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HomeMy WebLinkAbout14-0228 Supreme Court of Pennsylvania " Cou Co m Pleas y For Prothonotary Use Only: a i%1 Covefi eet T BE D • a County Docket No: � � �r The information collected on this form is used solely court administration purposes. This fornt does not supplement or replace the filing and service. of • pleadings or other tapers as required by law or rules of court. Commencement of Action: S (9 Complaint ❑ Writ of Summons El Petition ❑ Notice of Appeal ❑ Transfer from Another Jurisdiction ❑ Declaration of Taking E C Lead Plaintiff's Name: Lead Defendant's Name: . Iron Haven Gym & Chiropractic, P.C. Progressive Preferred Insurance Co. I ❑ Check here if you are a Self- .Represented (Pro Se) Litigant O Name of Plaintiff /Appellant Attorney: ANDREW C. SPEARS, ESQUIRE N Are money damages requested? : DYes ❑ No Dollar Amount Requested: within arbitration limits y g re q (Check one) X outside arbitration limits A Is this a Class Action Suit? ❑ Yes 0 No + Nature of the Case Place an "X" to the left of the ONE case category that most accurately describes your PRIMARY CASE. If you are making more than one type of claim, check the one that you consider most important. 1 TORT (do not include Mass Tort) CONTRACT (do not include Judgments) CIVIL APPEALS ❑ Intentional ❑ Buyer Plaintiff Administrative Agencies ❑ Malicious Prosecution ❑ Debt Collection: Credit Card ❑ Board of Assessment 0 Motor Vehicle ❑ Debt Collection: Other ❑ Board of Elections ❑ Nuisance ❑ Dept. of Transportation ❑ Premises Liability ❑ Zoning Board S ❑ Product Liability (does not include ❑ Statutory Appeal: Other { mass tort) Employment Dispute: E 11 Slander/Libel/ Defamation Discrimination ❑ C ❑Other: Employment Dispute: Other Judicial Appeals T ❑ MDJ - Landlord/Tenant l ❑ Other: ❑ MDJ - Money Judgment O MASS TORT ❑ Other: ❑ Asbestos N ❑ Tobacco ❑ Toxic Tort - DES ❑ Toxic Tort - Implant REAL PROPERTY MISCELLANEOUS ❑ Toxic Waste ❑ Ejectment ❑ Common Law /Statutory Arbitration ❑ Other: ❑ Eminent Domain /Condemnation ❑ Declaratory Judgment B ❑ Ground Rent ❑ Mandamus ❑ Landlord/Tenant Dispute ❑ Non - Domestic Relations ❑ Mortgage Foreclosure Restraining Order PROFESSIONAL LIABLITY ❑ Partition ❑ Quo Warranto ❑ Dental ❑ Quiet Title ❑ Replevin ❑ Legal ❑ Medical ❑ Other: ❑ Other: ❑ Other Professional: I Pa.R. C.P. 205.5 212010 NOTICE Pennsylvania Rule of Civil Procedure 205.5. (Cover Sheet) provides, in part: Rule 205.5. Cover Sheet (a)(1) This rule shall apply to all actions governed by the rules of civil procedure except the following: (i) actions pursuant to the Protection from Abuse Act, Rules 1901 et seq. .(ii) actions for support, Rules 1910.1 et seq. (iii) actions for custody, partial custody and visitation of minor children, Rules 1915.1 et seq. (iv) actions for divorce or annulment of marriage, Rules 1920.1 et seq. (v) actions in domestic relations generally, including paternity actions, Rules 1930.1 et seq. (vi) voluntary mediation in custody actions, Rules 1940.1 et seq. (2) At the commencement of any action, the party initiating the action shall complete the cover sheet set forth in subdivision (e) and file it with the prothonotary. (b) The prothonotary shall not accept a filing commencing an action without a completed cover sheet. (c) The prothonotary shall assist a party appearing pro se in the completion of the form. (d) A judicial district which has implemented an electronic filing system pursuant to Rule 205.4 and has promulgated those procedures pursuant to Rule 239.9 shall be exempt from the provisions of this rule. (e) The Court Administrator of Pennsylvania, in conjunction with the Civil Procedural Rules Committee, shall design and publish the cover sheet. The latest version of the form shall be published on the website of the Administrative Office of Pennsylvania Courts at www.pacourts.us • �:,. T1,'� YL VA COU i Andrew C. Spears (PA 87737) HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road, Suite 2 Harrisburg, PA 17110 Ph.: 717.238.2000 Fax: 717.233.3029 spears @hhrlaw.com Attorneys for Plaintiff IRON HAVEN GYM & CHIROPRACTIC, P.C., IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff CIVIL ACTION — LAW v. � Cly� NO. a� PROGRESSIVE PREFERRED INSURANCE CO., Defendant NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY LAWYER REFERRAL SERVICE 32 South Bedford Street Carlisle, PA 17013 71.7- 249 -3166 0 ��J -4163 7 6pd 1241 2,,6c�;a(o8 Andrew C. Spears (PA 87737) HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road, Suite 2 Harrisburg, PA 17110 Ph.: 717.238.2000 Fax: 717.233.3029 spears @hhrlaw.com Attorneys for Plaintiff IRON HAVEN GYM & CHIROPRACTIC, P.C., IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff CIVIL ACTION — LAW V. NO. PROGRESSIVE PREFERRED INSURANCE CO., Defendant AVISO USTED HA SIDO DEMANDADO /A EN CORRE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar acci6n dentro de los pr6ximos veinte (20) dias despues de la notificaci6n de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objecciones a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar acci6n como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamaci6n o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. CUMBERLAND COUNTY LAWYER REFERRAL SERVICE 32 South Bedford Street Carlisle, PA 17013 717- 249 -3166 Andrew C. Spears (PA 87737) HANDLER HENNING & ROSENBERG LLP 1300 Linglestown Road, Suite 2 Harrisburg, PA 17110 Ph. 717.238.2000 Fax 717.233.3029 spears @hhrlaw.com Attorneys for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IRON HAVEN GYM & CHIROPRACTIC, P.C., 290 Pomfret Street, Suite 3, CIVIL ACTION — LAW Carlisle, PA 17013, Plaintiff, V. NO. PROGRESSIVE PREFERRED INSURANCE CO, P.O. Box 6807, Cleveland, OH 44101, Defendant. COMPLAINT Plaintiff, Iron Haven Gym & Chiropractic, P.C. ( "Iron Haven "), by and through its attorneys, HANDLER, HENNING & ROSENBERG, LLP, by Andrew C. Spears, Esq., and makes this complaint against Defendant, Progressive Preferred Insurance Co. ( "Defendant "), and avers as follows: 1. Iron Haven is a professional corporation, organized and existing under the laws of the Commonwealth of Pennsylvania, with a registered office address of 290 Pomfret Street, Suite 3, Carlisle, Cumberland County, Pennsylvania. 2. Dr. Matthew Nicastro is a chiropractor licensed in the Commonwealth of Pennsylvania and is president of Iron Haven. 3. Defendant, upon information and belief, is an insurance company, licensed to do business in the Commonwealth of Pennsylvania, with its corporate headquarters in Cleveland, Ohio. Defendant regularly writes and sells insurance policies in Cumberland County, Pennsylvania. 4. Defendant provided automobile insurance to Jennifer Moore. 5. The policy of insurance issued by Defendant was intended to meet the requirements of the Pennsylvania Motor Vehicle Financial Responsibility Law, 75 Pa. C.S. § 1701 ( "MVFRL "), and to provide first party benefits to Jennifer Moore, in accordance with the law. 6. The benefits provided included coverage for medical and chiropractic services rendered to Jennifer Moore. 7. On August 20, 2012, Jennifer Moore was injured in a motor vehicle collision (the "Collision") caused by a third -party tortfeasor, David Dudley. The Collision took place on at the intersection of U.S. Route 15 and Willow Road in Frederick County, Maryland. 8. Jennifer Moore sustained serious injuries in the Collision. 9. Jennifer Moore sought and received care from Iron Haven, which consisted of chiropractic treatments, manipulations, and other modalities to aid in recovery from the personal injuries suffered. 10. Iron Haven routinely billed Defendant for the services performed, in accordance 2 with the MVFRL. 11. Defendant paid Iron Haven for some of the care provided. 12. Defendant has not paid certain bills provided to it by Iron Haven for chiropractic care of Jennifer Moore. Accordingly, Defendant has violated the MVFRL. 13. Defendant wrongfully obtained a records review of Jennifer Moore. 14. Defendant improperly termed the records review a "peer review." 15. Defendant has the burden of proving to the trier of fact that the records review met the requirements of 75 Pa. C.S. § 1797 and 31 Pa. Code § 69.52, and was legally a peer review. See Judge Bratton's Trial Court Opinion in Herd Chiropractic Clinic P.C. Mitten v. State Farm Mut. Auto. Ins. Co. 124 Dauph. 180 (2010), rev'd on other grounds, 64 A.3d 1058 (Pa. 2013). 16. Defendant failed to comply with the following statute and regulations applicable to peer reviews and therefore cannot convert the records review to a peer review: a. Defendant had no reasonable basis for referring Iron Haven's records to a review organization because a prudent person would not believe it was necessary at that time to review Jennifer Moore's records, because among other reasons, the care was providing pain relief Defendant's conduct violated 31 Pa. Code § 69.52(a). b. Without any established internal written guidelines, Defendant arbitrarily and unreasonably referred Iron Haven's bills to a peer review organization, thus violating 31 Pa. Code § 69.52(a). C. Defendant lacked sufficient understanding of the circumstances or conditions relating to Iron Haven's care that would cause a prudent person 3 b to refer the bills under 31 Pa. Code § 69.52(a). d. Defendant knew or should have known that treatment required to lessen a patient's pain is reasonable and necessary and therefore a prudent person would not have referred the review. e. The records review did not use national or regional norms as required by 31 Pa. Code § 69.53(e). f. No written criteria were provided to the reviewing doctor by the peer review organization. Pursuant to 31 Pa. Code § 69.53(e), if national or regional norms do not exist, then the PRO shall establish written criteria to be used in conducting the peer review based upon typical patterns of practice in the PRO's geographic area of operation. g. The review does not accurately represent all the relevant facts contained in Iron Haven's records and therefore Defendant's conclusion that Iron Haven's care was not reasonable and necessary is invalid. Such action violates 75 Pa. C.S. § 1797. h. The review report ignores the medical necessity presented by all the relevant facts contained in Iron Haven's records and therefore Defendant's conclusion that Iron Haven's care was not medically necessary is invalid. Said action violates 75 Pa. C.S. § 1797. 17. Defendant knowingly used the defective records review to deny payment to Iron Haven. 18. Defendant failed to comply with 75 Pa. C.S. § 1797 and 31 Pa. Code §§ 69.52 -53 when it used a records review that did not comply with the statutory requirements and MVFRL 4 0 regulations as the basis to deny payment of Iron Haven's bills. 19. A records review has no legal effect and is a nullity, therefore Defendant is liable to Iron Haven for payment of bills, interest, costs of challenge, and attorney fees. 20. Defendant's breach of the prudent person standard set forth in 31 Pa. Code § 69.52(a) and use of records review, under § 69.53(e), demonstrate Defendant's willful intent to deny Iron Haven payment for care and treatment. Because Defendant acted in an unreasonable manner in denying Iron Haven's bills, the bills are overdue, pursuant to 75 Pa. C.S. § 1716. Attorney fees are mandatory where 75 Pa. C.S. § 1716 is violated. 21. Defendant's failure to follow the statute and regulations as described in this complaint demonstrates no reasonable foundation for denying Iron Haven's billings and therefore mandates an award of attorney fees pursuant to 75 Pa. C.S. § 1798 for the reasons stated above and as follows: a. Defendant knew from prior litigation and opinions of this Commonwealth, or should have known, that the review did not contain references to national or regional norms as required by 31 Pa. Code § 69.53(e). b. Defendant knew from prior litigation and opinions of this Commonwealth, or should have known, that the peer review organization failed to provide the reviewing chiropractor with either national or regional norms or established writings as required by 31 Pa. Code § 69.53(e). C. Defendant knew from prior litigation and opinions of this Commonwealth that the reviewing doctor failed to use either national or regional norms and failed to use established writings from the peer review organization. d. Defendant may have further violated the review process, as shall be 5 determined during discovery by holding Plaintiffs bills longer than 30 days without paying the bills. See 31 Pa. Code § 69.52(b). e. Defendant may have further violated the review process, as shall be determined during discovery by holding Plaintiffs bills longer than 30 days without paying interest on the overdue bills. See 31 Pa. Code § 69.52(b). 22. The treatment and care that Jennifer Moore received from Iron Haven helped to lessen pain and as such is reasonable and necessary. 23. The records reviewing doctor failed to document in his report that Iron Haven's records indicate Jennifer Moore was experiencing pain relief. 24. Jennifer Moore continued to request treatment from Iron Haven because the care lessened her pain. 25. Defendant knew or should have known from a prudent review of the records submitted to Defendant by Iron Haven that the care was providing pain relief and as such was reasonable and necessary. 26. It is averred that all bills incurred before and after the records review are reasonable and necessary. A copy of the unpaid bills are attached as Appendix A. 27. The fair and reasonable sum due to Iron Haven for its care and treatment of Jennifer Moore is $5,500.00 together with treble damages, interest at twelve percent (12 %) per year, penalty as provided by the statute and attorney's fees. 28. Defendant has failed to comply with the statute and the regulation, has used an invalid records review, and has refused to pay the balance due under MVFRL as set forth above. As a result of the aforesaid, Plaintiff has been required to hire the services of an attorney to collect the medical bills due. Therefore, pursuant to §§ 1716, 1797, and 1798 of the MVFRL, 6 Plaintiff is entitled to a mandatory award of attorney fees, interest and the costs associated with bringing this action. 