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Home My WebLink About06-07-13 STATE OF In Re: t / Case I Z — f'��J In the L"kOln &d4L" //r Estate of: e 3 STATEMENT OF CLAIM 1. Hershey Medical Center/Bureau of Account Management hereby presents for filing against the above estate this statement of claim in the amount of VL/ � rv� 1 CIN M 2. The basis for the claim i ccount# /�S t��y/� for date of 1 o � o service 1:24 IZ - %Z " rn ' o z U, v Ay= r mrn 3. The tax identification number of the claimant is 23-2892355. r Z rn a Q � v? � o 0 0 -v n -*r 4. The name and address of the claimant is: Bureau of Account Managemens 3491 Rosemont Avenue Suite 502 Camp Hill, PA 17011. Phone#717-214-30(1?. r~a m 5. This claim is not contingent. a 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 t is 3,d day of u. e 20_1 3 Angel Brown hone# 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 3 "� day of SV, c� 20 13 Notary Public My Commision Expires: 1 I b COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL HEATHER E.SCHWEAR,Notary PuJ2016 Lower Allen Twp.,Cumberland Cou My commission Expires November 19, �� I [� STATEMENT OF PHYSICIAN SERVICES PENNSTATE HERSHEY GERALD L MANHOLLAN PAGE 1 of 1 35 WEST KELLER STREET Wton S. Hershey MECHANICSBURG PA 17055.8338 DATE 0STATEMENT 2113 Medical Center LAST STATEMENT ACCOUNT# 2133773 DATE: 02/22/13 IF ANY QUESTIONS,PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES __ FED TAX ID# 251857035 •o+.. .w ...v __ . ♦ X' ♦ w-...w.—.ary•y.yW+vw.r. _r'+w w DATE -PROCEDURE 'plpG � ."`- ' ' � PAYNIENTI GUARANTOR .CITY DESCRIPTION INS' CHARGE CODE CODE, ADJUSTMENT BALANCE 18529561 PERFORMED BY: CHRISTOPH E BREHM MD PLACE OF SVC: INPATIENT 12!04/12 99291 785.51 CRITICAL CARE FIRST HR 773.00 773,00 BALANCE: GERALD L MANHOLLAN 4773.00 AS A COURTESY TO OUR PATIENTS, MSHMC PHYSICIANS GROUP MILL SUBMIT BILLABLE CHARGES TO INSURANCE COMPANIES. IF YOU HAVE QUESTIONS ABOUT THE AMOUNT YOUR INSURANCE COMPANY PAID, PLEASE CONTACT THEM DIRECTLY. SEND TO KJF1/BAM/PO BMC 8875/CAMP HILL PA 17DOI THIS STATEMENT IS FOR PHYSICIAN SERVICES ONLY. IN ORDER TO KEEP YOUR ACCOLNT CURRENT, OUR POLICY IS TO APPLY YOUR PAYMENT TO THE OLDEST WITSTANDING BALANCE. YOU MAY ALSO RECEIVE A STATEMENT FOR HOSPITAL FEES. THANK YOU FOR USING MSHMC PHYSICIANS GROUP FOR YOUR PHYSICIAN SERVICES. N�BALANCE SUMMARY RESPONSIBLE PARTY POLICY It TOTAL e legit GUARANTOR RESPONSIBILITY 4 773.00 N IMPORTANT:PLEASE DETACH AND RETURN @07TbM PORTION OF STATE7{�ENT WITH YOUR PAYMENT STATEMENT DATE GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT: BFIS 05102/13 $ 773.00 $ 773.00 MSHMC PHYSICIANS GROUP BILLING SERVICES P 0 BOX 854 HERSHEY PA 17033-0854 00002133773 UP 0000000000077300050213 ••1111••• Id11�111E11EP141 IXIdXlllllr•t1...1'Ih1'11r1Eltll Mall MSHMC PHYSICIANS GROUP GERALD L MANHOLLAN T« MSHMC PHYSICIANS GROUP 35 WEST KELLER STREET PO BOX 643313 EGA PITTSBURGH PA 15264-3313 MECHANICSBURG PA 17055-6338 OFRCE USE ONLY CNUCKONE FOR CREDIT CARD PAYMENT,PLEASE FILL IN INFORMATION BELOW -"-"' R -11 -ACCOUNT-*: M!C CAR!NUMBER B I ' I I , ' I I EXP DATE $ 