03 670722 FEEDING BG ENTERAL 10 1 4.00
12/05/03 674 THER EXERCISE IS MIN 1 46.00
12/05/03 1333 SWALLOWING ORAL FUNC 1 31S.00
12/05/03 10145 T INTERMEDIATE CARE U 1 134S.00
12/05/03 104042 CREATININE, BLOOD 1 11.00
12/05/03 104065 UREA NITROGEN (BUN) , 1 10.00
12/05/03 104398 ELECTROLYTES 1 27.00
12/05/03 1050S2 PARTIAL THROMBOPLAS T 5 160.00
12/05/03 105054 PLATELET COUNT AUTO 1 14.00
12/05/03 111001 GLUCOSE BEDSIDE MONIT 4 100.00
12/0S/03 249S17 FAMOTIDINE 40MG/5M/ 2 25.90
12/0S/03 2S0620 FLUCONAZOLE 200MG 1 241.10
12/0S/03 27220S CLINDAMYCIN 600MG IV 6 78.78
12/0S/03 272911 HEPARIN 2S,000U/2S0ML 2 7.S0
12/0S/03 272979 FAMOTIDINE 20MG PRE-M 1 4.2S
12/05/03 274138 MOXIFLOXACIN 400MG IV 1 44.0S
12/05/03 600S10 PULSE OXYMETER SENSOR 1 13 . 00
12/0S/03 600S17 SNSR FOR BIS SEDAT MO 1 3S.00
12/0S/03 600S20 SPIROMETER INCENT ADU 1 7.00
12/0S/03 621044 I V SODIUM CHLORIDE 0 2 12.00
12/0S/03 630829 TRAY FOLEY 18FR 1 34.00
12/0S/03 670722 FEEDING BG ENTERAL 10 1 4.00
12/06/03 1303 DYSPHAGIA TX 60 ST 1 172.00
Continue -
A.Lj
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
PAGE:
5
Guarantor: HESS GER~EY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Patient: HESS GERNEY I
Visit #: 3971157
Date
I Svc Code I
Description
I Units I
Debits
Credits
12/06/03 10145 T INTERMEDIATE CARE U 1 1345.00
12/06/03 105052 PARTIAL THROMBOPLAS T 3 96.00
12/06/03 105059 PROTHROMBIN TIME 2 40.00
12/06/03 111001 GLUCOSE BEDSIDE MONIT 5 125.00
12/06/03 246515 WARFARIN SODIUM 2 MG 1 2.10
12/06/03 246703 LORAZEPAM 2 MG 2 17.40
12/06/03 249517 FAMOTIDINE 40MG/5M/ 2 25.90
12/06/03 250620 FLUCONAZOLE 200MG 1 241.10
12/06/03 272205 CLINDAMYCIN 600MG IV 6 78.78
12/06/03 272911 HEPARIN 25,000U/250ML 1 3.75
12/06/03 272979 FAMOTIDINE 20MG PRE-M 1 4.25
12/06/03 274138 MOXIFLOXACIN 400MG IV 2 88.10
12/06/03 516201 STERILE WATER UP TO 5 1600 16.00
12/06/03 516202 VENTILATOR DAY INITIA 1 441.00
12/06/03 516304 AEROSOL TREATMENT SUB 41 1886.00
12/06/03 516314 MDI TREATMENT SUBSEQU 6 276.00
12/06/03 516325 THAlRAPY VEST SUBSEQU 7 273.00
12/06/03 516351 AEROSOL TREATMENT INI 6 360.00
12/06/03 516354 MDI TREATMENT INITIAL 2 120.00
12/06/03 516363 THAlRAPY VEST INITIAL 4 156.00
12/06/03 516703 ARTERIAL PUNCTURE 1 46.00
12/06/03 516803 VENTILATOR CIRCUIT 1 20.00
12/06/03 516807 MDI SYSTEM SPACER 1 21. 00
12/06/03 516956 NEBULIZER 1 2.00
12/06/03 516970 HME 1 4.00
12/06/03 621044 I V SODIUM CHLORIDE 0 1 6.00
12/06/03 630828 FOLEY CATH 16 FR W/ME 1 34.00
12/06/03 670722 FEEDING BG ENTERAL 10 2 8.00
12/07/03 10145 T INTERMEDIATE CARE U 1 1345.00
12/07/03 104433 BASIC METABOLIC PANEL 1 36.00
12/07/03 105052 PARTIAL THROMBOPLAS T 4 128.00
12/07/03 105059 PROTHROMBIN TIME 2 40.00
12/07/03 105656 CBC W/PLT AUTO 1 27.00
12/07/03 111001 GLUCOSE BEDSIDE MONIT 4 100.00
12/07/03 246176 FUROSEMIDE 10 MG/ML 10 2.10
12/07/03 246'315 WARFARIN SODIUM 2 MG 1 2.10
12/07/03 246849 FUROSEMIDE 10 MG/ML 1 2.10
12/07/03 249:517 FAMOTIDINE 40MG/5M/ 2 25.90
12/07/03 250620 FLUCONAZOLE 200MG 1 241.10
12/07/03 272205 CLINDAMYCIN 600MG IV 6 78.78
12/07/03 272911 HEPARIN 25,000U/250ML 2 7.50
12/07/03 272979 FAMOTIDINE 20MG PRE-M 2 8.50
- Continue -
~-j
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
12/07/03
12/07/03
12/07/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12(08(03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/08/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
112/09/03
12/09/03
I Svc Code I
307101
600510
670330
674
680
10145
104433
105052
105059
105657
111001
246189
246515
246703
246849
249517
250620
272205
272911
272979
274138
621042
626078
670330
670722
703322
680
10255
102003
102105
102184
102214
102215
104048
104049
104111
105031
105037
105052
105059
105657
111001
Description
CHEST 1 VIEW
PULSE OXYMETER SENSOR
IV INFUSION SET, UNIV
THER EXERCISE 15 MIN
THERAPEUTIC EXERCISE
T INTERMEDIATE CARE U
BASIC METABOLIC PANEL
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
CBC W/PLT/DIPF AUTO
GLUCOSE BEDSIDE MONIT
HALOPERIDOL 0.5 MG
WARFARIN SODIUM 2 MG
LORAZEPAM 2 MG
FUROSEMIDE 10 MG/ML
FAMOTIDINE 40MG/5M/
FLUCONAZOLE 200MG
CLINDAMYCIN 600MG IV
HEPARIN 25,OOOU/250ML
FAMOTIDINE 20MG PRE-M
MOXIFLOXACIN 400MG IV
I V SODIUM CHLORIDE 0
I V DILUENT DEX 5% 50
IV INFUSION SET, UNIV
FEEDING BG ENTERAL 10
IP NUTR, 15 MIN,ORL/TB
THERAPEUTIC EXERCISE
T INTERMEDIATE CARE U
SENSI, DISK METHOD/PL
CULTURE, BLOOD
CULTURE, URINE PRESUM
CULTURE, URINE QUANT
CULTURE TYPE IMM/ANTI
MYOGLOBIN
TROPONIN
BLOOD GAS PANEL W/02
D-DIMER ULTRASENSITIV
HEMOGLOBIN
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
CBC W/PLT/DIFF AUTO
GLUCOSE BEDSIDE MONIT
- Continue -
ft.fo
PAGE:
6
Patient: HESS CERNEY I
Visit #: 3971157
I Units I
1
1
1
1
1
1
1
1
1
1
3
4
1
4
1
2
1
8
2
2
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
2
1
2
1
1
1
5
Debits
Credits
104.00
13.00
16.00
46.00
46.00
1345.00
36.00
32.00
20.00
32.00
75.00
8.40
2.10
34.80
2.10
25.90
241.10
105.04
7.50
8.50
44.05
6.00
8.00
16.00
8.00
68.00
46.00
1345.00
35.00
75.00
25.00
34.00
24.00
70.00
51.00
262.00
50.00
30.00
32.00
20.00
32.00
125.00
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19(04 at 08:17 AM
Guarantor: HESS CERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09(03
12(09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09/03
12/09(03
12/09/03
12/09/03
12/09(03
12/09/03
12/09/03
12/10(03
12/10/03
12/10/03
12/10(03
12/10/03
12/10/03
12/10(03
12/10/03
,12/10(03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
I Svc Code I
245985
246189
246465
246518
246703
246706
246849
249517
250620
272205
272911
272979
273399
273600
274138
274274
307101
516304
516351
516703
521211
621042
670722
428
1303
10255
100025
102105
102214
104042
104049
104065
104111
104398
104591
105037
105052
105059
105656
106011
111001
245481
Description
ACETAMINOPHEN 600 MG
HALOPERIDOL 0.5 MG
ASPIRIN 300 MG
WARFARIN SODIUM 7.5 M
LORAZEPAM 2 MG
MORPHINE SULFATE 2 MG
FUROSEMIDE 10 MG/ML
FAMOTIDINE 40MG/5M/
FLUCONAZOLE 200MG
CLINDAMYCIN 600MG IV
HEPARIN 25,000U/250ML
FAMOTIDINE 20MG PRE-M
ISOSOURCE 250ML CAN
RISPERIDOL .5MG TAB
MOXIFLOXACIN 400MG IV
VANCOMYCIN HCL INJ
CHEST 1 VIEW
AEROSOL TREATMENT SUB
AEROSOL TREATMENT INI
ARTERIAL PUNCTURE
12 LEAD ELECTROCARDIO
I V SODIUM CHLORIDE 0
FEEDING BG ENTERAL 10
THER EXERCISES 15 MIN
DYSPHAGIA TX 60 ST
T INTERMEDIATE CARE U
CLOSTRIDIUM DIFFICILE
CULTURE, BLOOD
CULTURE, URINE QUANT
CREATININE, BLOOD
TROPONIN
UREA NITROGEN (BUN),
BLOOD GAS PANEL W/02
ELECTROLYTES
VANCOMYCIN LEVEL
HEMOGLOBIN
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
CBC W/PLT AUTO
URINALYSIS-BASIC & MI
GLUCOSE BEDSIDE MONIT
DEXTROSE 5% IN WATER
- Continue -
A7
PAGE:
7
Patient: HESS GERNEY I
Visit #: 3971157
I Units I
1
1
2
1
1
1
1
2
-1
6
1
2
-6
1
1
1
1
15
:3
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
4
2
Debits
Credits
2.10
2.10
4.20
2.10
8.70
2.30
2.10
25.90
241.10-
78.66
3.75
8.50
25.20-
8.30
44.05
22.50
104.00
690.00
180.00
46.00
101.00
6.00
4.00
46.00
172 . 00
1345.00
76.00
150.00
34.00
11.00
51.00
10.00
131.00
27.00
76.00
15.00
32.00
20.00
27.00
19.00
100.00
31.50
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12(10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12(10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/10/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
I Svc Code I
245483
245504
245706
245985
246465
246517
246849
249517
272205
272911
272979
273132
273401
273600
274138
274274
521211
621042
630928
670.330
670334
670'722
680
10255
102019
102100
102118
102303
104111
104433
104586
104591
105037
105052
105059
105656
111001
245481
245483
245504
246517
249517
Description
DEXTROSE 5% 50ML
TOBRAMYCIN 1200 MG/30
ASPIRIN 325 MG
ACETAMINOPHEN 600 MG
ASPIRIN 300 MG
WARFARIN SODIUM 5 MG
FUROSEMIDE 10 MG/ML
FAMOTIDINE 40MG/5M/
CLINDAMYCIN 600MG IV
HEPARIN 25,000U/250ML
FAMOTIDINE 20MG PRE-M
AZITHROMYCIN 500 MG V
ZOSYN 3.75GM BAG
RISPERIDOL .5MG TAB
MOXIFLOXACIN 400MG IV
VANCOMYCIN HCL INJ
12 LEAD ELECTROCARDIO
I V SODIUM CHLORIDE 0
FOLEY CATH 16 FR W/ME
IV INFUSION SET, UNIV
IV INFUSION SET, UNIV
FEEDING BG ENTERAL 10
THERAPEUTIC EXERCISE
T INTERMEDIATE CARE U
GRAM STAIN
CULTURE, BACTERIAL
SMEAR, FLUOR/ACID FAS
CULTURE, FUNGUS OTHER
BLOOD GAS PANEL W/02
BASIC METABOLIC PANEL
TOBRAMYCIN LEVEL
VANCOMYCIN LEVEL
HEMOGLOBIN
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
CBC W/PLT AUTO
GLUCOSE BEDSIDE MONIT
DEXTROSE 5% IN WATER
DEXTROSE 5% 50ML
TOBRAMYCIN 1200 MG/30
. WARFARIN SODIUM 5 MG
FAMOTIDINE 40MG/5M/
- Continue -
A.6
PAGE:
Patient: HESS GERNEY I
visit #: 3971157
I Units I
3
3
1
1
-1
2
1
2
2
2
2
2
3
2
1
2
1
1
1
2
1
1
1
1
2
2
1
1
1
1
1
1
1
2
1
1
4
1
3
3
1
2
Debits
10.65
33.15
2.10
2.10
4.20
2.10
25.90
26.20
24.10
8.50
139.70
140.85
16.60
44.05
45.00
101.00
6.00
34.00
32.00
8.00
4.00
46.00
1345.00
46.00
114.00
30.00
34.00
131.00
36.00
85.00
76.00
15.00
64.00
20.00
27.00
100.00
15.75
10.65
33.15
2.10
25.90
8
Credi ts
2.10-
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02(19/04 at 08:17 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
12/11/03
12/11/03
12/11/03
12(11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/11/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12(12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
112/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
I Svc Code I
272911
272979
273132
273401
273600
274274
307101
307331
310516
637032
503
10255
100025
101003
101004
101005
101021
101213
102105
102214
104106
104110
104129
104319
104371
104383
104433
104:;86
104:,91
105059
105656
105657
106011
111001
245481
245504
245985
246465
246517
246703
2468.~9
247842
Description
HEPARIN 25,000U/250ML
FAMOTIDINE 20MG PRE-M
AZITHROMYCIN 500 MG V
ZOSYN 3.75GM BAG
RISPERIDOL .5MG TAB
VANCOMYCIN HCL INJ
CHEST 1 VIEW
ABDOMEN 1 VIEW AP
CT THORAX ENHANCED
TUBE FEEDING W/GUIDE
DYSPHAGIA THERAPY 30
T INTERMEDIATE CARE U
CLOSTRIDIUM DIFFICILE
ABO BLOOD GROUP
ANTIBODY SCREEN
RH TYPE
COMPAT, IMMED SPIN
RED BLD CELLS EA U
CULTURE, BLOOD
CULTURE, URINE QUANT
MAGNESIUM
BLOOD GAS PANEL
PHOSPHORUS, BLOOD
CHLORIDE, URINE
POTASSIUM, URINE
SODIUM, URINE
BASIC METABOLIC PANEL
TOBRAMYCIN LEVEL
VANCOMYCIN I,EVEI,
PROTHROMBIN TIME
CBC W/PLT AUTO
CBC W/PLT/DIFF AUTO
URINALYSIS-BASIC & MI
GLUCOSE BEDSIDE MONIT
DEXTROSE 5% IN WATER
TOBRAMYCIN 1200 MG/30
ACETAMINOPHEN 600 MG
ASPIRIN 300 MG
WARFARIN SODIUM 5 MG
LORAZEPAM 2 MG
FUROSEMIDE 10 MG/ML
CAL GLUCONATE 10ML
~ Continue -
AI
PAGE:
9
Patient: HESS GERNEY I
Visit #: 3971157
I Units I
1
2
1
4
2
1
1
1
1
1
1
1
1
1
2
1
1
1
2
1
1
1
1
1
1
1
2
2
1
1
1
1
1
5
1
o
1
1
1
1
1
1
Debits
Credits
12.05
8.50
69.85
187.80
16.60
22.50
104.00
143.00
1344.00
24.00
172.00
1345.00
76.00
18.00
64.00
17.00
61. 00
152.00
150.00
34.00
42.00
110.00
11.00
29.00
22.00
22.00
72.00
170.00
76.00
20.00
27.00
32.00
19.00
125.00
15.75
16.55
2.10
2.10
2.10
8.70
2.10
2.10
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
12/12/03
12/12/03
12(12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/12/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
, 12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/13/03
12/14/03
I Svc C::>de I
249517
272979
273132
273399
273.~01
273600
274274
307101
621042
621044
626081
670722
703:322
10;,55
100025
104433
105052
105059
105656
111001
245481
245985
246465
246:;17
246703
272979
273132
273401
273600
274274
307101
307331
310519
310567
310703
347001
621043
637032
670330
670335
670722
10255
Description
FAMOTIDINE 40MG/5M/
FAMOTIDINE 20MG PRE-M
AZITHROMYCIN 500 MG V
ISOSOURCE 250ML CAN
ZOSYN 3.75GM BAG
RISPERIDOL .5MG TAB
VANCOMYCIN HCL INJ
CHEST 1 VIEW
I V SODIUM CHLORIDE 0
I V SODIUM CHLORIDE 0
IV DILUENT NML SALINE
FEEDING BG ENTERAL 10
IP NUTR, 15 MIN,ORL/TB
T INTERMEDIATE CARE U
CLOSTRIDIUM DIFFICILE
BASIC METABOLIC PANEL
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
CBC W/PLT AUTO
GLUCOSE BEDSIDE MONIT
DEXTROSE 5% IN WATER
ACETAMINOPHEN 600 MG
ASPIRIN 300 MG
WARFARIN SODIUM 5 MG
LORAZEPAM 2 MG
FAMOTIDINE 20MG PRE-M
AZITHROMYCIN 500 MG V
ZOSYN 3.75GM BAG
RISPERIDOL .5MG TAB
VANCOMYCIN HCL INJ
CHEST 1 VIEW
ABDOMEN 1 VIEW AP
CT ABDOMEN ENHANCED
CT PELVIS ENHANCED
OMNIPAQUE 300MG/ML 10
MRI BRAIN UNENHANCED
I V SODIUM CHLORIDE 0
TUBE FEEDING W/GUIDE
IV INFUSION SET, UNIV
SET IN-LINE FILTER W/
FEEDING BG ENTERAL 10
T INTERMEDIATE CARE U
- Continue -.