29. 75 Pa. C.S. § 1797 grants standing to the provider to challenge before a court an insurer's refusal to pay for past or future medical treatment. See Terminato v. Penn National Ins. Co., 538 Pa. 60, 645 A.2d. 1287 (1994). 30. 75 Pa. C.S. §§ 1716 and 1798 provide for an award of attorney fees and interest. 31. 75 Pa. C.S. § 1797(b)(4) and (6) provide for an award of treble damages where a carriers' conduct is wanton. The actions of Defendant here are wanton for the reasons stated in this Complaint. 32. The amount of Iron Haven's outstanding bills, together with interest, costs, and attorney fees does not exceed the $75,000.00 amount in controversy necessary to remove this case from the jurisdiction of the Cumberland County Court of Common Pleas. 33. Defendant cannot avail itself of the protection from an award of attorney fees granted by the Supreme Court in Herd Chiropractic Clinic, P.C. v. State Farm Mut. Auto. Ins. Co., 64 A.3d 1058 (Pa. 2013). The Supreme Court in Herd held that Defendant State Farm conducted a peer review. Plaintiff Iron Haven has averred that Defendant conducted a records review and therefore Herd has no applicability. 34. The Superior Court in Levine v. Travelers 69 A.3d 671 (Pa. Super. Ct. 2013), held that an IME (i.e. a records review with a physical exam) does not afford an insurance company immunity from an award of attorney fees to the health care provider. WHEREFORE, Plaintiff, Iron Haven Gym & Chiropractic, P.C., demands judgment against Defendant, Progressive Preferred Insurance Co., for compensatory damages of 7 v s $5,500.00, treble damages, interest at the rate of 12% per annum, attorney fees, and costs of challenge. Respectfully submitted, HANDLER, HENNING & ROSENBERG, LLP Dated: December 18, 2013 By: Fk Andrew C. pears 87737) 1300 Linglestown Road, Suite 2 Harrisburg, PA 17110 Ph. 717.238.2000 Fax 717.233.3029 spears @hhrlaw.com Attorneys for Plaintiff. 8 VERIFICATION The undersigned hereby verifies that the statements in the foregoing document are based upon information which has been furnished to counsel by me and information which has been gathered by counsel in the preparation of this lawsuit. The language of the document is of counsel and not my own. I have read the document and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the contents of the document are that of counsel, I have relied upon my counsel in making this Verification. The undersigned also understands that the stat m nts made therein are made subject to the penalties of 18 Pa., C.S. Section 490 r ating to unsworn falsification to authorities. �`N`�icstro Date: I � PROGRESSIVE INSURANCE IS00 PO BOX 512926 W r HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 V PICA PICA y 1. MEDICARE MEDICAID CH MRE CHAMPVA HEA HE AU BUC LUNG OTHER 1a. INSURED's I.D. NUMBER (For Program in Item 1) (Medicare #) ❑ (Medicaid #) ❑ (Sponsor's SSN) E] (Member ID #) ❑ (SSN or ID) (SSN) (ID) 123838246 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S B BIRTH DATE SEX 4. INSURED's NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F 01' ];974 ME] F® MOORE, ANTHONY, J 5. PATIENT'S'ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self spouse Child other 271 S COLLEGE ST E 8. PATIENT STATUS CI STATE Z RLISLE 1 p kT 'FARLISLE PA p � Single � Married 0 Other 0 � ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) a 7 013 717 F 5 8 319 9 Ej Full - Time ❑Part -Time ❑ 17 013 71 2583199 0 Employed Student Student 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z Z W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED's DA OF BIRTH SEX YES �NO 11 041 1969 M� F co b.OT INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME a YY 0 M ❑ F 0 YES NO I- -� Z a c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z 11 YES EE NO PROGRESSIVE INSURANCE W a d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? p 11 YES ©NO 11 yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED's OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for 1 to process this claim. l also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 10/03/12 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OFF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION M DID ' yy INJURY (Accident) OR GIVE FIRST DATE MM DO YY MM DD YY MM DD YY 8 1 20 1 PREGNANCY(LMP) i FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES -- - -- -- --- MM 1 DD ) YY MM DD . YY 17b. NPI FROM TO ) 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES I E] YES aO 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22, MEDICAID RESUBMISSION p q ^7 CODE ORIGINAL REF. NO. 3. � . 4 23. PRIOR AUTHORIZATION NUMBER 2. 7124 4 , 4.1 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To ACE (Explain Unusual Circumstances) DIAGNOSIS p ID. RENDERING MM DD YY MM DD W S M EMG CPT /HCPCs MODIFIER POINTER $ CHARGES U Its Plan DUAL PROVIDER ID. # 1 8 �2 12 08 .22 12 11 ; 99213 25 ; 1 2 3 4 851 0 1 NPI 1306815568 1 r. r 1 2 82 12 OB ,22 12 11 98940 1 2 3 4 ; 701 0 1 NPI 1306815568 . 3 82 12 08 122 12 11 98943 I 1 1 2 3 4 751 6 1 NPI 1306815568 r l 8 �2 2 08 22 2 1 11 .97014 1 2 3 4 6a 0 1 "PI 1306815568 . 5 08 2 f2 08 1 22 2 11 97035 1 2 34 60 0 1 "PI r l 6 _'_ - -NPI- ------ --- --- --- -- - --- -- _ 2 7 9• I 1 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. ACCEPT 28. TOTAL CHARGE 29. AMOUNT PAID 1 30. BALANCE DUE 1 For govt cla ms, see ba F l 00081670 ❑E OOJE000 1201 ®YES �NO $ 49d.00 $ $ 45,0.00 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( 717) 2 4 3 63 9 6 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse I RON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this Will and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 rART.TST.E. PA 1701 3 IGNATURE ON FILE SIGNED 10 /03 /�� a•125553;5940 b. a' b I NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE 150 PO BOX 512926 LU HEALTH INSURANCE CLAIM FORM LOS ANGELES CA 90051 PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 06105 Q V PICA PICA �r 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) (Medicare #) ❑ (Medicaid # ❑GRAMPUS ❑ )❑ HEAL S or D)� El (SSN) LU ❑ (ID) 123838246 It (Sponsors SSN) ( M e mber PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PM TIENTSS BIRTH DATE SEX 4. INSUREDSS NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F 06 1 i974 M F© MOORE, ANTHONY, J 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSUREDSS ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self ❑ Spouse ®Child❑ Other❑ 271 S COLLEGE ST CARLISLE STATE S. PATIENT STATUS CITY STATE Single Married❑ Other ❑ CARLISLE PA O n ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) Full -Time Part-Time Z 7 013 717 ? 583199 Employed 11 Student ❑ student ❑ 17 013 71) 2 5 8 319 9 0 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER L Z_ D a.OTHER INSUREDS POLICY OR GROUP NUMBER a.EMPLOYMEN" (Current or Previous) a. tNSURE DA NSURED'S DATE OF BIRTH OF BIRTH SEX W ❑YES ®NO 1 O� 1969 Ma F ❑ Z b.OTHER I b. AUTO ACCIDENT? b. EMPLOYER'S NAME OR SCHOOL NAME MM , DD , YY SEX PLACE (State) M ❑ F ❑ ❑YES ❑ NO L� Q c, EMPLOYER'S NAME OR SCHOOL NAME C. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z ❑YES NO PROGRESSIVE INSURANCE W a d, INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? O. ' ❑ YES I 'IN0 If yes, return to and complete Item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSUREDSS OR AUTHORIZED PERSON'S SIGNATURE l authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the parry who accepts assignment services described below. below. SIGNATURE ON FILE 10/03/12 SIGNATURE ON FILE SIGNED DATE SIGNED I 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE 70 WORK IN CURRENT OCCUPATION i MM DD , YY INJURY (Accident) OR GIVE FIRST DATE MM ; DO ; YY MM ; DD , YY MM ; DO ; YY 8 19 2012 PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a` 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES - - -- - - -- -- - - - - ------------------ �___ MM ; DO , YY MM ; DD YY + 17b. NPI FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE lA6? $ CHARGES ❑ YES ❑NO 21\DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION 3. x_8__40.9 CODE ORIGINAL REF. NO. .. 23. PRIOR AUTHORIZATION NUMBER 2. 724 4. 4. L_139 7 24. A. DATE(S) OF SERVICE 8. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. �G� 6 r 1. J. From To I RALEOF (Explain Unusual Circumstances) DIAGNOSIS OR Psmiy ID. RENDERING p MM DD YY MM DD YY B ECG CPT/HCPCS MODIFIER POINTER $ CHARGES Uws Plan QUAL PROVIDER ID. # F t Q 08 25 2 08 25 2 11 98940 1 2 34 70 0., 1 NPI 1306815568 0 Z -- ---- - ----------------- _ 08 125 12 08 125 2 11 98943 1 2 3 4 ! 75 0 1 NPI 1306815568 W 08 '25 2 08 25 2 11 97014 1 1 2 3 4 60 0 1 _ NPI 1306815568 a _ .._ . _. 08 �25 12 08 i25 � 2 11 97035 1 2 3 4 ' 60 0 1 NPI 1306815568 C t 2 1 I q7j 2 q ' NPI - �- r) AIR 19 r, 6 -- - -- ------------------ OR127 i2 I OR i97 1 0 2 C4 R C) r NPI a 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. ' 27• rFo CEP clams see MENT? 26. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE ❑ YES ❑ NO $ $ $ .31,201 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # 717 2436396 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse IRON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) IGNATURE ON FILE 290 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 SIGNED 10 /03 /6AR a ' 125552:5940 b- a. ti NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) t PROGRESSIVE INSURANCE 1500 P BOX 512926 w r HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U PICA PICA FTT 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) CHAMPUS HEALTH PLAN BILK LUNG 123838246 (Medicare ❑ (Medicaid #) (Sponsors SSN) (MemberlD#) (SSN or ID) (SSN) (ID) 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENIT'SBIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F 0T X� D ]'974 M F D MOORE, ANTHONY, J 5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self spouse Child Other 271 S COLLEGE ST SE 8. PATIENT STATUS CITY ARLISLE PA STATE T 1�LISLE P AT C o Single 0 Married [] Other L] 1- ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) a 7 013 ( 717 Y 5 8 319 9 Employed Full -Time ❑ Part-Time ❑ 17 013 71 2583199 P Student Student IL 9. OTHER INSURER'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURER'S POLICY GROUP OR FECA NUMBER Z D W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX cc MM ; DD Y M 9 M F C0 YES ©NO 1',L 0 4 19 6 9 Z b. OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME p MM , DD YY Z M[] F ❑X YES NO 1 J a c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z YES ©NO PROGRESSIVE INSURANCE w d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? n YES E]�N0 If yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 10/03/12 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 1 M DD YY INJURY (Accident) OR GIVE FIRST DATE MM DD ; YY MM DO YY MM DD YY M $ 14 2 0;12 ' PREGNANCY(LMP) ; FROM TO ; 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES -- `- -- -------- --- MM i DD ; YY MM i DD i YY i 17b. NPI FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES ED YES a0 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1. $47 0 , 3. X40. 23. PRIOR AUTHORIZATION NUMBER 2. 4 4. L 7 3 9 . 7 24. A. DATE(S) OF SERVICE 8. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. 1. J. From To PIACEOF (Explain Unusual Circumstances) DIAGNOSIS P ID. RENDERING MM DD YY MM DO YY SERUC£ EMG CPT /HCPCS MODIFIER POINTER $ CHARGES UNITS Plan DUAL PROVIDER ID. # t 1 08 .27 12 08 i27 12 11 98943 i 12 3 4 75 0 1 NPI 1306815568 2 08 .27 12 08 i27 12 11 ! 97014 1 2 34 60 O NPI 13 06 81 55 68 -- 3 08 ,27 12 08 i27 2 11 97124 59 , 1 2 3 4 14a 60'i NPI 1306815568 r 4 08 ,27 12 08 1272 11 97035 ? i i 1 2 3 4 6Q 0 1 NPI 1306815568 ` 5 08 31 2 08 - 31 ' 2 11 98940 i 1 2 34 7 0 1 NPI 68 55 r -- - - -- -- 6 08 i31 i2 108 i31 i2 1 11 :98943 1 1234 7 0 1 "P' 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. QCEPT la PISSIGN�riF�NT? 28. TOTAL CHARGE , 29. AMOUNT PAID 30. BALANCE DUE or govt c me see ac) ' 00081670 00 MOOJE000 1201 [j] YE MNO $ 480-0 $ $ 4 O. 01 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( 717 ) 2 4 3 63 9 6 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse I RON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part theraof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE rDPT.TST,F PA 1701 rART.TAT-17 T> SIGNED (112 t 10 /03 / &aE a • 12555`7.5940 b. a. Ix NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE 1500 PO BOX 512926 ¢ W HEALTH INSURANCE CLAIM FORM L os ANGELES CA 90051 a a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105 V PICA PICA y 1. MEDICARE MEDICAID TRICAR S CHAMPVA HR H P LAN BL LAt1NG OTHER Ia. INSURED'S I.D. NUMBER (For Program in Item 1) (Medicare #) [] (Medica(d #) (Sponsor's SSN) (MemberlO #) 11 (SSN or ID) (SSN) [X (ID) 123838246 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATI BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F 06 1 1974 M F© MOORE, ANTHONY, J S. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST S ❑ Spouse ®Childo Other 271 S COLLEGE ST STATE 8. PATIENT STATUS CITY STATE CITY PA CARLISLE PA O Single Married � Other F ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) a PE 7013 (717 583199 Employed Full-Time deot 17013 711 2583199 p 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'$ POLICY GROUP OR FECA NUMBER Z a W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX Ir MM 1 DD 1 YY n YES QNO l 04 1969 Ma F z b.O IN YYA OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME p ME] F E] YES F NO I-� z a c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z Yes ®NO PROGRESSIVE INSURANCE a d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? d E YES aO If yes, return to and complete Item 9 a -d. I READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. i below. SIGNATURE ON FILE 10/03/12 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATII UNABLE TO WORK IN CURRENT OCCUPATION MM 1 OD I YY INJURY (Accident) OR GIVE FIRST DATE MM DD YY MM , DD YY MM DD YY 8 19 20;12 �PREGNANCY(LMP) FROM ; ; TO i 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a5 18. HOSPITAL D DATES RELATED TO CURRENT SERVICES Y -- --- - --- -- - ------- --- ---- - -- --- 17b. NPI FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES YES [:�q0 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION i CODE ORIGINAL REF. NO. 3. 