HomeMy WebLinkAbout10-09-13 . �
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IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
In re: Estate of Robert L. Surfield, decedent No. � �� ' ' �.;.�b
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PETITION FOR SETTLEMENT OF A SMAI;�i;, �STATE,
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TO THE HONORABLE JUDGES OF SAID COURT: k �� � `-`� "
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James D. Hughes, Esq., Petitioner, files this Petition for Settlement of a�mall Estate
under the provisions of Section 3102 of the Probate, Estates and Fidu�iaries Co�l� and in�support
thereof avers that: ��- ,--� • ....`;
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1. Your Petitioner, James D. Hughes, Esq., is a shareholder in the law firm of ,
Salzmann Hughes, P.C. and maintains a law office at 354 Alexander Spring Road, Suite 1,
Carlisle, PA 17013.
2. Decedent, Robert L. Surfield ("Decedent"), who died May 7, 2013,resided prior
to his death at 210 Big Spring Road, Cuinberland County, Carlisle, PA. He passed away at Life
Care of Mechanicsburg in Mechanicsburg, PA. A death certificate is attached hereto as Exhibit A
and incorporated herein by reference.
3. Decedent died testate, leaving a self-proving Last Will and Testament, dated July
� 19, 2005 ("Will"), the original of which is attached hereto as Exhibit B and incorporated herein
by reference. The Will has not been probated.
4. The Executor named in Decedent's Will is Joseph C. Bowen. Due to health
concerns, Joseph C. Bowen executed a Renunciation to decline the right to administer to the
estate of Robert L. Surfield, whereby passing the duty to the substitute Executor, James D.
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Hughes. Mr. Bowen subsequently died on July 7, 2013. A copy of the signed Renunciation
form is attached hereto as Exhibit C and incorporated herein by reference.
5. The Executor is not required to post bond.
6. The sole beneficiary under the Will is Joseph C. Bowen, per stirpes.
7. There is no claim for family exemption.
8. Neither the Petitioner nor anyone else has received or retained any property of the
Decedent by payment of wages under Section 3101 of the Probate, Estate and Fiduciaries
Code, or otherwise. The Decedent at the time of his death was unemployed.
9. The entire inventory of decedent's estate is listed below with a total balance of
$4,346.23, itemized as follows:
a. F&M Trust checking account $ 3,189.60
b. Refund check from Presbyterian Homes
Senior Living $ 486.37
c. Presbyterian Homes, refund of petty cash $ 162.01
d. Cash on hand $ 5.14
e. Adams Electric Coop patronage
capital account $ 503.11
Total...........$ 4,346.23
10. The debts of the decedent's estate (prioritized pursuant to 20 Pa.C.S.A. §3392) are
as follows:
Cate�y#1:
(a) Filing fee to Cumberland County Orphan's Court $ 43.50
(b) Filing inheritance tax return - Cumberland County Reg. of Wills $ 15.00
(c) Salzmann Hughes, P.C., estate administration fee $ 500.00
(d) Certified mail costs, advanced by Salzmann Hughes, P.C. $ 7.00
(e) Salzmann Hughes: power of attorney services provided
(pre-death) regarding decedent's medical care and
deteriorating condition, for period of 4/30/13 to 5/7/13 $ 2,280.00
(Invoice is attached as Exhibit D and incorporated herein)
(� Engraving of headstone $ 140.00
(g) Executor commission $ 500.00
Total.........$ 3,485.50
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Cate�ory#2: None
Category#3: Balance Remaining
Dire Share
(h) Pennsylvania Department of Public Welfare
(See Exhibit E incorporated herein by reference) $ 25,475.50 $860.73
(there are no other creditors to share pro rata)
Cate�y#4: None
Categorv#5: None
Cate�orv#5.1: Pennsylvania Department of Public Welfare $ 424,341.68
(See Exhibit E incorporated herein by reference)
Categorv#6: None
11. Petitioner respectfully request the Court's approval to distribute assets of the
Decedent's estate to satisfy the debts in Category#1 (a), (b), (c), (d), (e), (� and (g) in full, and
any remaining funds to satisfy Category#3 (h) Penna. Department of Public Welfare; at which
time all funds will be exhausted entirely.
WHEREFORE, Petitioner prays that your Honorable Court direct that the assets of the
Estate of Robert L. Surfield, deceased, be distributed as above stated.
Respectful submi ,
S MA G S, P.C.
Dated: J d. �. �3 By:
am ug es, Esq.
Petitio er
Att ey I.D. #58884
4 Alexander Spring Rd., Suite 1
Carlisle, PA 17015
717-249-6333
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VERIFICATION
I verify that the statements set forth in the foregoing Petition are true and correct to the best of
my knowledge, information and belief. I understand that false statements made herein are
subject to the penalties of 18 Pa. C.S.A. § 404, relat' to uns orn f sification to authorities.
a s D. Hughes, Petitioner
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF �rq,� � �� ;�, :
Sworn and subscribed before me
this�day of Qc�� , 2013.
��Y----�
Notary Public
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N0IARIAL��AL
KAREM1f P. i;EFLIN
Nutaiy Fuolic
CHAMBERSBUF�BOHG.,FHANKIIN CNTY
My Cumm�ssion Exp�res Jun 14,2017
4
H105.905 REV.(8/11) � ' �
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in acccnrdance wvith
the Vital Statistics Law of 1953, as amended. �
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WARNING: it is illegal to duplicate this copy by photostat or photograph.
,,,,,,,,,,,,,,,,,... `"�atn.w.� ��1��`'IN�c�.�Cd�Q.w
,���,,���p�1H OF PF,yy:_
`����`o� J'�_� Marina O'Reilly Matthew
��_ = Z z State Registrar
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_* - *'°' MAY 16 2013
7386079 ��`���91M E��;a`�''��
ENT 0,,,,,
No. �""iA� Date
�� TyPe�p��t�� � COMMONWEALTH OF VENNSYLVANIA•DEPARTMENT OF HEALTH�VITAL RECORDS
,«,,,a„e„z CERTIFICATE OF DEATH Stafe Flle Number:
Black Ink Last,Suffix 2.Sex 3.Social Security Number 4.Date of Death(MO/Day/Vr)(Sp�ll Mo)
1.Decedeni's legal Name(First,Middle, ) 19 g-1 8-5 6 9 5 May 7, 2 O 1 3
Robert L. Surfield male
Sa.Age-Last Birthday(Yrs) Sb.Unda�1 Year Sc.Undcr 1 Oa 6.Oafa of BiKh(MO/Oay/Vea�)(Spell Month) 'a�DoPn a 1 d s on���rPA g�co,,.,c.vi
�� 87 Moncns oav� Ho�� ^^�^1Ce5 November 18 , 1925
7b.Birthplace(COUnfy) SCYlU Z}C 11
Sa.Residence(Siate or Foreign Country) 8b.Residence�Street antl Nu ber-�^��R o a d�-� 8c.Ditl Decedent Live in a Tp�wn�sNP� P enn sbo r o
2 1 O B i g S p r�n g ves.a«�eeoe u��a io w t cM,v.
pennsylvan i a .. . .
Sd.Resitlence(COUnCy) �No,decetlant IIV�G within Ilmits of ciiy/bo�o.
Cumbe Y 1 a nd sa.ae:iae.,ea(ziP coae�l'7 2 4 1 � �io ri.sc..,a���ae�l
9.Ever in US Arm�d ForcesT 10.Marital Status at Tima of Death �Married �[W�dow¢d 11.SurvivinQ Spouse's Name(If wife,give name p�o
�Ves Q No OUnknown 0�WOrcad 0 NeverMarrletl �Unknown
12.Faiher's IVam�(Firs�,Mitltlle,LasS,Sufflx) 13.M Nam Prlo Firsi Marri Fir M'ddle,Lasc)
Thomas John Surfieid �'anna� �:gnus �b���
14a.Informani'S Nam . 14h p lat 3�_P L �ecedent 14c-JniorA�anLS MaiIlQ6.�������e�ya��y�Clt��ateG.TigiP�e i S 1 e
James f-IUghes ALLV Ile .�7`t H1e
� '"""'"' Factl �""""'"' �ced�nt 5 Home ��""
G .............'••....."""'""�+."'""•••..�.••.....••.......•••.-..•••"""':If Death Occu��etl SomewhereCOthe�Th n a HosPital:'• •..�'HOSPice " '�ity""
"'."""""...'""."'"""_"""""" a _ _ . ...
...t J D
s If Death Occ��red In a Hospital: LJ �^Pat e^� rsin Home/LOng-T�rm Care Facility Other(Spectfy)
° �Emergency Room/OUipatlent O Dead nn A��IVaI � B
°d ISb.FaciliTy Name�ir.,o:�.,:c�c.,cioo,s��e sc�eec��d��mbe�, l$O.°{�e c�ia n i c s7bPU r g PA 1 7 O 5 O l�ux°t'��tYe°�f�n d
Life Care of Mechanicsbur P��. � ry,��m�co P �
16a.Me[hod of DisposiYion �(]�BUNaI � Cremation 16b.Dace of�isposition 16c.Vlace of Dis (ion Name of cemete ry,or oihar lace
m pReR1OV„f�o,,,s�,�e poa�ec�o., 5/13/2013 Newville Cemetery
� Other(Sp�cify)
16d.Location of DlsposlHOn(CISy or Town,Stafe,and 2ip) 1'la.SignacypCOf Servi e License�or Person in Charge of I�termeM 17b.License N�amber
� Newville PA 17241 ''� � Fo �3a95L
�
I7c.Name and Complete Address ot Funeral Facllity
,g E er Funeral Home Inc 15 Big Sprin Ave Newviile. PA 172
� 18.Decetlent's Education-Check the box thaf besf describes She 19.Deceden[of Hispanic OriQin-Check the 20.Decedent's Race-Ch�ck ONE OR MORE racls to indicat�what
high�zt degree or Iwal of school compleCed at tl�a timo of tleath. box ihat bes�tlescribes whether the decetlent th decedeni consitleretl Fiimself or herse�Korean
�StM1 grade or less Is Spanish/Hispanic/Latino. Check ihe"NO" �Whlte �Vietnamase
� No Alploma,9th-12th grade box if decedent is not Spanish/Hispanic/Latino. �e�sck or African American � Othe�Aslan
� 0 HiQh school graduate or GEO compleCetl �No,not Spanish/Hispanic/Latina 0 American Indtan or Alaska Native �
Q Vcz,M�x�can,Mcxican Ameriwn,Chicano �Asian InA�an 0 NativO Hawailan
�Some colleQe eredit,but no tlearee Q y�s,Puerco Rican 0 Fhi iese O Guamanian or Chamo�ro
0 Assotlato degree(e.g.M.AS) 0 yas,Cuban Q P^° Samoan
� Bachelor'S tleQ�ee(e.Q.BA,AB,BS) y�s,other 5 ish Hispanic/Latino Q Japanese 0 Othe�Pacific Islander
Q Mastar's degree(e.Q.MA,M5,MEng,MEtl,MSW,MBA) O Pa� � O Other(Sp�clfy)
O Dottorate(e.g.PhD,EtlD)or Professlonal Aagr�e (Spaclly) �
.MD DOS DVM LLB JD
21.Oeced¢nt's Sin61e Race Self-Oaslgnailon-Check ONLV ONE to Intlicate w1�a�the tlecedeni consitl�reG hims�lf or I��rself to b�. tlone tlu�ingenYs`ofawo`ki�g Iife.1]O NiOT U E RETIRED.