A -10
PAGE: 10
Patient: HESS GERNEY I
Visit #: 3971157
I Units I
2
2
1
64
4
2
3
1
1
1
1
1
1
1
1
1
1
1
1
4
1
1
1
1
2
2
1
5
2
2
1
2
1
1
1
1
1
1
1
2
3
1
Debits
Credits
25.90
8.50
69.85
268.80
187.80
16.60
67.50
104.00
6.00
6.00
8.00
4.00
68.00
1345.00
76.00
36.00
32.00
20.00
27.00
100.00
15.75
2.10
2.10
2.10
11.95
8.50
69.85
234.75
16.60
45.00
104.00
286.00
929.00
1054.00
48.00
1409.00
6.00
24.00
16.00
34.00
12.00
1345.00
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
PAGE: 11
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Patient: HESS GERNEY I
Visit #: 3971157
Date
I Svc Code I
Description
I Unitsj
Debits
Credits
12/14/03 104106 MAGNESIUM 1 42.00
12/14/03 104129 PHOSPHORUS, BLOOD 1 11.00
12/14/03 104433 BASIC METABOLIC PANEL 1 36.00
12/14/03 10:;656 CBC W/PLT AUTO 1 27.00
12/14/03 111001 GLUCOSE BEDSIDE MONIT 4 100.00
12/14/03 245481 DEXTROSE 5% IN WATER 1 15.75
12/14/03 246465 ASPIRIN 300 MG 1 2.10
12/14/03 246517 WARFARIN SODIUM 5 MG 1 2.10
12/14/03 247842 CAL GLUCONATE 10ML 1 2.10
12/14/03 272979 FAMOTIDINE 20MG PRE-M 2 8.50
12/14/03 273132 AZITHROMYCIN 500 MG V 1 69.85
12/14/03 273401 ZOSYN 3.75GM BAG 4 187.80
12/14/03 273600 RISPERIDOL . 5MG TAB 2 16.60
12/14/03 274274 VANCOMYCIN HCL INJ 1 22.50
12/14/03 621044 I V SODIUM CHLORIDE 0 1 6.00
12/14/03 626081 IV DILUENT NML SALINE 1 8.00
12/14/03 669072 MATTRESS DECUBITUS LG 1 47.00
12/14/03 670330 IV INFUSION SET, UNIV 1 16.00
12/14/03 670334 IV INFUSION SET, UNIV 1 8.00
12/15/03 680 THERAPEUTIC EXERCISE 2 92.00
12/15/03 10255 T INTERMEDIATE CARE U 1 1345.00
12/15/03 101120 THAW FROZ PLASMA/U 2 36.00
12/15/03 101220 FFP SINGLE DONOR EA U 2 280.00
12/15/03 104049 TROPONIN 2 102.00
12/15/03 104106 MAGNESIUM 1 42.00
12/15/03 104110 BLOOD GAS PANEL 1 110.00
12/15/03 104129 PHOSPHORUS, BLOOD 1 11.00
12/15/03 104433 BASIC METABOLIC PANEL 1 36.00
12/15/03 105052 PARTIAL THROMBOPLAS T 2 64.00
12/15/03 105059 PROTHROMBIN TIME 2 40.00
12/15/03 105656 CBC W/PLT AUTO 1 27.00
12/15/03 111001 GLUCOSE BEDSIDE MONIT 4 100.00
12/15/03 245481 DEXTROSE 5% IN WATER 1 15.75
12/15/03 250369 HEPARIN 5000U/ML 1ML 1 2.10
12/15/03 272979 FAMOTIDINE 20MG PRE-M 2 8.50
12/15/03 273132 AZITHROMYCIN 500 MG V 1 69.85
12/15/03 273401 ZOSYN 3.75GM BAG 4 187.80
12/15/03 307101 CHEST 1 VIEW 1 104.00
12/15/03 307331 ABDOMEN 1 VIEW AP 1 143.00
12/15/03 511209 BILEVEL NIV DAY SUBSE 6 2646.00
12/15/03 511250 BILEVEL NIV VENT DAY 1 441.00
12/15/03 511304 AEROSOL TREATMENT SUB 34 1564.00
- Continue -
A.1f
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
12/15/03
12/15/03
12/15/03
12(15/03
12/15/03
12/15/03
12/15/03
12/15/03
12/15/03
12/15/03
12/15/03
12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
12(16(03
12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
12/16(03
12/16(03
12/16/03
12/16/03
12/16/03
'12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
12/16/03
I svc Code I
511305
511351
511703
511956
511963
511964
521211
625011
670330
670334
670722
1303
10255
102019
102100
102115
102118
102303
102312
104049
104158
104398
104546
104549
111001
192070
245207
246169
246;;:99
246=,17
246703
249517
250369
251846
272979
273401
307331
310519
310567
310703
559153
6210H
Description
CPT TREATMENT SUBSEQU
AEROSOL TREATMENT INI
ARTERIAL PUNCTURE
NEBULIZER
BIPAP MASK
BILEVEL CIRCUIT
12 LEAD ELECTROCARDIO
IV ADMIN SET BLOOD FI
IV INFUSION SET, UNIV
IV INFUSION SET, UNIV
FEEDING BG ENTERAL 10
DYSPHAGIA TX 60 ST
T INTERMEDIATE CARE U
GRAM STAIN
CULTURE, BACTERIAL
CULTURE, AFB
SMEAR, FLUOR/ACID FAS
CULTURE, FUNGUS OTHER
CONCENTRA POR INF AGE
TROPONIN
TRANSFERRIN
ELECTROLYTES
IRON (FE), BLOOD I
FERRITIN
GLUCOSE BEDSIDE MONIT
SMEARS,CONCENTR,INTER
LIDOCAINE 1 ML
FOLIC ACID 5 MG/ML
MEPERIDINE HCL 100 MG
WARFARIN SODIUM 5 MG
LORAZEPAM 2 MG
, FAMOTIDINE 40MG/5M/
HEPARIN 5000U/ML 1ML
VERSED 5MG/5ML
FAMOTIDINE 20MG PRE-M
ZOSYN 3.75GM BAG
ABDOMEN 1 VIEW AP
CT ABDOMEN ENHANCED
CT PELVIS ENHANCED
OMNIPAQUE 300MG/ML 10
BRONCHOSCOPY W/LAVAGE
I V SODIUM CHLORIDE 0
- Continue -
A-/L
PAGE: 12
Patient: HESS GERNEY I
Visit #: 3971157
I Units I
3
7
3
2
1
1
1
1
1
1
2
1
1
1
1
1
2
1
1
2
1
1
1
1
4
1
1
1
1
1
1
-27
3
1
2
4
1
1
1
1
1
1
Debits
117.00
420.00
138.00
4.00
52.00
14.00
101.00
23.00
16.00
8.00
8.00
172.00
1345.00
23.00
57.00
85.00
60.00
34.00
13.00
102.00
58.00
27.00
22.00
55.00
100.00
30.00
2.10
3.35
2.20
2.10
8.70
6.30
3.70
8.50
187.80
143.00
929.00
1054.00
48.00
528.00
6.00
Credits
349.65-
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02(19(04 at 08:17 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
12/16/03
12(16/03
12/16/03
12/16/03
12(17/03
12(17/03
12/17/03
12(17 (03
12/17/03
12/17/03
12/17/03
12/17/03
12/17/03
12/17/03
12/17/03
12/17/03
12/17/03
12/17/03
12(17/03
12/17/03
12/17/03
12/17/03
12(17/03
12/17/03
12(17/03
12/17/03
12/17/03
12/17/03
12/17/03
12/17/03
12/17/03
12/17/03
12/17/03
12/17/03
12/18/03
,12/18/03
12/18/03
12/18/03
12/18/03
12/1.8/03
12/18/03
12/18/03
I Svc Code I
626080
682102
682103
703322
674
1303
10255
101003
101004
101C105
101C121
101213
102214
104111
105037
1C15C152
105059
1C15065
105656
1C16011
111001
245985
246127
246170
246465
246516
249441
250369
272979
273401
621042
625011
670335
670722
428
434
674
675
6EW
1303
102';5
104042
Description
I-V DILUENT NML SALIN
SEDATION IV/IM/INHALA
RECOVERY ROOM PER 15M
IP NUTR, 15 MIN,ORL/TB
THER EXERCISE 15 MIN
DYSPHAGIA TX 60 ST
T INTERMEDIATE CARE U
ABO BLOOD GROUP
ANTIBODY SCREEN
RH TYPE
COMPAT, IMMED SPIN
RED BLD CELLS EA U
CULTURE, URINE QUANT
BLOOD GAS PANEL W/02
HEMOGLOBIN
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
RETICULOCYTE COUNT, A
CBC W/PLT AUTO
URINALYSIS-BASIC & MI
GLUCOSE BEDSIDE MONIT
ACETAMINOPHEN 600 MG
DIPHENHYDRAMINE 25 MG
FOLIC ACID 1 MG
. ASPIRIN 300 MG
WARFARIN SODIUM 2.5 M
FAMOTIDINE 20MG UD
HEPARIN 5000U/ML 1ML
FAMOTIDINE 20MG PRE-M
ZOSYN 3.75GM BAG
I V SODIUM CHLORIDE 0
IV ADMIN SET BLOOD FI
SET IN-LINE FILTER W/
FEEDING BG ENTERAL 10
THER EXERCISES 15 MIN
THERAPEUT ACTIVITIES
THER EXERCISE 15 MIN
NEUROMUSCULAR RE ED 1
THERAPEUTIC EXERCISE
DYSPHAGIA TX 60 ST
T INTERMEDIATE CARE U
CREATININE, BLOOD
- Continue -
ft- 13
PAGE: 13
Patient: HESS GERNEY I
Visit #: 3971157
I Units I
1
1
1
1
2
1
1
1
2
1
1
1
1
2
2
1
1
1
1
1
4
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Debits
Credits
8.00
348.00
30.00
68.00
92.00
172.00
1345.00
18.00
64.00
17.00
61.00
152.00
34.00
262.00
30.00
32.00
20.00
20.00
27.00
19.00
1C10.00
2.10
2.10
2.10
2.10
2.10
2.10
4.20
4.25
46.95
6.00
23.00
17.ClO
4.00
46.00
46.00
46.00
46.00
46.00
172.0Cl
1345.00
11.00
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
12/18/03
12/18/03
12/18/03
12/18/03
12/18/03
12/18/03
12/18/03
12/18/03
12/18/03
12/18/03
12/18/03
12(18/03
12/18/03
12/18/03
12/18/03
12/18/03
12/19/03
12/19/03
12/19/03
12/19/03
12/19/03
12/19/03
12/19/03
12/19/03
12/19/03
12/19/03
12/19/03
12/19/03
12/19/03
12/19(03
12/19/03
12/19/03
12/19(03
12/19/03
12/19/03
12/19/03
12/19/03
12/20/03
12/20/03
12/20/03
12/20/03
12(20/03
I Svc CQde I
104065
104398
105052
105059
105656
111001
246170
246'165
246:516
249441
2721375
307331
621044
630iJ31
637032
670722
67:5
680
818
B25
10255
13 =;4 7
104433
105052
105059
105657
111001
246170
246465
246516
249441
272875
307104
621044
627068
670330
670722
10255
104433
1050'02
1050'09
1056:57
Description
UREA NITROGEN (BUN),
ELECTROLYTES
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
CBC W/PLT AUTO
GLUCOSE BEDSIDE MONIT
FOLIC ACID 1 MG
ASPIRIN 300 MG
WARFARIN SODIUM 2.5 M
FAMOTIDINE 20MG UD
AMOXICILLIN-CLAVULANI
ABDOMEN 1 VIEW AP
I V SODIUM CHLORIDE 0
FOLEY CATH 16 FR W/BA
TUBE FEEDING W/GUIDE
FEEDING BG ENTERAL 10
NEUROMUSCULAR RE ED 1
THERAPEUTIC EXERCISE
THER EXCERCISES 15 MI
FUNCT THERAPY ACT 15M
T INTERMEDIATE CARE U
ACTIV DAILY LIVING 15
BASIC METABOLIC PANEL
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
CBC W/PLT/DIFF AUTO
GLUCOSE BEDSIDE MONIT
FOLIC ACID 1 MG
ASPIRIN 300 MG
WARFARIN SODIUM 2.5 M
FAMOTIDINE 20MG UD
AMOXICILLIN-CLAVULANI
REHAB SWALLOW PHARYNX
I V SODIUM CHLORIDE 0
IV EXT ST 42IN W/2 SI
IV INFUSION SET, UNIV
FEEDING BG ENTERAL 10
T INTERMEDIATE CARE U
BASIC METABOLIC PANEL
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
CBC W/PLT/DIFF AUTO
- Continue -
It - IL{
PAGE: 14
Patient: HESS GERNEY I
Visit #: 3971157
I Units I
1
1
1
1
1
4
3
1
2
3
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
4
1
2
1
2
2
1
2
1
1
1
1
1
1
1
1
Debits
Credits
10.00
27.00
32.00
20.00
27.00
100.00
6.30
2.10
4.20
6.30
28.70
286.00
6.00
11. 00
24.00
4.00
46.00
46.00
46.00
46.00
1345.00
46.00
36.00
32.00
20.00
32.00
100.00
2.10
4.20
2.10
4.20
28.70
276.00
12.00
6.00
16.00
4.00
1345.00
36.00
32.00
20.00
32.00
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
12/20/03
12/20/03
12/20/03
12/20/03
12/20/03
12/20/03
12/20/03
12/20/03
12/20/03
12/20/03
12/20/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/21/03
12/22/03
12/22/03
12/22/03
12/22/03
12/22/03
12/22/03
12/22/03
12/22/03
12/22/03
12/22/03
12/22/03
I Svc Code I
111001
246042
246170
246'165
246~i16
246703
249441
274287
621044
626081
670722
10223
104433
105C59
105656
111001
246170
246465
246515
246703
249441
274287
511209
511304
511351
511703
511956
511964
621044
661HO
670722
434
sin
674
675
6<10
10222
1040~2
104065
104398
105052
105059
Description
GLUCOSE BEDSIDE MONIT
ZINC OXIDE 2 OZ
FOLIC ACID 1 MG
ASPIRIN 300 MG
WARFARIN SODIUM 2.5 M
LORAZEPAM 2 MG
FAMOTIDINE 20MG un
AUGMENTIN 400MG ORAL
I V SODIUM CHLORIDE 0
IV DILUENT NML SALINE
FEEDING BG ENTERAL 10
P PRIVATE MED/SURG RM
BASIC METABOLIC PANEL
PROTHROMBIN TIME
CBC W/PLT AUTO
GLUCOSE BEDSIDE MONIT
FOLIC ACID 1 MG
ASPIRIN 300 MG
WARFARIN SODIUM 2 MG
LORAZEPAM 2 MG
FAMOTIDINE 20MG UD
AUGMENTIN 400MG ORAL
BILEVEL NIV DAY SUBSE
AEROSOL TREATMENT SUB
AEROSOL TREATMENT INI,
ARTERIAL PUNCTURE
NEBULIZER
BILEVEL CIRCUIT
I V SODIUM CHLORIDE 0
BAG URINARY DRAINAGE
FEEDING BG ENTERAL 10
THERAPEUT ACTIVITIES
DYSPHAGIA THERAPY 30
THER EXERCISE 15 MIN
NEUROMUSCULAR RE ED 1
THERAPEUTIC EXERCISE
T INTERMEDIATE CARE U
CREATININE, BLOOD
UREA NITROGEN (BUN),
ELECTROLYTES
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
Continue -
A-J5
PAGE: 15
Patient: HESS GERNEY I
Visit #: 3971157
I Units I
4
1
1
1
1
2
2
3
2
1
1
1
1
1
1
4
1
2
1
1
2
2
4
23
6
2
7
1
2
1
1
2
1
1
1
1
1
1
1
1.