773.00 G21337T3 05/23/13 ' � I ' � VISA DISC A]AOUNT- HCc F68O — CARDHOLDER NAME(PRINT) ENCLOSED: TYP-. DMND - - CREDIT CARD SIGNATURE MSHMC PHYSICIANS GROUP ❑CHECK BOX AND ENTER ANY ADDRESSOR INSURANCE CORRECTIONS ON BACK i IF THERE ARE ANY MISSPELLINGS OR ERRORS, PLEASE PRINT CORRECTIONS. Guarantor's Name Phone a Guarantor's Address City State Zip Code Patient-s Relationship to Insured Patients Relationship to Inau R PRIMARY Pa[3 SELF (^]SPOUSE SECONDARY INSURANCE COVERAGE QCHILD OOTHER INSURANCE COVERAGE ❑SELF ❑SPOUSE ❑CHILD (]OTHEfl Insurance Company Nome Phone B insurance Company Nam Phone s ( I I 1 insurance Company Address Insurance Company Address Policy Holder's Name Birthdato Policy Holder's Name Birthdato Policy 6 Group a Policy Effective Date Policy S Group s Policy Effective pate Employee's Name Phone N Employee's Name Phone a t J Employer's Address Employer's Address Page: 1 Document Name: Eclipsys MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 05/01/13 at 10:31 AM Guarantor: MANHOLLAN GERALD L 35 WEST KELLER STREET BGA MECHANICSBURG, PA 17055-0000 Patient: MANHOLLAN GERALD L Visit #: 18545699 - -- -- -- - --- - - --- - - -- - - -- - - - - - - -- - - -- - -- -- - -- -- - -- - - -- - - -- - - - -- - -- - -- --- - -- - -- - - - Date Svc Code I Description I Unitsl Debits I Credits - - --- - -- -- -- -- -- - - - - --- - - -- - - -- - -- - - -- - -- - - - -- - -- - - - - -- - - - - - - -- - -- - - -- - - - -- -- - - - 112/03/12 711107 AIR AMBULANCE TRANSPOI 1 1 14065.00 112/03/12 711108 AIR AMBULANCE MILEAGE113.2 1 2310.00 103/31 /13 980090 HOSPITAL BAD DEBT W 101 -1 1 1 16375.00- 1 103/31/13 980091 HOSPITAL BAD DEBT PLAN 1 16375.00 More to Display - Press Return to Continue or * to Quit 1 Sess-2 150.231 .5. 14 1 24/76 Date: 05/01/13 Time: 10:31 :45 Page: 1 Document Name: Eclipsys MS HERSHEY MEDICAL CENTER PAGE: 2 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 05/01/13 at 10:31 AM Guarantor: MANHOLLAN GERALD L 35 WEST KELLER STREET BGA MECHANICSBURG, PA 17055-0000 Patient: MANHOLLAN GERALD L Visit N: 18545699 - -- - -- - -- - - -- - - --- - - - Date - -- - -- - - - Svc Code Description Unitsl Debits - - -- - -- - - - -- - - Credits - -- -- - - - -- - -- - - -- - - -- - - - -- - - - - - - - - - - - -- - -- - - -- - -- - - - -- - - - - - - - - - - - - - -- -- - - - -- -- - -- -- - - -- - -- - - - - - * - Not posted '- ' -' - - - -- - -- - - Balance: 1 16375.00 >End of Display - Press RETURN to Continue 1 Sess-2 150.231 .5. 14 1 22/12 Date: 05/01/13 Time: 10:31 :48 Page: 1 Document Name: Eclipsys MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 05/01/13 at 10:32 AM Guarantor: MANHOLLAN GERALD L 35 WEST KELLER STREET BGA MECHANICSBURG, PA 17055-0000 Patient: MANHOLLAN GERALD L Visit #: 18529561 - - - • - - -- -- - -- - - -- - Date --- --- - -- Svc Code Description I Unitsl Debits I Credits 112/03/12 273954 DOPAMINE 400 MG BAG 10 21 .65 112/03/12 275615 NEXTERONE 360MG/200MLI 12 78. 10 112/03/12 600504 AMBUBAG ADULT W/MASK 1 1 41 .00 112/03/12 621043 IV 0.9%NACL 500ML 7 112/03/12 3.00 661154 ORAL ENDOTRACH TUBE Al 1 41 .00 More to Display - Press Return to Continue or * to Ouit 1 Sess-2 150.231 .5. 