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Home My WebLink About01-22-13STATE OF In Re: ~ J C I ~i~,~~p Case # [.+ - I Z- ~ J J In the ~'~"~Q"`~ Estate of U" 3 STATEMENT OF CLAIM Hershey Medical Center/Bureau of Account Management hereby pre ents or fil' g against the above estate this statement of claim in the amount of $_~`=~ 3;. ~a The basis for the claim is Account # ~~~G ~ for date of ra',., ..~ i~ ~ service Sir-~u~~ • ~' 1~U33-s ~ ~'` `"; r ~, r~ ~ti n ~7 %~> Y ,;:~ ~., ~r~ r ,.y r cn y~ -c: ~_... 3. The tax identification number of the claimant is 23-2892355. r ;,> `: ;- N 4. The name and address of the claimant is: Bureau of Account Management=360 - Rosemont Avenue Suite 502 Camp Hill, PA 17011. Phone#717-214-3005. 5. This claim is not contingent. 6. This claim is not secured. I under penalties of perjury, declare that I have read the foregoing, and the facts alleged are true, to the best of my knowledge and belief. ,~- Executed this I ~ day of , l d ~ u a r y , 20 13 Phone# 717-214-3005 Bureau of Account Management ~,rau,rar,~ abrown@outtechinc.com State of Pennsylvania, County of Cumberland +'- IN WITNESS WHEREOF, I have set my hand and notarial seal this I'-I- day of _]a_~ua~ ,2013 My Commision Expires: I I G 'E~ -;, ..,~ t„ 1 ': `'~Y ;~ ~r 11 ~(, c~ %_l ,a~m,~ Notary Public COMMONWEALTH OF PENNSYLVANIA NOTARIALSEAL HEATHER E. SCHWEAR, Notary Public Lower Allen Twp., Cumberland County My Commission Expires November 19, 2076 Page: 1 Document Name: Eclipsys MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 12/21/12 at 07:17 PM Guarantor: BOUDER GAIL L 621 WHISKEY SPRINGS RD BOILING SPRINGS, PA 17007-0000 PAGE: 1 Patient: BOUDER GAIL L Visit N: 17033575 -------------------------------------------------------------------------------- ~ Date ~ Svc Code ~ Description ~ Units Debits ~ Credits ~ ~O1/03/12 X01/03/12 X03/04/12 X03/04/12 X04/15/12 X04/15/12 184447 ~ KNEE 1-2 VIEWS ~ 1 ~ 216 .00 184453 ~ ANKLE 3 OR MORE VIEWS 1 ~ 198 .00 910050 ~ BLUE SHIELD PAYMENT H~ 0 ~ 930119 ~ BLUE SHIELD CONT ADJ ~ -1 ~ 910050 ~ BLUE SHIELD PAYMENT H~ 2 ~ 97 .60 930119 ~ BLUE SHIELD CONT ADJ ~ 1 ~ 306 .40 More to Dis play - Press Return