�White �lapanese �Samoan COngtruCt1011 r�oreman
0 Black o�AfHWn ATe�ican Q KO�ean Q O<her Paciflc Islantleer
o �American Indiin or Alaska Native �VI¢tnamese 0 Don'[Know/NOt Sur
�Aslan Intllan �Oihe�Asian �Refusetl 22b.Kind of Buziness/Intlustry
p cnmese p nan�e r+ewaua., O ocne.(so�afv) A rm y B a r r a e 1c s
� p Filipi�l0 O��a�*+a��a^o�cn..,,o��o Government
ITEMS 23�-23tl MUST 6E COMPLETED 23a.Date Pronounced Dead Mo DaV r) 23b.Signaiure o Person Pronouncing Dea(h On1Y when applicable) 23c.License Number
BY PERSON WHO PRONOUNCES OR S`---�� ' r���� •yY
CERTIFIES DEATH
23d.Date SlgneA(MO/�ay/vr) 24.Timi�f�ea<�
I�� � 25. as Metlical Examiner or Coroner ContaccedT 0 Yes No
CAUSE OF UEATH App�oximete
y cause in�e�.a�:
26.Pavt 1. Enfer the hain of e encs-Giseasas,InJurles,or compliWtlons-that direccl A tlie tleach. �O NOT ent�r terminal evenCS such as ca�tliac arr�sx
r�spir�torv�rrwst,or vvnsr�wlar flbrlllat�on wicl+out sMOwing che o[lology. OO NOT ABBREVIATE. Enter only one cause on e Ilne. Add atltlltlonal Iines if ne<essary ; Onset[o Death
CoP O '•
IMMEDIATE CP.USE -------------> a� �
(Final dise ntlitlon oue co(or as e consaq nc�ei):
resultinQ In death)
b Duc fo(or as a conse
Sequentlally Iis2 contlitlons, quence o�:
If any,leading tn the ceuse
Ilscetl on Ilne a. Enter ihe �
UNDERLYINa GUSE Ouo�o(or as a consequence ofl: .
(tlisease or InJury thaS
iniiia[etl che wan�s resulting
W tl Due to(or as a consequence of): •
� In death)WST. �
� 26.PaR 11. Enter oiher i Ifl S tlitl tributina to ticaSh bu[nai resulting in the untlerlying cause given in Part 1 27.Was an a�topzy peAo�etlT
o�e� o��
� 28.Were autopsy flntlings avallable
�
S to complete the ceusey f deathT
0 Vcs gMo
� 29.If Female: 30.Ditl Tobacco Vsc Contribute to D�ach? 31.^M�n�r of Ocath
� � 0 Not pragnant within past year �Yes O Probably �r.. e�.si p No�.,i�me
0 Pregnant at Nme of deaHt � No ��Unknown 0 Accident Q Pending Invascigafion
$' � Not p�e6�sn�,buS prctnant witf+in 42 days of death Q Su�Cltlo Q Coultl�at be tlefe�minetl
0 Not pregnant,but preg�ant 63 days to 1 year before death 32.Date of Injury(MO/Day/Yr)(Spell Monih)
Q Unknawn if pr�anant withln tM1e pasc year 33.Time of Injury
34.Place of Injury(o.H-hame;const�uction slte;ta�m;sGhool) 35.LOCatio�of Inj�ary(Strect snd Numb«,C�ty,Stet�,Zip Cotic)
��
36.I�jury ac Work 37.If Transportatlon In7ury,Specify: 38.oescribe How Inj�ry Occurretl:
� 0 Ves 0��Ne�/Ope�etor � Petl�st�lan "
�JO �ViSUngef Q O(her($pBCify)
39a. rtHl¢�(Check only one):
�CerH1y1n6 Physielan-TO the best of my knowledge,death occurrrd dur to the cause(s)antl manner s�aYed
�Pronouncing 8.Certirying physician-To the bes�of my knowledge,death occurretl at the ilme,tlate,antl place,and tlue to the Cause(s)antl manner statetl
�MeEical Exeminar/Coronar-On tM1a�J bas/is•of ex mina lon,and/or Invostlgailon,In my opinlon,tlearths occurretl et the Ylme,tlace,and place,and due to th�ye caua�(s)and ee r stated
Sl�neturc of certifier: �S /`� � Title of certlFle�: /� � Licens�Numbe��/-"� �/�7 Y D �•
39b.Name,AEtlross and Zip Cotle of Pe�son Comp/leting a /vf Oe�f(Ifem 26) / Y � �'O y� 39cS.,,�D�1e Slj�'A(MO/Day/Vr)
/GNI�6L L. 6G UG/( (Og US.G�.r//!!iC � . L�� �✓C � � J
� 40.ReQistra�'s Distrlct Number 41.Regist�ar s Signatu�e � 62-R�gisaar F{le Date(Mo Day )
a1-a lo �-1.�'1 "-,��- �- \o ao t3
� 43.Amentlm�nH �
'� `� �' � ., � � � 4.
.. � ,. .. .r, �,Po.. ��c� �'�w ✓'" a � � °��?'.
G`6`z(3`�-I ��05-�<3
Disposition Permit No. REV 07/2013
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LAST WILL AND TESTAMENT
I, ROBERT L. SURFIELD, of West Pennsboro Township, Cumberland County,
Pennsylvania, being of sound mind, disposing memory and full legal age, do hereby make,
publish and declare this to be my Last Will and Testament, hereby revoking all Wills and
Codicils heretofore made by me.
ONE. I direct my Executor or Executrix, as the case may be, to pay all of my
debts, funeral and administrative expenses as soon as convenient after my decease. Furthermore,
I direct that all state, inheritance, succession and other death taxes imposed or payable by reason
of my death and interest and penalties thereon with respect to all property composing of my �
gross estate for death tax purposes, whether or not such property passes under this Will, shall be �
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paid by the Executor or Executrix of my estate. Further, to the extent that sufficient assets exist �
in my estate, any and all inheritance or other estate taxes, whether to non-charitable or charitable �
beneficiaries, shall be paid by my Executor or Executrix from the residuary of my estate. �
TWO. My Executor or Executrix may, at his or her discretion, compromise
claims, bonow money, retain property for such length of time as he or she may deem proper;
lease and sell property for such prices, on such terms, at public or private sales, as he or she may
deem proper; and invest estate property and income without restriction to legal investments
unless otherwise provided hereunder. I authorize and empower my Executor or Executrix to sell
any realty and/or personalty owned by me at my death and not specifically devised or
bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or
bills of sale therefor, in fee simple, as I could do if living. My Executor or Executrix is
authorized and empowered to engage in any business in which I may be engaged at my death, for
such period of time after my death as seems expedient to said Executor or Executrix.
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THREE. I give, devise and bequeath all of my estate of whatever nature and
wherever situate to JOSEPH C. BOWEN, per stirpes, which provides that the child or children of
any deceased beneficiary shall take the share their parent would have taken if living.
FOUR. I hereby nominate and appoint JOSEPH C. BOWEN to be the Executor of
this my Last Will and Testament. In the event for whatever reason he is unable to serve as the
Executor of my estate, then in that event I hereby appoint JAMES D. HIJGHES to be the
substitute Executor of this my Last Will and Testament, whereby the said substitute personal
representatives shall have the same powers as are given to the original Executor hereunder.
FIVE. No person(s) shall benefit hereunder unless such beneficiary shall survive
me by sixty(60) days.
SIX. No Executor acting hereunder shall be required to post bond or enter
security in this or any other jurisdiction.
SEVEN. No beneficiary may assign, anticipate or pledge its interest in any income
or principal held or distributable hereunder, and no beneficiary's creditors may levy, attach or
otherwise reach any such interest.
EIGHT. It is hereby my intent to specifically exclude my son, Robert L. Surfield
Jr., from any inheritance whatsoever under this my Last Will and Testament.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this �day of July,
2005.
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(SEAL)
ROBERT L. SURFIEL
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Signed, sealed, published and declared by the above-named person as and for a Last Will
and Testament, in our presence, who at said person's request, in said person's presence and in the
presence of each other have hereunto set our names as subscribing witnesses.
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ACKNOWLEDGMENT AND AFFIDAVIT
WE, ROBERT L. SURFIELD, RONDA L. WICKARD and KAMELA S.
CORNMAN, the testator and witnesses respectively, whose names are signed to the foregoing
instrument, being first duly sworn, do hereby declare to the undersigned authority that the
testator signed and executed the instrument as his Last Will, and that he had signed willingly,
and that he executed it as his free and voluntary act for the purpose herein expressed, and that
each of the witnesses, in the presence and hearing of the testator, signed the Will as a witness and
that to the best of their knowledge the testator was, at that time, eighteen years of age or older, of
sound mind and under no constraint or undue influence.
� o�, �....��Yt�'
RO ER L. SU EL
- � c.�<-�,�
R . ND L. WICKA `
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KAM LA S. CORNMAN
COMMONWEALTH OF PENNSYLVANIA .