1 P40 j 23. PRIOR AUTHORIZATION NUMBER 2. 724 4 4. 739 24. A. DATE(S) OF SERVICE �SSE C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. 1. J. From To F (Explain Unusual Circumstances) DIAGNOSIS OA p � ID. RENDERING MM DD YY MM DD YY EMG CPT /HCPCS MODIFIER POINTER $ CHARGES Mrs Plan QUAL. PROVIDER ID. # t ° 1 08 131 12 08 131 12 11 97014 1 2 3 4 60 .0 1 NPI 1306815568 IT r 2 08 131 12 08 •31 2 11 ;97035 1 2 3 4 60 0 1 NPI 1306815568 3 08 1 31 12 08 1 31 2 11 97124 59 1 2 34 140 0 2 NPI 1306815568 ; .._.,.__ _ i _ ..... _ _.. -. -- NPI- --- ----- --- -- °----- -`- �. 4 ., - NPI 4 6 1 NPI -- ----- --------- ------ -- o 1 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. ACCEPT ASSIGNNvTT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE lFOr goN. dal- see 1 InnoRl 670 ❑ YES ONO $ 66 I nc $ $ V-1 MoOITF-000 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( 717)24-36396 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse I RON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE SIGNED 10 /03 /i�a2E a'1255575940 b. a. b NUCC Instruction Manual available at www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE 1 J roo PO BOX 512926 w HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08 /05 U PICA PICA y 1. MEDICARE MEDICAID CR MPUS CHAMPVA GROUP LTH PLAN FBLEKCLAt1NG OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) (Medicare #) ❑ (Medicaid #) (Sponsor's SSN) � (Member ID #) 1:1 (SSN or ID) ISSN) OD) 123838246 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENTS BIF TH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F 0 � f D 1; 9 7'4 M F© MOORE, ANTHONY, J 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED's ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self❑ Spouse [nChildo Other 271 S COLLEGE ST STATE 8. PATIENT STATUS CITY PA STATE i PA CARLISLE o LISLE Single F] Married [] Other ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) a . 7013 ( 717 Y 5 8 319 9 Emp loyed Full -Time ❑ Part -Time ❑ oc P Student student 17 013 { 71 2 5 8 319 9 LL 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z G W a.OTHER INSURED's POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED's DA OF BIRTH SEX MM : FIYES I Z11NO 11 04 1969 M[]I F Cl) b. OTHER INSURED'S YATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME a ME] FE] ❑X YES 0 NO �� Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME h Z YES NO PROGRESSIVE INSURANCE a d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? tL YES [2N0 H yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 10/03/12 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: A ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM ' DD ' YY INJURY (Accident) OR GIVE FIRST DATE MM DD YY M DD , YY MM DD YY 8 1 20.12 MM Do FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES -- -- -------- --------- ----- MM ; DO ; YY MM DD ; YY 17b. NPI FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES YES ao 21\DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1 . $47 0 . 3.1.840. j 23. PRIOR AUTHORIZATION NUMBER 2. 24 4 4. L739 . 7 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To RACEOF (Explain Unusual Circumstances) DIAGNOSIS ORS Pr I RENDERING C MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS Plan DUAL. PROVIDER to. # . 1 09 i05 12 09 05 i2 11 98940 1 2 3 4 7a 0 1 NPI 1306815568 rl - 2 09 05 12 09 05 12 11 98943 I 1 2 34 7S 0 1 NPI 1306815568 ' __ , .. __ ..., _ _ . ._... - .. - - - - - -- ------------ - - - - -- - - - -'- 3 09 05 2 09 05 2 11 97012 1 2 3 4 6a 0 1 NPI 1306815568 , U 4 09 05 2 09 05 2 11 97014 1 2 3 4 60 Od 1 1 NPI 1306815568 - - - -- --------------- - - - - -- c 5 9 ,0 2 7 3' 0 NPI , NPI 09 ii 98 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT /ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE (For govt. cla ms, see bac ) 00081670 ❑® 1 MQQjE000 1201 EYES []NO $ 47' t , p $ $ 47:5.0 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH It ( 717) 2436396 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse ERON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE SIGNED 10 /03 /I a•12555.7,5 I b• a' b. NUCC Instruction Manual available at: www.nucc.org APPROVED OMB- 0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE 1SOO PO BOX 512926 LOS ANGELES CA 90051 HEALTH INSURANCE CLAIM FORM a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U PICA PICA FT7 y 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER Ia. INSURED'S I.D. NUMBER (For Program in Item 1) GRAMPUS HEALTH PLAN ELK LUNG 123838246 (Medicare ft) ❑ (Medicaid #) (Sponsor's SSN) (Member ID#)❑ (SSN or 10) (SSN) r7- (ID) 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. P ATIENT S DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F 0e �1 1974 MD F© MOORE, ANTHONY, J S. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Bell[] Spouse ®Child other 271 S COLLEGE ST CITY STATE 8. PATIENT STATUS CITY STATE ARLISLE PA CARLISLE PA O Single Married 7 Other ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) Q 7 013 � 717 Y 5 8 319 9 Employed Student ❑ Student t 17 013 { 71 2583199 O 0 Student 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z C LU a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED's DATE OF BIRTH SEX IM MM ; DD , YY F] YES aNO 11 04 1969 Ma F 11 Z b.OTHER IN DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME C1 M YY M❑ FE] N YES El NO I -J Z a c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z YES ®NO PROGRESSIVE INSURANCE a im d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? 0. YES [_�40 ff yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 10/03/12 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATI OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD , YY INJURY (Accident) OR GIVE FIRST DATE MM DD YY MM DD YY MM , DO ; YY 8 19 2O `L 2 ' FROM TO PREGNANCY(LMP) 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE ija _ 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES -- - -- - --=- -'---- ---------- --- ---- -- - -- MM ; DD ; YY MM DD YY 17b. NPI FROM TO j 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES YES [:IN0 21\DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 00, 3. 1 84.0.9____ 23. PRIOR AUTHORIZATION NUMBER z. 724 4 4. 739 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. 1. J. From To RADEOF (Explain Unusual Circumstances) DIAGNOSIS OR p t, ID. RENDERING MM DO YY MM DD YY SERVICE EMG CPT /HCPCS MODIFIER POINTER $ CHARGES UM Plan DUAL PROVIDER ID. # _, - _... _ ,.., - 1 09 j10 12 09 !10 2 11 ;98943 1 2 3 4 75 0 1 NPI 1306815568 2 09 10 12 09 ;10 12 11 97014 1 2 34 6 1 NPI 1306815568 ;; r 1 - - _------------ - --- -- _ NPI- --- 3 09 10 2 09 10 2 11 97035 1 2 3 4 60 0 1 1306815568 c 09 10 12 09 10 12 11 97124 59 1 2 3 4 ! 14a 0 2 NPI 1306815568 .....__ ,.._.__.... _ - ----------------- 4 1 1 4 7 NPI r i _ NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27.'FCCEPT /SSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE OUE For govt. cle s see ba ) YES 0 NO $ $ 1 $ 4140 1 300081670 MOOJEOOO 1201 0 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # INCLUDING DEGREES OR CREDENTIALS 717 2436396 (I Certify that the statements on the reverse I RON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE SIGNED 10 /03 /�'E a'12555`7.5940 b. a' b NUCC Instruction Manual available at: www.nucc.org APPROVED OMB -0938 -0999 FORM CMS -1500 (08/05) j I � PROGRESSIVE INSURANCE 1 J rQO PO BOX 512926 HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105 V PICA PICA y 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program In Item 1) CHAMPUS HEALTH PLAN BLK LUNG 123838246 i (Medicare #) ❑ (Medicaid #) El (Sponsor's SSN) (Member ID #) ❑ (SSN or ID) (SSN) a (ID) 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENT' BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) OORE, JENNIFER, F Orr D 197 Y 4 Y M F© MOORE, ANTHONY, J 5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST [n F 271 S COLLEGE ST Self Spouse --�J Chiid Other STATE 8. PATIENT STATUS CITY STATE Z %WLISLE PA CARLISLE PA p Single 0 Married Other ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (include Area Code) a 7 013 ( 717 Y 5 8 319 9 Employed Student ❑ Student ¢ student Student 17 013 � 71'� 2 5 8 319 9 LL 9. OTHER INSURED's NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z W I a.OTHER INSURED's POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED's DATE OF BIRTH SEX M MM ; DD YY M D F 0 Ui YES QNO 11 04 1969 Z b.O INSURED'S Y DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME a M [] F ❑X YES � NO Z ' a c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z Yes NO PROGRESSIVE INSURANCE w d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? n YES �10 ff yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 10/03/12 SIGNATURE ON FILE SIGNED DATE SIGNED i 14. OFF CURRENT I LLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION A DID NJURY (Accident) OR GIVE FIRST DATE MM ; DD ; YY FROM MM , DD , YY TO MM , DD ; YY 8 1 20 12 YY PREGNANCY(LMP) l 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a - - - 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES --- '` - --------------- MM i DO ; YY MM i DD YY 17b. NPI FROM TO I 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES 1 YES [3NO 21\DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1. 47 0 3. 1 840 . 23. PRIOR AUTHORIZATION NUMBER 2. 124 4 4. L239 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. , G H. I. J. From To RACE OF (Explain Unusual Circumstances) DIAGNOSIS 0 F ry 10. RENDERING MM DD YY MM DD YY SEWU EMS CPTHCPCS MODIFIER POINTER $ CHARGES UNrrS Plan DUAL. PROVIDER ID. It 1 09 .14 12 09 .14 12 11 97014 1 2 3 4 6Q 0 1 NPI 1306815568 r r 2 09 .14 12 09 i14 12 11 :97035 1 2 34 6q 0 1 NPI 1306815568 ` _ .._,._..._ , .... -- 09 i14 12 09 ,14 12 11 97124 59 1 1 2 3 4 14a 0 2 NPI 1306815568 4 09 ,17 12 169 j17 t. 11 98940 1 2 3 41F 7Q 00 1 1 1306815568 ` 5 09 '17 2 09 17 ' 2 11 98943 1 2 3 4 7 0 1 NPI 1306815 68 r 6 09 17 2 09 17 2 11 97012 1 2 34 6d 0 1 NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. �CCEPT ASSIGNMW? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE or govt. Claims, see bee ) 00081670 ❑® MOOJE000 1201 [Z] �NO $ 46 .0 $ $ 465. C 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH k 717 2 4 3 63 9 6 INCLUDING DEGREES OR CREDENTIALS ( Icertity that the statements on the reverse E RON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE SIGNED 10 /03 /� E a•1255575940 b a' b- 12 .557 NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE 150 PO BOX 512926 ¢ U.1 HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U PICA PICA 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) CHAMPUS HEALTH PLAN BILK LUNG 123838246 (Medicare #) ❑ (Medicaid #) 1:1 (Sponsor's SSN) (Member 1D#) ❑ (SSN or 1D) (SSN) L (ID) 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PMTIENTDoIF TH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F OED1 ] 97 M F © MOORE, ANTHONY, J 5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self Spouse Child Other 271 S COLLEGE ST STATE 8. PATIENT STATUS CITY STATE CITY PA CARLISLE PA o Single Married [:] Other }. ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) Q 7 013 � 717 Y 5 8 319 9 Employed Student ❑Part-Time � LL Student student 17 013 71 2 5 8 319 9 0 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z Z 0 W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX MM I DD , YY YES ©NO 1 04 1969 MD F z b.O INSUREDS YY URED' DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME a MID F YES NO c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z W DYES NO PROGRESSIVE INSURANCE Q d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? d YES aO ff yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 10/03/12 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symprom M ) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD ; W INJURY (Accident) OR GIVE FIRST DATE MM ; DD ; YY MM , DD YY M DD ; YY $ 1 20112 ' PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. -- -_ -- 18. HOSPITALIZATION DZA DATES RELATED TO C M RENT DoRVICE Y --- - -- -- -- - - - - - --- ' 17b. NPI FROM i TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? CHARGES YES aO 21\DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1.a 7 0. 3.1 R40.4 23. PRIOR AUTHORIZATION NUMBER 2. ?24 4 4. 24. A. DATE(S) OF SERVICE PROCEDU B. RES, SERVICES, OR SUPPLIES E. F. G. H. I. J. Z OW From To RACE OF (Explain Unusual Circumstances) DIAGNOSIS OR PFamlly I RENDERING 0 MM DD YY MM DD YY SiRva EMG CPTMCPCS MODIFIER POINTER $ CHARGES UNITS Plan QUAL. PROVIDER 1D. # Q r - 1 09 Ill 12 09 117 12 11 .97014 1 2 3 4 60 0 1 NPI 1306815568 C 2 09 .17 12 09 117 12 11 97124 59 I 1 2 34 140 0 2 NPI 1306815568 r ....-, _..., .._........ ._.. ..._..... - ._ 3 ...._... -_.. ....._ NPI - - ---- -- ------- ------- o 09 122 2 09 122 ' 2 11 98940 1 2 34 70 0 1 1306815568 o 4 09 122 12 09 •22 . 