to Continue or 1 Sess-2 150.231.5.14 I 97.60-~ 306.40-~ to Quit 1 24/76 Date: 12/21/12 Time: 19:17:53 Page: 1 Document Name: Eclipsys MS HERSHEY MEDICAL CENTER PAGE: 2 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 12/21/12 at 07:17 PM Guarantor: BOUDER GAIL L 621 WHISKEY SPRINGS RD BOILING SPRINGS, PA 17007-0000 Patient: BOUDER GAIL L Visit #: 17033575 ~ Date ~ Svc Code ~ Description ~ Units Debits ~ Credits ~ X06/30/12 X06/30/12 ~ 980090 ~ HOSPITAL BAD DEBT W/0~ -1 ~ ~ 980091 ~ HOSPITAL BAD DEBT PLAN 1 ~ ~~~~ 414.00 ~ 414.00-~ ~ * N Balance: ~ 414.00 ~ - ot >End of Display - Press RETURN to Continue -•------------- ---------- 1 Sess-2 150.231.5.14 1 22/12 Date: 12/21/12 Time: 19:17:56 __:- r,~.! STATEMENT OF PHYSICIAN SERVICES GAIL L BOUDER 621 WHISKEY SPRINGS RD ey BOILING SPRINGS PA 77007-9578 ,, ~irit ., 'I a 9 "° ~ accouNr # Ts~oBSs ac : ~ ~- ~ ,zr, ~ `~ N., ";~SHMC PATIENT FINANCIAL SERYICES !'ROCEDUCdG DiAC BATE: ';!6 QTY ~~ . CODF. rpDr , .. ,;. -,.., ndrTFNT'~ -.;;- u'Yi8"p. 7g-i.^QRp 16927850 PERFORMED BY: STEPNMIIE A BERNARD ND DIV DF DI PLACE OF SVC: INPATIENT 2',:''OES, la ";~ . 9 - ANGLE COMPLETE 1)lll.1~'I'2 MA%INAI BENEFITS PAID 02/O:L~'T2 BLUE SHIELD PAYMENTN IT3~14,'l2 BLUE SHIELD PAYMEN f13~14/1.2 B SHIELD CDNTRACNAL A ~; ! ; 1; 6!!ii'1657035 +:'F~kfi+' CBUTrW ~:' ~~ parr' ~ I1drL • n~-`r: I+,.TID V.2IQii,'ll 73±°-~. "• ' KNEE LIMITED Oli1,L'12 NA%INlI BENEFITS PAID ' 912i0L'12 BLUE SHIELD PAYIR:Nf~ I D3i1;'12 BLUE SHIELD PAYMENT ' 113i1~'12 8 SHIELD CONTRACNAL A ~ LiN 12101!111 i'SS'.i?.. 1', +,I HAND >3 VIENS OL'1Li12 MAXIMBI BENEFIT'S PAID I OZ<'Ol./12 BLUE SHIELD PAYMENT* I' 03+'14/:!2 BLUE SHIELD PAYMEN i 03,'14/12 B SHIELD CONTRACTUAL A 0.110 12!08/11, '.C'*+~tar, . II +, '. KNEE LIMITED OL~11/12 MAXIMM BENEFITS PAID 02/01/12 BLUE SID:ELD PAYMENi1t 03/14/12 BLUE SHIELD PAYNEN 03,/14/12 B SHIELD CONTRACTUAL A ' 1•~ N - 12/08/11 P?