: SS:
COUNTY OF CUMBERLAND .
Subscribed, sworn to and acknowledged before me by ROBERT L. SURFIELD, the
testator herein, and subscribed and sworn t efore me by RO A L. WICKARD and
KAMELA S. CORNMAN,witnesses,this��day of July, 005. �
COMMONWEALTH OF PENNSYLVAMA
Notarial Seal �
Jacqueline L.Drawbaugh,Notary Public
South Middieton Twp.,Cumberland County o ary Public
My Commission Expires Aug.14,2007
Member,Pennsylvania Association of Notaries
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RENUNCIATION
REGiSTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA
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Estate of Robert L Surfleld , Deceased
�� Joseph C. Bowen in my capacity/relationship as
Executor of the above Decedent, hereby renounce the righf to
administer the Estate of the Decedent and respecffully request that Letters be issued to
James D. Hughes
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i le Dr.
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Carlisle,PA 17015
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Executed in Reg�ster's Offlce Executed out of Register's O�ce ;
Sworn to ar affirmed and subscribed Before the undersigned personally appeared the
before me this day party executing this renunciation and certified ,
that he or she execu�ed the�en n iation for the
� , , purpos��tated withm on t�.�day �
of , � . �
-.-----����� ��/..�,{�. I
Deputy far Register of Wills Notary Public �
My Commission Expires:
(Signature and seal W Ndery or dhar dfidal lifiad to !
adrMnister oalhs. �►y��t���f . M� !
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NOhllil SBSI �
Tewrlere S.SIeD�isl'r�'Y��
Souf!►Mlddlabon TV�.�Q�be�d�4
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Form RW-O8 Rev.fo-13-20D8 popyrigM(c�2006 tam eoRware onry 7Fie LaricnerGra��Inc, �
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Attorneys at Law
354 Alexander Spring Road, Suite 1 7/16/2013 25868
Carfisie, PA 17015
Robert Su�eld
c!a James D. Hughes, POA
354 Alexander Spring Road, Suite 1
Carlisfe, PA 17013
In Reference To: give invoice to Jen
Hrs/Rate Amount
4/30/2013 JDN Review File/Medica� Research/PC w/Dr/Status/Confer wl JMN 1.80 405.00
225.00/hr
JMN Review File re: Medical !Confer w/JDH/Process incoming mail/RF 2.00 150.00
75.QO/h r
5!1/2013 JMIV PC from Life Care/Fax from/to Life Care RE: consent I Review Consent/ 1.80 135.00
Confer w!JDH!PC from/to Dr/RF - 75.00/hr
JDH Canfer w/JMN re: various items/Review medical forms !RF 1.50 337.50
225.00lhr
5/2/2013 JDH PC w!Physicians/Amputation/Confer wl JMN 0.75 168.75
225.00/hr
JMN Confer w/JDH/Review File 8�LW info/Review Account 1.60 120.00
75.00/h r
5/3/2013 JMN Review of File/Research/Phone Calls/Canfer w/TS 1.8Q 135.00
75.00/hr
5/6/2013 JMN PC from/to Sue at Dr. Campbell's office/Email to JQH/Confer w/JDH/RF 1.00 75,00
75.00/hr
JDH Confer w/JMN/PC w/Dr re: medical update/RF 125 281.25
225.00/hr
5!7/2Q13 JMN PC from Dr. Inners RE:status!Confer w!JDH/Research File/Email to JDH 1.80 135.00
&TS 75.00/hr
JDH Canfer w/JMN/PCs w/Phy Care/Hospice/RF re: same 1.50 337.50
225.00lhr
For professional services rendered 16.80 $2,280.00
Previous balance $645.00
1 �
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Robert Su�eld Page 2
Amount
Accounts receivable transac#ions
5/2J2013 Payment-Thank You No. 163 ($645.Ofl}
Total payments and adjustments ($645.00)
Balance due $2,280.00
Please include invoice number and remit payment to address listed above. Thank you for your prampt payment. if you have
any questions concerning your invaice please contact Kandy Coyle at 717-249-6333
. �
�,�� pennsylvania
�1� DEPAFiTMENT OF PUBLIC WELFARE
June 25, 2013
SALZMANN HUGHES
JAMES HUGHES
79 ST PAUL DRIVE
CHAMBERSBURG PA 17201
Re: Robert Surfield
CIS #: 760191187
SSN: ###-##-5695
Date of Death: 05/07/2013
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Mr. Hughes:
Under State and Federal law, the Department of Public Welfare (the Department) is
required to recover medical assistance (MA) reimbursement from the probate estates of
deceased individuals who were over age 55 when such assistance was received. 42 U.S.C.
§1396p(b)(1). 62 P.S. § 1412. This letter sets forth the amount of the Department's claim
against the estate of the above referenced individual and explains the obligations of
executors, administrators, and persons receiving estate property.
Although the amount in the estate may be considerably less than that which
is owed to the Department, our claim is against the estate, no one else.
Statement of Claim Amount
The Department maintains a claim in the amount of $449,817.18 against the
above-mentioned estate. This claim is for repayment of MA granted on behalf of the
decedent. Enclosed is the Department's itemized statement of claim.
A portion of this medical expense, namely $25,475.50, was incurred during the last
six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of
the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the
claim, namely $424,341.68, is to be entered as a priority Class 5.1 claim against the
estate. You should refer to Section 3392 for a more complete explanation of the priority
rules.
If a lawsuit is filed for injuries sustained by the decedent prior to death, then the
Department may also have a lien against the personal injury action. A statement of claim
for that injury-related lien must be requested separately.
Bureau of Program Integrity � Division of Third Party Liability � Recovery Section
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
t �
F�� pehnsylvania
`� DEPAflTMENT OF PUBLIC WELFARE
Your Responsibility to Provide Information to the Department
Please acknowledge receipt of this letter and advise whether the Department's claim
is admitted and when payment may be expected. When the estate accounting is complete,
please provide a copy.
The Department audits all estate recovery claims and therefore we require
documentation to substantiate all deductions from the gross estate. The regulations
governing how the Department computes its estate recovery claim are found in 55 Pa. Code
Chapter 258. These regulations are readily available on the Internet, in addition to being
carried in most local law libraries.
In order to document computation of the amount due the Department, the following
items should be submitted to the address below:
1. For real estate:
a. Copy of the deed
b. Copy of the latest tax assessment
c. Copy of a current appraisal, if available
2. Copy of the funeral bill
3. Copy of the statement of the burial account if one existed
4. Copy of the statement of the personal care account balance at date of death, if the
decedent was in a nursing home
5. Copies of original and updated life insurance policy forms naming beneficiaries
6. Copies of any and all stocks and bonds
7. Copies of bank statements showing balances on the date of death
8. Copies of signature cards or other proof of when accounts were made joint
9. A list of any gifts or other transfers for less than fair market value made by the
decedent (personally or under a power of attorney)
Your Responsibilities to the Department
Under State law, executors or administrators may be personally liable to pay the
Department's estate recovery claim if they transfer estate property without the
Department's claim being paid. Persons who receive that property without paying valuable
and adequate consideration to the estate may also be personally liable. The responsibilities
of the primary next of kin/administrator/executor, is to advise the Department of any assets
in the estate and to ensure that the remaining money, after all funeral and administrative
costs are deducted, is sent to the Department. Accordingly, you must ensure the
Department's claim is satisfied before making distribution of assets to heirs.
Bureau of Program Integrity � Division of Third Party Liability � Recovery Section
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
i . ,
< <
�• pennsylvania
'�!� DEPAFTMENT OF PUBLIC WELFARE
Insolvent Estates and the Fiduciary Responsibility to Creditors
If there are not enough estate assets to pay the claims of all creditors in full, then
the executor or administrator has a duty to act in the best interest of creditors when
administering the estate. If you must spend the estate's money to administer it, you must
act prudently and make purchases as if the money were coming out of your own pocket.
The Department's approval is required if you expect the legal fees to exceed more than the
greater of 6% of the estate assets or $1,000. Contingent fees for estate administration will
generally not be approved. If you do not obtain approval, the Department may consider the
excessive fees to be a transfer for less than valuable and adequate consideration.