2 11 98943 I ! I 1 2 34 ' 75 0 1 NPI 1306815568 5 - , -- NPI 4 r - - ------------------ - - - - -- 6 09 1 i� -- -- - NPI - 25. FEDERAL TAX 1,0, NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27• CFO govnla�ms b IJT? 28. TOTAL CHARGE 29. AMOUNT PAID 3D. BALANCE DUE YES NO $ $ $ 7 .i 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32, SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # 717) 2 4 3 63 9 6 INCLUDING DEGREES OR CREDENTIALS j (l certify that the statements on the reverse IRON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE b. SIGNED 10 /03 /&•E x'12555.7.5940 a ' 12rS�7rq4i� (,2 NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08105) PROGRESSIVE INSURANCE ' ISOO PO BOX 512926 W HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 a a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 V PICA . PICA y 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) CHAMPUS HEALTH PLAN BLKWNG 123838246 (Medicare #) ❑ (Medicaid #) ❑ (Sponsor's SSN) ❑ (Member ID #) ❑ (SSN or 10) ❑ (SSN) [N (ID} 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) OORE, JENNIFER, F 0T �l 1;974 M❑ F X MOORE, ANTHONY, J 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (NO., Street) 71 SOUTH COLLEGE ST self❑ Spouse Child Other❑ 271 S COLLEGE ST ATE 8. PATIENT STATUS CITY STATE Z LISLE CARLISLE PA p Single 1:1 1:1 1:1 Other ❑ F. ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) 7 013 � 717 Y 5 8 319 9 ❑ Employed Student Full -Time ❑ Student O Part -Time 17 013 71 2583199 0 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z O W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX cc MM ; DD ; YY M(� F Cl) El �NO 11 0 4) 1969 Lam' ❑ Z b.OT n INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME p YY M ❑ F El ❑X YES ❑ NO I� Z a c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z Z 1:1 YES MNO PROGRESSIVE INSURANCE uJ Q d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? p ❑ YES [:�N0 It yes, return to and complete Rem 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of govemment benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 10/03/12 SIGNATURE ON FILE SIGNED DATE S IGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIF UNABLE TO WORK IN CURRENT OCCUPATION J I MM DD YY INJURY (Accident) OR GIVE FIRST DATE MM ; DD , YY MM , DD YY MM , DD ; YY 8 1 20 2 PREGNANCY(U MP) FROM TO ; 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. -: - 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES -- -- - -- -- - -- - -- - - MM DD YY MM ; DD YY 17b. NPI FROM TO 19, RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES ❑ YES aO 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. N0. 1. 47 0, 3. 840 23. PRIOR AUTHORIZATION NUMBER 2. 124 4 4. 1 739 7 - 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. 1. J. , From To RA(EOF (Explain Unusual Circumstances) DIAGNOSIS DO F�hr' 10. RENDERING MM DD YY MM DD YY SEANCE EMG CPT/HCPCS MODIFIER POINTER $CHARGES lXdrS Plan DUAL. PROVIDER ID. # 1 o9 12 09 ,22 12 11 ! 1 59 1 2 34 140; 0 2 NPI 1306815568 2 0 1306815568 `�09 6 12 09 .26 12 11 98943 1 1 2 34 751 0 1 NPI 1306815568 r C 4 09 �6 22 09 )26 12 11 97014 1 2 3 4 6a 0 1 NPI 1306815568 ` rl = 5 9 6 2 09 )26 r 2 11 97110 1 2 34 75 0 1 NPI 1306815568 r1 6 _ . - - 12 3 _._..- _.... _ - - - ------------------------ 9 6 2 09 )26 2 11 97124 , 59 1 2 3 4 210 0 3 NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. F�CCEPT I SSIGNVENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE ( or goW. da ms. see ackl 00081670 ❑� OOJE000 1201 ®YES NO $ 631 .00 $ $ 630.00 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # 717 2436396 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse ERON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE 10 /03 /laE 55' SIGNED a•1257;5940 b a. ... b APPROVED OMB-0938-0999 FORM CMS 7500 (08/05) NUCC Instruction Manual available at: www.nucc.01g it PROGRESSIVE INSURANCE 1 500 PO BOX 512926 w HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U PICA PICA �r 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) CHAMPUS HEALTH PLAN BLK LUNG 123638246 (Medicare #) ❑ (Medicaid #) 1-1 (Sponsor's SSN) ❑ (Member ID #)❑ (SSN or /D) ❑ (SSN) M (ID) 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENTS BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) OGRE, JENNIFER, F ow �� O 1;974 M❑ F® MOORE, ANTHONY, J 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self❑ Spouse' child Other❑ 271 S COLLEGE ST ATE 8. PATIENT STATUS CITY STATE ZO LISLE )� CARLISLE PA Single ❑ Married ❑ Other . ZIP CODE TELEPHONE (Include Area Cade) ZIP CODE TELEPHONE (Include Area Code) . Q L 7013 ( 717 Y 5 8 319 9 Emp loyed E] Full-Time ❑ Part-Time F 17 013 71) 2583199 � P Student Student O 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z D W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX MM : DO I YY YES �NO 11 04 1969 M� F ❑ Z b.OTHER INSURED'S DATE OF BIRTH b. AUTO ACCIDENT? b. EMPLOYER'S NAME OR SCHOOL NAME p MM , DD , YY SEX PLACE (State} Z M ❑ F ❑X YES ❑ NO c. EMPLOYER'S NAME OR SCHOOL NAME C. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z Z ❑ YES NO PROGRESSIVE INSURANCE d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? P1 ❑ YES [�NIO ff yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 12/12/12 SIGNATURE ON FILE SIGNED DATE SIGNED _ 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY INJURY (Accident) OR GIVE FIRST DATE MM ; DD ; YY MM 1 DO YY MM , DD ; YY 8 1 M , 2 , PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE aja: - 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES --'- ---- -- -=--' - - -- - -- - -- - -- .__._ MM ; DD ( YY MM I DD YY 17b. NPI FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES aO 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1 . Q47 Q 3.1 -840. 23. PRIOR AUTHORIZATION NUMBER 2. 4 , 4. L739 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To RACEI (Explain Unusual Circumstances) DIAGNOSIS DAYS lo. RENDERING MM DO YY MM DD YY SERVICE EMG CPT /HCPCS MODIFIER POINTER $ CHARGES MIS Plan DUAL. PROVIDER ID. # (_.... 1 10 ,03 - 12 10 r032 11 98940 - 1 - 2 3 4 1 70 0 i NPI 1306815568 , 2 10 .03 12 10 ,03 12 11 98943 1 2 34 7S 0 1 NPI 1306815568 , 3 10 (03 2 10 03 12 11 97124 59 1 2 34 14O 0 2 NPI 1306815568 _ _.. _ ....... _- ... .... - _... - -- 4 10 103 2 10 iO3 2 11 97110 59 1 2 3 4 150 6 2 NPI --- 1306815568 5 10 '10 2 10 '10 ' 2 11 98940 1 2 4 7' 0 1 NPI 1 2 341 NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS r ACCOUNT NO. 27. q�CCEPT J'SIGN v�IF�NT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE 1 o govt. da ms, see c 1 00081670 ❑® 1 MOOJE000 1203 ®YES ONO $ 58 6 0 $ $ 59-0.0c 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH ;# 717 2436396 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse IRON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE a. > : b SIGNED 12 /12 /la a' 12555:715940 b. _- NUCC Instruction Manual available at www.nucc.org APPROVED OMB -0938 -0999 FORM CMS -1500 (08/05) t PROGRESSIVE INSURANCE IJr�� PO BOX 512926 w HEALTH INSURANCE CLAIM FORM Los ANGELES C A 90051 a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U PICA PICA �r 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) CHAMPUS HEALTH PLAN 13LKLUNG (Medicare #) [] (Medicaid #) 0 (Sponsor's,SSN) ❑ (Member1D #) ❑'(S5N or ID) ❑ (SSN) ❑ (ID) 123838246 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PMNIEN78 BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) DO GORE, JENNIFER, F 06 . 1 ] 974 M❑ F❑X MOORE, ANTHONY, J 5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self[] spouse ®Child other❑ 271 S COLLEGE ST CITY STATE S. PATIENT STATUS CITY STATE ARLISLE PA CARLISLE PA o Si ❑ rri Maed ❑ Other ❑ h 21P CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) Q b Full -Time Prt -Ti L 7013 ( 717 Y 5 8 319 9 Employed ❑ Student ❑student a me ❑ 17 013 71 2 5 8 319 9 p 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED'S DA OF BIRTH SEX ❑YES aN 11 04; 1969 M❑; F ❑ Z b.O�T INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME p M❑ F ❑ - YES NO I-J Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z W ❑YES ®NO PROGRESSIVE INSURANCE d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? fy ❑ YES aO If yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 12/12/12 SIGNATURE ON FILE SIGNED DATE SIGNED 14, DATE OF CURRENT: 4 ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD ; YY INJURY (Accident) OR GIVE FIRST DATE MM DD YY MM DO YY MM DD YY 8 19 20`12 PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE :17x:: ". 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES `--=-- --------- MM ; DD YY MM DD YY 17b. NPI FROM ; TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES ❑ YES E�N0 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22' M RESUBMISSION 3. L 8 ORIGINAL REF. N0. .4.0_ ..4-- 23. PRIOR AUTHORIZATION NUMBER z. 4 . 4. 73 7 24. A. DATE(S) OF SERVICE 8. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To RAtEOF (Explain Unusual Circumstances) DIAGNOSIS F ID. RENDERING MM DD YY MM DD YY SEIMLE EC G CPT /HCPCS MODIFIER POINTER $CHARGES LNRS Ran DUAL. PROVIDER 1D. # 1 10 10 12 10 10 12 11 97110 59 1 2 3 4 150 0 2 NPI 1306815568 LL 10 10 12 10 .10 12 11 97124 59 1 1 2 3 4 140 0 2 NPI 1306815568 3 0 2 2 10 12 2 11 98940 1 2 3 4 71} 0 1 NPI 130681 4 . -- �. 0 72 12 116 j12 1 11 98943 1 2 3 4 7 ... 0 ...1. NPI 1306815568 ` T - 1 - 0 , - -- ----------------------- od r l NPI 4 g ' 1 -- - - - -- -- - - - - -- - - - -- NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27., ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30'. BALANCE DUE or govt. claims see bac ) 81670 Mnr).Tpnnn 1, ❑ YES [] $ $ $ 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( 7 17 )2 4 3 63 9 6 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse E RON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE SIGNED 12 /12 /IA�E x'125557:5940 b x' NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) i PROGRESSIVE INSURANCE 15W PO BOX 512926 w HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 cc a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U PICA PICA y F2.PAT E MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) CHAMPUS HEALTH PLAN BU( LUNG 123838246 #) El (Medicaid #) (SponsoYs SSN) (Member ID #) ❑ (SSN or ID) 1:1 (SSN) (lO) NAME (Last Name, First Nam e, Middle Initial) 3. PATIENT'S BBIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) JENNIFER, F Or j1 1;974 M F� MOORE, ANTHONY, J 5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self[ spouse' Child Other 271 S COLLEGE ST 1 STATE B. PATIENT STATUS CITY STATE Z ARLISLE PA CARLISLE PA 0 Single 1:1 Married � Other ❑ F- ZIP CODE EL HONE TEPHONE (Include Area Code) ZIP CODE TELEP (Include Area Code) a 7 013 {717 F 5 8 319 9 Employed Full -Time ❑ Part-Time ❑ 0 17013 71 2583199 Student Student LL 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z 0 W a.OTHER INSURED'S POLICY OR GROUP NUMBER &EMPLOYMENT? (Current or Previous) a. INSURMMS DA OF BI�RTTH SEX YES MNO 11 04) 1969 M D F ❑ z b.O IN YYA OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME 0 M F �X YES F NO I� Z a c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z YES NO PROGRESSIVE INSURANCE a d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? p, 11 YES ©NO If yes, velum to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 12/12/12 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15, IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION M DD YY INJURY (Accident) OR GIVE FIRST DATE MM DO , YY MM , DD ; YY MM ; DD YY M $ 1 d 2 0 }, �2 / PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a: 1B. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES °- - - --- -`.` - -- -- -° - -- - MM I DD YY MM ; DD ; YY 17b. NPI FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES 0 YES aO 21 \ OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION p 4 CODE ORIGINAL REF. NO. 1. 147 0 , . 3. 1 840 . - 23. PRIOR AUTHORIZATION NUMBER 2. 4. 1 739 . 7 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. From To RACE OF (Explain Unusual Circumstances) DIAGNOSIS OR5 PFr D. OR c. MM DD YY MM DO YY SI3WU EMG CPT /HCPCS MODIFIER POINTER $ CHARGES UNRS Plan DUAL PROVIDER ID. # , - -, - .... -, -... - - -� 70 _ ----------------- ----- - - - - -- - 1 0 18 ] 2 10 )18 12 11 98940 ) 1 2 3 4 0 1 NPI 1306815568 , 2 0 8 7 2 10 .18 12 11 98943 1 2 3 4; 75.0 1 NPI 1306815568 ; , . _... __ -- - - - - -- -- - ---- - - - - -- - -- - 0 18 12 10 X16 12 11 97110 ; 59) 1 2 3 4 150) 0 2 NPI 1306815568 3 , v 4 0 �8 ] 2 10 118 12 11 97124 59 1 2 3 4 140:0 2 NPI 1306815568 `- NPI 4 ------------------------ NPI n 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. PCCEPT ASSIGN6'&' T? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE Fargovl. claims 00081670 ❑� OOJE000 1203 1 27. EYES NO s , see a 43 .00 $ $ 435.0 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # 7 17 24 3 63 9 6 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse I RON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE SIGNED 12/12/�E a•1255575940 a a. a NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) I i ' PROGRESSIVE INSURANCE 1SOO PO BOX 512926 W HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 C1 PICA PICA �r 1. MEDICARE MEDICAID CRICARE CHAMPVA HEALTH PLAN BLEKCA OTHER la. INSURED'S I.D. NUMBER (For Program in Item 1) (Medicare #) ❑ (Medicaid #) ❑ (Sponsor's SSN) ❑ (Member ID#) ❑ (SSN or ID) ❑ (SSN) ❑ (10) 123838246 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATI SBIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F 06 , 1 ]974 M F® MOORE, ANTHONY, J 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self❑ spouse ®Child❑ other❑ 271 S COLLEGE ST CITY STATE 8. PATIENT STATUS CITY I STATE Z ARLISLE PA 9 ❑ ❑ ❑ CARLISLE PA o Sin Married Other ZIP CODE TELEPHONE (include Area Code) Fuli•Time ZIP CODE TELEPHONE (Include Area Code) Q Part -Time L 7013 717 5 8 319 9 Employed 1:1 Student ❑student ❑ 17 Q 13 71 2 5 8 319 9 LL 9. OTHER INSURED'S NAME (Last Name, First Name, Middle initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED's POLICY GROUP OR FECA NUMBER Z W a.OTHER INSURED's POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED's DATE OF BIRTH SEX MM ; DD ( YY �{, ❑YES ❑NO 1� 04; 1969 M ❑ ; F ❑ Z b.OT IN YYATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b• EMPLOYER'S NAME OR SCHOOL NAME p M ❑ F ❑ ❑YES IF NO �_ J Q Z c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z El YES NO PROGRESSIVE INSURANCE 4 d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? IL 1:1 YES aO If yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED's OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 12/28/12 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM OD YY INJURY (Accident) OR GIVE FIRST DATE MM ; DD YY MM DD , YY MM DD YY 8 19 2Q�.2 PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a: 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES _____ MM DD , YY MM DD ; YY 17b. NPI FROM TO i 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES ❑ YES aO 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 3. 