~~^'+tb -,'F sP TIBIA A FIBULA 1 JOINT OL1L12 MA7fAwRl BENEFITS PAID I' 02/DL12 BLUE SHIELD PAYNENff I 03/14/12 BLUE SHIELD PAYMENT' " 03/14/12 B SHIELD CQRRACNAL A I' AI•~ PERFOIED BY: JOSHUA 6 TILE MD DIV OF DIA6 RA 12/06/11 ;i<<;i7 d1 it CT ABD/PELVLS W CdiTRAST OLIL12 MAIfD1111 BENEFIT'S PAID 02JOL32 BLUE SHIELD PAYMENf1E I ' 03114112', BLUE SHIELD PAYMEN ~' I ' 03/14/12' B SHIELD CDRRACNAL A II, DO 12/06/11 7~FOht.i„='h tS'- ''~ ANGLE LIMITED DL1L12', MA%INM BL7EFITS PAID 02/OLli". BLUE SHIELD PAYNBrtT3r D3/14/li!', BLUE SHIELD PAYMEN 03/14/1.. B SHIELD GOMTRAH:iUAI A ID,00 12J06/lIl T.irltr, i~ f "~ ' 91'9 CIES'f 1 VIEM DL1L12 MAXIMM BENEFITS PAID 021OL12 BLUE SHIELD PAYMFMIF ; D3/14/12'. BLUE SHIELD PAYHENI ~ I ~1, ~~~ ~ N 4 i i ~ I r n IVD ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON E ~ I I II l ' I f I 51 AICmCn1 Vr rnian,wn aonr n.w ~® ,y BOILING SPRINGS PA 17007-9518 v ACCOUNT # 7570989 ~~HAAC PATIENT FINANCIAL SERVICES ,. ,,.. ,m x ~~? B SNIfaD CONTRACTUAL A i Tt 'i' EMENT ~'A°~' 12/24J12 :.M'i' STATEMENT ~'b' '~ ' 07,125112 ~'Ell~ TAX ID #251857035 irkF;rd ~ dlDvU~ :a r`„• ~~. 74.23- D.DD JT TIDRIIX ILCOlITRAS7 ENH ~I~!i ~'J, MA7IIMJl1 BENEFITS PAID O.DO BLUE SHIELD PAYMENTS O.DO BLUE SHIELD PAYlHiN 111.67- B SHIELD CONTRACTUAL A 1113.33- D.DD CLAVICLE S.. :I NAXINIAI BENEFITS PAID D•~ I I BLUE SNIELD PAY1RiM* 0.00 1 BLUE SHIELD PAYMEN 8.09- 1 B SHQELD CWTRACTUAL A 116.91- 0.00 PERfORNED BY: JdIATHAN 6 RAI!'ES MD DIY OF DIRE '7.x:511 I' ~ I CHEST 1 VIEN rl' . I; i I MAXIMM BETB:FTTS PAID D.00 I BLUE SHIELD PAYMENTS 0.00 ,. BLUE SHIELD PAYMENT B•77- B SHIELD CONTRACTUAL d '14.23- O.OD PERFORMED BY: PAUL KALAPOS MD DIV OF DIA6 RADI I'^i ', CT CERVICAL SPD~E UNE1a1Ni '~''" !1 I+,'. NAXO^AAI BENEFITS PAID 0.00 II : ^ 1 BLUE SHIELD PAYMENII: O.DO 18!,. BLUE SHIELD PAYNEN 50.49- 11! ,,' B SiQELD CONTRACTUAL A 4rT6.51- 0.00 u . , .:,I ' GT L.UIBAR SPAIE UNENIANCE !! is " 1 '~ ~ IIL~ I NAXIMIM BENEFIT'S PAID 0.00 II.. I, " BLUE SHIELD PAYMENTf D.00 il'.li'' BLUE SHIELD PAYMEN ~•49- p L, I i" B SHIELD CQ11'RACTUAL A +176.51- D.00 lf, ;fN" : CT T1flRACIC SPDdE UENIAN !I2i', 'II 1:., 1 l " NAXINI)I BENEFITS PAID O.DO ;r'd. It I. ^ ~ BLUE 31IELD PAYMFNI3: 0.00 T~,,.li+, BLUE SHIELD PAYMEN 50.49- F!, ; ~i + B SHIELD COlI1IACTUAL A 4.76.51- 0.00 1I:r4'^dl~+ ~ CT HEAD @ENIAICED IIlA~. Ali GI::.L+ . MARIMAI BENEFITS PAID O.DO C~::'I?:Lr, BLUE SHIELD PAYMENTiE O.DO [~! 