2
1
Debits
Credits
100.00
11.05
2.10
2.10
2.10
17.40
4.20
63.00
12.00
8.00
4.00
1015.00
36.00
20.00
27.00
100.00
2.10
4.20
2.10
8.70
4.20
42.00
1.764.00
1058.00
360.00
92.00
14.00
14.00
12.00
7.00
4.00
92.00
172.00
46.00
46.00
46.00
1345.00
11..00
10.00
27.0U
64.00
20.00
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
PAGE: 16
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Patient: HESS GERNEY I
Visit #: 3971157
Date
I svc Code I
Description
I Units I
Debits
Credits
12/22/03 105656 CBC W/PLT AUTO 1 27.00
12/22/03 111001 GLUCOSE BEDSIDE MONIT 4 100.00
12/22/03 246170 FOLIC ACID 1 MG 1 2.10
12/22/03 246465 ASPIRIN 300 MG 1 2.10
12/22/03 249'141 FAMOTIDlNE 20MG UD 2 4.20
12/22/03 272911 HEPARIN 25,000U/250ML 1 12.05
12/22/03 273399 ISOSOURCE 250ML CAN 56 235.20
12/22/03 274287 AUGMENTIN 400MG ORAL 3 63.00
12/22/03 621044 I V SODIUM CHLORIDE 0 1 6.00
12/22/03 627068 IV EXT ST 42IN W/2 SI 1 6.00
12/22/03 627070 IV EXT SET 90" W/FLAS 1 17.00
12/22/03 670722 FEEDING BG ENTERAL 10 1 4.00
12/23/03 428 THER EXERCISES 15 MIN 1 46.00
12/23/03 429 NEUROMUSCULAR REED 15 1 46.00
12/23/03 675 NEUROMUSCULAR RE ED 1 1 46.00
12/23/03 680 THERAPEUTIC EXERCISE 1 46.00
12/23/03 10222 T INTERMEDIATE CARE U 1 1345.00
12/23/03 104042 CREATININE, BLOOD 1 11.00
12/23/03 104065 UREA NITROGEN (BUN) , 1 TO.OO
12/23/03 104398 ELECTROLYTES 1 27.00
12/23/03 105052 PARTIAL THROMBOPLAS T 4 128.00
12/23/03 105054 PLATELET COUNT AUTO 1 14.00
12/23/03 111001 GLUCOSE BEDSIDE MONIT 4 100.00
12/23/03 245793 TRAZODONE 50 MG 1 2.10
12/23/03 246170 FOLIC ACID 1 MG 1 2.10
12/23/03 246703 LORAZEPAM 2 MG 2 17 .40
12/23/03 249441 FAMOTIDINE 20MG UD 2 4.20
12/23/03 272911 HEPARIN 25,000U/250ML 1 12.05
12/23/03 274287 AUGMENTIN 400MG ORAL 2 42.00
12/23/03 703322 IP NUTR,15 MIN,ORL/TB 1 68.00
12/24/03 428 THER EXERCISES 15 MIN 1 46.00
12/24/03 434 THERAPEUT ACTIVITIES 1 46.00
12/24/03 503 DYSPHAGIA THERAPY 30 1 172.00
12/24/03 674 THER EXERCISE 15 MIN 1 46.00
12/24/03 680 THERAPEUTIC EXERCISE 1 46.00
12/24/03 6134 GAIT TRAINING 15 MIN 1 46.00
12/24/03 10222 T INTERMEDIATE CARE U 1 1345.00
12/24/03 1050',2 PARTIAL THROMBOPLAS T 3 96.00
12/24/03 111001 GLUCOSE BEDSIDE MONIT 4 100.00
12/24/03 245706 ASPIRIN 325 MG 1 2.10
12/24/03 245793 TRAZODONE 50 MG 1 2.10
12/24/03 246170 FOLIC ACID 1 MG 1 2.10
- Continue -
It--I ~
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:17 AM
Guarantor: HESS GEF~EY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
I Svc Code I
12/24/03
12/24/03
12/24/03
12/24/03
12/24/03
12/24/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/25/03
12/26/03
12/26/03
12/26/03
12/26/03
12/26/03
12/26/03
12/26/03
12/26/03
12/26/03
12/26/03
12/26/03
12/26/03
112/26/03
12/26/03
246703
249441
272911
274287
703321
703322
10222
104042
104065
104398
105052
105059
105656
111001
245706
245793
246170
246703
249441
272911
274287
513304
513351
428
674
680
105052
111001
245706
246170
246517
249441
249519
272911
274287
274324
667220
*
Not posted
Description
LORAZEPAM 2 MG
FAMOTIDINE 20MG UD
HEPARIN 25,000U/250ML
AUGMENTIN 400MG ORAL
IP CALORIE COUNT,PER
IP NUTR,15 MIN,ORL/TB
T INTERMEDIATE CARE U
CREATININE, BLOOD
UREA NITROGEN (BUN),
ELECTROLYTES
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
CBC W/PLT AUTO
GLUCOSE BEDSIDE MONIT
ASPIRIN 325 MG
TRAZODONE 50 MG
FOLIC ACID 1 MG
LORAZEPAM 2 MG
FAMOTIDINE 20MG lm
HEPARIN 25,000U/250ML
AUGMENT IN 400MG ORAL
AEROSOL TREATMENT SUB
AEROSOL TREATMENT INI
THER EXERCISES 15 MIN
THER EXERCISE 15 MIN
THERAPEUTIC EXERCISE
PARTIAL THROMBOPLAS T
GLUCOSE BEDSIDE MONIT
ASPIRIN 325 MG
FOLIC ACID 1 MG
WARFARIN SODIUM 5 MG
FAMOTIDINE 20MG UD
ALBUTEROL SOLN 0.5% 2
. HEPARIN 25,000U/250ML
AUGMENTIN 400MG ORAL
HUMULIN R
UNDERPAD, DRIFLO 23"
/t-17
PAGE: 17
Patient: HESS GERNEY I
Visit #: 3971157
I Units I
1
2
1
2
1
1
1
1
1
1
3
1
1
4
1
1
1
1
2
1
2
16
4
1
1
1
2
4
1
1
1
1
1
1
1
200
1
Debits
Credits
8.70
4.20
12.05
42.00
30.00
68.00
1345.00
11.00
10.00
27.00
96.00
20.00
27.00
100.00
2.10
2.10
2.10
8.70
4.20
12.05
42.00
736.00
240.00
46.00
46.00
46.00
64.00
100.00
2.10
2.10
2.10
2.10
6.10
12.05
21.00
18.00
11.00
Balance:
93042.07 I
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:18 AM
Guarantor: HESS GER~EY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
12/26/03
12(26/03
12/26/03
12/26/03
12/26/03
12/27/03
12(27/03
12/27/03
12/27/03
12/27/03
12/27(03
12/27/03
12/27/03
12(27/03
12/27/03
12/27/03
12/27/03
12/28/03
12/28/03
12/28/03
12/28/03
12/28/03
112/28/03
12/28/03
12/28/03
12/28/03
12/28/03
12/28/03
12/29/03
12(29/03
12/29/03
12/29/03
12/29/03
12/29/03
12/29/03
12/29/03
12/29/03
12/29/03
12/29/03
12/29/03
12/29/03
12/29/03
I Svc Code I
10199
231076
245793
249441
274324
~02
601
10198
105052
105059
111001
231076
245345
245793
246517
249441
272911
10198
1050'52
1050:54
1050:59
1110Cl1
231076
245345
245793
246517
249441
272911
308
434
435
675
680
10198
11516
105052
105059
111001
231076
24534';
245793
246517
Description
F SEMI PRIV REHAB RM
PRAVACHOL 40MG TABS
TRAZODONE 50 MG
FAMOTIDINE 20MG UD
HUMULIN R
SPEECH/HEARING EVAL-S
INITIAL EVALUATION-PT
D PRIVATE REHAB RM
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
GLUCOSE BEDSIDE MONIT
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM 5 MG
FAMOTIDINE 20MG UD
HEPARIN 25,000U/250ML
D PRIVATE REHAB RM
PARTIAL THROMBOPLAS T
PLATELET COUNT AUTO
PROTHROMBIN TIME
GLUCOSE BEDSIDE MONIT
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM :5 MG
FAMOTIDINE 20MG un
HEPARIN 25,000U/250ML
INITIAL EVALUATION-OT
] THERAPEUT ACTIVITIES
ACT DAILY LIVING 15 M
NEUROMUSCULAR RE ED 1
THERAPEUTIC EXERCISE
D PRIVATE REHAB RM
COGNITIVE THERAPY 15
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
GLUCOSE BEDSIDE MONIT
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE :50 MG
WARFARIN SODIUM :5 MG
- Continue -
k(~
PAGE:
1
Patient: HESS GERNEY I
Visit #: 4052348
I Units I
1
1
1
1
200
1
1
1
3
1
4
1
1
1
1
2
2
1
1
1
1
4
1
1
1
1
2
1
1
1
1
1
1
1
2
1
1
4
1
1
1
1
Debits
895.00
2.10
2.10
2.10
18.00
268.00
137.00
895.00
96.00
20.00
100.00
2.10
2.10
2.10
2.10
4.20
24.10
895.00
32.00
14.00
20.00
100.00
2.10
2.10
2.10
2.10
4.20
12.05
137.00
46.00
46.00
46.00
46.00
895.00
92.00
32.00
20.00
100.00
2.10
2.10
2.10
2.10
Credits
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:18 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
01/10/04
01/10/04
01(10/04
01/10/04
01/10/04
01/10/04
01/11/04
01/11/04
01/11/04
01/11/04
01/11/04
01/11/04
01/11/04
01/12/04
01/12/04
01/12/04
01/12/04
01/12/04
01/12/04
01/12/04
01/12/04
01/12/04
01/12/04
01/12/04
01/12/04
01/12/04
01/12/04
01/12/04
01/12/04
01/13/04
01/13/04
01/13/04
01/13/04
01/13/04
01/13/04
01/13/04
01/13/04
01/13/04
01/13/04
01/13/04
01/13/04
01/13/04
I Svc Code I
10~)052
231076
245345
24:;793
246517
249441
10198
10':;059
231076
245345
245793
246517
249441
434
435
674
675
684
10198
11516
11618
105059
231076
245.345
245793
246127
246470
246!317
249441
434
435
674
680
684
10198
11:,16
11618
105059
231076
245345
245793
246518
Description
PARTIAL THROMBOPLAS T
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM 5 MG
FAMOTIDlNE 20MG UD
D PRIVATE REHAB RM
PROTHROMBIN TIME
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM 5 MG
FAMOTIDINE 20MG UD
THERAPEUT ACTIVITIES
ACT DAILY LIVING 15 M
THER EXERCISE 15 MIN
NEUROMUSCULAR RE ED 1
GAIT TRAINING 15 MIN
D PRIVATE REHAB RM
COGNITIVE THERAPY 15
THERAPEUT ACTIV-RT 15
PROTHROMBIN TIME
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
DIPHENHYDRAMINE 25 MG
SENNA CONCENTRATE TAB
WARFARIN SODIUM 5 MG
FAMOTIDINE 20MG UD
THERAPEUT ACTIVITIES
ACT DAILY LIVING 15 M
THER EXERCISE 15 MIN
THERAPEUTIC EXERCISE
GAIT TRAINING 15 MIN
D PRIVATE REHAB RM
COGNITIVE THERAPY 15
THERAPEUT ACTIV-RT 15
PROTHROMBIN TIME
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM 7.5 M
- Continue -
it -1/
PAGE:
6
Patient: HESS GERNEY I
Visit #: 4052348
I Units I
1
1
1
1
1
2
1
1
1
1
1
1
2
2
2
2
1
3
1
2
2
1
1
1
1
1
1
1
2
2
2
2
1
.3
1
2
2
1
1
1
1
1
Debits
32.00
2.10
2.10
2.10
2.10
4.20
895.00
20.00
2.10
2.10
2.10
2.10
4.20
92.00
92.00
92.00
46.00
138.00
895.00
92.00
92.00
20.00
2.10
2.10
2.10
2.10
2.10
2.10
4.20
92.00
92.00
92.00
46.00
13 8.00
895.00
92.00
92.00
20.00
2.10
2.10
2.10
2.10
Credits
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:18 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
01/13 / 04
01/13/04
01/14(04
01/14/04
01/14/04
01/14/04
01/14/04
01(14/04
01/14/04
01/14/04
01/14/04
01/14/04
01/14/04
01/14/04
01/14/04
01(14/04
01(14/04
01/15/04
01(15/04
01/15/04
01/15/04
01/15/04
01/15/04
01/15/04
01/15/04
01/15/04
01/15/04
. 01/15/04
01/15/04
01/16/04
01/16/04
01/16/04
01/16/04
01/16/04
01/16/04
01/16/04
01/16/04
01/16/04
01/16/04
01/16/04
01/16/04
01/16/04
I Svc Code I
249441
272967
434
435
436
606
674
680
684
10199
11516
105059
231076
245345
245793
246518
249441
435
G74
684
10199
11516
11618
105059
231076
245345
245793
246515
249441
434
435
674
684
10199
11618
105059
231076
245345
245793
246037
246517
249441
Description
FAMOTIDINE 20MG UD
BAZA CR 60GM TUBE
THERAPEUT ACTIVITIES
ACT DAILY LIVING 15 M
COMMUNITY/WORK TRN 15
COMMUNITY/WORK TRN 15
THER EXERCISE 15 MIN
THERAPEUTIC EXERCISE
GAIT TRAINING 15 MIN
F SEMI PRIV REHAB RM
COGNITIVE THERAPY 15
PROTHROMBIN TIME
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM 7.5 M
FAMOTIDINE 20MG UD
ACT DAILY LIVING 15 M
THER EXERCISE 15 MIN
GAIT TRAINING 15 MIN
F SEMI PRIV REHAB RM
COGNITIVE THERAPY 15
THERAPEUT ACTIV-RT 15
PROTHROMBIN TIME
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM 2 MG
FAMOTIDINE 20MG UD
THERAPEUT ACTIVITIES
ACT DAILY LIVING 15 M
. THER EXERCISE 15 MIN
GAIT TRAINING 15 MIN
F SEMI PRIV REHAB RM
THERAPEUT ACTIV-RT 15
PROTHROMBIN TIME
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
BISACODYL 10 MG
WARFARIN SODIUM 5 MG
FAMOTIDINE 20MG UD
- Contlnue -
A-JO
PAGE:
7
Patient: HESS GERNEY I
Visit #: 4052348
I Units I
2
1
2
2
2
1
2
1
1
1
2
1
1
1
1
1
2
2
2
3
1
1
2
1
1
1
1
1
2
2
2
2
4
1
2
1
1
1
1
1
2
Debits
4.20
15.00
92.00
92.00
92.00
46.00
92.00
46.00
46.00
895.00
92.00
20.00
2.10
2.10
2.10
2.10
4.20
92.00
92.00