1 P40..4 _ 23. PRIOR AUTHORIZATION NUMBER 2.724 4. 4. L739 . 24. A. DATE(S) OF SERVICE B. 1 0. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. L J. From To RPLEOF (Explain Unusual Circumstances) DIAGNOSIS D F� ID. RENDERING �- MM DD YY MM DD YY S9it•CE EMG CPT /HCPCS MODIFIER POINTER $ CHARGES UNRS Plan QUAL PROVIDER ID. if - ,. e 1 10 ) 6 12 10 (26 2 11 98940 1 2 3 4 70 0 1 NPI 1306815568 r 10 26 2 10 126 ' 2 11 98943 1 2 3 4 75 0 1 NPI 1306815568 r� 3 -- _ _ _ ., . _ _ _ _ - ----------------------------------- - 6 2 1 7014 1 2 3 6d 0 1 NPI r 6 .. . __- . ' _ - - - - -- ------------------------ q i 7 NPI - r. NPI p 15568 4 r NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. ACCEPT SIGN�JiENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE IFor gavl. cla ms, see cs) , E -MOOJE000 12 YES ❑ NO $ 496 nn $ $ 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # 717 2436396 INCLUDING DEGREES OR CREDENTIALS ( Icertity that the statements on the reverse I RON HAVEN GYM. CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE SIGNED 12/28/ a'125557.5940 fx - -- NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) i PROGRESSIVE INSURANCE ] 500 PO BOX 512926 W HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08!05 V PICA PICA y 1. MEDICARE MEDICAID CHICARE CHAMPVA GR PLAN BLK LUNG O THER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) (Medicare #) ❑ (Medicaid #) E:] (Sponsor's SSN) (Member ID #) ❑ (SSN or ID) (SSN) (ID) 123838246 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F 0T j1 1;974 M F F X MOORE, ANTHONY, J 5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self❑ spouse [n Child❑ Other 271 S COLLEGE ST I STATE 8. PATIENT STATUS CITY STATE Z RLISLE P CARLISLE PA p Single D Married D Other � f„ ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) Q 717 T 5 8 319 9 Full TI ❑Part -Time ❑ ( 1 Employed student Stud 013 17 013 \ 71 2 5 8 319 9 0 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z a w a.OTHER INSURED'S POLICY OR GROUP NUMBER &EMPLOYMENT? (Current or Previous) a. INSURMMs DA OF BIRTH SEX ❑YES �NO 11 04: 1969 M F z b.OMMER IN RED'Y OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME Z M F � YES NO u Q c. EMPLOYER'S NAME OR SCHOOL NAME C. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z DYES RNO PROGRESSIVE INSURANCE a d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? IL ❑ YES ©NO If yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED's OR AUTHORIZED PERSON'S SIGNATURE I authorize j 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of govemment benefits either to myself orto the parry who accepts assignment - services described below. below. SIGNATURE ON FILE 12/28/12 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM ' DD I ' , YY INJURY (Accident) OR GIVE FIRST DATE MM ; DD ; YY MM DD YY MM ; DD YY 8 19 M2 IPREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES - -- --- ----- -------- -- -- ---- ----- MM ) DO YY MM DD YY 17b. NPI I FROM ; TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES ❑ YES �NO 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1 , 47 0. 3. L$_24_. 23. PRIOR AUTHORIZATION NUMBER 2. 7124 4 . 4. L739 . 7 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To RACECF (Explain Unusual Circumstances) DIAGNOSIS DAYS ID. RENDERING MM DD YY MM DD YY SETACE EMG CPTIHCPCS MODIFIER POINTER $ CHARGES UNITS Plan DUAL. PROVIDER ID. # .. t 1 1 07 ] 2 11 X07 12 11 98943 1 2 3 4 ! 75. 00 1 NPI 1306815568 , u - - - - -- - - - - -- --- '_ 1306815568 2 1 07 ];2 11 .07 12 11 97124 5 9 I 1 2 3 4 � 140. 00 2 NPI 1 3 1 07 12 11 (07 12 11 97110 ) ) 1 2 3 4 75( OO 1 NPI 1306815568 rl _ 1 1 07 7 11 !07 12 11 '97014 1 2 60I OO 1 . - NPI 1306815568 ` 1 0 ( 2 11 ( 10 2 11 98940 1 2 3 4 70 00 1 NPI 5568 4 6 1' 0 ( 2 111 ) 10 i2 1 11 98943 1 2 3 4 75! 00 1 NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 1 27. QCEPT F SSIGN6J1E 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE (� or got. cla ms, see ac I 1:10 00081670 OOJE000 12034 ®YES ❑NO $ 49 '.00 $ 1 $ 49 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # 717 ) 2 4 3 63 9 6 INCLUDING DEGREES OR CREDENTIALS ( certify thatthe statements on the reverse IRON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 29.0 E POMFRET ST SUITE 3 IGNATURE ON FILE SIGNED 12/28/1i2rE a b- I a. 240 1 1 NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE PO BOX 512926 w HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08 /05 V FM PICA PICA � 1. MEDICARE MEDICAID TRICARUS CHAMPVA HEALTH PLAN BI U OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) NG (Medicare #) [] (Medicaid #) ❑ (Sponsor's SSN) ❑ (Member ID #) ❑ (SSN or ID) El (SSN) ❑ (ID) 123838246 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PM TIENT'S DATE SEX 4. INSURED's NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F 06 11 1974 M F© MOORE, ANTHONY, J 5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED's ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self[] spouse ®Child Other❑ 271 S COLLEGE ST CITY STATE 8. PATIENT STATUS CITY STATE Z IMR LISLE PA CARLISLE PA o Single ❑ Married ❑ Other F] � ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) Full -Time Part-Time 7 013 ( 717 � 5 8 319 9 Employed ❑ Student ❑ student ❑ 17 013 71) 2 5 8 319 9 0 LL 9. OTHER INSURED's NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z � O W a.OTHER INSURED's POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED's DATE OF BIRTH SEX rx MM ; DO , YY �{, ❑YES ©NO 1 O4 1969 M a F ❑ z b.OTHER INSURED's DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME Z MM , DD , YY M F ❑ I YES F NO L� Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z Z ❑YES NO PROGRESSIVE INSURANCE a d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? a ❑ YES aO If yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 12/28/12 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15, IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY , INJURY (Accident) OR GIVE FIRST DATE MM ; DD , YY. MM ; DD YY MM DD YY 8 19 2012 PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE i7a7 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES ____ MM ; DD ; YY MM DD YY 17b FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES ❑ YES [:3N0 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1.8_x. 3. 1 8 4 n . 23. PRIOR AUTHORIZATION NUMBER 2. 4 , 4. 7 , 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. 1. J. From To RACE OF (Explain Unusual Circumstances) DIAGNOSIS OARS FPSOr OR Fa lo. RENDERING O MM DO YY MM DD YY SSM ECG CPT /HCPCS MODIFIER POINTER $ CHARGES UNIMM Plan mily DUAL. PROVIDER ID. # Q 1 11 70 2 11 10 2 11 97110 59 1 2 3 4 150 Od 2 NPi 13068155E8 0 LL 2 ii0 12 11 :10 12 11 97124 59 1 2 34 140 0 2 NPI 1306815568 W CL I r J 1 S 3 2 11 15 2 11 97014 1 2 3 4 6d 0 1 NPI q � - -` -- ------------------------ 1 1 5 2 11 j15 2 11 97124 59 - 1 2 3 4 `. 140 0 2 NPI 1 3068155cs C ---- ---------------- r� a NPI t U. i i NPI c; QAQAQ 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT N0. 27• ( CEP clams see V 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE nnnsi 6,7n ❑ YES ❑ NO $ $ $ M001TRO 12 121 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # 717 1 4 - 365396 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the re I RON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 i IGNATURE ON FILE SIGNED 12 /28 /jbt2rE x'125557.5940 Ib. a. �� b. NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE 1500 Po Box 512926 W HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 • a P APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105 C.1 PICA PICA FTT y 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER Ia. INSURED'S I.D. NUMBER (For Program in Item 1) CHAMPUS HEALTH PLAN BLK LUNG 123838246 (Medicare #) (Medicaid #) (Sponsor's SSN) (MemberlD #)Fj (SSN or 10) (SSN) (ID) 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENTS BIRTH DATE SEX 4. INSURED's NAME (Last Name, First Name, Middle Initial) OGRE, JENNIFER, F A 1 Y M F X MOORE, ANTHONY, J 5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED's ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self❑ Spouse Child Other 271 S COLLEGE ST STATE 8. PATIENT STATUS CI [STATE Z R'LISLE A ARLISLE PA p Single � Married F� Other F� f. ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) Q 7 013 117 4 583199 Em loyed Full -Time ❑ Part Time ❑ 0 a student student 17 013 71 2 5 8 319 9 LL 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED's POLICY GROUP OR FECA NUMBER Z 0 LU a.OTHER INSURED'S POLICY OR GROUP NUMBER &EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX CC MM ; DD ; YY :D YES NO 11 0411969 M F � Cr b.OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? MM DD YY PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME p , 0 M E F - 1 YES NO U Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME YES NO PROGRESSIVE INSURANCE d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? n YES ©NO ff yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE 1 authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 12/2$/12 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM ; DD ' YY INJURY (Accident) OR GIVE FIRST DATE MM ; DD I YY MM ; DO YY MM DD YY 8 19; 2012 PREGNANCY(LMP) FROM TO j 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 117a.� L 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES `------ - ----- --- --- -- - --° -- -_ - MM DO YY MM DD ; YY 171b. NPI FROM TO l 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES YES ®NO 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1 8 147 0 . a. 81 40 4 23. PRIOR AUTHORIZATION NUMBER 2 7 21 4 4 4. L139 . 7 24. A. DATE(S) OF SERVICE 8. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To RACE OF (Explain Unusual Circumstances) DIAGNOSIS oa F�N ID. RENDERING MM DD YY MM DD YY SSA' U EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UM1S Plan QUAL. PROVIDER ID. # 1 1 �5 1:2 11 15 7t2 11 98943 � I NPI 1306815568 r r 2 06 12 12 06 1 2 11 97110 59 , 1 1 2 3 4 150; 00 2 NPI 1306815568 ; , _ ... _.. _._ _ ._.... - -- 11 98940 NPI ` , 2 06 1)2 112 06 �2.. 11 198943 1 2 3 4 75j 00 1 NPI 1306815568 ` T 5 2 6 2 12 b6 '2 11 97124 59 ' 1 2 3 4'' 140 00 2 NPI 130681556 NPI 25. FEDERAL TAX I.D. NUMBER SSN EI IN- N 11 26. PATIENTS ACCOUNT NO. 27. I C EP t. e S see PT T? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE 00081670 F I E] CJ O 000 12034 OYES ONO $ 510.00 $ $ 51.0 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32, SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( 717 2 4 3 63 9 6 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse IRON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE SIGNED 12/28/Zo2TE a-12555759.40 tb I a. j2S NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE 1500 PO BOX 512926 W HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 Q RPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U PICA PICA 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. !NUMBER (For Progr7initem 1) LUNG CAPS (Medicare #) ❑ (Medicaid #) [] (Sponsors SSN) ❑ (Member ID #) ❑ (SSN or ID)� ❑ (SSN) ❑ (ID) 123838246 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PMMIENTSS BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) Do Y OORE, JENNIFER, F 06;11 X974 M FD MOORE, ANTHONY, J 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self ❑spouse ®Child❑ other❑ 271 S COLLEGE ST CITY STATE 8. PATIENT STATUS CITY STATE ARLISLE PA CARLISLE PA o Single ❑ Married ❑ Other ❑ H ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) Q a Full -Time Part -Time 17 013 ( 717 )2 5 8 319 9 Employed ❑ student ❑ Student ❑ 17 013 71 2583199 p LIL 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z D W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURMMS OF BIB SEX IM ❑YES DNO 1;l 04 1969 M❑x F ❑ z b.O INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME p M ❑ F ❑ ©YES ❑ NO I-� Z Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z ❑ W YES ®NO PROGRESSIVE INSURANCE a d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? p ❑ YES ❑ ff yes, return to and complete Item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 02/25/13 SIGNATURE ON FILE SIGNED DATE SIGNED 14. OFF CURRENT: 4 ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION INJURY (Accident) OR GIVE FIRST DATE MM DD ; YY FROM MM , DD ; YY TO MM , DD 1 YY $ 1 20;12 PREGNANCY(LMP) 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a: 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES `-- --- --- -- ------ --- --- - -- --- --- MM DD YY MM DD ; YY 17b. NPI FROM TO .1 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES ❑ YES ❑WO 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION p 47 '7 CODE - ORIGINAL REF. NO. 1. Q I R4n 3. . 4_ 23. PRIOR AUTHORIZATION NUMBER 2. 4 4. L 739 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. i. J. From To RACECF (Explain Unusual Circumstances) DIAGNOSIS OR F � lo. RENDERING MM DD YY MM DD YY SffM0E EMIG CPT /HCPCS MODIFIER POINTER SC HARGES UUM Plan DUAL PROVIDER ID. # _ -- - _...... ..... T o 12 12 2 12 (12 2 11 98940 I 1 2 3 4 7 0 1 NPI T r T - -- --------------- - - - - -- - 2 12 12 12 12 I12 2 11 98943 1 2 3 4 75 06 1 1 NPI it T 12 1 12 2 L NPI ^- u _. 