'J 4,+' l BLUE SHIELD PAYNQI 41.77- li'i;'4r'1, B SNIELD CONTRACTUAL A '.146.23- D.OD J!,'C1~6r'.l Ift:' I.IiPi l [1>, 'O'a,,' l ITi.'L~i,° 1. ICI ~'li~l~i~- PERFORMED BY: NENRY BOAT'B6 MD ORI•IDPAEDICS C fX BI-MALL SMP/C!P OP RED MAXIMUI BENEFITS PAID BLUE SHIELD PAYMENI* BLUE SHIELD PAYMENT 1D ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON B ;pl !ili=A~ IIq o.ao D.DO 760.68- omnn nom~n nmuu nom~~r __ GAIL L BOUDER 2 d g 621 WHISKEY SPRINGS RD STATEMENT OF PHYSICUIN SERVICES ' ~, , GAIL L BOUDER B21 WHISKEY SPRINGS RD BOILING SPRINGS PA 17007-9518 ' ! ' „y , ,. ACCOUNT # 7510989 i ~SHMC PATIENff FINANCIAL SERVICES ~ r ;: lii7Cl to i RreF ( _,. ~ : ~ ' ' .,, r, n ~~._ ¢, J 1r1 e P,t t,i FYL __ B SIQELO CONTR~TUAL A ~ . ~EBRIDE SKINMI3C/BQJE,FX MAXIMIl1 BENEFIT'S PAID I BLUE SHIELD PAYNENi~ I BLUE SHIELD PAYMENT B SHIELD CONTRACTUAL A I ,I', APPL UNIPL UNI EXf FI1C SY MAFUMlI BENEFITS PAID ' r !' BLUE SHIELD PAYMENI~ ~ I BLUE SHIELD PAYMENT B SHIELD CONTRACTUAL A I I!I ~,+~ INf REP TR LN 7-12 1 MAF~M BENEFITS PAID I F BLUE SHIELD PAYMENf* I 7' BLUE SIQEID PAYMENT I ~ B SNiELD CONTRACTUAL A 1- ~ I ' PERFORIffD BY: STEPHANIE A BERNARD MD DIV OF DI I; lluh AMCLE COMPLETE .; ".7i MAXIMI9I BENEFIT'S PAID I :~t '~.G BLUE SHIELD PAYMENiV 1 ;~~ '.: ,, :. BLUE SHIELD PAYMEN I 'i '~, B SHIELD CONTRACTUAL A i I !' PERFORMED BY: ,IOSNUA 6 TILE MD D1V OF DIA6 RA6 :. ':Far 1 3D REN RFf Cf,MRI ~ IMA D ' ! 4 ! MAXDIAI BENEFIT'S PAID : ~ D: ' C ° ! BUJE SHIELD PAYFIENt1: :' ~ II' ''l i I BLUE SHIELD PAYMEN :' D:'~ti 'I B SHIELD CONTRACTUAL A ~' 1~'I PERFORMED BY: SELTNA N READ MD a. ''IFIL'I °~ ANE OPN PR/BNS LR L6 A FT 11 ''I!I 'I MCC OR AUTO PAYMEM' . - D I I , I ~ L. ~"JEL'1 ART CATH PEACUTAN 0 x'1.11:'1 MCC OR AUTO PAYMENT . I q'~d1'I BLUE SHIELD PAYMENT 'fI gl;+'F~i';, BLUE SHIELD PAYlEN , °'I q ~ lei ':, B SHIELD COIIRACNAL A i I' gis,''F~Il;, B SHIELD CONTRACTUAL A I~ I ~ irl l'I'OJR:':. EMERGENCY SERVICE D'.~'311~,1;. MCC OR AUTO PAYMENT I>! [: I IIIH PERFORMED BY: KD6ERLY R SCIDLFIELD MD DIY OF PLACE OF SYC: EIER6@CY RDOfI I;i:~'C'4h.rl EMERGENCY VISIT D ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON 8~ STATEMENT OF PHYSICIAN SERVICES ' i ! ' ~ I ' '' GAIL L BOUDER B27 WHISKEY SPRINGS RD ,y BOILING SPRINGS PA 1 70 07-9 57 8 ~ ' .. ~ ., ACCOUNT # 7510989 ' ~wHMC PATIENT FINANCIAL SERVICES "; ~ "!''