138.00
895.00
46.00
92.00
20.00
2.10
2.10
2.10
2.10
4.20
92.00
92.00
92.00
184.00
895.00
92.00
20.00
2.10
2.10
2.10
2.10
2.10
4.20
Credits
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:18 AM
PAGE:
8
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Patient: HESS GERNEY I
Visit #: 4052348
D;ate
I Svc Code I
Description
I Units I
Debits
Credits
01/17/04 674 THER EXERCISE 15 MIN 1 46.00
01/17/04 684 GAIT TRAINING 15 MIN 1 46.00
01/17/04 10199 F SEMI PRIV REHAB RM 1 895.00
01/17/04 105059 PROTHROMBIN TIME 1 20.00
01/17/04 231076 PRAVACHOL 40MG TABS 1 2.10
01/17/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/17/04 245793 TRAZODONE 50 MG 1 2.10
01/17/04 249441 FAMOTIDINE 20MG un 2 4.20
01/17/04 251922 COUMADIN 1MG UD 1 2.10
01/18/04 10199 F SEMI PRIV REHAB RM 1 895.00
01/18/04 105059 PROTHROMBIN TIME 1 20.00
01/18/04 231076 PRAVACHOL 40MG TABS 1 2.10
01/18/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/18/04 245793 TRAZODONE 50 MG 1 2.10
01/18/04 249441 FAMOTIDINE 20MG un 2 4.20
01/18/04 251922 COUMADIN 1MG UD 1 2.10
01/19/04 434 THERAPEUT ACTIVITIES 2 92.00
01/19/04 435 ACT DAILY LIVING 15 M 2 92.00
01/19/04 674 THER EXERCISE 15 MIN 2 92.00
01/19/04 680 THERAPEUTIC EXERCISE 2 92.00
01/19/04 684 GAIT TRAINING 15 MIN 2 92.00
01/19/04 10199 F SEMI PRIV REHAB RM 1 895.00
01/19/04 11618 THERAPEUT ACTIV-RT 15 2 92.00
01(19/04 1050'09 PROTHROMBIN TIME 1 20.00
01(19/04 105656 CBC W/PLT AUTO 1 27.00
01/19/04 231076 PRAVACHOL 40MG TABS 1 2.10
01/19/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/19/04 245793 TRAZODONE 50 MG 1 2.10
01/19/04 246517 WARFARIN SODIUM 5 MG 1 2.10
01/19/04 249441 FAMOTIDINE 20MG UD 2 4.20
01/19/04 25192;2 COUMADIN 1MG UD 1 2.10
01/20/04 434 THERAPEUT ACTIVITIES 2 92.00
01/20/04 435 ACT DAILY LIVING 15 M 2 92.00
01/20/04 674 THER EXERCISE 15 MIN 3 138.00
01/20/04 684 GAIT TRAINING 15 MIN 3 138.00
01/20/04 10199 F SEMI PRIV REHAB RM 1 895.00
01/20/04 11516 COGNITIVE THERAPY 15 2 92.00
01/20/04 11616 GROUP TX RT BRIEF 1 71.00
01/20/04 105059 PROTHfWMBIN TIME 1 20.00
01/20/04 231076 PRAVACHOL 40MG TABS 1 2.10
01/20/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/20/04 245793 TRAZODONE 50 MG 1 2.10
- Continue -
kJ-j
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement Oil: 02/19/04 at 08:18 AM
PAGE:
9
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Patient: HESS GERNEY I
Visit #: 4052348
Date
I Svc Code I
Description
I Units I
Debits
Credits
01/20/04 246518 WARFARIN SODIUM 7.5 M 1 2.10
01/20/04 249441 FAMOTIDINE 20MG UD 2 4.20
01/21/04 434 THERAPEUT ACTIVITIES 2 92.00
01/21/04 435 ACT DAILY LIVING 15 M 2 92.00
01/21/04 674 THER EXERCISE 15 MIN 3 138.00
01/21/04 675 NEUROMUSCULAR RE ED 1 1 46.00
01/21/04 684 GAIT TRAINING 15 MIN 1 46.00
01/21/04 10199 F SEMI PRIV REHAB RM 1 895.00
01/21/04 11516 COGNITIVE THERAPY 15 2 92.00
01/21/04 11618 THERAPEUT ACTIV-RT 15 2 92.00
01/21/04 105059 PROTHROMBIN TIME 1 20.00
01/21/04 231076 PRAVACHOL 40MG TABS 1 2.10
01/21/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/21/04 245793 TRAZODONE 50 MG 1 2.10
01/21/04 246470 SENNA CONCENTRATE TAB 1 2.10
01/21/04 246517 WARFARIN SODIUM 5 MG 1 2.10
01/21/04 249441 FAMOTIDINE 20MG UD 2 4.20
01/22/04 434 THERAPEUT ACTIVITIES 2 92.00
01/22/04 'U5 ACT DAILY LIVING 15 M 2 92.00
01/22/04 ::;35 REHAB SWALLOW EVAL RA 1 315.00
01/22/04 674 THER EXERCISE 15 MIN 2 92.00
01/22/04 680 THERAPEUTIC EXERCISE 1 46.00
01/22/04 684 GAIT TRAINING 15 MIN 3 138.00
01/22/04 10199 F SEMI PRIV REHAB RM 1 895.00
01/22/04 11516 COGNITIVE THERAPY 15 2 92.00
01/22/04 105059 PROTHROMBIN TIME 1 20.00
01/22/04 231076 PRAVACHOL 40MG TABS 1 2.10
01(22 (04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/22/04 245793 TRAZODONE 50 MG 1 2.10
01/22/04 2460;18 WARFARIN SODIUM 7.5 M 1 2.10
01/22/04 249441 FAMOTIDINE 20MG UD 2 4.20
01/22/04 307104 REHAB SWALLOW PHARYNX 1 276.00
01/23/04 434 THERAPEUT ACTIVITIES 2 92.00
01/23/04 435 ACT DAILY LIVING 15 M 2 92.00
01/23/04 680 THERAPEUTIC EXERCISE 1 46.00
01/23/04 684 GAIT TRAINING 15 MIN 4 184.00
01/23/04 10199 F SEMI PRIV REHAB RM 1 895.00
01(23/04 11516 COGNITIVE THERAPY 15 2 92.00
01/23/04 11617 GROUP TX RT EXTENDED 1 71.00
01/23/04 105059 PROTHROMBIN TIME 1 20.00
01/23/04 105656 CBC W/PLT AUTO 1 27.00
01/23/04 231076 PRAVACHOL 40MG TABS 1 2.10
- Continue -
A -J.- )..
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:18 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
PAGE: 10
Patient: HESS GERNEY I
Visit #: 4052348
Date
I Svc Code I
-------------------,------------------------------------------~------------------
Credits
Description
I Units I
Debits
------------------_._--------~---------------------------------------------------
I
--------------------------------------------------------------------------------
I Balance:
01/23/04
01/23/04
01/23/04
01/23/04
01(24/04
01/24(04
01/24/04
01/24/04
01/24/04
01/24/04
01/24/04
01/24/04
01/24/04
01/25/04
01/25/04
01/25/04
01/25/04
01/25/04
01/25/04
01/25/04
01/26/04
01/26/04
01/26/04
01/26/04
01/26/04
01/26/04
01/26/04
01/26/04
01/26/04
01/26/04
01/26/04
01/26/04
01(26/04
01/26/04
01/27/04
01/27/04
01/27/04
01/27 /04
245345
245793
246:;17
249441
674
684
10199
105059
231076
245345
245793
246518
249441
10199
105059
231076
245345
245793
246518
249441
434
435
674
680
684
10199
11516
11616
105059
231076
245345
245793
246515
249441
11620
105059
24534:;
249441
* - Not posted
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM 5 MG
FAMOTIDlNE 20MG UD
THER EXERCISE 15 MIN
GAIT TRAINING 15 MIN
F SEMI PRIV REHAB RM
PROTHROMBIN TIME
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM 7.5 M
FAMOTIDINE 20MG UD
F SEMI PRIV REHAB RM
PROTHROMBIN TIME
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM 7.5 M
FAMOTIDINE 20MG UD
THERAPEUT ACTIVITIES
ACT DAILY LIVING 15 M
THER EXERCISE 15 MIN
THERAPEUTIC EXERCISE
GAIT TRAINING 15 MIN
F SEMI PRIV REHAB RM
COGNITIVE THERAPY 15
GROUP TX RT BRIEF
PROTHROMBIN TIME
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM 2 MG
FAMOTIDINE 20MG UD
COMMUNITY/WORK TRN 15
PROTHROMBIN TIME
MULTIVITAMIN 1 TAB
FAMOTIDINE 20MG UD
A -if J
1
1
1
3
1
2
1
1
1
1
1
1
2
1
1
1
1
1
,
~
2
1
2
3
1
1
1
2
1
1
1
1
1
1
2
1
1
1
1
2.10
2.10
2.10
6.30
46.00
92.00
895.00
20.00
2.10
2.10
2.10
2.10
4.20
895.00
20.00
2.10
2.10
2.10
2.10
4.20
46.00
92.00
138.00
46.00
46.00
895.00
92.00
71.00
20.00
2.10
2.10
2.10
2.10
4.20
46.00
20.00
2.10
2.10
45530.90 I
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:18 AM
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Date
12(29/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/30/03
12/31/03
12/31/03
12/31/03
12/31/03
12/31/03
12/31/03
12/31/03
12/31/03
12/31/03
12/31/03
12/31/03
12/31/03
12/31/03
12/31/03
12/31/03
12/31/03
01/01/04
01/01/04
01/01/04
01/01/04
01/01/04
I Svc Code I
249441
429
435
675
680
684
10198
11516
11618
104433
105052
105059
105656
111001
231076
245345
245793
246515
249441
272911
670330
435
504
674
675
684
10198
11618
105052
105059
111001
231076
245345
245793
246515
247831
249441
435
675
680
10198
105059
Description
FAMOTIDINE 20MG UD
NEUROMUSCULAR REED 15
ACT DAILY LIVING 15 M
NEUROMUSCULAR RE ED 1
THERAPEUTIC EXERCISE
GAIT TRAINING 15 MIN
D PRIVATE REHAB RM
COGNITIVE THERAPY 15
THERAPEUT ACTIV-RT 15
BASIC METABOLIC PANEL
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
CBC W/PLT AUTO
GLUCOSE BEDSIDE MONIT
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM 2 MG
FAMOTIDINE 20MG UD
HEPARIN 25,000U/250ML
IV INFUSION SET, UNIV
ACT DAILY LIVING 15 M
SPEECH/LANG THERAPY
THER EXERCISE 15 MIN
NEUROMUSCULAR RE ED 1
GAIT TRAINING 15 MIN
D PRIVATE REHAB RM
THERAPEUT ACTIV-RT 15
PARTIAL THROMBOPLAS T
PROTHROMBIN TIME
GLUCOSE BEDSIDE MONIT
PRAVACHOL 40MG TABS
MULTIVITAMIN 1 TAB
TRAZODONE 50 MG
WARFARIN SODIUM 2 MG
ACETAMINOPHEN 325 MG
FAMOTIDINE 20MG lID
ACT DAILY LIVING 15 M
NEUROMUSCULAR RE ED 1
THERAPEUTIC EXERCISE
D PRIVATE REHAB RM
PROTHROMBIN TIME
- Continue -
A'~Y
PAGE:
2
Patient: HESS GERNEY I
Visit #: 4052348
I Units I
2
2
3
2
1
2
1
2
2
1
3
3
1
4
1
1
1
1
2
1
1
2
1
1
1
4
1
2
1
1
4
1
1
1
1
1
2
2
1
1
1
1
Debits
Credits
4.20
92.00
138.00
92.00
46.00
92.00
895.00
92.00
92.00
36.00
96.00
60.00
27.00
100.00
2.10
2.10
2.10
2.10
4.20
12.05
16.00
92.00
172.00
46.00
46.00
184.00
895.00
92.00
32.00
20.00
100.00
2.10
2.10
2.10
2.10
2.10
4.20
92.00
46.00
46.00
895.00
20.00
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:18 AM
PAGE:
3
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Patient: HESS GERNEY I
Visit #: 4052348
Date
I Svc Code I
Description
I Unitsl
Debits
Credits
01/01/04 106043 HEMOCCULT, STOOL 1 7.00
01/01/04 111001 GLUCOSE BEDSIDE MONIT 4 100.00
01/01/04 231076 PRAVACHOL 40MG TABS 1 2.10
01/01/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/01/04 245793 TRAZODONE 50 MG 1 2.10
01(01/04 246515 WARFARIN SODIUM 2 MG 1 2.10
01/01/04 249441 FAMOTIDINE 20MG UD 2 4.20
01/01/04 272967 BAZA CR 60GM TUBE 1 15.00
01/02/04 434 THERAPEUT ACTIVITIES 2 92.00
01/02/04 435 ACT DAILY LIVING 15 M 2 92.00
01/02/04 504 SPEECH/LANG THERAPY 1 172.00
01/02/04 10198 D PRIVATE REHAB RM 1 895.00
01/02/04 11618 THERAPEUT ACTIV-RT 15 2 92.00
01(02/04 105059 PROTHROMBIN TIME 1 20.00
01/02/04 111001 GLUCOSE BEDSIDE MONIT 4 100.00
01/02/04 231076 PRAVACHOL 40MG TABS 1 2.10
01/02/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/02/04 245793 TRAZODONE 50 MG 1 2.10
01/02/04 246515 WARFARIN SODIUM 2 MG 1 2.10
01/02/04 249441 FAMOTIDINE 20MG UD 2 4.20
01/03/04 1487 GAIT TRAINING 15 MIN 1 46.00
01/03/04 10198 D PRIVATE REHAB RM 1 895.00
01/03/04 12',38 GROUP TX BRIEF PT 1 71.00
01/03/04 105059 PROTHROMBIN TIME 1 20.00
01/03/04 111001 GLUCOSE BEDSIDE MONIT 4 100.00
01/03/04 231C176 PRAVACHOL 40MG TABS 1 2.10
01/03/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/03/04 245793 TRAZODONE 50 MG 1 2.10
01/03/04 246!:;17 WARFARIN SODIUM 5 MG 1 2.10
01/03/04 249441 FAMOTIDINE 20MG UD 2 4.20
01/04/04 435 ACT DAILY LIVING 15 M 2 92.00
01/04/04 10198 D PRIVATE REHAB RM 1 895.00
01/04/04 105052 PARTIAL THROMBOPLAS T 1 32.00
01/04/04 105059 PROTHROMBIN TIME 1 20.0Cl