Sincerely,
Katie ]. East
TPL Program Investigator
717-772-6713
717-772-6553 FAX
Enclosure
Bureau of Progrem Integrity � Division of Third Party Liability � Recovery Section
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
COMMONWEALTH OF PENNSYLVANIA � '
BUREAU OF PROGRAM INTEGRITY
DIVISION OF�fHIRD PARfY LIABILITY
RECOVERY SECTION
' ' PO BOX 8486
HARRISBURG,PA 17105-8486
June 24,2013
STATEMENT OF CLAIM SUMMARY
NAME Estate of SURFIELD,ROBERT
ID 760 191 187
MEDICAL CLASS 3 CLASS 5.1 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT 80.00 587.81 667.81
LONG TERM CARE 25,390.31 423,133.86 448,524.17
DRUG 5.19 620.01 625.20
REIMBURSEMENT TO DPW 25,475.50 424,341.68 449,817.18
__ _ _------ ----- __ __ .. _ _ _ _ - — - _ _ _ __ --
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN- 23-6003113
Page 1 of 37
COMMONWEAI�TH OF P'ENNSYLVANIA ,
� DEPARTMENT OF PUBLIC WELFARE �
I ' '
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
CARLISLE REGIONAL SPU
246 PARKER ST
CARLISLE PA 17013
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/26/06 - 04/26/O6 07/24/06 20062010500020001 20062010500020001 5,363.40 266.67
DIAGNOSIS 1 : 36616 SENILE NUCLEAR CATARACT
DIAGNOSIS 2: 2449 HYPOTHYROIDISM NOS
PROC CODE: 66984 CATARACT SURG W/IOL 1 STAGE
PROVIDER SUB TOTAL CARLISLE REGIONAL SPU 5,363.40 266.67
01 100775085 0001
Page 2 of 37
� COMMONWEA�_TH OF P'ENNSYLVANIA
i . , DEPARTMENT OF PUBLIC WELFARE
_ J
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
SWAIM HEALTH CENTER
210 BIG SPRiNG RD
NEWVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
12/01/05 - 12/31/05 08/07/O6 69061954021880001 69061954021880001 5,281.47 5,281.47
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2 : 0
PROC CODE: 000000
01/01/06 - 01/31/O6 08/O7/06 69061954021800001 69061954021800001 5,308.13 5,308.13
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2: 0
PROC CODE: 000000
02/01/06 - 02/28/O6 08/07/06 69061954021820001 69061954021820001 4,794.44 4,794.44
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2 : 0
PROC CODE: 000000
03/01/O6 - 03/31/O6 08/07/06 69061954021840001 69061954021840001 5,308.13 5,308.13
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2: 0
PROC CODE: 000000
04/01/O6 - 04/30/06 08/07/06 69061954021850001 69061954021850001 5,265.60 5,265.60
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2: 0
PROC CODE: 000000
05/01/06 - 05/31/06 O8/07/O6 69061954021860001 69061954021860001 5,441.12 5,441.12
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2: 0
PROC CODE: 000000
06/01/O6 - 06/30/O6 03/12/07 69070454022760001 69070454022760001 5,265.60 5,265.60
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2: 0
PROC CODE: 000000
07/01/06 - 07/31/O6 04/16/07 55071034521830001 55071034521830001 5,441.12 5,881.94
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2: 0
PROC CODE: 000000
Page 3 of 37
i COMMONWEA._TH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE ,
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
SWAIM HEALTH CENTER
210 BIG SPRING RD
NEINVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
08/01/O6 - 08/31/O6 04/16/07 55071034521820001 55071034521820001 5,441.12 5,881.94
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2: 0
PROC CODE: 000000
09/01/O6 - 09/30/06 04/16/07 55071034521840001 55071034521840001 5,265.60 5,692.20
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2: 0
PROC CODE: 000000
10/01/O6 - 10/31/O6 04/23/07 55071085045180001 55071085045180001 5,441.12 5,741.20
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2: 0
PROC CODE: 000000
11/01/06 - 11/30/O6 04/23/07 55071085045190001 55071085045190001 5,265.60 5,556.00
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2: 0
PROC CODE: 000000
12/01/06 - 12/31/O6 04/23/07 55071085045200001 55071085045200001 5,441.12 5,741.20
DIAGNOSIS 1 : 25002 DIABETES MELLITUS WITHOUT MENTION OF COM
DIAGNOSIS 2: 0
PROC CODE: 000000
01/01l07 - 01/31/07 04/30/07 55071154902500001 55071154902500001 5,441.12 5,572.87
DIAGNOSIS 1 : 436 CVA
DIAGNOSIS 2: 0
PROC CODE: 000000
02l01/07 - 02/28/07 04/30/07 55071154902870001 55071154902870001 4,914.56 4,860.76
DIAGNOSIS 1 : 436 CVA
DIAGNOSIS 2: 0
PROC CODE : 000000
03/01/07 - 03/31/07 06/11/07 69071374021980001 69071374021980001 5,572.87 4,800.87
DIAGNOSIS 1 : 436 CVA
DIAGNOSIS 2: 0
PROC CODE: 000000
Page 4 of 37
I COMMONWEAL.TH OF P�ENNSYLVANIA ' • �
, DEPARTMENT OF PUBLIC WELFARE
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD, ROBERT
ID 760 191 187
SWAIM HEALTH CENTER
210 BIG SPRING RD
NEWVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/01/07 - 04/30/07 06/04/07 20071284032810001 20071284032810001 5,175.00 4,403.00
DIAGNOSIS 1 : 436 CVA
DIAGNOSIS 2: 0
PROC CODE: 000000
05/01/07 - 05/31/07 07/09/07 20071634032790001 20071634032790001 5,347.50 4,575.50
DIAGNOSIS 1 : 436 CVA
DIAGNOSIS 2: 0
PROC CODE : 000000
06/01/07 - O6/30/07 08/06/07 20071924028210001 20071924028210001 5,175.00 4,403.00
DIAGNOSIS 1 : 436 CVA
DIAGNOSIS 2: 0
PROC CODE : 000000
07/01/07 - O7/31/07 10/22/07 55072904286120001 55072904286120001 5,347.50 4,791.61
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE : 000000
08/01/07 - 08/31/07 09/01/08 69082184022850001 69082184022850001 5,347.50 5,558.61
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE : 000000
09101/07 - 09/30/07 09/01/08 69082184022910001 69082184022910001 5,175.00 5,379.30
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE: 000000
10/01/07 - 10/31/07 09/01/08 69082184022930001 69082184022930001 5,788.01 5,788.01
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE: 000000
11/01/07 - 11/30/O7 09/01/08 69082184022950001 69082184022950001 5,601.30 5,601.30
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE: 000000
Page 5 of 37
� -- -- ' �
I COMMONWEALTH OF PENNSYLVANIA — — �
. . DEPARTMENT OF PUBLIC WELFARE
June 24, 2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
SWAIM HEALTH CENTER
210 BIG SPRING RD
NEWVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
12/01/07 - 12/31/07 09/01/08 69082184022970001 69082184022970001 5,788.01 5,788.01
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE: 000000
01/01/OS - 01/31/08 09/01/08 69082184022990001 69082184022990001 6,103.28 6,103.28
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE: 000000
02/01/08 - 02/29/O8 09/01/08 69082184023000001 69082184023000001 5,709.52 5,709.52
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE: 000000
03/01/08 - 03/31/OS 09/01/08 69082184023030001 69082184023030001 6,103.28 6,103.28
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE: 000000
04/01/08 - 04/30/08 09/01/08 69082184023060001 69082184023060001 5,906.40 5,906.40
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE : 000000
05/01l08 - 05/31/08 09/01/08 69082184023080001 69082184023080001 6,103.28 6,103.28
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE: 000000
O6/01/08 - O6/30/08 09/01/08 69082184023090001 69082184023090001 5,906.40 5,906.40
DIAGNOSIS 1 : 7812 ABNORMALiTY OF GAIT
DIAGNOSIS 2: 0
PROC CODE: 000000
07/01/08 - 07/31/08 03/02/09 55090574555340001 55090574555340001 6,103.28 6,205.58
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE: 000000
Page 6 of 37
' COMMONWEAZTH OF P'ENNSYLVANIA , • �
j , DEPARTMENT OF PUBLIC WELFARE _ J
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
SWAIM HEALTH CENTER
210 BIG SPRING RD
NEWVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
08/01/08 - 08/31/08 03/02/09 55090574555580001 55090574555580001 6,103.28 6,205.58
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : 0
PROC CODE: 000000
09/01/08 - 09/30/08 03/02l09 55090574555770001 55090574555770001 5,906.40 6,005.40
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE : 000000
10/01/08 - 10/31/08 03/23/09 55090774644020001 55090774644020001 6,103.28 5,978.97
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
11/01/08 - 11/30/08 03/23/09 55090774644200001 55090774644200001 5,906.40 5,000.10
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE : 000000
12/01/08 - 12/31/08 03/23/09 55090774644610001 55090774644610001 6,103.28 5,192.97
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE : 000000
01/01/09 - 01/31/09 04/13/09 55090984541660001 55090984541660001 6,103.28 5,031.82
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE : 000000
02/01/09 - 02/28/09 04/13/09 55090984542050001 55090984542050001 5,298.16 4,464.16
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
03/01/09 - 03/31/09 09/21/09 69092474020800001 69092474020800001 5,865.82 5,031.41
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 4779 ALLERGIC RHINITIS NOS
PROC CODE: 000000
Page 7 of 37
I COMMONWEAZTH OF PENNSYL1fANIA �
' , DEPARTMENT OF PUBLIC WELFARE I
--
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD, ROBERT
ID 760 191 187
SWAIM HEALTH CENTER
210 BIG SPRING RD
NEWVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/01/09 - 04/30/09 09/21/09 69092474020830001 69092474020830001 6,060.30 5,225.89
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 4779 ALLERGIC RHINITIS NOS
PROC CODE: 000000
05/01/09 - 05/31/09 09/21/09 69092474020840001 69092474020840001 6,262.31 5,427.90
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 4779 ALLERGIC RHINITIS NOS
PROC CODE: 000000
06/01/09 - 06/30/09 09/21/09 69092474020880001 69092474020880001 6,060.30 5,225.89
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 4779 ALLERGIC RHINITIS NOS
PROC CODE: 000000
07/01/09 - 07/31/09 11/08/10 55103094362620001 55103094362620001 6,262.31 5,178.35
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 4779 ALLERGIC RHINITIS NOS
PROC CODE : 000000
08/01/09 - 08/31i09 11/08/10 55103094362560001 55103094362560001 6,262.31 5,274.35
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
09/01l09 - 09/30/09 11/08/10 55103094363000001 55103094363000001 6,060.30 5,080.39
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE : 000000
10/01/09 - 10/31/09 12/13110 55103424781170001 55103424781170001 6,262.31 5,637.05
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
11/01/09 - 11/30/09 12/13/10 55103424781500001 55103424781500001 6,060.30 5,431.39
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
Page 8 of 37
� COMMONWEALTH OF P'ENNSYLVANIA ;
_ . , _ DEPARTMENT OF PUBL�C WELFARE _ J
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD, ROBERT
ID 760 191 187
SWAIM HEALTH CENTER
210 BIG SPRING RD
NEWVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
12/01l09 - 12/31/09 12/13/10 55103424781890001 55103424781890001 6,262.31 5,637.05
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
01/01/10 - 01/31/10 01/10/11 55110044188620001 55110044188620001 6,262.31 5,302.25
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
02/01l10 - 02/28/10 01/10/11 55110044188950001 55110044188950001 5,656.28 4,717.67
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
03/01/10 - 03/31/10 01/10/11 55110044189350001 55110044189350001 6,262.31 5,302.25
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
04/01/10 - 04/30/10 02/14/11 55110394186810001 55110394186810001 6,060.30 4,810.39
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
OS/01/10 - 05/31/10 02/14/11 55110394187130001 55110394187130001 6,262.31 4,995.35
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
06/01/10 - 06I30/10 02/14/11 55110394187530001 55110394187530U01 6,060.30 4,810.39
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
07/01/10 - 07/31/10 10/17/11 55112854129580001 55112854129580001 6,262.31 5,044.95
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
Page 9 of 37
;r COMMONWERLTH OF WENNSYLVANIA , I
I . DEPARTMENT OF PUBLIC WELFARE �
June 24, 2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
SWAIM HEALTH CENTER
210 BIG SPRING RD
NEVINILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
O8/01/10 - 08/31I10 10/17/11 55172854129940001 55112854129940001 6,262.31 5,044.95
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE : 000000
09/01/10 - 09/30/10 10/17/11 55112854130320001 55112854130320001 6,060.30 4,858.39
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
10/01/10 - 10/31/10 10/24/11 55112924462720001 55112924462720001 5,733.76 5,085.87
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
11/01/10 - 11/30/10 10/24/11 55112924463070001 55712924463070001 5,425.49 4,772.74
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
12/01/10 - 12/31/10 10/24/11 55112924463430001 55112924463430001 5,733.76 5,085.87
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
01/01/11 - 01/31/11 10/31/11 55112994455900001 55112994455900001 5,733.76 4,755.10
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
02/01/11 - 02/28/11 10/31/11 55112994456250001 55112994456250001 5,178.88 4,223.47
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
03/01/11 - 03/31/11 10/31/11 55112994456730001 55112994456730001 5,733.76 4,765.00
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : 4779 ALLERGIC RHINITIS NOS
PROC CODE: 000000
Page 10 of 37
COMMONWEA�TH OF PENNSYLVANIA , ' i
, . DEPARTMENT OF PUBLIC WELFARE
�
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD, ROBERT
ID 760 191 187
SWAIM HEALTH CENTER
210 BIG SPRING RD
NEWVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGlNAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/01/11 - 04/30/11 11/07/11 55113054403500001 55113054403500001 5,548.80 4,692.25
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 4779 ALLERGIC RHINITIS NOS
PROC CODE: 000000
05/01/11 - 05/31/11 11/07/11 55113054403400001 55113054403400001 5,733.76 4,876.13
DIAGNOSIS 1 : 7812 ABNORMA�ITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
06/01/11 - 06/30/11 11/07/11 55113054403820001 55113054403820001 5,548.80 4,692.25
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
07/01/11 - 07/31N1 05/07/12 55121254696750001 55121254696750001 2,774.38 1,910.35
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE : 000000
09/01/11 - 09/30/11 05/O7/12 55121254697380001 55121254697380001 5,516.40 4,644.85
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
10/01/11 - 10/31/11 05/21/12 55121374222050001 55121374222050001 5,700.28 4,873.96
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE : 000000
11/01/11 - 11/30/11 05/21/12 55121374222430001 55121374222430001 5,516.40 4,690.15
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
12l01/11 - 12/31/11 05/21/12 55121374222830001 55121374222830001 5,700.28 4,873.96
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: 0
PROC CODE: 000000
Page 11 of 37
COMMONWEAtTH OF F�ENNSYLVANIA r , �
I I
� DEPARTMENT OF PUBLIC WELFARE_ I
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD, ROBERT
ID 760 191 187
SWAIM HEALTH CENTER
210 BIG SPRING RD
NEWVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
01/01/12 - 01/31/12 06/18/12 55121644136330001 55121644136330001 5,700.28 4,760.09
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
02/01/12 - 02/29/12 06/18/12 55121644136740001 55121644136740001 5,332.52 4,397.61
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
03/01/12 - 03/31/12 06/18/12 55121644137100001 55121644137100001 5,700.28 4,760.09
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
04/01/12 - 04/30/12 06/04/12 20121294024310001 20121294024310001 5,646.90 4,788.55
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
05l01/12 - 05/31/12 07/02/12 20121604023560001 20121604023560001 5,835.13 4,976.78
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
06/01/12 - 06/30/12 07/30/12 20121914026530001 20121914026530001 5,646.90 4,788.55
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
07/01/12 - 07/31/12 01/14/13 55130094249550001 55130094249550001 5,835.13 5,069.16
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
08/01/12 - 08/31/12 01/14/13 55130094249930001 55130094249930001 5,835.13 5,069.16
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
Page 12 of 37
COMMONWEAL'TH OF P'ENNSYLVANIA
; . DEPARTMENT OF PUBLIC WELFARE
�— —
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
SWAIM HEALTH CENTER
210 BIG SPRING RD
NEINVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
09/01/12 - 09/30/12 01/14/13 55130094250410001 55130094250410001 5,646.90 4,877.95
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
10/01/12 - 10/31/12 01/28/13 55130245108380001 55130245108380001 5,835.13 5,069.16
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
11/01/12 - 11/30/12 01/28/13 55130245108840001 55130245108840001 5,646.90 4,877.95
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
12/01/12 - 12/31/12 02/04/13 55130245109290001 55130245109290001 5,835.13 5,069.16
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
01/01/13 - 01/31/13 03/04/13 20130394033650001 20130394033650001 5,888.14 5,017.19
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
02/01/13 - 02/28/13 04/01/13 20130674030440001 20730674030440001 5,318.32 4,447.37
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
03/01/13 - 03/31/13 05/06/13 20130994025070001 20130994025070001 5,888.14 5,017.19
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
Page 13 of 37
'I COMMONWEALTH OF PENNSYLVANIA
� . _ DEPARTMENT OF PUBLIC WELFARE I
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
SWAIM HEALTH CENTER
210 BIG SPRING RD
NEWVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/01/13 - 04/18/13 06/03N3 20131284030780001 20131284030780001 1,345.93 961.45
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2: V5867 LONG-TERM(CURRENT)USE OF INSULIN
PROC CODE: 000000
PROVIDER SUB TOTAL SWAIM HEALTH CENTER 496,175.73 448,524.17
03 100749488 0012
Page 14 of 37
� f
I� I
COMMONWEALTH OF�ENNSYLVANIA
i DEPARTMENT OF PUBLIC WELFARE I,