~' '. ~. .. :. :: ~ 9tI i. ;.,. ~ ~. E'1 G f MAXIMA BENEFITS PAID BLUE SHIELD PAYNENTit ~ERFDRMED BY: DEBORAH L NOLBRETTE MN ELECTADPH^• GLACE Df SVC: INPATIENT .C6 ELECTROCARD INTERP HAXIMAM BENEFITS PAID BLUE SHIELD PAYMEN B SHIELD CONTRACTUAL ADJ !, ' EC6 EIECTROCARD ]TJTERP HAXIMAI BENEFIT'S PAID I , BLUE SHIELD PAYHENf I. B SHIELD CONTRACTUAL ADJ I !• ~ PERFORMED BY: DAVID C HAN MN VASCULAR SURIERY DUPLEX SCAN EA- COIR~LETE NAXIMII BENEFITS PAID I ',I BLUE SHIELD PAYM3IT* I 'I BLUE SHIELD PAYIENI' I ''.• B SIU:ELD CONTRACTUAL ADJ 'f I dIPLEX SCAN EV - CONWLETE HAXTMM BENEFIT'S PAID i BLUE SHIELD PAYHENI':[ ~ I BLUE SHIELD PAYMENT ~ '' B SHIELD CONTRACTUAL AQ! I e `• PERFDRHED BY: URS A LEIENBER6ER M1 1lIA6D6 i TTE 11/D~PLER A COLOR fLD ~ HAXIMM BENEFITS PAID ~ i BLUE SHIELD PAYMiIT~ 'i ~ BLUE SHIELD PAYM71 ~~ ' ~ : B SHIELD CDNITRACTUAL ADJ 1?~ '~ I '1 PERFDRNED BY: S1TiPNANIE A BERNARD M) DIV OF D1 I r ANCLE CaIN.EIE II <, MAX71'RAI BENEFITS PAID I i II `', BLUE SHIELD PAYNEM'f I ~ II BLUE SHIELD PAYM~1 I 11 `, B St1IELD CDIITRACTUAL A ' . ' ~ ' I ' t PERFTBSED BY: IICHAEL A NAHLOIJ DO DIV OF DIA6 ',B CIEST I VIER II '? HAXIMM BENEFIT'S PAID I I I [I ".. BLUE SHIELD PAYM]IT~ I I I IL "I BLUE SHIELD PAYHEN I '' IL "i : B SHIELD CONTRACTUAL A li '. I I PERFOIBED BY: RICICHESVAR MAHRiU Mt DIV DF DIA{ l ''Cr-- ', CHFST 1 VIDI l'4' ~, f )ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BA I ' STATEMENT OF PHYSICIAN SERVICES GAIL L BOUDER 621 WHISKEY SPRINGS RD ,y BOILING SPRINGS PA 17007-9518 '' 6n~ ACCOUNT # 7510989 %~-^ HMC PATIENT FINANCIAL SERVICES 1 9 if ;ac r ,,, r ~ ~, Ia ~'rsN~ ._, kX4rwi'.. fD1CGRTP'TItyN J .. ~~ ~i, ~:at rcyir If+~ ~'' MAXD~AAI BENEFIT'S PAID BLUE SNIEID PAYMENI~ BLUE SHIELD PAYMEN B SHIELD CONTRACTUAL A PERFORMED BY: DEBORAH L IDLBRETTE MD ELECTAdPIF" ~!I DEVICE PR06 EVAL DUAL MAXIMUM BENEFITS PAID BLUE SHIELD PAYMENfH BLUE SHIELD PAYMENT B SNIEID CONTRACTUAL ADJ I PERFORMED BY: ERIC N BRADBURN DD TRAUMA SURBEIf :RITICAL CARE FIRST NR MAXUAJl1 BENEFITS PAID BLIP SHIELD PAYMENIt: i PERFORMED BY: JOR~I D PDTOCNNY MD DIV PLASTIC R'' DAILY HOSPITAL CARE MAXIMM BENEFITS PAID BLUE SHIELD PAYMENf~ BLUE SHIELD PAYMENT I° ' B SHIELD CRTIRACTUAL ADJ PERFORMED BY: DONALD J FLEMMItM MD DIV OF DIA6 CIEST 1 VIEM MAXINBI BENEFIT'S PAID i BLUE SHIELD PAYMENR~ e _ BLUE SHIELD PAYFR3J B SHIELD CDIITRACRUAL A ' , PERFORMED BY: T SHANE JdR1S0d MD WV PLASTIC R ' DAILY In4PITAL CARE NAXDAAI BENEFIT'S PAID BLUE SHIELD PAYMENf~ ~+ _ , ' I BLUE SHIELD PAYMENT ?'! , ~~ I B SHIELD CWTRACTUAL ADJ i' ' , , PERFOIBIED BY: ERIC N BRADBIAIN DO TRAIMA SIRI6ER . ', I CRITICAL CARE FIRST IR r3. !?'I. MAXIMUM BENEFITS PAID (k'.! !;'I~ BLUE SHIELD PAYMENT I: !.i iN'i' I B SHIELD C0IFRACTUAL A i' , ~ PERFOIBED BY: DONALD J FLE?IODl6 MD DIV OF DIA6 ,I'I CHEST I VIEM 161 '. i ' I MAX1Ml1 BENEFITS PAID I IB,' i ' I BLUE SHIELD PAYIENf1t Ip', .i'I BLUE SHIELD PAYlEIN IN', ;i ' I B SHIELD CONRRACTUAL A ~ , ~ ' ~ ' I :)ENTER ANY ADDRESS OR INSURANCE C0RRECT10N5 ON BA ~ r ~ _._._ __ _..... __. __... _.. __.. .... . _.. ~ STATEMENT OF PHYSICIAN SERVICES GAIL L BOUDER 621 WHISKEY SPRINGS RD ,y BOILING SPRINGS PA 17007-9516 ACCOUNT # 7510989 i tf,HA1C PATIENT FINANCIAL SERVICES ' ~ .. ~ ~ ~_ '~~ r' 4 ~, il' ~ERFDRMED BY: ERIC H BRADBURN DD TRAUMA SURGERI IAILY HOSPITAL CARE MAXIIAM BENEFITS PAID BLUE SHIELD PAYIIENfI~ BLUE SHIELD PAYNENf B SHIELD CONTRACTUAL ADJ ~RFDRMED BY: REKHA CNERIAN ha DIV OF DIAL RAD:" :HEST I VIEN NA1C{M!1 BENEFITS PAID BLUE SHIELD PAYMENf3~ BLUE SHIELD PAYMEN B SHIELD CONTRACTUAL A aERFORID:D BY: SCOR BARMEN MD TRAUMA SURGERY 9ATLY HOSPITAL CARE I MAXIMM 6@EFIiS PAID BLUE SHIELD PAYMENI'~ ~ERFOIBED BY: REKHA CIERIAN MD D1V DF DIAG RAD: , NEST I VIEN MAKIMJfI BEIEFTTS PAID BLUE SHIELD PAYMENT ' BLUE SHIELD PAYMEN ' B SHIELD CONTRACTUAL A PERFORIED BY: SCOTT B AIBEN LID TRAUMA SUIGERY ' n CRITICAL CARE FIRST HR u ~ I NAXIMM BENEFIT'S P#ID ' ! BLUE SHIELD PAYIEMH I ', CRITICAL CARE FIRST HR ' MAiQlIl1 BENEFITS PAID ' '~ BLUE SHIELD PAYMENf~ FM:RFORMED BY: NICOLE N DSEVALA MD HERSHEY INf °' 'I, DAILY IRSPITAL CARE i'' ' I, MAXIIAM BENEFITS PAID I 'l BLUE SHIELD PAYMEN PERFOIBIED BY: RICKIESVAR MAWW MD DIV OF OIAG I' 'I I I CREST I