14 1 24/76 Date: 05/01 /13 Time: 10:32: 19 Page: 1 Document Name: Eclipsys MS HERSHEY MEDICAL CENTER PAGE: 2 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 05/01/13 at 10:32 AM Guarantor: MANHOLLAN GERALD L 35 WEST KELLER STREET BGA MECHANICSBURG, PA 17055-0000 Patient: MANHOLLAN GERALD L Visit #: 18529561 -- -- -- - -- - -- - - - -- - - - -- - - -- - -- - -- - _ __ - - - - -- - - - - - - -- - - - - - - - - -- - Date Svc Code I Description P I Unitsl Debits I Credits � -- - -- - - - - - - - - - - -- - - -- - - - -- - - -- - -- - - - - - 112/03/12 670520 TRACH CARE SYSTEM 14 1 1 1 79.00 112/03/12 670710 KIT MONITOR ADD-ON W/ 1 2 1 48.00 112/04/12 11440 I ADULT ICU/1 : 1 CARE 1 4986.00 112104112 111702 I STAT GASES 112/04/12 111703 I STAT NA I 1 142.00 1 � 29.00 � More to Display - Press Return to Continue or * to Quit 1 Sess-2 150.231 .5. 14 1 24/76 Date: 05/01/13 Time: 10:32:21 Page: 1 Document Name: EClipsyS MS HERSHEY MEDICAL CENTER PAGE: 3 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 05/01 /13 at 10:32 AM Guarantor: MANHOLLAN GERALD L 35 WEST KELLER STREET BGA MECHANICSBURG, PA 17055-0000 Patient: MANHOLLAN GERALD L Visit #: 18529561 - - -- - -- - - - - - - -- - - -- - � Date - - • - - -- - - Svc Code Description Unitsl Debits Credits 112/04/12 111704 I STAT K 112/04/12 111705 1 I STAT ION CA 1 1 I 29.00 112/04/12 111706 1 I STAT HCT 1 1 1 47.00 112/04/12 246144 EPINEPHRINE HCL 1 MG/ I I 30 I 30.00 112/04/12 1 246264 I LIDOCAINE 100 MG/5 ML 10 1 21 .90 1 6.80 I 1 More to Display - Press Return to Continue or * to Quit 1 Sess-2 150.231 .5. 14 1 24/76 Date: 05/01/13 Time: 10:32:23 Page: 1 Document Name: Eclipsys MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE PAGE: q HERSHEY, PA 17033 Statement on: 05/01/13 at 10:32 AM Guarantor: MANHOLLAN GERALD L 35 WEST KELLER STREET BGA MECHANICSBURG, PA 17055.0000 Patient: MANHOLLAN GERALD L Visit #: 18529561 - -- - -- - - --- - - Date I Svc Code - -- Description Unitsl Debits - -- - - - Credits 112/04/12 246475 SODIUM BICARBONATE 501 3 1 46.50 112/04/12 246633 ATROPINE SULFATE 1 MGM 100 11 .85 112/04/12 511202 VENTILATOR DAY INITIAL 1 1202.00 112/04/12 661154 ORAL ENDOTRACH TUBE Al -1 112/04/12 670850 CRASH CART DRAWER 3 1 1 41 .00- 1 233.00 More t0 Display - Press Return to Continue or * to Quit 1 Sess-2 150.231 .5. 14 1 24/76 Date: 05/01/13 Time: 10:32:25 Page: 1 Document Name: Eclipsys MS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE PAGE. 5 HERSHEY, PA 17033 Statement on: 05/01/13 at 10:32 AM Guarantor: MANHOLLAN GERALD L 35 WEST KELLER STREET BGA MECHANICSBURG, PA 17055-0000 Patient: MANHOLLAN GERALD L Visit #: 18529561 Date Svc Code -- - -- - --- - - - - -- - -- - - I Description Unitsi Debits Credits � 103/31 /13 980090 HOSPITAL BAD DEBT W/01 -1 103/31/13 980091 HOSPITAL BAD DEBT PLAN 1 7055.80 - -- - • - -- - - - - -- - - - - - - -- - - - - - - -- - -- - I 7055.80 * Not >End of Display - Press RETURN to Continue Balance: 7055.80 1 Sess-2 150.231 .5. 14 1 22/12 Date: 05/01/13 Time: 10:32:27