01/04/04 111001 GLUCOSE BEDSIDE MONIT 4 100.00
01/04/04 231076 PRAVACHOL 40MG TABS 1 2.10
101/04/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/04/04 245"793 TRAZODONE 50 MG 1 2.10
01/04/04 246470 SENNA CONCENTRATE TAB 1 2.10
01/04/04 246517 WARFARIN SODIUM 5 MG 1 2.10
01/04/04 247831 ACETAMINOPHEN 325 MG I 1 2.10
01/04/04 249441 FAMOTIDINE 20MG UD 2 4.20
--------------------------------------------------------- '"-------,--- ..--..--------
- Continue -
Ft . ~5"
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02/19/04 at 08:18 AM
PAGE:
4
Guarantor: HESS GERNEY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Patient: HESS GERNEY I
Visit #: 4052348
-------------------_._--~-----------------------------------~--------------------
Date
I Svc Code I
Description
I Units I
Debits
Credits
01/05/04 434 THERAPEUT ACTIVITIES 2 92.00
01/05/04 435 ACT DAILY LIVING 15 M 2 92.00
01/05/04 674 THER EXERCISE 15 MIN 2 92.00
01/05(04 675 NEUROMUSCULAR RE ED 1 2 92.00
01/05/04 680 THERAPEUTIC EXERCISE 1 46.00
01/05/04 684 GAIT TRAINING 15 MIN 1 46.00
01/05/04 10198 D PRIVATE REHAB RM 1 895.00
01/05/04 11618 THERAPEUT ACTIV-RT 15 2 92.00
01/05/04 104398 ELECTROLYTES 1 27.00
01/05/04 105059 PROTHROMBIN TIME 1 20.00
01/05/04 105656 CBC W/PLT AUTO 1 27.00
01/05/04 111001 GLUCOSE BEDSIDE MONIT 4 100.00
01/05/04 231076 PRAVACHOL 40MG TABS 1 2.10
01/05/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/05/04 245793 TRAZODONE 50 MG 1 2.10
01/05/04 246517 WARFARIN SODIUM 5 MG 1 2.10
01/05/04 247831 ACETAMINOPHEN 325 MG 1 2.10
01/05/04 249441 FAMOTIDINE 20MG UD 2 4.20
01/06/04 434 THEPAPEUT ACTIVITIES 2 92.00
01/06/04 435 ACT DAILY LIVING 15 M 2 92.00
01/06/04 504 SPEECH/LANG THERAPY 1 172.00
01/06(04 674 THER EXERCISE 15 MIN 3 13 8.00
01/06/04 675 NEUROMUSCULAR RE ED 1 1 46.00
01/06/04 680 THERAPEUTIC EXERCISE 1 46.00
01/06/04 683 WHEELCHAIR MGMT 15 MI 1 46.00
01/06/04 10198 D PRIVATE REHAB RM 1 895.00
01/06/04 11618 THERAPEUT ACTIV-RT 15 2 92.00
01/06/04 70094 LARYNGOSCOPY W/STROBO 1 350.00
01/06/04 105059 PROTHROMBIN TIME 1 20.00
01/06/04 111001 GLUCOSE BEDSIDE MONIT 4 100.00
01(06/04 231076 PRAVACHOL 40MG TABS 1 2.10
01/06/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/06/04 24579J TRAZODONE 50 MG 1 2.10
01/06/04 24651" WARFARIN SODIUM 5 MG 1 2.10
01/06/04 249441 FAMOTIDINE 20MG DO 2 4.20
101/0"1/04 434 THERAPEUT ACTIVITIES 2 92.00
01/07/04 435 ACT DAILY LIVING 15 M 2 92.00
01/07/04 504 SPEECH/LANG THERAPY 1 172.00
01/07/04 674 THER EXERCISE 15 MIN 2 92.00
01/07/04 680 THERAPEUTIC EXERCISE 1 46.00
01/07/04 684 GAIT TRAINING 15 MIN 3 138.00
.01/07/04 10198 D PRIVATE REHAB RM 1 895.00
- Continue -
A -J., k;
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 02(19/04 at 08:18 AM
PAGE:
5
Guarantor: HESS GEP~EY I
PO BOX 99
SHERMANS DALE, PA 17090-0000
Patient: HESS GERNEY I
Visit #: 4052348
Date
I Svc Code I
Description
I Units I
Debits
Credits
01/07/04 105059 PROTHROMBIN TIME 1 20.00
01/07/04 111001 GLUCOSE BEDSIDE MONIT 4 100.00
01/07(04 231076 PRAVACHOL 40MG TABS 1 2.10
01/07/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/07/04 245793 TRAZODONE 50 MG 1 2.10
01/07/04 246517 WARFARIN SODIUM 5 MG 1 2.10
01/07/04 249411 FAMOTIDINE 20MG UD 2 4.20
01/08/04 B4 THERAPEUT ACTIVITIES 2 92.00
01(08(04 .D5 ACT DAILY LIVING 15 M 2 92.00
01/08/04 504 SPEECH/LANG THERAPY 1 172.00
01/08/04 674 THER EXERCISE 15 MIN 2 92.00
01/08/04 680 THERAPEUTIC EXERCISE 2 92.00
01/08/04 684 GAIT TRAINING 15 MIN 2 92.00
01/08/04 10198 D PRIVATE REHAB RM 1 895.00
01/08/04 11618 THERAPEUT ACTIV-RT 15 2 92.00
01/08/04 105059 PROTHROMBIN TIME 1 20.00
01/08/04 111001 GLUCOSE BEDSIDE MONIT 4 100.00
01/08/04 231076 PRAVACHOL 40MG TABS 1 2.10
01/08/04 245345 MULTIVITAMIN 1 TAB 1 2.10
01/08/04 245793 TRAZODONE 50 MG 1 2.10
01/08/04 2465,17 WARFARIN SODIUM 5 MG 1 2.10
01/08(04 249441 FAMOTIDINE 20MG UD 2 4.20
01/08/04 600520 SPIROMETER INCENT ADU 1 7.00
01/09/04 434 THERAPEUT ACTIVITIES 1 46.00
01/09/04 504 SPEECH/LANG THERAPY 1 172.00
01/09/04 674 THER EXERCISE 15 MIN 2 92.00
01/09/04 675 NEUROMUSCULAR RE ED 1 1 46.00
01/09/04 680 THERAPEUTIC EXERCISE 1 46.00
01/09/04 684 GAIT TRAINING 15 MIN 2 92.00
01/09/04 10198 D PRIVATE REHAB RM 1 895.00
01/09/04 105059 PROTHROMBIN TIME 1 20.00
01/09/04 111001 GLUCOSE BEDSIDE MONIT 2 50.00
01/09/04 231076 PRAVACHOL 40MG TABS 1 2.10
01/09/04 2453,j5 MULTIVITAMIN 1 TAB 1 2.10
01/09/04 245793 TRAZODONE 50 MG 1 2.10
01/09/04 246517 WARFARIN SODIUM 5 MG 1 2.10
01/09/04 246593 CALAMINE 12 0 ML 1 2.60
01/09/04 249441 FAMOTIDINE 20MG UD 2 4.20
01/10/04 674 THER EXERCISE 15 MIN 2 92.00
01/10/04 680 THERAPEUTIC EXERCISE 1 46.00
01/10(04 624 GAIT TRAINING 15 MIN 1 46.00
01/10/04 10198 D PRIVATE RER~B RM 1 895.00
- Continue -
{\.;).7
.
PENNSTATE
!!!l The Milton S. Hershey Medical Center
. The College of Mecticme
PAGE
GERNEY I HESS
200A MARION AVENUE
CARLISLE PA 17013-1138
1 ., 7
ACCOUNT #
752711
STATEMENT
DATE: 02110/04
LAST STATEMENT
DATE: 02/04/04
FED TAX ID # 251857035
INS CHARGE PAYMENTI GUARANTO~
ADJUSTMENT BALANCE
lTfi IF ANY QUESTIONS, PLEASE CO>lTACT: MSHMC PATIENT FINANCIAL SERVICES
DATE PROCEDURE DIAG QTY DESCRIPTION
CODE CODE
>>> PATIENT: GERNEY I HESS 752711
3971157
PERFORMED BY, DIV OF DIAG RADIOLOGY
. PLACE OF SVC, INPATIENT
11/30/03 7054426,GC 436 MRA HEAD UNENHANCED 30L DO
01/15/04 BALANCE TRANSFER TO GUAR 301.00
11/30/03 7054726,GC 436 HR A NECK 11/0 CONTRAST 30L DO
01/15/04 BALANCE TRANSFER TO SOAR 301,00
11/30/03 7055126,GC '136 MRIBRAIN UNENHANCEO 373,00
01/15/04 BALANCE TRANSFER TO SOAR 373,00
11/30/03 7045026.GC 47LO CT HEAD UNENHANCEO 2'10.00
12/20/03 8LUE SHIELD PAYMENfo 0.00 2'10,00
PERFORMED 8Yr TRAUMA SURGERY DIV
11/30/03 99233, GC 518.5 DAILY. HOSPITAL CARE 176.00
12/31/03 INSURANCE NOT IN.. EFFECT 0,00 176,00
PERFORMED 8Y, DIVISION OF NEUROlOGY
11/30/03 99291 '134.91 CRITICALCARE FIRST HR 466,00
12/31/03 INSURANCE NOT IN EFFECT 0.00 466.00
PERFORMED 8Y,DIVOF CARDIOLOGY
11/30/03 93010 'I26.n ECGELECTROCARD INTERP 59;00
01/15/04 8ALANCETRANSFER TO GUAR 59.00
PEIlFORMEDBY, DIV RESP & INTENSIVE CARE
12/01/03 99233 518.5 DAILY HOSPITAL CAllE 176 .00
01115/04 INSORANCENOT IN EFFECT 0.00 176,00
PERFORMED 8Y' DIVISION OF NEUROLOGY
12/01/03 99291.GC 434,91 CRITICAL CARE FIRST HR 466.00
01/07/04 INSURANCE NOT IN EFFEC 0,00 466.00
. PERFOR/'lED BY, oIV OF OIAG RADIOLOGY
12/02/03 7101026.GC 514 CHEST 1 VIEH 5LoO
01/15/04 8ALANCE TRANSFER TO GUAR 51.00
PERFOR/'lEO BY: OIV RESP & INTENSIVE CARE
12/02/03 99233 518.5 DAILY HOSPITAL CARE 176.00
01115/04 INSURANCE NOT IN EFFECT 0,00 176,00
PERFORMED BY, DIVISION OF NEUROLOGY
12/02/03 99233.GC 434.91 DAILY HOSPITAL CARE 176.00
01105/04 INSURANCE NOT IN EFFECT 0.00 176.00
PERFORMED BY, DIV Of DIAG RADIOLOGY
12/03/03 7'10oo26.GC V51l.82 A8DOMEN SINGLE VIEH 51. DO
01115/04 BALANCE TRANSFER TO GUAR 5LOO
PERFORMED BY: DIV RfSP & INTENSIVE CARE
1U03/03 99Z33 518.5 DAILY HOSPITAL CARE 176,00
01/15/04 INSURANCE NOT IN EFFECT 0.00 176.00
PERFORMED BY, DIVISION OF NEUROLOGY
1U03/03 99232.GC 43'1.91 DAILY HOSPITAL CARE 124.oD
01/05/04 INSURANCE NOT IN EFfECT 0.00 124,00
PERFORMED BY: OIV OF OIAG RADIOLOGY
12/04/03 7045026 34/1.9 CT HEAD UNENHANCEO 2'10.00
01/15/04 8ALANCE TRANSFER TO GUAR 2'10.00
12/04/D3 7101026,GC 786.09 CHEST 1 VIEH 51. 00
12/26/03 BLUE SHIelD PAYMENfo 0.00 51,00
A'J,.1>
PAOE
PENN STATE GERNEY I HESS 2 of J
20M MARION AVENUE
;I The Milton S. Hershey Medical Center CARLISLE PA 17013.1138 STATEMENT
The College of Medicine DATE: 02110104
LAST STATEMENT
ACCOUNT # 752711 DATE: 02104104
~ IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT fiNANCIAL SERVICES FED TAX 10 # 251857035
DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENTI GUARANTO
CODE CODE ADJUSTMENT 8ALANCE
PERFORMED 8V, DIVISION OF NEUROlOGV
12104/03 9923l.GC 434.91 DAILV HOSPITAL CARE 114,00
01/05/04 INSURANCE NOT IN EFFECT 0.00 124,00
12105/03 99232 434,91 DAIlV HOSPITAL CARE 124,00
01115/04 INSURANCE NOT IN EFFECT 0.00 114,00
1210./03 99232 434,91 DAILY HOSPITAL CARE 124,00
01/15/04 INSURANCE NOT IN EFFECT 0.00 124.00
PERFORMED BV, DIV OF DIAG RADIOLOGY
12/01/03 710102. 786,09 CHEST 1 VlEH 51,00
12120/03 8lUE SHIELD PAVMENT* 0.00 51. 00
PERFORMED 8Y, DIVISION OF NEUROlOGV
12107/03 99232 434,91 DAILY HOSPITAL CARE 114.00
01/05/04 INSURANCE NOT IN EFFECT 0,00 124, DO
12108/03 99232 434,91 DAILY HOSPITAL CARE 124.00
01/05/04 INSURANCE NOT IN EFFECT 0.00 124. DO
PERFORMED BY: DIV OF DIAGRADIOLOGV
12109/03 7l01026.GC 518.119 CHEST 1 VIEH 51.00
01/15/04 8ALANCE TRANSFER TOOOAR . 51.011
PERFORMEII BV, IIIVISIDNIIF NEUROLOGY
12109/03 99232,GC 434;91 DAILY HOSJllTAL CARE 124.00
01/05/04 INSURANCE NOT IN EfFECT 0.00 124.00
PERFOIlMED8Y:DIVOF CARDIIIlOGV
12/09/03 93010 426;53 ECG UECTRtlCARD. INTERP 59.00
01/15/04 BALANCE TRANSFER TO GUAR 59.00
PERFORMED BY, DIVISION OF NEUROlOGV
12110/03 99232.GC 434.91 DAILY HOSPIT Al CARE 124.00
01/07/04 INSURANCE NOT IN EFFEC 0.00 124.00
PERFORMED 8V: OIVOF CARDIOLOGV
12110/03 93010 426,4 ECG ElECTROCARD INTERP 59.00
01/19/04 8AlANCE TRANSFER TOGUAR 59,00
PERFORMED 8Y: DIV OFDIAG RADIOLOGY
ll/11/D3 7101026.GC 786.09 CHEST IVIEH 51.00
01/15/04 BALANCE TRANSFER TO GUAR 51. 00
ll/11/03 7400026,GC V.58.82 ABDOMEN SINGLE VIEH 5LOD
01/15/04 BALANCE TRANSFER TO GUAR 5LOO
ll/11/03 712602..GC 518.0 CT THORAX ENHANCED 347.00
01/15/04 BALANCE TRANSFER TO GUAR 347,00
PERFORMED BY: DIV OF INFECT DIS & EPIDM
ll/11/03 99254,GC 780.6 . INITIAL INPT CONSULTATION 307,00
01/15/04 BALANCE TRANSFER TO GUAR 307,00
PERFORMED BY: DIV OF 01AG RADIOLOGY
11/12/03 7101026.GC 518,0 CHEST 1 VIEH 5LOO
01/15/04 BALANCE TRANSFER TO GUAR 51.00
PERFORMED BV: DIVISION OF NEUROlOGV
1l/12103 99232 434.91 DAILV HOSPITAL CARE 114,00
01/07/04 INSURANCE NOT IN EFFEC 0,00 1%4. DO
PERFORMED BY: DIV OF PULMONARV MEDICINE
12/12103 99254.GC 518.0 INITIAL INPT CONSULTATION 307,00
01/03/04 BLUE SHIELD PAYMENT* 0.00
01115/04 BLUE SHIELD PAYMENT 0,00 307, DO
it ),1
PEN N STATE
~ The Milton S. Hershey Medical Center
.. The College of Medicme
HI IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES
DATE PROCEDURE DIAG QTY DESCRIPTION
CODE CODE
PERFORMED BY: DIY DF INFECT DIS & EPIDM
HDSP YISIT EXTEN CC
. BALANCE TRANSFER TO SUAR
PERFDRMED BY: DIY OF DIAG RADIDLOGY
CHEST 1 VIEW
BALANCE TRANSFER TO GUAR
MRI BRAIN UNENHANCED
BALANCE TRANSFER TO GUAR
C T ABDOMEN ENHANCED
BALANCE TRANSFER TO GUAR
ABDOMEN SINGLEYIEW
BALANCE TRANSFER TO SUAR
CT PHYIS ENHANCED
$ALANCE TRANSFER TD SUAR
ABDOMEN SINGLE YI~W
IUtANCE TRANSFER TO SUAR
PERfORMED BY: DIVlSIllN OF NEUIlOLOGY
DAlLY HO$PITALCARE
BLlI~SIlIE(j) PAyMENT!<
PERFOR/'iEb flY . DIY OFPlILl10NARY MEIlICIN~
HOSPYISIT INTER CC
BLLlESIlIELOPAYI1ENT1l
BLLlE5HIE(D PAYMENT
P~R~ORf1ED BY :DIYDF INFECT DIS I EPIDM
HOSP YISIT INTER CC
BALANCE TRANSFER TO SUAR
. PERFORMED BY, DIVISION OF NEURO(OGY
DAILY HOSpITAL CARE
BLUE SHIELD PAYHENmO
PERfORMED BY: DIY OF PULMONARY MEDICINE
HOSP VISIT INTER CC
BLUE SHIELD PAYMENT*
BLUE SHIELD PAYMENT
PERFORMED BY: DIY DF INFECT DIS I EPIOM
HDSP VISIT INTER CC
BALANCE TRANSFER TO SUAR
PERFORMED BY: OIY OF DIAG RADIOLOGY
ABDOMEN SINGLE VIEW
BLUE SHIELD PAYMENT*
CHEST 1 VIEW
BLUE SHIELD PAYMENT1l
PERFORMED BY: DIYISION OF NEUROLOGY
DAILY HOSPITAL CARE
INSURANCE NOT IN EFFEC
PERfORMED BY, DIY OF PULMONARY MEDICINE
HOSP YISIT INTER CC
BLUE SHIELD PAYMENT
PERFORMED BY: DIY OF INFECT DIS I EPIDM
HOSP YISIT INTER CC
BALANCE TRANSFER TO SUAR
12/12103
01/15104
99233.GC
12/13/03 7101026,GC
Dl115/04
12/13/03 7055126.GC
01115/04
12/13/03 7416026.GC
01/15/04
12/13/03 7400026.GC
01/15/04
12/13/03 7219326.GC
01115/04
12113/03 7400D26.GC
D1I15/04
12113/03
01103/04
99232.GC
1Z113/03 99232
01/03/04
01/15/04
1Z113/D3 99232
01/15/04
lZ114/03
01103/04
99232.GC
1Z114/03 99232
01103/04
01l15/D4
1Z114/03 99232
01/15/04
780.6
786.05
436
789,9
Y58.81
789.9
Y58.82
434.91
518.0
780.6
434,91
518,D
780.6
lZ115/03 7400026 Y58,82
01/03/04
12/15/03 71DI026.GC 348.1
01/03/04
lZ115/03 99232,GC 434.91
01/07/04
1Z115/03 99232.GC li18.0
01/1li/04
lZ115/03 99232 780,6
01115/04
GERNEY I HESS
200A MARION AVENUE
CARLISLE PA 17013-1138
ACCOUNT #
752711
PAGE
3.' J
STATEMENT
DATE: 02{10{04
LAST STATEMENT
DATE: 02{04{04
F~D TAX 10 # 251857035
INS CHARGE PAYMENTI GUARANTOI
ADJUSTMENT BALANCE
176,00
176,00
51.00
51,00
3H.00
373,00
356,00
356,00
51.00
5LOO
326,00
326,00
5LOO
51.00
124; DO
0.00 124.00
1Z4',00
0,00
0.00 1Z4.00
124. DO
124,00
U4',QO
0.00 124,00
124.00
0,00
0.00 124. DO
124.00
124',00
51.00
0.00 51.00
51.00
0,00 51.00
124'.00
0,00 124,00
124.00
0.00 124.00
124.00
124.00
A ,30
~ .. ~
PENN STATE
!SI The Milton S. Hershey Medical Center
. The College of Medicme
GERNEY I HESS
200A MARION AVENUE
CARLlSl.E PA 17013-1138
iii] IF ANY QUESTIONS. PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES
DATE PROCEDURE DIAG QTY DESCRIPTION
CODE CODE
PERFORHEO BY, DIV OF CARDIOLOGY
ECG ELECTROCARD INTERP
BALANCE TRANSFER TO GUAR
PERfORMED BY, OIV Of DIAG RADIOLOGY
ABDllI1EN SINGLE VIE"
BLUE SHIELD PAYMENT*
CT PELVIS ENHANCED
BALANCE TRANSfER TO GUAR
C T ABDOMEN ENHANCED
BALANCE TRANSFER TO GUAR
PERFORMED BY, DIVoF PUlMONARY MEDICINE
BRONCH KlAVEoLAR LAVAGE
BALANCE TRANSFER TO GUAR
PERfORMED BY , DIVISIllNof NEUROLOGY
DAILY HDSPITALCARE
BALANCE TRANSFER TO GUAR
PERFORMED BY' DIVoF PULHllNARY MEDICINE
HDSP VISIT BRIH. CC
BALANCE. TRANSfER TOGUAR
PERFORMED BY, DIV OF INfECT DIS & EPIOM
HoSP VISIT INTER CC
BALANCE TRANSfER TO GUAR
PERfORMED BY, DlVOf ANATOMIC PATHOLOGY
CYTO CDNCENKlSlfEARS
BALANCE TRANSFER TO GUAR
PERFORMED BY:.DIVISIllN OF NEUROLOGY
DAILY HOSPITAL CARE
BALANCE TRANSFER TO GUAR
PERFORMED BY: DIV OF DIAG RADIOLOGY
ABDOMEN SINGLE VIEW
BLUE SHIELD PAYMENT*
ABDOMEN SINGLE VIEW
BLUE SHIELD PAYMENT*
PERFORMED BY: DIYISIllN Of NEUROLOGY
DAILY HOSPITAL CARE
BALANCE TRANSFER TO GUAR
PERFORMED BY: DIY OF DIAG RADIOLOGY
COMPLX DYNAN PHARY SPCH E
. BALANCE TRANSFER TO GUAR
PERFORHED BY: DIVISION OF NEUROLOGY
DAILY HOSPITAL CARE
BALANCE TRANSFER TO GUAR
DAILY HOSPITAL CARE
BALANCE TRANSFER TO GUAR
DAILY HOSPITAL CARE
BALANCE TRANSFER TO GUAR
DAILY HOSPITAL CARE
BALANCE TRANSFER TO GUAR
DAILY HOSPITAL CARE
BALANCE TRANSFER TO GUAR
DAILY HOSPITAL CARE
1Z/15/03
01l2D/04
'3010
12/16/03 7400026.GC
01/03/04
12/16/03 721'326.GC
01/15/04
12/16/03 7416026.GC
01/15/04
12116103
01/15/04
1Z/16/03
01115/04
12116/03
01115/04
12116/03
01/15/04
31624
'9233,GC
'9231. 25
99232,GC
12/17/03 8810826
01/15/04
12/17/03
01/15/04
99233.GC
12/18/03 7400026.GC
01/03/04
12/18/03 7400026.GC
01/03/04
1Z/18/03
01/15/04
99232,GC
12/19/03 7037126.GC
01115/04
12119/03
01115/04
12/20/D3
01/15/04
12/Z1/03
01/15/04
12/22/03
01/15/04
12/23/03
01/15/04
12/24/03
99232.GC
99232.GC
99232,GC
99232.GC
99232,GC
99232.GC
426,4
Y58.82
789.9
789,9
518,0
434.91
578.0
780.6
518.0
434. 91
V58.82
V58.82
434.91
787,2
434. 91
434. 91
434.91
434,91
434.91
434. 91
ACCOUNT #
752711
PdJ
PAGE
PENN STATE GERNEY I HESS 5 of ~
200A MARION AVENUE
;; The Milton S. Hershey Medical Center CARLISLE PA 17013.1138 STATEMENT
The College of Medicme DATE: 02/1 0/04
LAST STATEMENT
ACCOUNT # 752711 DATE: 02/04/04
IiII IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX 10 # 251857035
DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENTI GUARANTO
CODE CODE ADJUSTMENT BALANCE
01/15/04 BALANCE TRANSFER TO SUAR 124.00
12/Z5/03 99232.GC 434.91 . DAILY HOSPITAL CARE 124,00
01/15/04 BALANCE TRANSFER TO SUAR 124, 00
12/26/03 99238.GC 434.91 HOSP DISC DAY HGT <3D MIN 149.00
01/15/04 BALANCE TRANSFER TO GUAR 149.00
405Z3411
PERFORMED 8Y: DIVISION OF NEUROLOGY
PLACE OF SVC: INPATIENT
12/27/03 99232 V57.89 DAILY HOSPITAL CARE WhOO
01/15/04 BALANCE TRANSFER TO SUAR 124,00
12/28/03 99232.GC V57,89 DAILY HOSPITAL CARE 124,00
01/15/04 BALANCE TRANSFER TO GUAR 124.00
12/29/03 99232 V57,89 DAILY HOSPITAL CARE 124.00
01/15/04 BALANCE TRANSFER TO GUAR 124.00
12/30/03 99232.GC V57,89 DAILY HOSPITAL CARE 124,00
01/15/04 BALANCE TRANSFER TO GUAR 124.00
12/31/03 99232 V57.89 DAILY HOSPITAL CARE 124.00
01/15/04 BALANCE TRANSFER TO GUAR 124.00
01/01/04 99232 V57.89 OAILY,HOSPlTAL CARE 124,00
01/15/04 BALANCE TRANSFER TO GUAR WhOO
01/02/04 99232 V57.89 DAILY HOSPITAL CARE 124,00
01/15/04 BALANCE, TRANSFER TOGUAR 124.00
PERFORMED BY: OIVOF PULMONARY MEDICINE
01/03/04 99232 V57,89 DAILY HOSPITAL CARE 124,00
01/15/04 BALANCE TRANSFER TO GUAR 124.00
01/04/04 99232 V57,89 DAILY HOSPITALCARE 124,00
01/15/04 BALANCE TRANSFER TO GUAR 124,00
PERFORMED BY: DIVISION OF NEUROLOGY
01/05/04 99232 V57,89 DAILY HOSPITAL CARE 124,00
01/15/04 BALANCE TRANSFER TO GUAR 124.00
01/06/04 99232 V57.89 DAILY HOSPITAL CARE 124, 00
01/15/04 BALANCE TRANSFER TO SUAR 124.00
01/07104 99232.GC V57 ,89 DAILY HOSPITAL CARE 124.00
01/19/04 BALANCE TRANSFER TO SUAR 124.00
01/08/04 99232,GC V57,89 DAILY HOSPITAL CARE 124,00
01/19/04 BALANCE TRANSFER TO SUAR 124,00
01/09/04 99232,GC V57.89 DAILY HOSPITAL CARE 124.00
01/19/04 BALANCE TRANSFER TO GUAR 124,00
01/10/04 99232 V57,89 DAILY HOSPITAL CARE 124.00
01/19/04 BALANCE TRANSFER TO SUAR 124.00
01/11/04 99232 V57 ,89 DAILY HOSPITAL CARE 124.00
01/19/04 BALANCE TRANSFER TO GUAR 124.00
0111 2/04 99232.GC V57.89 DAILY HOSPITAL CARE 124.00
01/19/04 BALANCE TRANSFER TO GUAR 124,00
01/13/04 99232,GC V57 . 89 DAILY HOSPITAL CARE 124.00
01/19/04 BALANCE TRANSFER TO GUAR 124.00
01/14/04 99232 V57.89 DAILY HOSPITAL CARE 124.00
01/19/04 BALANCE TRANSFER TO GUAR 124,00
01/15/04 99232 V57.89 .DAILY HOSPITAL CARE 124.00 124.00
01/17/04 99232 V57,89 DAILY HOSPITAL CARE 124,00 124. 00
A .3;0
PENNSTATE
IS The Milton S. Hershey Medical Center
. The College of Medicme
GERNEY I HESS
200A MARION AVENUE
CARLISLE PA 17013-1138
PAGE
601 7
STATEMENT
DATE: 02/10/04
LAST STATEMENT
DATE: 02/04/04
ACCOUNT # 752711
III I IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES
DATE PROCEDURE DIAG QTY DESCRIPTION
CODE CODE
01118/04 .99232 Y57.89 OAILY HOSPITAL CARE
01119/04 99232 Y57,89 OAILY HOSPITAL CARE
01120/04 99232 Y57.89 DAILY HOSPITAL CARE
01/21/04 99232 Y57.89 DAILY HOSPITAL CARE
PERFORMED BY. DIY OF DIAG RADIOLOGY
COMPLX DYNAH PHA~Y SPCH E
PERFORMED BY. DIVISION OF NEUROLOGY
DAILY HOSPITAL CARE
DAILY HOSPITAL CARE
DAILY HOSPITAL CARE
DAILY HOSPITAL CARE
DAILY HOSPITAL CARE
HOSPDISC DAYMGT <3D NIN
INS
FED TAX I D # 251857035
CHARGE PAYMENTI G~ARANTOI
ADJUSTMENT BALANCE
124, DO
124, DO
124,00
124,00
124,00
124.00
124.00
124,00
01/22/04 7037126
436
236.00
236,00
01/22/04
01/23/04
01124/04
01125/04
01126/04
01/27/04
99232
99232
99232
99232
99232
99238
Y57.89
Y57,89
Y57,89
Y57,89
Y57,89
V57.89
124,00
124.00
124.00
124.00
124,00
149.00
124,00
124,00
124,00
124,00
124,00
149,00
01/14/04 11721 110,1
01114/04 99203. Z5 729.5
4081260
PERFORMED BY, ORTHOPAEDICS DIVISION
PLACE OF SVC: OP PHYSICIAN
DE8RID NAIlS 6 OR HORE
OUTPATIENT YISIT f.E"
BALANCE. GERNi:Y I HEss $16508.00
129,00
128,00
129.00
128;00
IF YOU HAVE ANY QUESTIONS MIOUT THE AMOlM YOUR INSURANCE
cCi1PANY PAID, CONTACT THEM DIRECTlY. FOR ANY OTHER ~STIoNs
REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE, IF PAYMENT
HAS BEEN MAOE, THANK YOU AND DISREGARD THIS BIll,
PLEASEFND TO C"RIGHT, CUSi SE~V A-K, A58 SUnE 1140
THANK yOU FOR USING HSHMC PHYSICIANS GROUP FOR YOU~PHYSICIAN
SERVICES. IF YOU HAVE ANY QUESiIONS REGARDING THIS BIll,PlEASE
CON"fACTUS AT 717.;n-6069 OR 800.264-2619, BEil4E.EN 8:00AM AND
S:JOPM MONI)AY THRtlJGH "EONESDAY OR BEil4EEN 8.00AHAI4o 4:30PM
THURSDAY AND FRIDAY,
CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
AJ3
PAGE
PENNSTATE
I!!,"; The Milton S. Hershey Medical Center
. The College of Medicme
GERNEV I HESS
200A MARION AVENUE
CARLISLE PA 17013-1138
7 or 7
STATEMENT
DATE; 02/10/04
LAST STATEMENT
DATE: 02104/04
FED TAX 10 # 251857035
CHARGE PAYMENTJ GUARANTOR
ADJUSTMENT BALANCE
ACCOUNT #
752711
J'f IF ANY QUESTIONS, PLEASE CONIACT; MSHMC PATIENT FINANCIAL SERVICES
DATE PROCEDURE DIAG QTY DESCRIPTION
CODE CODE
INS
BALANCE SU1l1ARY
RESPONSIBLE. PARTY
lOOl GUARANTOR RESPONSIBILITY
POLICY I
TOTAL
$ 16508.00
,____~___________~__________l_L~eQti.IA!!._"_.l..t'.tfA~.F...!l~!At;ft.!o.lJrt!f.t...rYJ!r:Ul9-.nQ~U'}2f!.L1Q':!J)f.~X~!.!~#!I~~/LJt~r9-'lttt'ArM~~-t3_~_.;.____~__~___~~_~_~w_~__w____.