12 ( 12 2 12 ( 12 ' 2 1 7 4 NPI 5 _ _..... _ - . _ -- - - -- ------------------------ NPI v _ . ... .. .. . .. .. .. _ ._._ -- ----------------------- T NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. �C 9 claims see b E 28. TOTAL CHARGE 29. AMOUNT PAID 0. A D 0 08167 ❑ YES ❑NO $ $ $ 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # 717 ) 2436,396 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse IRON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE GA SIGNED 02/25/dA3E a ' 1255575940 b' a. b NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE 150 PO BOX 512926 W HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 Cr a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 V PICA PICA y 1. MEDICARE MEDICAID GRAMPUS CHAMPVA HEALTH PLAN BL A OTHER Ia. INSURED's I.D. NUMBER (For Program in Item 1) (Medicare #) ❑ (Medicaid #) ❑ (Sponsor's SSN) ❑ (Member 10#) 1:1 (SSN or IO) ❑ (SSN) Q (ID) 123838246 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENTS BBIE�TH DANE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) MM OORE, JENNIFER, F 06 �1 IN7 M F MOORE, ANTHONY, J 5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self Spouse ® Child ❑ Other❑ 271 S COLLEGE ST CITY STATE 8. PATIENT STATUS CITY STATE ARLISLE PA CARLISLE PA o Single ❑ Married ❑ Other ❑ � ZIP CODE TELEPHONE (include Area Code) ZIP CODE TELEPHONE (Include Area Code) a Full -Time Part-Time L 7013 1( 717 Y 5 8 319 9 Employed ❑ Student ❑ student ❑ 17 013 ( 71 2583199 p 9. OTHER INSURED's NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z G LU a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURMMS DA OF BIRTH SEX (-�, ❑YES ❑NO 1-1 04 1969 M F ❑ z b.OTHER IN DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME a YY MM M F ❑ ❑X YES ❑ NO �J Z a c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z W ❑YES NO PROGRESSIVE INSURANCE a d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? p, I ❑ YES aO If yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSONS SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 02/25/13 SIGNATURE ON FILE � SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY INJURY (Accident) OR GIVE FIRST DATE MM ; DO ; YY MM DD YY MM , DO YY 8 19 20a.2 PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 97g; 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES t --- -- -- -- - --- -- - -'-- -- ------ - - MM ; DO YY MM DD ; YY 17b. NPI t FROM TO I 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? •$ CHARGES ❑ YES [3N0 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION R � ^7 CODE ORIGINAL REF. N0. t. a47 0� . 3. 8 40 - . 4 23. PRIOR AUTHORIZATION NUMBER 2. 124 4 . 4. L739. 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To RACEOF (Explain Unusual Circumstances) DIAGNOSIS Fa ID. RENDERING MM DD YY MM DD YY S3NKE EMG CPTMCPCS MODIFIER POINTER $ CHARGES UvmS PI'an DUAL PROVIDER ID. # 1 2 9 7i2 1 12 j19 12 11 ;98943 1 2 3 4 75 0 1 NPI 130681556 1- - 2 2 �9 ] 2 12 19 12 11 97014 1 2 3 4 60i 0 1 NPI 1306815568 r 3.. . 9 T2 12 19 2 11 97110 .. 1 2 ------------------------ 59 3 4' 150 00 2 NPI r __.. 2 9 12 112 '19 12 11 97124 59 112 341 70 00 1 NPI 130681 ` 2 2 2 12 2 2 7 6 00 I NPI 6 6 -- -------------------- NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. I C go �. claims see MENT? 28. TOTAL CHARGE 29. AMOUNT PAID [ 36. BALANCE DUE 00 81670 ❑ YES ❑NO $ $ $ 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # 717 24 - 165 -9 9 6 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse IRON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE SIGNED 02 /25 /bZrE a-12555`75940 b. a. ` :. tz NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE + 1500 PO BOX 512926 w LOS ANGELES CA 90051 HEALTH INSURANCE CLAIM FORM i a P APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U PICA PICA y 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER Ia. INSURED'S I.D. NUMBER (For Prog7in 1) i CHAMPUS HEALTH PLAN BLK LUNG 123838246 (Medicare #) ❑ (Medicaid #) (Sponsor's SSN) (Member ID#) ❑ (SSN or ID) (SSN) (ID) 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F d lvl jl D 1�74 Y M EJ F 7X MOORE, ANTHONY, J 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self Spouse Child Other 271 S COLLEGE ST STATE 8. PATIENT STATUS CI STATE Z i�LISLE A Single MaMed Other CARLISLE PA p ZIP CODE TELEPHONE (include Area Code) ZIP CODE TELEPHONE (Include Area Code) 7 013 (717 4583199 ❑ Full-Time � Port•Time 17 013 ( 717 2583199 Employed Student Student p 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z i D W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED'S DA OF BIRTH SEX YES NO 17 04:1969 M F Z b. OTHER ID OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME D M F Lai YES NO Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z YES NO PROGRESSIVE INSURANCE Q d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? d D YES EZNO i( yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 02/25/13 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY INJURY (Accident) OR GIVE FIRST DATE MM ; DD , YY MM ; DD , YY MM DD ; YY 8 191 , 2012 'PREGNANCY(LMP) FROM TO I 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 1Za; 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES --- - -- -- - -- - - -- - --`--- MM DO 1 YY MM DD YY 17b. NPI I FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES 11 YES ONO I 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1. 814 _7 � . 3. 81_ 4 � .4_ 23. PRIOR AUTHORIZATION NUMBER 2 7 21 4 4 4. 7j 39 7 J. 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E, F. G. H. I. From To RACE OF (Explain Unusual Circumstances) DIAGNOSIS P � ID. RENDERING MM DD YY MM DD W SSWM EMG CPT/HCPCS MODIFIER POINTER $ CHARGES lA n5 Plan DUAL. PROVIDER ID. # --------------------------------- - 1 2 22 L2 12 22 12 11 98943 1 2 3 4 75. 00 1 NPI 1306815568 1. , u 2 2 22 L2 12 22 12 11 97110 59 1 2 3 4, 1501 00 2 NPI 1306815568 '1 2 59 1 1 2 34 701 00 1 NPI 1306815568 ° 0 4 _ .. , _ - -- - -- ------ - - - - -- .r NPI � 5 -- . -. - -, . -.- . __.__. _- __ ._...._ _____ _...__.__ _.__,____,_____ ___ -._.._ __..._._ __ -- -- ------------_--_ - NPI t 6 NPI -------- ---- - - - - -- ----------------- 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. CCEPT ASSIGNMF�NT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE I� t� Imo or govt. claims see bac ) 00081670 I-IX_I OOJE000 12047 VIYES MNO $ 295 $ $ 29 .0 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( 717 )2 4 3 63 9 6 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse RON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) I 290 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 I IGNATURE ON FILE SIGNED 02/25/31ATE a•12555759.40 b a. 71 b 19 NUCC Instruction Manual available at: www.nuce.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) I� PROGRESSIVE INSURANCE 1500 PO BOX 512926 w HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08 /05 C1 PICA PICA 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER Ia. INSURED'S I.D. NUMBER (For Program in Item 1) CHAMPUS HEALTH PLAN BLK LUNG 123838246 (Medicare #j ❑ (Medicaid #) (Sponsor's SSN) (Member ID #) ❑ ISSN or ID) ISSN) ❑X (1D) 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIEPIT'S H1 DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F 0l X974 M F© MOORE, ANTHONY, J S. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED's ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self[:] Spouse[n Childo Other 271 S COLLEGE ST STATE 8. PATIENT STATUS CITY STATE - 5LISLE PA CARLISLE PA p Single Married F� Other F� f , ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) a L 7013 ( 717 Y 5 8 319 9 Employed Full -Time ❑ Part-Time ❑ 17 013 71) 2583199 0 � Student Student O '9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z i G W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED's DA OF BIRTH SEX Mm : YES � NO 11 04; 1969 M �'i F ❑ co b. OTHER IN DU YDATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME Z i M F ❑X YES NO U a c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z 1 NNO PROGRESSIVE INSURANCE a d. INSURANCE PLAN NAME OR PROGRAM NAME I Od. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? Q YES F_�NO If yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of govemment benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 02/25/13 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ' MM DD YY INJURY (Accident) OR GIVE FIRST DATE MM ; DD , YY MM DD YY MM OD YY ) 8 16 20',12 PREGNANCY(LMP) i FROM ) TO ) 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a' - 18. HOSPITALIZATION D DATES TO CURRENT SSEERVICES� --- -- -------- -------- -- -- - -- - , ; M DO 17b. NP[ FROM i TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES 11 YES E�NO 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION ^7 CODE ORIGINAL REF. NO. Q 1. `-L7 - 3. �Q . 4 23. PRIOR AUTHORIZATION NUMBER 2 .7_?_ 4. 4. L-7 39 . 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. + From To RACE OF (Explain Unusual Circumstances) DIAGNOSIS oA F ID. RENDERING O MM DD YY MM DO YY SHMM ECG CPT /HCPCS MODIFIER POINTER $CHARGES A Pan QuAL. PROVIDER ID. # t - r1 a ----- ----- -- --- - r 1 2 �8 12 12 .28 12 11 97124 59 12 3 4 70 0 1 NPI 1306815568 u - - - _.: - _ _....... - ---------------------- 1306815568 1 2-i X82 12 ,28 12 11 98940 1 2 3 4 ; 7a 0 1 NPI ---- - - - - -- _ 1 3 2 28 2 12 28 2 11 98943 ) I 1 2 3 4 75 O l NPI -- - 4 2 8 '2 1 12 12 1 11 97110 59' ) ' 112 34 150 0 2 NPi ` _ 1 5 2 8 2 12 2 11 7 NPI 2 g ---------- - - - - -- - - °-- _ 1 NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27.CCEPT i�SSIGNMF�NT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE or govt. da ms, see bac 1 00081670 ❑� OOJE000 12048 ®YES NO $ 48 .00 $ $ ) 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( 717) 2 4 3 63 9 6 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse IRON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE SIGNED 02 /25 /l A�rE a• 1255 57':5940 b. a- " b _ NUCC Instruction Manual available at: www.nucc.org APPROVED OMB -0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE T 1500 PO BOX 512926 w {' HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105 C.1 PICA PICA y 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER Ia. INSURED'S I.D. NUMBER (For Prog7initem 1) CHAMPUS HEALTH PLAN BLKLUNG (Medicare #) 11 (Medicaid #) ❑ (Sponsor's SSNJ ❑ (Member ID #) ❑ (SSN or ID) ❑ (SSN) ❑ (ID) 123838246 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3, PMTIIENTppIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F 06 1 1974 M F © MOORE, ANTHONY, J 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self❑Spouse ®Child Other❑ 271 S COLLEGE ST CITY STATE B. PATIENT STATUS CITY STATE ARLISLE PA CARLISLE PA 0 Single ❑ Married ❑ Other ❑ I i= ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) Q Full -Time Part-Time 7 013 717 5 8 319 9 Employed ❑ Student ❑ Student ❑ 17 013 71 2 5 8 319 9 0 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z D W a.OTHER INSURED'S POLICY OR GROUP NUMBER &EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX M MM ; DD ; YY �{� n ❑YES ❑NO 1� 04 1969 M F ❑ Z b.OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME a MM , DID , YY Z M❑ F E] ❑YES ❑NO u Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z ❑YES N PROGRESSIVE INSURANCE a d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? p, ❑ YES aO ff yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this, claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. ' below. SIGNATURE ON FILE 02/25/13 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCYPATION MM DD ; YY INJURY (Accident) OR GIVE FIRST DATE MM ; DD ; YY MM , DD , YY MM DD YY $ 19 2 012 PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE j7a: 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES -- -- --` -- ---- MM , DD I YY MM , OD ; YY 17 t NPI FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES ❑ YES E:31N0 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 3. 1 S4 0 .4 23. PRIOR AUTHORIZATION NUMBER 2.724 4. 4. L23 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To RACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS F�ty ID. RENDERING MM DD YY MM DD 11 EMG I CPT/HCPCS MODIFIER POINTER $ CHARGES UNM3 Plan QUAL PROVIDER to. # 1 _ . -- -- -- ----------------- 1 2 29 T2 12 )29 12 11 '98940 ) 1 2 3 4 70) 00 1 NPI 3068155 �1 _ -- -- _ _._.... __.. - - - -- - - -- ----------- - - - - -- - - 2 �9 12 12 �9 12 11 98943 11 2 34 . 75 00 1 NPI 1306815568 r 3 2 9 2 12 129 2 11 97110 59 1 2 3 4 150: 00 2 NPI " 4 1 02 103. )0.2 j3 11 98940 1 2 4 70' 00 1 NPI ------------------------ NPI t NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. �CCEPT ASSIGNIVENT? 28. TOTAL CHARGE 29. AMOUNT PAID [ 36. BALANCE DUE or govt. claim see ack) ❑ r YES NO $ $ $ 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( 717 )2 4 3 63 9 6 ' INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse !IRON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE GARLiSLE SIGNED 02/25/I&E _ a . 1255 575940 tz a. b. NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE 1Jr00 PO BOX 512926 w HEALTH INSURANCE CLAIM FORM Los ANGELES CA 90051 a PAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U PICA PICA y 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED's I.D. NUMBER (For Program in Item 1) CHAMPUS HEALTH PLAN BLK LUNG 12 3 8 3 8 2 4 6 {Medicare #) ❑ (Medicaid #) (Sponsor's SSN) [:j (Member /D #) ❑ (SSN or ID) D (SSN) M (ID) 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENTS BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) GORE, JENNIFER, F or i1 1;974 M FFX MOORE, ANTHONY, J 5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 71 SOUTH COLLEGE ST Self Spouse Child Other 271 S COLLEGE ST I STATE 8. PATIENT STATUS CITY STATE LISLE CARLISLE PA z Single E] Martied � Other � 0 a ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) � 7 013 717 5 8 319 9 ❑ Full•Time ❑ Part -Time 17 013 71 2583199 Employed Student Student O 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER z G LU a.OTHER INSURED's POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED's DATE OF BIRTH SEX Ex MM : DD : YY N FIYES ❑X NO 11 0C 1969 M F Z b.OT ER IN DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME Z YY MM M F M YES NO L-J Q c. EMPLOYER'S NAME OR SCHOOL NAME C. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME z Z YES �NO PROGRESSIVE INSURANCE a d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? y YES ©NO ft yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED's OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 02/25/13 SIGNATURE ON FILE SIGNED DATE SIGNED 14. M DATE OFF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION INJURY (Accident) OR GIVE FIRST DATE MM DD ; YY MM DD ; YY MM DD YY 8 9 2 O 2 PREGNANCY(LMP) i i FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a: 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES ----- --- - ------------ --- -- ------ --- - ------ MM DD YY MM ; DD YY 17b. NPI FROM i TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES D YES DNO 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION �, � ^1 CODE ORIGINAL REF. N0. 1. . 3. 1 840 . 23. PRIOR AUTHORIZATION NUMBER 2 7 21 4 4 4. 24. A. DATES) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To RPLEO (Explain Unusual Circumstances) DIAGNOSIS F r lo. RENDERING r MM DD YY MM DD YY SERVICE E CPT /HCPCS MODIFIER POINTER $ CHARGES VIM P. QUAL PROVIDER ID. # ...... _ _...' _.. r 1 1 02 ];3 01 �2 13 11 97110 1 2 3 4 - _ __,__. _ 1 75. 00 1 NPI 1306815568 u NPI 3 -, _ ...._ ...._ ..:... _ - - - -- ---------- - - - - -- - - -- -- NPI NPI i 5 _ � NPI r 6 _._ -- - --------------- - - - - -- -- NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. ' 1 27. ACCEPT ISSIGNMF 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE or govt. clams we be ) 00081670 ❑E] 00JE000 12048 ®YES []NO $ 75.00 $ $ 7 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( 717 )2 4 3 63 9 6 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse IRON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO DC apply to this bill and are made a part thereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE 02/25/b�E a•1255575940 b. a ' " b SIGNED � NUCC Instruction Manual available at: www.nueo.org APPROVED OMB- 0938 -0999 FORM CMS -1500 (08/05) PROGRESSIVE INSURANCE PO BOX 512926 1500 LOS ANGELES CA 90051 w P HEALTH INSI a APPROVED BY NATIONAL I Think I Broke It! v PICA . I \1 Orthopedic Injury Ch IC . PICA y 717 -756 739 % . — 1. MEDICARE MF �' a111�@ @ Q@ nll&MBER (For Program in Item 1) (Medicare #) � (M UAIENTSM /)n f. NAf�teisFirst tame, Middle Initial) 57P1ATI 1 3 tS nE Lf i °ESte O aYi 1 . vt i I STAT O C E TELEPH To l'- �� fS q' o 9. OTHER INSURED'S ^ 11. INSURED'S POLICY GROUP OR FECA NUMBER Z U f7 W ICLAV a.OTHER INSURED'S P j u INSURER DA F � IF�Ty SEX 1 Mhi 14; ��(b 9 M ❑ F Z_ b.OTMER IN . E 'S Y MPLOYER'S NAME OR SCHOOL NAME p a c. EMPLOYER'S NAME y INSURANCE PLAN NAME OR PROGRAM NAME Z (PROGRESSIVE INSURANCE w d. INSURANCE PLAN N tI i. IS THERE ANOT R HEALTH BENEFIT PLAN? IL YES NO M yes, return to and complete item 9 a=d. j , A 3. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTI payment of medical benefits to the undersigned physician or supplier for to processtt�s�l�i servicesdescrl bel �'It TURE ON FILE ow. S� Ci SIGNED A J gyp, pp 0�� �Ey A I6. DATES M MTIENT D pNABLE Tn 0 WORK IN CU A M NT Opp UPATIYY � tS tlA FROM ; ; TO 17. NAME OF REFERRI r 8. HOSPITML DATES TO CURRENT DDRVICEB Y I. FROM TO I 19" RESERVED FOR LO Darn%%` cwsn z S0. OUTSIDE LAB? X , $ CHARGES 717 - 761 -5530 • 800 - 834 -4020 D YES ONO 21\D1 OR NA N�W.Oip.COnl 2. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. OF Vr14N3Y7 'VA1Vf1%. ------ _.. __— .. - �3. PRIOR AUTHORIZATION NUMBER 724 4 739 7 2. L , 4. 1—. 24. A. DATES) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. L J. From To RACE OF (Explain Unusual Circumstances) DIAGNOSIS AY p� Ic. RENDERING MM DD YY MM DD YY SRiVCE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS Pian QUAL PROVIDER ID. # ...01._,09---J3---- .__ 1.1..._._ .9 4 ... .89-0.. _ _..: ,....:_.,.. _._.1 `2 34 NP{ r u 9.8.9.4.3. _ 1.2_..3 4 Z.S, ..0 -0 ..1.... -- - -i U- 6H.11�ti- NPI 3D!--,09 ._..1.3 - ....0.1 -... O.g....1-3.--- ...- .- 11_...__.... _ 9.7.1.1 p.... _._ ...., -. .. 1._2...3..4 15 0...0.0..2....__ . .. - - - -- - - -:4 NPI i 4 09 13 01. ( 09 13 11- _._. 97124-- 5 1...2 -34 .- 70,. O ...1 . -------- - -- ' ( NPI 50-1 16 -1 -3 - .. 01. _16 - -13 - 11 - 98 94-0---- - -- .-F 1 2--3-4 - -- 7 -0,- -0 -1 - __... - - -- - -- 3 k3i L,3 6 - -- It NPI 6 16 �3 .. 0.1..;16 13 ... _..11 - 98943— __..(.._. _ .,_...._... -1-2-3 4 75,. 0 . l.. -- - - - -- -- 13 F}6�fi�3 6 -- NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. ' 27. �,CCEPT ASSIG E DUE 9 fflNT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE I 00081670 Et] OOJE000 1206 YES cl QNO �I $ 510.00 $ $ 51 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFO 33. BI P OVIDER IN F 8 PH # INCLUDING DEGREES OR CREDENTIALS RON HAVEN GYM CHIx0PRACTIC MATTHEW M ICAS RO D (I certify that the statements on the reverse this UREIa a m ad e artthereof.) 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 I dffM ARLISLE PA 17013 CARLISLE PA 17013 05/01/13 5 94A a, b. I a. b SIGNED DATE NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) I r PROGRESSIVE INSURANCE PO ` B 2 15�� LOS ANGELESCA 90051 w P HEALTH INSURANCE CLAIM FORM a APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U PICK PICA FTT 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1ailn�f�J�nt6UMBER (For Program in Item 1) GRAMPUS HEALTH PLAN SJ(LUNG (Medicare #) ❑ (Medicaid #) [] (Sponsor's SSN) � (Member ID #) ❑ (SSN or ID) (SSN) (ID) aENTS91V9, FirName, Middle Initial) 3..2A,TIEA7�S BAR�H,DATE ME] FM F � 4. WSIIBED:S NA F(d _11ast�,Rrst filame, Middle Initial) VAIDM 41oD1' IY4Y L�1VUtC� F�NLri �J ST 6. PATIENT RELAT109SHIPTO INSURED 7.24 ftF1 %S tP&ftt{ k8SI P Self ❑ Spouse❑ Child❑ Other $4TE 8. PATIENT STATUS cIDARLISLE STATRA Z Single [:] Married F Other 7 O �b QAE TETTO FIIpc)UdeLr §a Code) ZIL�GApE TELEPHO) IMTf! Cl 1133 // 11 / 2tii ii 11 ` � y Employed ❑ Student ❑ St dent1e 1 I U 1 I 1 O 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z n w a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX Ix YES NO mil 4941 19 9 M F Z b.OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME 1 � n MM DO YY M F YES NO I_J a c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z YES NO PROGRESSIVE INSURANCE W � d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? p, YES NO If yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING &SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also re uesI a ment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATUR FILE 05/01/13 SIGNATURE ON FILE SIGNED DATE SIGNED 74 ATE O E YY I P ILLNESS JURY (Accident) symptom) OR 15. GIVE FIRST DATE MM ME pp SIMILAR ILLNESS. 16 FROM MM tF�N DONABLE� WORK IN COU MM DD OCCUPATION 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a: 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES i - = - -- - --- ---- -- -- ---- MM 1 DD I YY MM DD ; YY 17b, NPI FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES E YES 'dNO 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION 8 47 0 840 4 CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 724 4 739 7 2. L-. 4 . L-. 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. - From To RACE OF (Explain Unusual Circumstances) DIAGNOSIS OA P y lo. RENDERING C_ MM DD YY MM DD YY SBiVCE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES LNr5 Plan QUA PROVIDER ID. # 1 )1....16- ..13... . O1 -- 16...13__ _.1.1_ ....._ 971 -1.0.. _:._._..1 2...3.4 _150,..0.0.2_. - - __L_ibbF3lSSbti- a NP i IT 2)1- 1- 6...- 1.3_. - -- 01-- 16 - -13 - -11... - -- 9-712.41.---- 5 -9 , -- - - v._.....1 - -2.3 4 _ -..:_ ,.:.7 -0 .00_.1- NP u 3)1-23 13......01 13 - -- 11 .. _.._.. .9894.0.. _.:.. , -.. 1_.2..3 4 ...... 70,...00 ..1_,_:_ ... - - -- - �b>f��b� - -- in N in PI 4 4 _. ; . ; _ 75, 00 .1 - - -- - -ba 1 23 13 01 23 13 11 98943- 1 2 -3 4 NPI � C 1 X3..13 0.1.. 23..._}3._.. .- 1.1 -..... 971..10.. . - - 1 -23 -4 -_ - 150 -2 -- NPI 6 6)l 23 3 23 � 3 1 11 ..... - - 97124.. 59. _ 1 12 34 70; 00 1 -- - � NPI - 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. QCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE 00081670 a� OOJE00o 12060 �YES'OIai Ne $ 5851.00 $ $ 581x1.0 31, SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # INCLUDINGDEGREESORCREDENTIALS I HAVEN GYM CHIROPRACTIC MATTHEW M NICAS T`RO D I cert made a there the 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 apply to o bill this bill and are made a part thereof.) IGNATURE ON FILE ARLISLE PA 17013 CARLISLE PA 17013 05/01/13 a b. a. y SIGNED DATE - NUCC Instruction Manual available at: www.nuco.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) I • PROGRESSIVE INSURANCE 150 PO BOX 512926 LOS ANGELES CA 90051 P HEALTH INSURANCE CLAIM FORM a APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105 V PICA PICA �r 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1e11ntS16R UMBER (For Program in Item 1) CHAMPUS HEALTH PLAN BLK LUNG (Medicare #) ❑ (Medicaid #) 1:1 (Sponsor's SSN) (Member ID#) ❑ ISSN or ID) (SSN) (ID) aNTSjRe, FirName, Middle Initial) 3.A2h�TIERJ�S E SEX 4. iNS119EDS NAM1GF_LlastOlargFlrst Name, Middle Initial) 1111AADDMM �11�D LL'yy ��44 M F 1�ll1UiC� AA1LVViSririVV1I�� J jATI9jMTjPR� jn_L%NRt) ST 6. PATIENT RELATIOkSHIP TO INSURED 7.2jt11EgS tfffft ' Str@a9P Salto Spouse❑ Child Other TE 8. PATIENT STATUS cf ARLISLE sTA Z Single F_] Married F� Other F j Z1 15 C H Q ZIP �LE�O F IprJude Ar ❑ Student Full-Time ❑ Student Part-Tim e L 1 U 13 TEL �PHQN1 T`MIM C 11 LLff ii 11 `JJ a Code) Employed �� 11 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z D W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX IM YES NO M� I @�P4i 19169 M� F N Z b. ER I DDURED' Y DATE OF BIRTH S� b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME M F � YES r NO I_ -1 Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME Z Yes NO PROGRESSIVE INSURANCE w Q d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? p, YES NO N yes, return to and complete Item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. 1 also re uest a me of government benefits either to myself or to the parry who accepts assignment services described below. below. SIGNATUR FILE 05/01/13 SIGNATURE ON FILE SIGNED DATE SIGNED 7,4.pp O l}R�ENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCYPATION tS a1k1 � 1L YY ' INJURY (Accident) OR GIVE FIRST DATE MM DD ; YY MM ; DD , YY MM ; DO , YY PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES - -- =- - - ------ ------ MM DO 1 YY MM i DO YY 17b. NPI j FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES dNO 21\75IAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION l 8 47 0 840 4 CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 724 4 739 7 2. L- . 4. L.- . 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. 1. J. Z From To RACE CF (Explain Unusual Circumstances) DIAGNOSIS Qq F Y 1D. RENDERING O MM DD YY MM DO YY SBMCE EMG CPT/HCPCS MODIFIER POINTER S CHARGES UNns Plan QUA PROVIDER ID. # Q 12.._.02...13- 02....0.2 13_......11.- 989.43 .. _.__..1.2...3.4 NPI O 2 1 -9 1,3-- x. 13 - -_._ -_ -1 - - -- 97-11.0 -..- 1_2,.3..4 _150,._00 .2 NPI cc W 3 2._02- 13 -- 02 02.13._,_.. 11 97124. _.5.9 __ _ - -1- 2...34 _ 7.0,...0.0._1_._... a. NPI 4D2 08 13.. 02 .08 ... 11__ 98940 1 -2 -.3 4 ....... 70, 00 - -1 NPI O Z j 2 0 8--- .1.3 .. __ . 0.2 .0 8 13 11 .......... 9 8 9 4 3 - .. _ .. _.. - .- ... ...... - - -- 1- 2 -3 4 7 5 - 0 0 NPI N 6 2 98 21-3 02 Q8 13 1 11 97032 ; ; ; 1 2 601 00 1 rvPi- --- i3t�bti-i�t7�3- -- a 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. ' 27. iFor F ala S Ssea M§T? 28. T CHARGE 29. AMOUNT PAID 30. BALANCE DUE 00081670 ❑X OOJE000 12060 'YES E]NO $ 500;.00 $ $ 50;0.0 ­396 1 31. SIGNATURE OF PHYSICIAN OR SUPPLIER SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( INCLUDING DEGREES OR CREDENTIALS I RON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO D (1 certify that the statements on the reverse apply to this bill and are made a part thereof.)" 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE ARLISLE PA 17013 CARLISLE PA 17013 05/01/13 a. b. a. b SIGNED DATE NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) j • PROGRESSIVE INSURANCE PO BOX 512926 • (1500 LOS ANGELES CA 90051 w M P HEALTH INSURANCE CLAIM FORM Cc APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U PICA PICA 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a112b38E5)85A I(dj1MBER (For Program in Item 1) CHAMPUS HEALTH PLAN BLK LUNG (Medicare #) [] (Medicaid #) ❑ (Sponsor's SSN) ❑ (Member /D #)❑ (SSN or ID) ❑ (SSN) (ID) >Z)0RIjgNTSy jrsM FirFName, Middle Initial) 3. jg@EQ! % SEX 4. tqM� NA( q ft ej First P,ame, Middle Initial) ADD V4 M F i -T. F1AT{€jRn j{@PR jN� R t) ST 6. PATIENT RELATIOXSHIP TO INSURED 7.2qLjREgS /OD , -t�Str5eT Self[] Spouse ❑Child❑ Other[:] TE 8. PATIENT STATUS C STA Z Single ❑ Married ❑ Other ❑ V 1JE T jL fppo�F5(tckrde jy Code) Z1�8;l TELEPHGN jnclrsd e �e��" ` 31 Full -Time ED Parl -Time ( l L 1 y 7 a J Employed ❑ Student Student ❑ ` / 0 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z ' O LU a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. A INSURE Y pF SI SEX ❑ M J. [�4( 1Y�tb 9 N ❑ YES t NO M F Z b. OTHER INSURED'S Y DATE OF BIRTH SEX b. AUTO ACC ENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME z M ❑ F ❑ YES r7 NO I_J Q c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. NSURANCE PlA N E OR P OGRA NAME ~ )�'ROGRESS�IV INSURANCE El f NO d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOT R HEALTH BENEFIT PLAN? Q a ❑ YES InNO N yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13, INSURED'S OR AUTHORIZED PERSON'S SIGNATURE i authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process tgy6TjJ , nest ffmjgT ffemment benefits either to myself onto the party h � c eP13ssignment services descd� MN.TURE ON FILE below. LVA 1 UtCC VLV 1L SIGNED DATE SIGNED �p pA7� O M L tJ ENT: ILLNESS (F symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 18. DATES PATII UNABLE TO WORK IN CURRENT OCCUPATION tf Mti T YY INJURY (Accident) OR GIVE FIRST DATE MM , DO , YY MM , DD ; YY MM , DD ; YY PREGNANCY(LMP) FROM ; TO ; 18. HOSPITALI ZfON DATES RELATED TO CURRENT SERVICES 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE DD YY MM , DD YY - - ---- -- ----=--- ----- -----'---- M TO F 17b. NPI FROM 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? X $CHARGES ❑ YES ONO 21 IIA, N d IS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 o 84 0 4t Item 24E by ine) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 724 4 739 7 2. L -. 