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD, ROBERT
ID 760 191 187
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
MECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
03/13/10 - 03/13/10 04/12/10 25100725344030001 25100725344030001 10.51 10.51
DIAGNOSIS 1 : 0
NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS
05/21/10 - 05/21/10 06/14/10 25101415585390001 25101415585390001 4.20 4.20
DIAGNOSIS 1 : 0
NDC CODE: 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS
06/14/10 - 06/14/10 07/12/10 25101655237230001 25101655237230001 4.20 4.20
DIAGNOSIS 1 : 0
NDC CODE: 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS
O8/16/10 - 08/16/10 09N 3/10 25102285243360001 25102285243360001 2.88 2.88
DIAGNOSIS 1 : 0
NDC CODE: 45802006001 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS
09/06/10 - 09/06l10 10/04/10 25102495285370001 25102495285370001 2.88 2.88
DIAGNOSIS 1 : 0
NDC CODE : 45802006001 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS
12/09/10 - 12/09/10 01/03/11 25103435682550001 25103435682550001 4.20 4.20
DIAGNOSIS 1 : 0
NDC CODE : 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS
04/07/12 - 04/07/12 05/07/12 25120985261860001 25120985261860001 6.54 6.54
DIAGNOSIS 1 : 0
NDC CODE : 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS
08/02112 - 08/02N 2 08/27/12 25122155570760001 25122155570760001 2.45 2.45
DIAGNOSIS 1 : 0
NDC CODE : 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS
Page 15 of 37
��� COMMONWEArTH OF�NNSYLVANIA
. � DEPARTMENT OF PUBLIC WELFARE
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
MILLENNIUM PHARMACY SYSTEMS!NC
5020 RITTER RD
STE 110
MECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
12/17/12 - 12/17/12 01/14/13 25123525382870001 25123525382870001 2.45 2.45
DIAGNOSIS 1 : 0
NDC CODE: 45802006003 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS
12/26/12 - 12/26/12 01/28/13 25123665515640001 25123665515640001 16.99 2.72
DIAGNOSIS 1 : 0
NDC CODE: 00591024005 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
12/26/12 - 12/26/12 02/25/13 25130305515940001 25130305515940001 5.41 .02
DIAGNOSIS 1 : 0
NDC CODE: 00591024005 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
PROVIDER SUB TOTAL MILLENNIUM PHARMACY SYSTEMS INC 62.71 43.05
24 001887261 0008
Page 16 of 37
i
COMMONWEALTH OF PENNSYLVANIA
, � DEPARTMENT OF PUBLIC WELFARE
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
CONTII�UING CARE RX
28 S 2ND ST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
12/26l05 - 12/26/05 07/17/06 25061735374820001 25061735374820001 84.86 5.45
D�AGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
12/26/05 - 12/26/05 07/17/06 25061735376500001 25061735376500001 79.21 10.92
DIAGNOSIS 1 : 0
NDC CODE: 00088222033 LANTUS 100 UNITS/ML VIAL - DIABETIC THERAPY
12/26/Q5 - 12/26/05 07/17/06 25061735377030001 25061735377030001 81.94 6.01
DIAGNOSIS 1 : 0
NDC CODE: 00456201001 LEXAPRO 10 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
12/26/05 - 12/26/05 07/17/06 25061735382700001 25061735382700001 56.07 9.14
DIAGNOSIS 1 : 0
NDC CODE : 61570011201 ALTACE 5 MG CAPSULE - OTHER ANTIHYPERTENSIVES
12/26/05 - 12/26/05 07/17/O6 25061735385200001 25061735385200001 8.21 5.67
DIAGNOSIS 1 : 0
NDC CODE: 00781196610 FUROSEMIDE 40 MG TABLET - DIURETICS
12/26/05 - 12/26/05 07/17/06 25061735386320001 25061735386320001 126.63 4.29
DIAGNOSIS 1 : 0
NDC CODE : 00008084181 PROTONIX DR 40 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
12/26/05 - 12/26/05 07/17/06 25061735387990001 25061735387990001 12.37 5.16
DIAGNOSIS 1 : 0
NDC CODE: 00527134310 LEVOTHYROXINE 75 MCG TABLET - THYROID PREPS
12/26/05 - 12/26/05 07/17/O6 25061735389230001 25061735389230001 124.30 9.33
DIAGNOSIS 1 : 0
NDC CODE: 00007413920 COREG 3.125 MG TABLET - OTHER CARDIOVASCULAR PREPS
Page 17 of 37
COMMONWEALTH OF!°ENNSYLVANIA , ,
I DEPARTMENT OF PUBLIC WELFARE
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
CONTINUING CARE RX
28 S 2ND ST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
12/26/05 - 12/26/05 07/17/06 25061735393890001 25061735393890001 25.50 6.00
DIAGNOSIS 1 : 0
NDC CODE : 50111043003 METOCLOPRAMIDE 10 MG TABLET - ANTINAUSEANTS
01/02/O6 - 01/02/O6 07/17/06 25061735379560001 25061735379560001 78.71 10.92
DIAGNOSIS 1 : 0
NDC CODE: 00088222033 LANTUS 100 UNITS/ML VIAL - DIABETIC THERAPY
01/09/06 - 01/09/06 07/17/06 25061735380280001 25061735380280001 13.54 6.00
DIAGNOSIS 1 : 0
NDC CODE : 00904190705 GENTAMICIN 3 MG/ML EYE DROPS - OPHTHALMIC PREPARATIONS
01/10/06 - 01/10/06 07/17/06 25061735380930001 25061735380930001 84.86 5.45
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
01/18/06 - 01/18/O6 07l17/06 25061735381970001 25061735381970001 30.56 7.98
DIAGNOSIS 1 : 0
NDC CODE: 00002324030 CYMBAITA 30 MG CAPSULE - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
01/79/O6 - 01/19/06 07/17/06 25061735394380001 25061735394380001 25.50 6.00
DIAGNOSIS 1 : 0
NDC CODE : 50111043003 METOCLOPRAMIDE 10 MG TABLET - ANTINAUSEANTS
01/20/06 - 01/20/06 07/17/06 25061735383370001 25061735383370001 56.07 9.14
DIAGNOSIS 1 : 0
NDC CODE: 61570011201 ALTACE 5 MG CAPSULE - OTHER ANTIHYPERTENSIVES
01/20/06 - 01/20/06 07/17/06 25061735384080001 25061735384080001 79.21 10.92
DIAGNOSIS 1 : 0
NDC CODE : 00088222033 LANTUS 100 UNITS/ML VIAL - DIABETIC THERAPY
Page 18 of 37
i COMMONWEALTH OF WENNSYLVANIA I
DEPARTMENT OF PUBLIC WELFARE �
-- — �
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD, ROBERT
ID 760 191 187
CONTINUING CARE RX
28 S 2ND ST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
01/20/06 - 01/20/06 07/17/06 25061735386740001 25061735386740001 126.63 4.29
DIAGNOSIS 1 : 0
NDC CODE: 00008084181 PROTONIX DR 40 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
01/20/06 - 01/20/06 07/17/06 25061735388300001 25061735388300001 12.37 5.16
DIAGNOSIS 1 : 0
NDC CODE: 00527134310 LEVOTHYROXINE 75 MCG TABLET - THYROID PREPS
01/20/06 - 01/20/O6 07/17/06 25061735389850001 25061735389850001 124.30 9.33
DIAGNOSIS 1 : 0
NDC CODE: 00007413920 COREG 3.125 MG TABLET - OTHER CARDIOVASCULAR PREPS
01/20/06 - 01/20/06 07/17/06 25061735399100001 25061735399100001 95.06 5.51
DIAGNOSIS 1 : 0
NDC CODE: 00002323730 CYMBALTA 60 MG CAPSULE - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
01/23/06 - 01/23/O6 07/17/06 25061735391540001 25061735391540001 84.86 5.45
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
02/08/06 - 02/08/06 07/17/O6 25061735394610001 25061735394610001 25.50 2.00
DIAGNOSIS 1 : 0
NDC CODE : 50111043003 METOCLOPRAMIDE 10 MG TABLET - ANTINAUSEANTS
02/09/O6 - 02/09/06 07/17/06 25061735391980001 25061735391980001 87.70 5.45
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
02/17/06 - 02/17/O6 07/17/O6 25061735384570001 25061735384570001 81.85 6.11
DIAGNOSIS 1 : 0
NDC CODE: 00088222033 LANTUS 100 UNITSlML VIAL - DIABETIC THERAPY
Page 19 of 37
COMMONWERLTFi OF PENNSYLVANIA , ,
� • DEPARTMENT OF PUBLIC WELFARE
�-- - - --
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
CONTINUING CARE RX
28 S 2ND ST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
02/19/06 - 02/19/06 07/17/06 25061735387290001 25061735387290001 126.63 4.29
DIAGNOSIS 1 : 0
NDC CODE: 00008084181 PROTONIX DR 40 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
02/19/06 - 02/19/06 07/17/06 25061735388600001 25061735388600001 12.37 5.16
DIAGNOSIS 1 : 0
NDC CODE: 00527134310 LEVOTHYROXINE 75 MCG TABLET - THYROID PREPS
02/19/O6 - 02/19/06 07/17/06 25061735390220001 25061735390220001 124.30 9.33
DIAGNOSIS 1 : 0
NDC CODE: 00007413920 COREG 3.125 MG TABLET - OTHER CARDIOVASCULAR PREPS
02/19/06 - 02/19/06 07/17/06 25061735390780001 25061735390780001 56.07 9.14
DIAGNOSIS 1 : 0
NDC CODE: 61570011201 ALTACE 5 MG CAPSULE - OTHER ANTIHYPERTENSIVES
02/19/06 - 02/19/06 07/17/O6 25061735399900001 25061735399900001 117.83 4.63
DIAGNOSIS 1 : 0
NDC CODE: 00002323730 CYMBALTA 60 MG CAPSULE - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
02/21/06 - 02/21/06 07/17/06 25061735392340001 25061735392340001 87.70 5.45
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
03/03/06 - 03/03/06 07117/06 25061735395240001 25061735395240001 25.50 6.00
DIAGNOSIS 1 : 0
NDC CODE : 50111043003 METOCLOPRAMIDE 10 MG TABLET - ANTINAUSEANTS
03/O6/O6 - 03/06/O6 07117/O6 25061735397180001 25061735397180001 87.70 5.45
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
Page 20 of 37
I COMMONWEAtTH OF pENNSYLVANIA ,
� . DEPARTMENT OF PUBLIC WELFARE i
June 24, 2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
CONTINUING CARE RX
28 S 2ND ST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
03/21/06 - 03/21/O6 07/17/06 25061735393330001 25061735393330001 56.07 9.14
DIAGNOSIS 1 : 0
NDC CODE: 61570011201 ALTACE 5 MG CAPSULE - OTHER ANTIHYPERTENSIVES
03/21/06 - 03/21l06 07/17/06 25061735400330001 25061735400330001 724.11 4.63