VIER 'I,I MAXDIaI BENEFITS PAID I 'I,I BLUE SHRELD PAYIENT~ ~ ., ~' I~'Il BLUE SHIELD PAYHEN C I ' L'. B SHIELD COfifRACT1IAL A PERFORED BY: SCOTT B AAMEN MD TRAUMA S!AffiERY ' L 'L' DAILY HOSPITAL CARE r~ II ~ L.. MAXDAM BE?EF1TS PAID .: c ~',I. BLUE SHIELD PAYIENf~ f: ;I I ~ ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BA I i I I ~ STATEMENT OF PHYSICIAN SERVICES ~I I~, ~' GAIL L BOUDER -- - 621 WHISKEY SPRINGS RD ~Ir ~;~`1'=1 !! '~,I ~ . I i BOILING SPRINGS PA 17007-9518 ~y ' ACCOUNT # 7510989 IF d,piA SIP°nlfiOrtYl~ Pl i n ai' 1 ~HMC PATIENT FINANCIAL SERVICES ,_'s ~ {:. I::ATI' i~IiO~"EOL16tl: ;~1 t, ~,~Ik}L. ,-r D. r, ~, ,,, '~i"N9 _~IT~ ',~11kiRl~N'd4?F+ ?TV L~It1PT ~~,a ` ' ~ k `.SFrIfEPY? ?41!JONCid °ERFDRMED BYc CLAUDIA J KASALES MD DIV OF DIAL " 12a°u.'11 rLO~D2~ ~~ ~~ :xESr 1 vIEN i;l.i'S!1,,12', MAXIMIM BENEFITS PAID q2:i>ia,12' BLUE SHIELD PAYMENAE q3~"Lh~,12 BLUE SHIELD PAYNEN g3,i:L~,'12 8 SHIELD CONTRACTUAL A ,ERFORMED BY: SCOTT B AIBEII MD TRAUMA SURGERY D 2/alJll 9R2~PL ! ,i RITICAL CARE FIRST HR q2/'IIL'12 MAIO:MIAI BENEFITS PAID g2,+i!!T12 BLUE SHIELD PAYNENi1E 'ERFOIBR:D BY: MILENA PILIPOVIC MD DIV DF ANESTH :!2/1~E/11 11162:11,!iil d ,I' I '11 CLS PRD RAD ULNA N~NBN D;all!V12 MAXIMaI BENEFITS PAID D4,/pF/12 BLUE SHIELD PAYMEN D4,+pi/12 B SHIELD CONTRACTUAL ADJ 12,+1ii/11 iAb62:11 ! ,I I !RT CATH PERCUTAN 03,+211V12 MAXIMM BENEFITS PAID 04,+pV12 BLUE SHIELD PAYMEN D4/pi/lY B SHIELD CONTRACTUAL ADJ , "ERFORMED BY: RICKJH:SSVAR MAIRW MD DIV OF DIAL 1L+1T/11 '~11I1:LD2'.I~ ! „1 ~ eNEST 1 VIEN DL+Y~L/12 MAXIM/I 8@IEFITS PAID DL+Li/12 BLUE SHIELD PAYFB~R1: N DS,+l~i/12 BLUE SHIELD PAYFEN o DS.+L~L/12 B SHIELD CONTRACTUAL A ~'ERFORNED BY: SCOTT B ARMEN MD TRAUMA SUAGERY D 12,+1a'/11 1M~19:! ! I , I °RITICAL CARE FIRST tRL D2,+0:1/12 NA>QFKM BENEFIT'S PAID D,L+2.!/1P BLUE SHIELD PAYMENTIE ~'ERFOAMED BY: ROGERIO I NEVES MD DIV PLASTIC R@ ,~< LL,1;~/11 !N!231! ! !,1 SAILY HOSPITAL CARE D~L'1?i/12 MA>@KM BENEFITS PAID DiSVD;'/12 BLUE SHIELD PAYMENTS ~ r 71/lsi/IY Bl.lk SHIELD PAYMENT , 1iS/lb/1P 8 SHIELD CONTRACTUAL ADJ 6 ii ERF'dB1ED BY: RICKNESVAR MAHRAJ MD DIV OF DIAL I'.' 1.