HomeMy WebLinkAbout11-05-13 STATE OF
In Re:
Case# °2 3 l�P I In the �U Qh�u u I dX
Estate of•�.o jL •lM LJ R G1J
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
$ lon-)O"
2. The basis or h�e-clam is ?ccount# for date of
serviceJ�' r` 7
3. The tax identification number of the claimant is 23-2892355.
4. The name and address of the claimant is: Bureau of Account ManagemenP07 w rn n
Rosemont Avenue Suite 502 Camp Hill, PA 17011. Phone#717-214-300 _ c u' o
5. This claim is not contingent.
6. This claim is not secured. " °
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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 30 day of 0 c t 0 �e I' 20 13
Angel Br ofn Phone# 717-214-3005 Bureau of Account Management Claimant
abrown @outtechinc.com
State of Pennsylvania, County of Cumberland ft.
IN WITNESS WHEREOF, I have set my hand and notarial seal this 30 day of
0 , 20 13
Notary Public
My Commision Expires: I I I I b COMMONWEALTH OF PENNSYLVANIA
LNOTARIAL SEAL
H E.SCHWEAR,Notary Public
en Twp.,Cumberl and County
sion Expires November 19,2016
SSH CENTRAL PA HARRISBURGSSH CENTRAL PA HARRISBURG 538 0011806-01
111 SOUTH FRONT STREET PO BOX 642369 2855 0111
HARRISBURG PA 171012010PITTSBURGH PA 15264
888-868-1103 251885943 011813 020713
FEM102763094001 1100 GRANDON WAY
URANI LORETTA M MECHANICSBURG PA 17050
03141936 F 01181318 3 4 13 03
URANI LORETTA M
1100 GRANDON WAY 80 2000
APT 514
MECHANICSBURG PA 17050
0120 ROOM & BOARD 1285 . 00 14 1799000
0120 ROOM & BOARD 1390 . 37 6 834222
0250 PHARMACY GENERAL 271 265567
0258 PHARMACY IV SOLUTIONS 11 11775
0270 MED/SUR SUPPLIES GENERAL 447 278945
0300 LABORATORY GENERAL 59 693624
0386 BLOOD-OTHER COMPONENTS 2 204828
0410 RESPIRATORY SERVICES GENE 26 129310
0420 PHYSICAL THERAPY 8 85615
0430 OCCUPATIONAL THERAPY GENE 17 150611
0730 EKG/ECG GENERAL 1 19954
0731 HOLTER MONITOR 20 484000
0921 PERIPHERAL VASCULAR LAB 1 116952
0942 EDUCATION/TRAINING/DIETAR 4 12693
r
0001 1 1 021813 5087096
1346248333
HIGHMARK FREEDOM BLUE HMO Y Y 1657
URANI LORETTA M 18 FEM102763094001 01999905
6331684
584 . 9 Y 261 Y 284 . 19Y 202 . 80Y 276 . 0 Y 288 . 50Y 794 . 8 Y 427 . 31N V87 .41
9 707 . 02Y 707 .22Y V15 . 3
584 . 9 682 682
1366407165 1GC33423
99 . 04 012513 CUMMINGS CARY
1366407165 1GC33423
CUMMINGS CARY
HIGHMARK FREEDOM BL B3282E000OOX
PO, BOX 890062
CAMP HILL PA 17089-0514
POST DATE: 2/18/13 538 0011806 Elec Billed * REPRINT
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