HomeMy WebLinkAbout04-22-13 STATE OF (ehn5 Y/VU n
In Re:
Case# t� � �l - l �/cI In the C u i $r)AND +�r6bcJe.('06W-'1
Estate of: S n t3, hIVY' a C U L),--f n W'5 e-
f &(`I15 l 013
STATEMENT OF CLAIM
1. Select Medical Corporation/Bureau of Account Management hereby presents for
filing against the above estate this statement of claim in the amount of
$ 7 D dy
(-.> ;�o rn
2. The basis for the clai is Account# 13 '715- for date of =0 G
service/D/(,//J 7�d-. '
r-' m ry
3. The tax identification number of the claimant is 23-2892355. n ��
3 C-) C' -71 '
43 C)
4. The name and address of the claimant is: Bureau of Account Man a ent 360.7 M
Rosemont Avenue Suite 502 Camp Hill, PA 17011. Phone#717-2i-4- 005. r}
5. This claim is not contingent.
6. This claim is not secured. f
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.
+l,
Executed tbis�8_day of A h t�1 L ' 2013
iT";—'&' I
Angel Brok Phone# 717-214-3005 Bureau of Account Management Claimant
abrown @outtechinc.com
State of Pennsylvania, County of Cumberland }�
IN WITNESS WHEREOF, I have set my hand and notarial seal this day of
Ap- i 1 52013
I CC
Notary Public
My Commision Expires: COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
HEATHER E.SCHWEAR,Notary Public
Lower Allen Twp.,Cumberland County
My Commission Expires November 19,2016
SSH CAMP HILL SSH CAMP HILL 476 0013715-01
503 NORTH 21ST STREET PO BOX 642369 5336 0111
CAMP HILL PA 170112288PITTSBURGH PA 15264
717-972-1100 251885943 101612 111712
211181705A 103 W KELLER STREET
BINGHAM STANLEY MECHANICSBURG PA 17055
08051924 M 10161218 3 4 20 20
BINGHAM STANLEY
103 W KELLER STREET O1 12850080 3200
MECHANICSBURG PA 17055
PHONE (717) 350-0865
0120 ROOM & BOARD 1285 . 00 32 4112000
0250 PHARMACY GENERAL 1267 1038350
0258 PHARMACY IV SOLUTIONS 590 289425
0270 MED/SUR SUPPLIES GENERAL 1317 857900
0300 LABORATORY GENERAL 70 667537
0320 RADIOLOGY DIAGNOSTIC GENE 8 374884
0350 CT SCAN GENERAL 2 449466
0410 RESPIRATORY SERVICES GENE 807 1651980
0420 PHYSICAL THERAPY 18 182820
0430 OCCUPATIONAL THERAPY GENE 16 136730
0440 SPEECH PATHLOGOY GENERAL 6 98450
0730 EKG/ECG GENERAL 1 19954
0731 HOLTER MONITOR 32 774400
0940 OTH THERAPEUTIC SERVICES 3 73314
0942 EDUCATION/TRAINING/DIETAR 10 23760
0001 1 1 112712 10750970
1346248333
CAPITAL BC SR BLUE HMO Y Y 390299
MCR SHADOW NS 392039 Y Y 392039
BINGHAM STANLEY 18 YWW80104675000 00520168
BINGHAM STANLEY 18 211181705A
121002791
518 . 84Y 428.21Y 425 .4 Y 263 . 0 Y 584 .9 N 518 . 0 N 276 .4 N 276 . 0 N 428 . 0 Y
9 414 . 01Y 585.3 Y 250 . 02Y 244 . 9 Y 272 .4 Y 281 . 9 Y 787 .20Y 294 .20Y 719 .41Y
428 .21 189 189
1790786499 1GC30374
93 . 90 110212 99 .60 111712 COHEN HOWARD
1790786499 1GC30374
COHEN HOWARD
MCR SHADOW NS B3282E000OOX
PO BOX 890122
CAMP HILL PA 17089-0122
POST DATE: 11/27/12 476 0013715 Elec Billed * REPRINT
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