DIAGNOSIS 1 : 0
NDC CODE: 00002323730 CYMBALTA 60 MG CAPSULE - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
03/21/O6 - 03/21/06 07/17/06 25061735439250001 25061735439250001 126.63 4.29
DIAGNOSIS 1 : 0
NDC CODE: 00008084181 PROTONIX DR 40 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/21/06 - 03/21/O6 07/17/06 25061735441300001 25061735441300001 12.37 5.16
DIAGNOSIS 1 : 0
NDC CODE: 00527134310 LEVOTHYROXINE 75 MCG TABLET - THYROID PREPS
03I21/06 - 03/21/06 07/17/06 25061735442310001 25061735442310001 124.30 9.33
DIAGNOSIS 1 : 0
NDC CODE: 00007413920 COREG 3.125 MG TABLET - OTHER CARDIOVASCULAR PREPS
03/22/06 - 03/22/06 07/17/06 25061735397460001 25061735397460001 87.70 5.32
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
03/27/06 - 03/27/06 07/17/06 25061735436030001 25061735436030001 81.85 6.01
DIAGNOSIS 1 : 0
NDC CODE: 00088222033 LANTUS 100 UNITS/ML VIAL - DIABETIC THERAPY
04/06/06 - 04/06/06 07/17/06 25061735445170001 25061735445170001 13.46 4.31
DIAGNOSIS 1 : 0
NDC CODE : 50111043003 METOCLOPRAMIDE 10 MG TABLET - ANTINAUSEANTS
Page 21 of 37
' COMMONWEALTH OF F�ENNSYLVANIA �
' DEPARTMENT OF PUBLIC WELFARE I
i ' �
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD, ROBERT
ID 760 191 187
CONTINUING CARE RX
28S2NDST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/10/06 - 04/10/06 07/17/06 25061735397780001 25061735397780001 87.70 5.32
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/M�VIAL - DIABETIC THERAPY
04/17/06 - 04/17/O6 O7/17/06 25061735395550001 25061735395550001 3.45 3.45
DIAGNOSIS 1 : 0
NDC CODE: 00168001131 BACITRACIN ZN 500 UNIT/GM OINT - OTHER ANTIBIOTICS
04/17/O6 - 04/17/06 07/17/06 25061735436700001 25061735436700001 81.85 6.01
DIAGNOSIS 1 : 0
NDC CODE: 00088222033 LANTUS 100 UNITS/ML VIAL - DIABETIC THERAPY
04/17/06 - 04/17/06 07/17/06 25061735446050001 25061735446050001 13.46 .31
DIAGNOSIS 1 : 0
NDC CODE: 50111043003 METOCLOPRAMIDE 10 MG TABLET - ANTINAUSEANTS
04/20/06 - 04/20/06 07/17/06 25061735396020001 25061735396020001 56.07 5.12
DIAGNOSIS 1 : 0
NDC CODE: 61570011201 ALTACE 5 MG CAPSULE - UTHER ANTIHYPERTENSIVES
04/20/O6 - 04/20/O6 07/17/06 25061735396270001 25061735396270001 50.79 7.20
DIAGNOSIS 1 : 0
NDC CODE : 00023218103 ACULAR 0.5%EYE DROPS - OPHTHALMIC PREPARATIONS
04/20/O6 - 04/20/O6 07/17/06 25061735396570001 25061735396570001 64.38 6.69
DIAGNOSIS 1 : 0
NDC CODE: 00023921805 ZYMAR 0.3%EYE DROPS - OPHTHALMIC PREPARATIONS
04/20/O6 - 04/20/06 07/77/06 25061735400840001 25061735400840001 124.11 4.39
DIAGNOSIS 1 : 0
NDC CODE: 00002323730 CYMBALTA 60 MG CAPSULE - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
Page 2Z of 37
� COMMONWEALTH OF�ENNSYLVANIA �
� . DEPARTMENT OF PUBLIC WELFARE _�
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD, ROBERT
ID 760 191 187
CONTINUING CARE RX
28S2NDST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/20/06 - 04/20/06 07/17/06 25061735440930001 25061735440930001 130.75 7.69
DIAGNOSIS 1 : 0
NDC CODE: 00008084181 PROTONIX DR 40 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
04/20/06 - 04l20/06 07/17/O6 25061735441690001 25061735441690001 12.37 5.16
DIAGNOSIS 1 : 0
NDC CODE: 00527134310 LEVOTHYROXINE 75 MCG TABLET - THYROID PREPS
04/20/06 - 04/20/06 07/17/06 25061735442530001 25061735442530001 124.30 9.33
DIAGNOSIS 1 : 0
NDC CODE: 00007413920 COREG 3.125 MG TABLET - OTHER CARDIOVASCULAR PREPS
04/21/O6 - 04/21/06 07/17/O6 25061735398220001 25061735398220001 87.70 5.32
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
OS/03J06 - 05/03/06 07/17/O6 25061735398540001 25061735398540001 79.33 5.32
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
05/04/O6 - 05/04/O6 07/17/06 25061735446420001 25061735446420001 23.35 2.16
DIAGNOSIS 1 : 0
NDC CODE: 50111043003 METOCLOPRAMIDE 10 MG TABLET - ANTINAUSEANTS
05/16/06 - 05/16/06 07/17/06 25061735437310001 25061735437310001 81.33 5.32
DIAGNOSIS 1 : 0
NDC CODE : 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
05/20/06 - 05/20/O6 07/17/O6 25061735401120001 25061735401120001 114.10 4.39
DIAGNOSIS 1 : 0
NDC CODE : 00002323730 CYMBALTA 60 MG CAPSULE - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
Page 23 of 37
. ,
Ii COMMONWEAtTH OF PENNSYLVANIA
' • DEPARTMENT OF PUBLIC WELFARE
—i
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
tD 760 191 187
CONTINUING CARE RX
28 S 2ND ST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
05/20/O6 - 05/20/06 07/17/06 25061735435230001 25061735435230001 52.86 5.12
DIAGNOSIS 1 : 0
NDC CODE: 61570017201 ALTACE 5 MG CAPSULE - OTHER ANTIHYPERTENSIVES
OS/20/06 - 05/20/06 07/17/06 25U61735440540001 25061735440540001 120.07 4.13
DIAGNOSIS 1 : 0
NDC CODE: 00008084181 PROTONIX DR 40 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
05/20/06 - 05/20/06 07/17/06 25061735441860001 25061735441860001 13.53 5.16
DIAGNOSIS 1 : 0
NDC CODE: 00527134370 LEVOTHYROXINE 75 MCG TABLET - THYROID PREPS
05/20/06 - 05/20/06 07/17/06 25061735442790001 25061735442790001 118.61 9.33
DIAGNOSIS 1 : 0
NDC CODE: 00007413920 COREG 3.125 MG TABLET - OTHER CARDIOVASCULAR PREPS
05/23/06 - 05/23/06 07/17/06 25061735437800001 25061735437800001 81.33 5.32
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
05/30/O6 - 05/30/O6 07/17/06 25061735446550001 25061735446550001 25.35 2.16
DIAGNOSIS 1 : 0
NDC CODE: 50111043003 METOCLOPRAMIDE 10 MG TABLET - ANTINAUSEANTS
05/31/06 - 05131/06 07/17/06 25061735436850001 25061735436850001 76.06 6.01
DIAGNOSIS 1 : 0
NDC CODE: 00088222033 LANTUS 100 UNITS/ML VIAL - DIABETIC THERAPY
06/02/06 - O6/02/06 07/17/06 25061735437860001 25061735437860001 81.33 5.32
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
Page 24 of 37
�-- COMMONWEAtTH OF PENNSYLVANIA ,
j DEPARTMENT OF PUBLIC WELFARE i
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
CONTINUING CARE RX
28 S 2ND ST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIG�NAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
06/19/06 - O6/19/06 O7/17/06 25061735441070001 25061735441070001 120.07 4.73
DIAGNOSIS 1 : 0
NDC CODE: 00008084181 PROTONIX DR 40 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
O6/19/06 - 06/19/06 07/17/06 25061735442030001 25061735442030001 13.53 5.16
DIAGNOSIS 1 : 0
NDC CODE: 00527134310 LEVOTHYROXINE 75 MCG TABLET - THYROID PREPS
06/19/06 - 06/19/06 O7/17/06 25061735442930001 25061735442930001 118.61 13.30
DIAGNOSIS 1 : 0
NDC CODE: 00007413920 COREG 3.125 MG TABLET - OTHER CARDIOVASCULAR PREPS
06/19/06 - 06/19/06 07/17/O6 25061735443140001 25061735443140001 114.10 4.39
DIAGNOSIS 1 : 0
NDC CODE: 00002323730 CYMBALTA 60 MG CAPSULE - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
O6/19/O6 - 06/19/O6 07/17/O6 25061735443310001 25061735443310001 52.86 5.12
DIAGNOSIS 1 : 0
NDC CODE: 61570011201 ALTACE 5 MG CAPSULE - OTHER ANTIHYPERTENSIVES
06/23/06 - 06/23/O6 07/17/06 25061745315770001 25061745315770001 76.06 6.01
DIAGNOSIS 1 : 0
NDC CODE : 00088222033 LANTUS 100 UNITS/ML VIAL - DIABETIC THERAPY
06/23/O6 - 06/23/06 07/17/O6 25061745715270001 25061745715270001 81.33 5.32
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
07N 8/06 - 07/18/06 08/14/06 25061995255530001 25061995255530001 81.33 6.99
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
Page 25 of 37
�— COMMONWEP.LTH�OF pENNSYLVANIA ,
DEPARTMENT OF PUBLIC WELFARE
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
CONTINUING CARE RX
28 S 2ND ST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
07/19/O6 - 07/19/06 08/14/06 25062005639700001 25062005639700001 25.35 2.16
DIAGNOSIS 1 : 0
NDC CODE: 50111043003 METOCLOPRAMIDE 10 MG TABLET - ANTINAUSEANTS
07/19/06 - 07/19/06 08/14/06 25062025418770001 25062025418770001 118.61 2.19
DIAGNOSIS 1 : 0
NDC CODE: 00007413920 COREG 3.125 MG TABLET - OTHER CARDIOVASCULAR PREPS
07/19/06 - 07/19/O6 08/14/06 25062025418850001 25062025418850001 114.70 6.70
DIAGNOSIS 1 : 0
NDC CODE : 00002323730 CYMBALTA 60 MG CAPSULE - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
07/19/06 - 07/19/06 08/14l06 25062025418940001 25062025418940001 52.86 6.16
DIAGNOSIS 1 : 0
NDC CODE: 61570011201 ALTACE 5 MG CAPSULE - OTHER ANTIHYPERTENSIVES
07/19/O6 - 07/19/O6 08/21/O6 25062065614510001 25062065614510001 120.07 6.56
DIAGNOSIS 1 : 0
NDC CODE : 00008084181 PROTONIX DR 40 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
07/19/06 - 07/19/06 08/21/06 25062065614870001 25062065614870001 13.53 5.33
DIAGNOSIS 1 : 0
NDC CODE : 00527134310 LEVOTHYROXINE 75 MCG TABLET - THYROID PREPS
07/26/06 - 07/26/06 08/21/06 25062075224750001 25062075224750001 3.45 3.45
DIAGNOSIS 1 : 0
NDC CODE: 00168001131 BACITRACIN ZN 500 UNIT/GM OINT - OTHER ANTIBIOTICS
07/26/O6 - 07/26/O6 08/21/06 25062075314970001 25062075314970001 76.06 7.51
DIAGNOSIS 1 : 0
NDC CODE : 00088222033 LANTUS 100 UNITS/ML VIAL - DIABETIC THERAPY
Page 26 of 37
! COMMONWEA�TH C�F PENNSY�VANIA �!