>!1N/I1 '17dq'.02fEi 9 ~ .1' rHEST 1 VIEN 1:VIt4f./12 MAIDl1M BENEFITS PAID ,; )SV:Lk/lY BLUE SHIELD PAY!@R~ I 1?V14~,/lY BLUE SNIELO PAYMEN f , lVa4,/12 D SlD:ELD CONTRACTUAL A }, PERFOIBED BY: SCDIT B ARMEII MD TRAUMA SURGERY D:' C>J'1B/11 !W23:!I :+i !! .0 : AILY HOSPITAL CARE II III IIIII IIII I I I''L ~ ,] I~III'IIIIII 1 IiiC l; I! i I 1 =LATER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACI n m i n~i nu i IrZ~ ~gilton -_ .. __. _ S. ~-I~~`s~3e IViedical Cerat~r ~; ~MY ~ ~, PLEASE CONtACr~ AA$ 21IWH13KEy SP _ BOILINGSPRINCgIpq ~RD 7007-9518 4000UNT # 7510989 8a g -~~ S7AiEWE~ aarE: 12/ s ~ HA~r > usrsrarE~N? r' _ ` ~ ° LENT FINApIC1Al SERVICES uAre: 07/25/12 0201/12 ~ ~ ~'~~~~'~ ~ QT'Y' OESCRIP'TI(~, , 112,'2?J12 ~ MAkTH.IM '' ;~ FED TAX ID # 2S78S7p3g ti, BENEFITS PAID BLL `;I+T~i e° 12/19/11 7101026 01/24/12 D2l]5/12 03/14/12 D3/14/12 12/14/11 7356p26 D2/OL12 02/22/12 2/19/11 7361026 vDL12 2/22/12 B PAYMENI3E ~ r ^~~~ ~ t» , ?.. gy'p' .,,, 511.9 PERFCRHEJ BY: MICHAEL M MppRE HD DIV 0.00 ~.~ CNES7 `;il`W OF DIA6 RAD MA]ilr~f BENEFITS PAID BLlk '~~r'Et~B PAYHENAE BLUE :>wTER.D PAY~~ B ~',' ; TONTRACTUAL A 822.0 ~E~ ~').~~ TIIp1'HV J MOSHER MD ply OF MA%IM,at BENEFITS PAID BLUE Siil=; p PAY~,* 8~'4 AIKLE UiNi=! ETE• MAXIMA'! BENEFITS PAID BLUE SNT~,~ PAYMENT~t IOL06Y 83. ~ DIA6 RADIDL06Y 80.00 80.D0 '/19/11 99232 518.0 PERF~''~ ~Y: DANA 6ALVAH M1 TRAUMA 101/12 DAILY IRYtPZTAt CARE SlJA6ERY ply /22/12 MAXDIAy BENEFITS PAID Y29.00 BlllE SHIx),7 PAYIO:Nf3I 'YO/11 99232 518.D 01/12 DAILY IQ4laIt'di CARE 22/12 MAXIIIRI BENEFITS PAID BALANCE; GAIL L BQA7ER BLUE SID:F?.U PAYFIEIRS AS A ~JRT'ESY Tp p~ ;TATIENTS, ---..+' ~STIOIBLLABpIT ~ ~~ 111SURANCE CDlR~AIQES. IF ~~~ ~~T TIREII DIRECTLY. YDtM DANCE CMPANY PAID, PLEASE SHD TO KJFLBpI COLLEo"Tl'DNS/pp ~ ~~~ NILL PA 170p1 KEE~p ~ IS FOR PHYSICIAN SERVICES ONLY. 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ORES G'~p _~ _N- K- I SIGWATURE _~ ENTERANVADD ~~- R~ORINSURANCECORRECpO~. r 9w 8 punt Management Sox 8875` PA 17001-8875 nberly Brown ~(PSF•S POgl Oy qr'F`' 2 / r, ",~~i ..~ ...v ~ VITHEY BpYYFF 0003107362 JAN 18 ~ ~?:) b?AILED-FROM ZIP CObE 'i;l i Cumberland Probate Court Courthouse Square Room 10~ Carlisle, PA. 17013