STATEM~NTDATE: GUARANTOR_RESPONSIBILITY: MINIMUM PAYMENT:
02110/04 $ 16508.00 $ 16508.00
BF6
MSHMC PHYSICIANS GROUP
BILLING SERVICES
POBOX 854
HERSHEY PA 17033.0854
00000752711 UP
0000000001650800021004
1...11.1.1...1.1.11.,,1..1,.11...11..,.11.,11...,11..11.1..1.1
M8ff MSHMC PHYSICIANS GROUP
To:
1..,111..,111....,.11,,11.,..11..,11..11.1,.1,11...11,..,1.1.1
PO BOX 643313
PITTSBURGH PA 15264-3313
GERNEV I HESS
200A MARION AVENUE
CARLISLE PA 17013-1136
)FFICf USE aNt y
"CHECK ONE
FOR CREDIT CARD PAYMENT, PLEASE FILL IN INFO[U,lAT!ON BElOW
-- ~_ -Ifm~
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TYP, DMNO
CARDHOLDER NAME (PRINT)
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MSHMC PHYSICIANS GROUP
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CARD NUMBER EX? DATE
CREDIT CARD SIGNATURE
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11752711
$138,572.97 (Hosp)
16,508.00 (Phys)
VERIFICATION
LINDA SCHLADER hereby states that she is the Super-
visor of Financial Counselors and Collection of Milton S. Hershey
Medical Center, The Pennsylvania State University and verifies
that the statements made in the foregoing pleading are true and
correct to the best of her knowledge, information and belief.
The undersigned understands that the statements therein
are made subject to the penalties of 18 Pa. C.S. ~4904 relating
to unsworn falsification to authorities.
~J;uJ
LINDA SCHLADER
DATE:
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TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER, ESQUIRE
I.D. #60267
22nd Fl.,1845 Walnut Street
Philadelphia, PA 19103
(215)569-5050
Attorney for Plaintiff
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. Box 853
Hershey, PA 17033
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS
GERNEY I. HESS
200 A. Marion Avenue
Carlisle, PA 17013
NO. 04-5238
P RAE C I P E
TO THE PROTHONOTARY:
Please reinstate the attached Complaint.
~~--------..,
LEWIS C. T FFER, ESQUIRE
Attorney for Plaintiff
r-;)
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TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER
I.D. No. 60267
22nd Fl., 1845 Walnut Street
Philadelphia, PA 19103
(215) 569-5050
Attorney for Plaintiff
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. Box 853
Hershey, PA 17133
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs
GERNEY I. HESS
200 A. Marion
Carlisle, PA
NO. 04-5238
Avenue
17013
PLAINTIFF'S PETITION TO SERVE DEFENDANT, GERNEY I. HESS, PURSUANT
TO SPECIAL ORDER OF THE COURT IN ACCORDANCE WITH PENNSYLVANIA
RULE OF CIVIL PROCEDURE 430
Plaintiff, by its attorney, Lewis C. Trauffer, Esquire, respect-
fully requests this Honorable Court to enter an Order permitting
and authorizing service of the Civil Action Complaint in the
above-captioned case upon defendant, Gerney I. Hess, (hereinafter
defendant) by regular and certified mail at his last known
mailing address of P.O. Box 99, Shermans Dale, PA 17090. In
support of this Petition, plaintiff avers as follows:
1. Suit was instituted and service of process requested
against the defendant, Gerney I. Hess, on or about Oct. 19, 2004
at 200 A. Marion Ave., Carlisle, PA 17013 and again on or about
Dec. 15, 2004, as is evidenced by the attached Sheriff's Return
of Non-Service and Praecipe to Reinstate.
2. Thereafter, the Sheriff of Cumberland County reported
the inability to accomplish service of process because he was
advised that the defendant did not live at this address; his new
address is P.O. Box 99 Shermansdale, PA 17090.
3. Plaintiff has checked with the Post Office which shows
that the physical address for P.O. Box 99, Shermansdale, PA 17090
is 200 A Marion Ave., Carlisle, PA 17015.
4. plaintiff has called the Post Office in Shermans Dale,
PA and was informed that the physical address is at least two
years old, but mail is picked up at the post office box.
4. Plaintiff has performed a person search on accurint.com
which shows defendant's address as P.O. Box 99, Shermans Dale, PA
17090.
5. Plaintiff has made a good faith effort to serve the
defendant.
6. Plaintiff has complied with the legal requirements and
provisions set forth in Pennsylvania Rule of Civil Procedure 430,
and therefore requests that service be permitted by regular and
certified mail.
WHEREFORE, Plaintiff requests this Honorable Court to permit
service of process in accordance with the attached Order.
~ ,- ~.-==-----'
LEW S C. T FFER, ESQUIRE
Attorney for Plaintiff
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER, ESQUIRE
J.D. No. 60267
1845 Walnut Street, 22nd Fl.
Philadelphia, PA 19103
(215)569-5050
Attorney for Plaintiff
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. Box 853
Hershey, PA 17033
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS
NO. 04-5238
GERNEY I. HESS
200 A. Marion Avenue
Carlisle, PA 17013
AFFIDAVIT OF INVESTIGATION INTO THE WHEREABOUTS OF DEFENDANT,
GERNEY I. HESS, IN ACCORDANCE WITH PENNSYLVANIA RULE OF CIVIL
PROCEDURE 430
I, Maureen Smith, being duly sworn according to law, depose
and say that I am a secretary employed by the law firm of Tabas
and Rosen, P.C., and I was instructed by Lewis C. Trauffer,
Esquire to send out the following letter to confirm the address
of Stephen Butler (hereinafter defendant), the defendant
in the above-captioned matter.
I wrote to the United States Post Office to obtain a current
address, copy of which is attached as Exhibit "B".
A copy of a person search is attached as Exhibit "e".
NO other address has surfaced as a result of the above
inquiries other than the last known address.
The aforementioned information is true and correct to the
best of my knowledge, information, and belief.
l~~
Maureen Smith
Sworn to and subscribed
before me this 24th day
o January, .2005
COMMONWEAL -rH OF'PENNSVLV
NOTAR!!'~ ~U,L
KENNETH C. SL C' ,.v Notary Public
City 0\ PMad,'; ;.,<, County
M Commission E'p"es November 17,2008
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER, ESQUIRE
I.D. No. 60267
1845 Walnut Street, 22nd Fl.
Philadelphia, PA 19103
(215) 569-5050
Attorney for Plaintiff
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. Box 853
Hershey, PA 17033
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs
GERNEY I. HESS
200 A. Marion Avenue
Carlisle, PA 17013
NO. 04-5238
AFFIDAVIT
I, Lewis C. Trauffer, being duly sworn according to law,
depose and say that I am the attorney for The Milton S. Her-
shey Medical Center and I did file Civil Action Complaint with
the Office of the Prothonotary of Cumberland County on Oct. 19,
2004. The Complaint was forwarded to the Sheriff of Cumberland
County to be served on Gerney I. Hess. I received a Return of
Non-Service stating that the defendant does not live at 200
Marion Avenue, Carlisle; defendant's new address is P.O. Box
99, Shermansdale, PA 17090.
>-
LEWIS
~~;-:-;~~~~
Sworn to and subscribed
before me this 24th day
of Ja uary, 00
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER
I.D. NO. 60267
22nd Fl., 1845 Walnut Street
Philadelphia, PA 19103
(215) 569-5050
Attorney for Plaintiff
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. Box 853
Hershey, PA 17033
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs
NO. 04-5238
GERNEY I. HESS
200 A. Marion Avenue
Carlisle, PA 17013
AFFIDAVIT OF SERVICE
I, Maureen Smith, being duly sworn according to law depose
and say that I am secretary to Lewis C. Trauffer, Esquire and I
did mail Plaintiff's Petition to Serve Defendant, Gerney I. Hess,
pursuant to Special Order of the Court in Accordance with
Pennsylvania Rule of Civil Procedure 430 in the above matter to
Gerney I. Hess at P.O. Box 99, Shermans Dale, PA 17090 by
certified mail and regular mail.
tlJb);-
Dat'e
/7(~
Maureen Smith
~
k~
Sworn to and subscribed
before me this 24th day
o Ja u 0
NO
COMMONWEALTH 0.. I'ENNSVLVANI
NOTARIAL SEAL
KENNETH C. SLOV"S
City of Philadel ' KY: NOlary Public
My Commission, E plI,a Phlla. County
'Pires November 17. 2008
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER, ESQUIRE
I.D. No, 60267
22nd FL., 1845 Walnut Street
Philadelphia, PA 19103
(215) 569-5050
Attorney for Plaintiff
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. Box 853
Hershey, PA 17033
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs
GERNEY I. HESS
200 A. Marion Avenue
Carlisle PA 17013
NO. 04-5238
PLAINTIFF'S MEMORANDUM OF LAW IN SUPPORT OF MOTION TO SERVE
DEFENDANT, GERNEY I. HESS, PURSUANT TO SPECIAL ORDER OF THE
COURT IN ACCORDANCE WITH PENNSYLVANIA RULE OF CIVIL PROCEDURE 430
Pennsylvania Rule of civil Procedure 430 provides as
follows:
DCa) If service cannot be made under the
applicable rule, the plaintiff may move the
Court for a special Order directing the method
of service. The Motion shall be accompanied
by an Affidavit stating the nature and extent
of the investigation, which has been made to
determine the whereabouts of the defendant,
and the reasons why service cannot be made."
The Advisory Committee's Note, concerning the above-cited
rule, provides that "a good faith effort" to locate the defendant
must be made. An illustration of a good faith effort, as
described in the Note, includes inquiries of postal authorities,
inquiries of relatives, neighbors, friends, and employers of the
defendant, and examination of local telephone directories, voter
registration records, and motor vehicle records.
Plaintiff has made a comprehensive good faith effort to 10-
cate the whereabouts of said defendant, as is more fully set
forth in the attached Motion and Affidavit.
Said defendant has obstructed and/or prevented service of
process under the ordinary channels of service.
WHEREFORE, plaintiff requests that the attached Order be
entered so that service of process may be effectuated on said
defendant by posting a copy of the Civil Action Complaint at
his last known address and by regular and certified mail.
Respectfully submitted,
~ ....-(""~------_.
LEW ~. T F;;;;;':-~~Q~~;E
Attorney for Plaintiff
unc>.t\...1.~ J:' i::> n.J,:.,J. uru'J - l'JUJ. .t' UU1\JLJ
. )
, ~<~
CASE NO: 2004-052? IP_~
COMMONTWSALTH OF PID,-NSYLVANIA
COUNTY OF CUMBERLAND
1
,.
HERSHEY MILTON S MEDICAL CENTE
VS
HESS GERNEY I
R. Thomas Kline
,Sheriff or Deputy Sheriff, who being
duly sworn according to law, says, that he made a diligent search and
inquiry for the within named DEFENDANT
HESS GERNEY I
but was
unable to locate Him in his bailiwick. He therefore returns the
COMPLAINT & NOTICE
, NOT FOUND , as to
the within named DEFENDANT
, HESS GERNEY I
200 A MARION AVENUE
CARLISLE, PA 17013
DEFENDANT DOES NOT LIVE AT 200 MARION AVENUE CARLISLE.
DEFENDANT'S NEW ADDRESS IS PO BOX 99 SHERMANSDALE, PA 17090.
Sheriff~s Costs:
Docketing
Service
Not Found
Surcharge
18.00
3.70
5.00
10.00
.00
36.70
so~C' ../...""
/'/ . :~EP~~e' ~
Sheriff of cumberland County
.?
TABAS & ROSEN
11/12/2004
Sworn and subscribed to before me
this
day of
A.D.
Prothonotary
A ~ (
~
..
,
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER, ESQUIRE
I.D. #60267
22nd Fl.,1845 Walnut Street
Philadelphia, PA 19103
(215) 569-5050
Attorney for Plaintiff
J
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. Box 853
Hershey, PA 17033
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS
GERNEY I. HESS
200 A. Marion Avenue
Carlisle, PA 17013
NO. 04-5238
P RAE C I P E
TO THE PROTHONOTARY:
Please reinstate the attached Complaint.
.JI
::.- ~ ~------=::~
LEWIS C. T FFER, ESQUIRE
Attorney for Plaintiff
A -)-
..."
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Tab as &RQsen,p!-c.
ATTORNEYS ATLAW
ALLAN M. TABAS' (1953-1999)
RONALD I. ROSEN'
RICHARD D. LUCENTE'"".
HOWARD R. MANILOFF"
LEWIS C. TRAUFFERm
1845 WALNUT STREET
22ND FLOOR
PHILADELPHIA, PA 19103
215569-5050
FAX: 215 569-0809
OF COUNSEL
A. MARTIN HERRING'
36 TANNER STREET
HADDON FIELD, NJ 08033
856 429-8123
FAX: 856 429-2038
PARALEGALS
KEN C. SLOVITSKY
CAROL H. JOHNSON
December I, 2004
. MEMBER OF PA BAR
o MEMBER OF NJ BAR
. MEMBER OF NY BAA
* NJ MANAGING ATTORNEY
HARRISBURG AREA
717 232-0608
Postmaster
Shermans Dale, P A 17090
WiWmj{~.~~~~~nl~~_~
.i;nl;hjm~;I\\UIOOltlmll~I~~llt~
Request for Change of Address or Boxholder
Information Needed for Service of Lee:al Process
Please furnish the new address or the name and street address (if a boxholder) for the following:
Hess, Gerney I. -. Case Reference #196240,196241
P _0. Box 99
Shermans Dale, P A J 7090
~~
fl' ~b1[~
The following information is provided in accordance with 39 C.P.R. ~ 265.6(d)(6)(ii). There is no fee for providing
boxholder information, The fee for providing change of address information iswaived in accordance with 39 C.F.R 9 265(d)l) and
(2) and corresponding Administrative Support Manual 9 352.44a and b.
I.
Capacity of requester:
Attorney
2. Statute or regulation that empowers me to serve process: Not required.
3. The names of all known parties to the litigation: THE MILTON S. HERSHEY MEDICAL CENTER VS. Hess,
Gerney L.
4. The court in which the case has been or will be heard: The Court of Conunon Pleas.
5. The docket or other identifying number if one has been issued: Not assigned yet.
6. The capacity in which the individual is to be served: Defendant(s).
WARNING
The submission offalse information either(l) to obtain and use boxholder information for any purpose other than
the service of legal process in connection with actual or prospective litigation or (2) to avoid payment of the fee
for change of address information could result in criminal penalties including a fine of up to $10,000 or
imprisonment of not more than 5 years or both (Title 18 U.S,c. 1001).
I certify that the above information is true and that the
of legal process in connection with actual or prospective litigati
is needed and will bc used solely for service
o No change of address order on file.
D Not known at address given.
D Moved, left no forwarding address.
D No such address.
;vv-L-
~
U
11
.~
,
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I
Tab as & Ros~en,p.c.
ATTORNEYS AT LAW
--~
ALLAN M. TABAS' (1953-1999)
RONALD I. ROSEN'
RICHARD D. LUCENTE*.:l+
HOWARD R. MANILOFFH
LEWIS C. TRAUFFER*"'.
1845 WALNUT STREET
22ND FLOOR
PHILADELPHIA, PA 19103
215569-5050
FAX: 215 569-0809
OF COUNSEL
A MARTIN HERRING'
PARALEGALS
KEN C. SLOVITSKY
CAROL H. JOHNSON
January 13, 2005
36 TANNER STREET
HADDONFIELD, NJ 08033
856429-8123
FAX: 856 429-2038
.. MEMBER OF PA BAA
'I> MEMBER OF NJ BAR
.. MEMBER OF NY BAR
.. NJ MANAGING ATTORNEY
HARRISBURG AREA
717 232.0606
Postmaster
Shennans Dale, P A 17090
i~ilirlii~lI!ilIli!lliJjl!!lllllll!llllll!ll~IIl!~I!lI1!_
i~...m~~~_IlII_~1
Request for Change of Address or Boxholder
Information NeeQ~d for Service of Legal Process
Please furnish the new address or the name and street address (if a boxholder) for the following:
Hess, Gerney I. -- Case Reference #196240, 196241
P.O. Box 99
Shennans Dale, PAl 7090
The following infonnation is provided in accordance with 39 C.F.R. 9 265.6(d)(6)(ii). There is no fee for providing
boxholder information. The fee for providing change of address infonnation is waived in accordance with 39 C.F.R. S 265(d) 1) and
(2) and corresponding Administrative Support Manual 9 352.44a and h.