, DEPARTMENT OF PUBLIC WELFARE j
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
CONTINUING CARE RX
28 S 2ND ST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
07/26/06 - 07/26/06 08/28/O6 25062155356830001 250627 55356830001 1.95 1.95
DIAGNOSIS 1 : 0
NDC CODE: 45802006070 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS
11/29/06 - 11/29l06 12/25/06 25063335600170001 25063335600170001 7.82 7.00
DIAGNOSIS 1 : 0
NDC CODE: 00168001131 BACITRACIN ZN 500 UNIT/GM OINT - OTHER ANTIBIOTICS
12/01/O6 - 12/01l06 01/15/07 25063535410350001 25063535410350001 4.18 4.07
DIAGNOSIS 1 : 0
NDC CODE: 45802006070 BACITRACIN 500 UNIT/GM OINTMNT - OTHER ANTIBIOTICS
04/05/07 - 04/05/07 04/30/07 25070955505690001 25070955505690001 15.47 14.52
DIAGNOSIS 1 : 0
NDC CODE: 00067399885 LAMISIL AT 1%CREAM - ANTIFUNGALS
04/09/07 - 04/09/07 05/07/07 25070995311350001 25070995311350001 15.47 14.52
DIAGNOSIS 1 : 0
NDC CODE: 00067399885 LAMISIL AT 1%CREAM - ANTIFUNGALS
04/18/07 - 04l18/07 05/14/07 25071085350520001 25071085350520001 15.68 14.52
DIAGNOSIS 1 : 0
NDC CODE : 00067399885 LAMISIL AT 1%CREAM - ANTIFUNGALS
O6/24/07 - 06/24/07 07/23/07 25071755262880001 25071755262880001 15.68 14.52
DIAGNOSIS 1 : 0
NDC CODE: 00067399885 LAMISIL AT 1%CREAM - ANTIFUNGALS
07/02/07 - 07/02/07 07/30/07 25071835671750001 25071835671750001 15.68 14.52
DIAGNOSIS 1 : 0
NDC CODE : 00067399885 LAMISIL AT 1%CREAM - ANTIFUNGALS
Page 27 of 37
� COMMONWEPILTH'OF PENNSYLVANIA ,
�
�i DEPARTMENT OF PUBUC WELFARE I
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
CONTINUING CARE RX
28 S 2ND ST
NEWPORT PA 17074
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
11/05/07 - 11/05/07 12/03/07 25073095441010001 25073095441010001 7.82 7.00
DIAGNOSIS 1 : 0
NDC CODE: 00168001131 BACITRACIN ZN 500 UNIT/GM OINT - OTHER ANTIBIOTICS
11/15/07 - 11/75/07 12/24/07 25073315424480001 25073315424480001 7.82 7.00
DIAGNOSIS 1 : 0
NDC CODE : 00168001131 BACITRACIN ZN 500 UNIT/GM OINT - OTHER ANTIBIOTICS
12/10/07 - 12/10/07 01/07/O8 25073445290470001 25073445290470001 7.82 7.00
DIAGNOSIS 1 : 0
NDC CODE : 00168001131 BACITRACIN ZN 500 UNIT/GM OINT - OTHER ANTIBIOTICS
PROVIDER SUB TOTAL CONTINUING CARE RX 5,871.89 582.15
24 100731447 0011
Page 28 of 37
i COMMONWEALT�i OF I�ENNSYLVANIA I
I_ ___ _ DEPARTMENT OF PUBLIC WELFARE I
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD, ROBERT
ID 760 191 187
CUMBERLAND-GOODWILL FIRE&RESCUE
519 S HANOVER ST
CARLISLE PA 17013
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
12/14/12 - 12/14/12 02/04/13 21130166120540001 21130166120540001 990.67 80.00
DIAGNOSIS 1 : 78009 OTHER
PROC CODE: A0432 PARAMEDIC INTERCEPT,RURAL AREA,TRANSPORT
PROVIDER SUB TOTAL CUMBERLAND-GOODWILL FIRE 8 RESCUE 990.67 80.00
26 000969193 0007
Page 29 of 37
� „
COMMONWEALTH OF PENNSYLVANIA �
DEPARTMENT OF PUBLIC WELFARE _�
June 24, 2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
AMERICAN DIAGNOSTIC SERVICE INC
4818 N CRESCENT BLVD
STE B
PENNSAUKEN NJ 08109
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
09/28/06 - 09/28/06 10/30/06 20062991327900001 20062991327900001 100.00 3.33
DIAGNOSIS 1 : 78900 ABDOMINAL PAIN UNSPEC SIT
PROC CODE: T6700 US EXAM ABDOM COMPLETE
09/28/06 - 09I28/O6 10/30/06 20062991327950001 20062991327950001 170.00 .67
DIAGNOSIS 1 : T8900 ABDOMINAL PAIN UNSPEC SIT
PROC CODE: 76700 US EXAM ABDOM COMPLETE
PROVIDER SUB TOTAL AMERICAN DIAGNOSTIC SERVICE INC 270.00 4.00
29 001502633 0006
Page 30 of 37
COMMONWEALTW bF�'ENNSYLVANIA •
I DEPARTMENT OF PUBLIC WELFARE i
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
MOBILE X-RAY IMAGING INC
5120 LANCASTER ST
HARRISBURG PA 17111
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
07/24/07 - 07/24/07 09/03/O7 20072421028710002 20072421028710002 27.00 .76
DIAGNOSIS 1 : 7955 TUBERCULIN TEST REACTION
PROC CODE: 71010 CHEST X-RAY 1 VIEW FRONTAL
07/01l08 - 07/01/08 09/08/08 20082451099870004 20082451099870004 27.00 .67
DIAGNOSIS 1 : 7955 TUBERCULIN TEST REACTION
PROC CODE: 71010 CHEST X-RAY 1 VIEW FRONTAL
07/01/09 - O7/01/09 08/31/09 20092371043660001 20092371043660001 69.30 .47
DIAGNOSIS 1 : 78650 CHEST PAIN UNSPECIFIED
PROC CODE: 77010 CHEST X-RAY 1 VIEW FRONTAL
PROVIDER SUB TOTAL MOBILE X-RAY IMAGING INC 123.30 1.90
29 001523132 0008
Page 31 of 37
. • , ,
', COMMONWE/�LT�i bF�ENNSYLVANIA I
DEPARTMENT OF PUBLIC WELFARE I
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
ROBISON CAROL K
100 S HIGH ST
NEWVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
01/24/07 - 01/24/07 02/05/07 20070321133980001 20070321133980001 60.00 36.65
DIAGNOSIS 1 : 41400 CORONARY ATHEROSCLEROSIS
PROC CODE: 99308 NURSING FAC CARE SUBSEQ
02/28/07 - 02/28/07 03/19/07 20070751044930001 20070751044930001 60.00 36.65
DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHO
PROC CODE: 99308 NURSING FAC CARE SUBSEQ
03/28/07 - 03/28/07 04/23/07 20071051068600001 20071051068600001 60.00 19.70
DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHO
PROC CODE: 99308 NURSING FAC CARE SUBSEQ
PROVIDER SUB TOTAL ROBISON CAROL K 180.00 93.00
31 001092384 0003
Page 32 of 37
, � , ,
COMMONWEf4LTN �OF I�ENNSYLVANIA �
' DEPARTMENT OF PUBLIC WELFARE �
— �
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
BLUE MOUNTAIN ANES ASSOC PC
PO BOX 249
GREENCASTLE PA 17225
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/26/06 - 04/26/06 08/14/06 27062191009750001 27062191009750001 533.00 10.69
DIAGNOSIS 1 : 3669 CATARACT NOS
PROC CODE: 00142 ANESTH LENS SURGERY
PROVIDER SUB TOTAL BLUE MOUNTAIN ANES ASSOC PC 533.00 10.69
31 001390303 0010
Page 33 of 37
. . , �
, COMMONWEALTH OF PENNSYLVANIA �
' DEPARTMENT OF PUBLIC WELFARE �
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
SMITH RADIOLOGY INC
1515 BRIDGE ST
NEW CUMBERLAND PA 17070
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
07/26/O6 - 07/26/06 09/04/06 11062376370230001 11062376370230001 34.00 2.21
DIAGNOSIS 1 : 7242 LUMBAGO
PROC CODE : 72100 X-RAY EXAM L-S SPINE 2/3 VWS
07/01/09 - 07/01/09 08/31/09 20092391080960001 20092391080960001 22.00 .40
DIAGNOSIS 1 : 7955 TUBERCULIN TEST REACTION
PROC CODE : 71010 CHEST X-RAY 1 VIEW FRONTAL
PROVIDER SUB TOTAL SMITH RADIOLOGY INC 56.00 2.61
31 100734251 0005
Page 34 of 37
� � � (
-__.. __-_ _ �
COMMONWEALT�f bF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
KINETIC IMAGING INC
4520 UNION DEPOSIT ROAD
HARRISBURG PA 17111
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
10/20/06 - 10/20/06 04/09/07 27070961007460001 27070961007460001 175.00 6.08
DIAGNOSIS 1 : 78900 ABDOMINAL PAIN UNSPEC SIT
PROC CODE : 76700 US EXAM ABDOM COMPLETE
10/20/O6 - 10/20/06 04/09/07 27070961007570001 27070961007570001 200.00 8.53
DIAGNOSIS 1 : 78900 ABDOMINAL PAIN UNSPEC SIT
PROC CODE: 78223 HEPATOBILIARY DUCTAL SYSTEM IMAGING, INC
PROVIDER SUB TOTAL KINETIC IMAGING INC 375.00 14.61
31 101709146 0001
Page 35 of 37
• � 1 f
'I COMMONWEl�LTH l�F PENNSYLVANIA
I DEPARTMENT OF PUBLIC WELFARE
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
GUISTWITE DARRYL K
56 ASHTON ST
CARLISLE PA 17015
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
01/09/08 - 01/09/08 05/26/08 27081216218320001 27081216218320001 75.00 36.65
DIAGNOSIS 1 : 5990 URIN TRACT INFECTION NOS
PROC CODE: 99308 NURSING FAC CARE SUBSEQ
01/24/O8 - 01/24/08 04/07/08 27080716227660001 27080716227660001 75.00 36.65
DIAGNOSIS 1 : 4280 CHF UNSPECIFIED
PROC CODE : 99308 NURSING FAC CARE SUBSEQ
02/08/08 - 02/08/08 04/14/08 27080806125270001 27080806125270001 75.00 22.42
DIAGNOSIS 1 : 25001 DIABETES MELLITUS WITHOUT
PROC CODE: 99308 NURSING FAC CARE SUBSEQ
01/02/09 - 01/02/09 03/02/09 27090376284250001 27090376284250001 75.00 36.65
DIAGNOSIS 1 : 25001 DIABETES MELLITUS WITHOUT
PROC CODE: 99308 NURSING FAC CARE SUBSEQ
01/12/09 - 01/12/09 03/09/09 27090436225790001 27090436225790001 100.00 51.27
DIAGNOSIS 1 : 4011 BENIGN HYPERTENSION
PROC CODE : 99309 NURSING FAC CARE SUBSEQ
PROVIDER SUB TOTAL GUISTWITE DARRYL K 400.00 183.64
31 101796105 0002
Page 36 of 37
. . � r
j COMMONWEALTH OF PENNSYLVANIA
� _ DEPARTMENT OF PUBLIC WELFARE _ �
June 24,2013
STATEMENT OF CLAIM
NAME SURFIELD,ROBERT
ID 760 191 187
CENTRAL PENN MEDICAL GROUP/LANCAST
45 SPRINT DR
CARLISLE PA 17013
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/26/06 - 04/26/06 09/25/06 27062621003880001 27062621003880001 119.28 10.69
DIAGNOSIS 1 : 36616 SENILE NUCLEAR CATARACT
PROC CODE: 00142 ANESTH LENS SURGERY
PROVIDER SUB TOTAL CENTRAL PENN MEDICAL GROUP/LANCASTER HMA ��g.Zg 10.69
32 001776576 0076
Page 37 of 37