1.
Capacity of requester:
Attorney
2 Statute or regulation that empowers me t'o serve process: 1,rot required.
3. The names ofall known parties to the litigation: THE MILToN S. HERSHEY MEDICAL CENTER YS. Hess,
Gerney L
4. The court in which the case has been or will be heard: The Court of Common Pleas Cumberland County.
5. The docket or other identifying number if one has been issued: 04-5238.
6. The capacity in which the individual is to be served: Defendant(s).
W ARNlNG
The ::::ab:-rj3sion offalse informatIon eIther (I) to obtain and use boxholder information for any purpose other than
the service oflegal process in connection with actual or prospective litigation or (2) to avoid payment of the fee
for change of address information could result in criminal penalties including a fine of up to $10,000 or
imprisonment of not more than 5 years or both (Title 18 U.S.c. S 1001).
n is needed and will be used solely for service
I certify that the above infonnation is true and that the address.
of legal process in connection with actual or prospective litigation.
\.
KY, Paralegal
FOR POST OFFICE USE ONLY ~
o No change of address order on file.
D Not known at address given.
o Moved, left no forwarding address.
D No such address.
NEW ADDRESS or BOXHOLDER'S
NAME and STREET ADDRESS
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Pe~son Search
Page 1 of2
Last Name
First Name
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SSN
1187-30-2356
City
I
State Zip
r-q
County
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Reference
1196240
Street Address
I
Phone
DOB
Age Range
r.r
r Search for other possible name spellings r Include Bankruptcies ($0.25)
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Records: 1 to 11 of 11
CJiCk [-cons B(JI(!'\V To. R.un
a Reporl . "
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. All Full Name Age/DOB Address Dates Phone Information ..
, ~ DONALD L ZEPP .., SUNSET BLVD (410) 673-7556 ..
=
cow 187.30.2356 PRESTON MD 21655 ZEPP DONALD
, ~ GERNEY HESS PO BOX 99 (717) 258-1598 .
cow 187.30.2356 SHERMANS DALE PA 17090.0099 Mar 04 - Nov 04
I. ~ GERNEY HESS 200A MARION AVE APT A Jun 93 ~ Feb 04 .
cow 187.30.2356 CARLISLE PA 17013.1138
, ~ GERNEY I HESS 65 200 MARION AVE APT A Jun 93 . Oel 03 (717) 258-1598 .
cow 187.30.2356 Oel39 CARLISLE PA 17013.1138
\I. ~ DONALD L ZEPP PO BOX 28 Mar 98 . 2003 (410) 673-7556 .
cow 187.30.2356 PRESTON MD 21655.0028
, ~ DONALD L ZEPP 127 SUNSET BLVD 2000 - 2003 (410) 673-7556 .
cow 187.30.2356 PRESTON MD 21655-2259
,~ GERNEY D HESS I 65 RR 9 BOX 455 Mar 94 986-2662 .
187.30.2356 Oel39 CARLISLE PA 17013
,~ GERNEY I HESS I 65 455 BOX MT ZION RD Ocl92 986-2662 .
187.30.2356 Oel39 CARLISLE PA 17013
I~ GERNEY I HESS 64 1160 BELVEDERE ST May 90 . Dee 91 .
cow 187.30.2356 1940 CARLISLE PA 17013-4003
GERNEY I HESS 64 566 PO Jun 88
http://go.accurint.comJapplbps/main ~ 12/28/04
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FEa 0 2 2005 ~
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TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER
I.D. No. 60267
22nd Fl., 1845 Walnut Street
Philadelphia, PA 19103
(215)569-5050
Attorney for Plaintiff
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. Box 853
Hershey, PA 17033
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs
GERNEY I. HESS
200 A. Marion Avenue
Carlisle, PA 17013
NO. 04-5238
o R D E R
AND NOW, to wit, this 3-' day of F~
, 2005,
it is hereby ORDERED, ADJUDGED and DECREED that the Plaintiff be
permitted to make substitute service on defendant, Gerney I. Hess
by regular mail and certified mail,
J.
{) c, ~ " CD.:! '''t"'. "
V ~ ,. . .' us
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER, ESQUIRE
I.D. #60267
22nd Fl.,lS45 Walnut Street
Philadelphia, PA 19103
(215) 569-5050
Attorney for Plaintiff
THE MILTON S. HERSHEY MEDICAL CENTER
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS
GERNEY I. HESS
NO. 04-5238
P RAE C I P E
TO THE PROTHONOTARY:
Please reinstate the attached Complaint.
~'
~E~S ~. ~FFER' ESQ::
Attorney for Plaintiff
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SHERIFF'S RETURN - NOT FOUND
CASE NO: 2004-05238 P
COMMONTWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
HERSHEY MILTON S MEDICAL CENTE
VS
HESS GERNEY I
R. Thomas Kline
,Sheriff or Deputy Sheriff, who being
duly sworn according to law, says, that he made a diligent search and
inquiry for the within named DEFENDANT
HESS GERNEY I
but was
unable to locate Him in his bailiwick. He therefore returns the
COMPLAINT & NOTICE
, NOT FOUND , as to
the within named DEFENDANT
, HESS GERNEY I
200 A MARION AVENUE
CARLISLE, PA 17013
DEFENDANT DOES NOT LIVE AT 200 MARION AVENUE CARLISLE.
DEFENDANT'S NEW ADDRESS IS PO BOX 99 SHERMANSDALE, PA 17090.
Sheriff's Costs:
Docketing
Service
Not Found
Surcharge
18.00
3.70
5.00
10.00
.00
36.70
S:~~C>>"
R. Thomas ~ine
Sheriff of Cumberland
../
County
TABAS & ROSEN
11/12/2004
Sworn and subscribed to before me
this .~- day of ~f
.;(ro~/l A. D.O h < .
J1..L...... II" d'L --' tJ.nt:..
Pro h notary - I I r
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER
I.D. #60267
22nd Fl.,1845 Walnut Street
Philadelphia, PA 19103
(215) 569-5050
Attorney for plaintiff
THE MILTON S. HERSHEY MEDICAL CENTER
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS
GERNEY I. HESS
NO. 04-5238 Civil
AFFIDAVIT OF SERVICE
I, Maureen Smith, depose and say that I am secretary to
Lewis C. Trauffer, Esquire and I did mail Civil Action Complaint
in the above matter to Gerney I. Hess at P.O. Box 99, Shermans
Dale, PA 17090 by regular mail and certified mail on Feb. 16,
2005. Certified mail was returned "Unclaimed." Regular mail
was not returned.
, "l.eU 0-LIV . ;htJ-.{ "c
Maureen Smith
Sworn to and subscribed
b fore me this 14t day
Ma ch, 2
COMMON EAL TH OF PENNSYLVANIA
NOTARIAL SEAL
KENNETH C SLOVITSKY, Notary Public
City of PMadelphia,f'hila; COlInly
M Commission Expires November 17, 2008
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. Complete items 1, 2, and 3. Also complete
Item 4 If Restricted Delivery is desired.
I . Print your name and address on the reverse
so that we can return the card to you.
. Attach this card to the back of the mailpiece,
or on the front if space permits.
x
o Agel11 ,
o Addressee '
C. Daleo/Delivery
B. Flecelved by (Printed Name)
D. Is delivery address different from item 1? 0 Yes
If YES, enter delivery address below; 0 No
1. Article Addressed to:
:..;crnel.( J-- HC'SS
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Sherfn(J()5 i}tlf,
OR
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3. Serviceiype
rti Certified Mail 0 E>:press Mail
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o Insured Mail 0 C.O.D.
4. Restricted Delivery? (Extra Fee) 0 Yes
2. Article Number
{TransffJffrom service labe/)
PS Form 3811, August 2001
7004 0750 0000 4735 3339
Domestic Return Recelpl
102.595-02-M-1540
r
\
U.S. Postal Service",
CERTIFIED MAIL" RECEIPT
(Domestic Mall Only,; No In~urance Coverage Provided)
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or
Postage
0 CerlllledFee
0
0 AetumRecleptFoo
0 (E~dorsll'll'Hln1flequlrlld)
0 RestrlCled Oelfvery Fee
en (EndorsemenIAequlred)
C-
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or
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TABAS " ~OSEN., P .C.
BY, LllWIS C. TRAUFFBR, ESQUIRE ID No.: 60267
1845 Walnut Street,. 22nd Floor
philadelphia, PA 19103
(215) 569-5050 .
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. BOX 853
HERSHEY, PA 17033
VS.
-'f.'*' GER'-Je'f
~RY I. HESS
P.O. BOX 99
SHERMANS DALE, PA 17090-0099
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
NO.: 04-5238
ORDER FOR JUDGMENT FOR WANT OF AN
ANSWER AND ASSESSMENT OF DAMAGES
TO THE PROTHONOTARY:
Kindly enter judgment in the sum of $155,251.47
in favor of the Plaintiff(s) in the above entitled matter
for failure of the Defendant(s) to file an Answer 'to
Plaintiff(s) Complaint in Civil Action and assess Plaintiff(s)
damages as follows:
Amount of Claim:
$155,080.97
Interest at 6% per
annum from date of 11(30(03
discharge 1(10(04 & 1/14/04
Total
170.50
$ 155,251.47
~~--
. ~ _u ...)
Attorney or Plaintiff(s)
I assess damages
. k.
ove
Pro Prothonotary
Ad~tQII
APRIL 15, 2005
> "'--Z;:;:!../ --........
;~;;'~~~"~'~~~~"~~'~;'~~;;;~;"~;~~';;h:- p~~i:
Residence Address 01 the Judgment creditor is
Address ......... .....-... ......$..~!!!~............ ..........."..._...,
Address 01
.1P-feMants ..................Ji.am@..............____
iO.d.~~~~~a:;~:i:a:~~~:
J/.4.- ~lmlJf:Y
- -GENERY 1. HES S
Defendant P . O. BOX 99
SHERMANS DALE, PA 17090-0099
n.la
.....
THE MILTON S. HERSHEY MEDICAL CENTER
COURT OF COMMON PLEAS
VS
CUMBERLAND
NO.
COUNTY
04-5238
Gl: RIVE'r'
ElENER't I. HESS
AFFIDAVIT OF NON MILITARY SERVICE
COMMONWEALTH OF PA
~
COUNTY OF PHILADELPHIA
LEWIS C. TRAUFFER being legally sworn, deposes and says:
(a)
that the defendant(s) is/are not in the Military or
Naval Service of the United States or of its allies,
or otherwise within the provisions of the Soldiers' and
Sailors' .Civil relief action of Congress of 1940
as amended; ~ -
GE~IVEi'
that defendant GEN!'.RY" 1. HESS is over 21 year~ of
age and resides at P.O. BOX 99, SHERMANS DALE, PA 170'10-00 9
and is employed in Private Business.
(b)
(0) that defendant is over 21 years of
age and resides at
and is employed in Private Business.
Affiant has ascertained the foregoing information by inquiry and
belief and makes this Affidavit with due authority.
~~~-
LEWIS C. T FFER, ESQUIRE
Attorney for the Plaintiff
-.......
)
Sworn to and subscribed
before me on this .?'1V\ day
of ~I(Q. \. l... '~OD ')
~~~~~l\ts=--
COM
EA\.n1OF'PE_V\,V
NOlARIAL SEAl
KENNETH C. SLovrtSKv, Notary Public
cny of Philadelphia:Phila. COC:l1Iy
M Commission E'p<res November 17,2008
""'
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER, ESQUIRE ID No.: 60267
1845 Walnut Street, 22nd Floor
Philadelphia, PA 19103
(215)569-5050
The Milton S. Hershey Medical Center
P.O. BOX 853
HERSHEY, PA 17033
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS
GERAle;'
6ll!llTEVY I. HESS
P.O. BOX 99
SHERMANS DALE, PA 17090-0099
NO. 04-5238
TO:
NOTICE OF INTENTION TO TAKE DEFAULT JUDGMENT
~~R~~ I. HESS
P.O. BOX 99
SHERMANS DALE, PA 17090-0099
DATE OF NOTICE/FECHA DEL AVISO:
APRIL 15, 2005
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO TAKE ACTION REQUIRED OF YOU IN THIS
CASE. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE A JUDGMENT MAY
BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER
IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE GO TO OR TELEPHONE THE FOLLOWING OFFICE TO
FIND OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, PA 17013
(717) 249-3166 or (800) 990-9108
AVISO IMPORTANTE
USTED ESTA EN REBELDIA PORQUE HA FALLADO EN TOMAR LA ACCION EXIGIDA DE SUP PARTE
EN ESTE CASO. A MENOS DE QUE USTED ACTUE ENTRO DE DIEZ DE LA FECHA DE ESTE
AVISO, SE PUEDE REGISTRAR UNA SENTENCIA CONTRA USTED SIN EL BENEFICIO DE UNA
AUDIENCIA Y PUEDE PERDER SU PROPIEDAD 0 DERECHOS IMPORTANTES. US TED DEBE LLEVAR
ESTE AVIOS A UN ABOGADO ENSEGUIDA, SI US TED NO TIENE UN ABOGADO Y NO PAGAR POR
LOST SERVICIOS DE UN ABOGADO, DEBE COMUNICARSE CON LA SIGUIENTE OFICINA PARA
AVERIGUAR DONDE PUEDE OBTENER AYUDA LEGAL.
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, PA 17013
(717) 249-3166 or (800) 990-9108
LEWIS C. TRAUFFER, ESQUIRE
ATTORNEY FOR THE PLAINTIFF
THIS CORRESPONDENCE IS BEING USED TO COLLECT A DEBT AND
THE INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
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OFFICE OF THE PROTHONOTARY
COURT OF COMMON PLEAS
ONE COURTHOUSE SQUARE
CARLISLE, PA 17013-3387
Prothonotary
.....t-&awf;L(
To. GENEKf I. HESS
P.O. BOX 99
SHERMANS DALE, PA 17090-0099
.
CUMBERLAND COUNTY
.
.
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. BOX 853
HERSHEY, PA 17033
COURT OF COMMON PLEAS
vs.
*~ G.l:RM:Y
GENHRY I. HESS
No.
04-5238
Notice
Pursuant to Rule 236 of the Supreme Court of Pennsylvania, you are hereby notifi~d th t a
Judgment has been entered against you in the above proceeding as indicated b.c:l.ow.
~ t<.. .""1/
CURT LONG {/
Prothonotary
~-/"J-It>S
ill Judgment by Default
o Money Judgment
o Judgment in Replevin
o Judgment for Possession
o Judgment on Award of Arbitration
o Judgment on Verdict
o Judgment on Court Findings
If you have any questions concerning this notice, please call:
Attorney LEWIS C. TRAUFFER , Esquire
(Insert Attorney's Name)
10-232
at this telephone number:
(215)569-5050
..
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER
IDENTIFICATION NO. 60267
22nd Floor, 1845 Walnut Street
Philadelphia, PA 19103
(215)569-5050
Attorney for Plaintiff
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. BOX 853
HERSHEY, PA 17033
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS.
NO.: 04-5238
GERNEY I. HESS
200 A. MARION AVENUE
CARLISLE, PA 12013
PRAECIPE TO REASSESS DAMAGES
TO THE PROTHONOTARY:
Kindly enter judgment in the sum of $168,189.91 and reassess
damages as follows:
Original Amount of Claim
$155.080.97
Interest at 6%
per annum from date
of discharge - 1/10/04, 1/14(04
$ 13,108.94
Total
$ 168,189.91
" ~~-------
L~ C. T FF'iR, ESQ. ~
Attorney for Plaintiff
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