4. L- . 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPL4ES E. F. G. H. D 1. J. 0 From To RACEOF (Explain Unusual Circumstances) DIAGNOSIS py 10. RENDERING O MM DD YY MM DD YY SBMM EMG CPT /HCPCS MODIFIER POINTER $ CHARGES trM Plan QUA PROVIDER ID. # Q 1.2. 3:.4 _ 75.:._00 1::_.. NPII 0 LL 2 2.._0.8. 13_. -_ 02...0.8 1.3....._11- ._ 9.7,124 ..._. 5.9 ; ._.. -. 70 _ ._.._- 1_2-3.4 __..0.0.1.__._ _ -- :__:0- Qh?�i�,S,h z NPI w 3 12_. ?3 ..13 -- _ 02 23 ..1.3 -_ -- ....1.1_.__ -;_. 989.40.. _ _.. ._......1.2.3.4 7.0,..0 -0 ✓ NPI co 4 2 . 3...13 ._ 02.. 23 -� 3 . 11.. __..... 98.94.3. _ __. __ 1.2. -3.4 7.5,...0.0 .1 .... _ .... -- ------ 0-IJ6.1:51I L>3 -- cc NPI 0 Z 5 2- .....23.- 13- .._.02_..3- .1.3_..._....11 --- 9.7032-- ...... 1_.2 -..3.4 NPI _.._- -- 60, 00- 1:.___ - --- 3t�bil��b�i cf) } 6 2.23 13 02 �3 13 11..:.. 97035.. 1 2..3 4 60, 00.1.... ....... NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. �CCEPT ASSIGNME 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE 00081670 ❑n 00JE000 12060 YES ��❑ $ 41x.00 $ 410.0 31. SIGNATU OF PH /IAN OR SUPPLIER L! � _AS L,1d?1 TIONCI�IF955TRACTIC 33. B L.L. ��iPB VEFt.iN_ E"TN O D ( I certify that the statements on the reverse 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 I ATUREI aON E m.,a l dL E part thereof.) ARLISLE PA 17013 CARLISLE PA 17013 05/01/13 a. b. a b SIGNED DATE - NUCC Instruction Manual available at: www.nucc.org APPROVED OMB- 0938-0999 FORM CMS -1500 (08/05) I I: PROGRESSIVE INSURANCE 1500 PO BOX 512926 LOS ANGELES CA 90051 w P HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 V PICA PICA y 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a111V1ngdN WMBER (For Program in item 1) CHAMPUS HEALTH PLAN BLK LUNG (Medicare #) ❑ (Medicaid #) 11 (Sponsor's SSN) (Member ID#) ❑ (SSN or ID) (SSN) � (ID) �( NTS91 fie, FirtName, Middle Initial) 3.,2ATIEALT)S DATE SEX 4.1NSLIF NAf�4ELf�sCM 9,First blame, Muddle Initial) r r UUIIt�aMM �} �IDD 11y /i�rddYY Lv1tCr 1llVlriVLV J M F gATg r WR NE t) S2 6. PATIENT RELA7lOkSHIP TO INSURED 7 -" R%S t&ft ft Str@ g ep Self] Spouse[] Child Other TE 8. PATIENT STATUS cCARL I S LE $TAIRA Z Single F] Married 0 Other E] O ZJP P-H TEL EO F Ipr de6r Code) ZI2 CAAE 3 TELEPHQJ 1 ncluda Fir �q>i� 11 JJ // // ttS3 11 Full•Time Part -Time 1 / U 1 L J tf `J Employed ❑ Student - Student O 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER 9 Z_ C a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPL.OYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX YES n NO Mq 1 X41 1 6 9 M� F W Z b.OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? b. EMPLOYER'S NAME OR SCHOOL NAME MM , DD , YY M F YES NO P LAC E L � (st ate) Z Z 11 It c: EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME F- YES NO PROGRESSIVE INSURANCE w � d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? 4. E] YES EINO H yes, return to and complete item 9 a -d. I READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process t a tpay n I f goovemment benefits either to myself or to the party who accepts assignment services described below. S I GNAT UR below. UU11VV L 05/01/13 SIGNATURE ON FILE SIGNED DATE SIGNED 74. O ENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION tf YY INJURY (Accident) OR GIVE FIRST DATE MM ; DD ; YY MM ; DD YY MM ; DD ; YY PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE d7a 1a. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES { -------------- MM i DD ; YY MM 'I DD ; YY 17b. NPI FROM TO j 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? 1 $ CHARGES YES dNO I 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) � 22. MEDICAID RESUBMISSION 8 47 0 840 4 CODE ORIGINAL REF. NO. 724 4 739 7 23. PRIOR AUTHORIZATION NUMBER 2. I-_ . 4. L _ . 24. A. DATE(S) OF SERVICE B. I C. I D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. 1. J. Z From To RAMOF (Explain Unusual Circumstances) DIAGNOSIS FPSDT m. RENDERING O MM DD YY MM DD YY 6EAa EMG CP T/HCPCS I MODIFIER POINTER $CHARGES tnm5 F Plao oUAL PROVIDER ID.# E- a 2 ; _._ :._; _ _ ...: __. 75, 00._1_._...'._ .: - - - -- -- -"L3.Ubli1-tbh1- tt -___ 2 23_._ 13... 02... 3 .3 1 1... - -- 9.71:10_.._. " 1.2 ..3 4 NPI o u . 2 .2 ._. 2 3 -..> 3. -...._ 0 -2... 23_: 3 :. _ ..1.1...._ - - - -. 9 -7.1.4 0 :_ -. -_ 5:9 -_; ... ;_..: - 1.2 .. - - 10,- NPI W 3 70, 00 1.._ ----- - -- 2- ..27...1,3..... 02 ..27.13.. 1.1 _,_.._ 98.94.0_ .. 1 2 3 4 ; NPI 4 2 27 13 02 27. 13. 11 9894.3. _ 12 34 ... - ........75,..00..1 .... --------- ¢ NPI O 2 -27 - -- 3 - -- 02 -,27_- �:3 -- 11- 97110 ._.. - 1 2 3 4 z 5 7 .. 0 NPI Cn Y 6 2 27 13 02 ; 27 ]3 11 1 97124 59 -; ) 1 2 34 140; 00 2 - NPI - - -- - i3{�bl3i�bli -- a 25. FEDERAL TAX L.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. I�CCEPT �SSIGNMg T? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE ( or govt. 00081670 r�X MOOJE000 12060 YES cI MNO $ 505;.00 $ $ 50;5.0 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( ' INCLUDING DEGREES OR CREDENTIALS IRON HAVEN GYM CHIROPRACTIC MATTHEW M NICASTRO D (I certify that the statements on the reverse 1 apply to this bill and are made a part thereof.) 290 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IGNATURE ON FILE ARLISLE PA 17013 CARLISLE PA 17013 05/01/13 SIGNED DATE a' a a' h NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) e , PROGRESSIVE INSURANCE PO BOX 512926 I i 1500 LOS ANGELES CA 90051 w P HEALTH INSURANCE CLAIM FORM a APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08106 0 PICA PICA yr 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1aJI29y8f Mpg 8l1MBER (For Program in Item 1) CHAMPUS HEALTH PLAN BUK LUNG (Medicare #) o (Medicaid #) 1-1 (Sponsor's SSN) (Member ID #) ❑ (SSN or ID) (SSN) (ID) ®( T NTSIJS � aRe, FirF Name, Middle initial) 3.fo H/D47E M❑ SEX F y 4.RWfiff NAnkf1jMj, First fame, Middle Initial) ST 6. PATIENT RELATIONSHIP TO INSURED riU`1 7. "t FlEgS n TTE:gM*E StSep Self ❑ Spouse Child Other TE 8. PATIENT STATUS C STA112A Z Single [_� Married [] Other ❑ 0 �I�C1t E TFLETONS(lnr�Ve ja Code) ZIP COD€ 3 TELEPHQt lE Llnclur Arad i� a Full T1 m 11 / LL� tf 11 y y7 Employed ❑ Student e ❑ $t denme / // 11 ll LL 22 33 33 Q 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z O W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSUREQ yg�DA E OF g1 SEX M� y4 1 B>L0 9 rY ❑ YES � NO M F Z u b.OTHER IN SATE OF BIRTH SEX b. AUTO ACC ENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME Z MD F YES NO c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME ~ YES NO PROGRESSIVE INSURANCE w d. INSURANCE PLAN NAME OR PROGRAM NAME 16d. RESERVED FOR LOCAL USE d. IS THERE ANO7 R HEALTH BENEFIT PLAN? Q IL YES NO 6 yes, return to and complete Item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process tlyclalro�l algQfgestpaymtpLfgvemment benefits either to myself or to the pa S who accepts assignment services descdhed pP.)q �TURE ON FILE below. S GN 11UUKK UUNN 11 0I01/13 luly SIGNED �q 7� $ A S DATE SIGNED t Mdiyl 6+6� ' INJURY (First t) ORm) OR 15. GIVE LEN DATE ME ',� DR SIMILAR ILLNESS. 16. DATES PATIENT Y R DNABLE YO WORK IN CURRENT OCCUPATION DID YY PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a:. , 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES ----- --- ---- --`-- ------- - -- MM I DD YY MM ; DD YY 17b. I NPI FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? X $ CHARGES El YES []NO 21 \DI 7 NOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 orr 4 by Line) 22. MEDICAID RESUBMISSION 8 O 0 4 CODE ORIGINAL REF. NO. 724 4 739 7 23. PRIOR AUTHORIZATION NUMBER 2. L _ , 4. L _ . 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. EL: G. H. I. J. Z From To RACEOF (Explain Unusual Circumstances) DIAGNOSIS DAYS pa ID. RENDERING O MM DD YY MM DD YY SERVICE EMG CPTMCPCS MODIFIER POINTER u Pan QUAa PROVIDER ID. # a 1 3....0.1 13.__....03...0.1. _13_: - .....11.. 989.4.0..__ -- - -; - -- _ i r NP 0 LL NP W 3 .3...01.._] 3.._..._ 03...01. 13 11 _ 9.71.1.0 _1.2..3 -4 ------ 7-5, " -0.0 1.:... NP N 4 13 .01 >3- " "__.03 P1 13 11.. ._. 9 -7124 59 ,._ _1.2 3.4. 1- 4.0,.0.0 .2:... -- -= 13l1k,8155htS -_ -- oc i NP 0 Z 5 3- ....02 -13- .._03.._02...3 3 _._ -_11- ....:. 9894.0 --- ----- ,....._ 1 -2 -3 "4 ; ._.. __._70.;. 00 -1. -._ - - -- - NP U in 6 3 02 13 03 02 13 11 98943 _1.2.3.4 ...._. ......75 1 ------ -- a NPI 25. FEDERAL TAX I.D. NUMBER SSN ElN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT /�SSIGN e v NT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE 00081670 ❑ OOJE000 12060 YES la ❑e a $ 505 $ $ 505.0 1 96 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. Bt LING P O lD E N! NICA R INFO & PH T O INCLUDING DEGREES OR CREDENTIALS RON HAVEN GYM CHIROPRACTIC M1TTH�W S D (I Certify that the statements o n the reverse 290 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 I&WTUREIaONfeFIZaE tnereof.) C ARLISLE PA 17013 CARLISLE PA 17013 05/01/13 SIGNED DATE a. b. a. b NUCC Instruction Manual available at: www.nucc.org APPROVED OMB- 0938 -0999 FORM CMS -1500 (08/05) r PROGRESSIVE INSURANCE i 1500 PO BOX 512926 LOS ANGELES CA 90051 P HEALTH INSURANCE CLAIM FORM a APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105 V PICA PICA �r 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a111V1SE"R 16UMBER (For Program in Item 1) CHAMPUS HEALTH PLAN ELK LUNG (Medicare #) ❑ (Medicaid #) (Sponsor's SSN) (Member ID#) ❑ (SSN or ID) (SSN) (IDJ b I NT Sy s iRe, Fir Name, Middle Initial) 3. RA71E CS SEX 4. M V LR NAI�diHtk ftR,;irst Name, Middle Initial) UUIII�IIMM uu�� ' {i4411 M❑ F LviVVYCP HH�LVVT1ririUU11VV J 57 JATI� 1TPR NE I) S T 6. PATIENT RELAT{OP SHIP TO INSURED 7.k�J�L�REgS I B E� ( Str Self[] Spouse[] Child❑ Other TE B. PATIENT STATUS c ARLISLE sTATDA Z Single F Married 0 Other F 7�P 1 71 F�Iprdetlr�a Code) ZI2 �OpE 3 TELEPHONE nclyld�Ar 1. g tt 11 yy yy Full - Time Part - Time 1 U 1 (( ! 1 G ii Employed Student Student l O 1L 9, OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z D W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or Previous) a. INSURER'S DATE OF BIRTH SEX M YES NO Mtt� �4; 16 9 M F E] fn Z b.OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME C1 MM , DD , YY M o F YES NO L� Z a c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME W Z YES NO PROGRESSIVE INSURANCE d. INSURANCE PLAN NAME OR PROGRAM NAME tOd. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? Q YES In NO ff yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also re est a ment of government benefits either to myself or to the parry who accepts assignment services described below. below. SIGNATUR FILE 05/01/13 SIGNATURE ON FILE SIGNED DATE SIGNED 77,4.D� O Ul��ipENT: ILLNESS (Firstsymptom) OR 15, IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCl+PA7ION ti MlA Un y`Y , INJURY (Accident) OR GIVE FIRST DATE MM DO YY MM DD YY MM DD , Yy PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES -' -=- - -- - ^--- ^ ---'- -- - -'--- - - -- - MM DO I YY MM I DO i YY 17b. NPI FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES �1NO 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION 8 47 0 840 4 CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 724 4 739 7 2. L_ 4 . L- . 24. A. DATE(S) OF SEAVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. L J. Z From To RACEOF (Explain Unusual Circumstances) DIAGNOSIS mo P y tD. RENDERING O MM DD YY MM DD YY SUNCE EMG CPT /HCPCS I MODIFIER POINTER $ CHARGES t,T11rs Plan QUAQ PROVIDER ID. # a V3 ._7 3- _..... 0.3 :A2 -13. _._...1.1.. _ 971- 10....._:. 1..2`3:4 -- 150,.:.0.0 :2. -.:. - - -- -- LUbEi15�b�t - -- NP O 2 D.3. .:..9.2 3 -.. -._ 0.3....0.2..-- 13--- .._:1.1_..1 1- 9712.4 _... �.g._ _..- -1- 2...3.9 ...__._;_ 70, -:p0.1 L Ubtil��6tt__:. z NP 13 W 3)3-08 13, ..._. 03. 0.8_._ 13._... _.11_. - -_.. 9.8..94.0 _ _ _.1 .2. 3 4 _ ....._.7 -0, 00 .1..:. - -.. - -- NP a 4 3. 08 13_. 03 D8 13 1.1 989.4.3. - ._1._.2.3.4 75.00.1..._...... _:. - ---- lr3Ub�i1��k.t_._ a� i NPI 0 Z 513- .08. 13 -.- 03 a8 ._13- - -11- _ 97130 ..... I. 1 -2.3 -4 - 7.5 NPI co co 6 3 08 1s3 03 a8 13 11 ., 9712.4..- 59 ,...._.. ....__._. 1...2.34 •- ......._._..70,- ..00..1- ,._... ---l" a NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. �CCEPT P)SS{GNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE 00081670 ❑3�I OOJE000 12060 YES Ge QNO a i $ 510;.00 $ $ 51;0.0 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( INCLUDING DEGREES OR CREDENTIALS IRON HAVEN GYM CHIROPRACTIC MATTHEW M NICAST`RO D (I certify that the statements on the reverse apply to this bill and are made a part thereof.) 2 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 SIGNATURE ON FILE ARLISLE PA 17013 CARLISLE PA 17013 05/01/13 a. a. a SIGNED DATE NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) I 1 �r PROGRESSIVE INSURANCE PO BOX 512926 �. ' 1500 LOS ANGELES CA 90051 w P HEALTH INSURANCE CLAIM FORM M APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105 V PICA PICA y 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a112S CHAMPUS HEALTH PLAN BLK LUNG �P1$t&�D} AMBER (For Program in Item 1) (Medicare #) (Medicaid #) 0 (Sponsor's SSN) (Member ID #) ❑ (SSN or ID) (SSN ( ID ) S NTS Iq 3 ?s I4e, Fir Name, Middle Initial) 3.LT TIE8IWenFE)L1ATE SEX 4. NAt �r First P�ame, Middle Initial) + ��DD�YY M F 1AT9VUTpjPM9 y5Mt) ST 6. PATIENT RELATIOXISHIPTOINSURED 7.VnFIESS , t(t�E. S19e Sell[] Spouse[] Child Other TE 8, PATIENT STATUS C STAI Z Single '� Married n Other F O �I�C1O�E TJLEP A{�ea Code) ZIR CJJDE 3 TELEPHMIE IJnclrt 6veaLa1 l C yy Employed ❑ Student ❑ Student 1 I ll l 11 l� L t5 J 1 J !` O 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'$ CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER u ' _Z D a.OTHER INSURED'S POLICY OR GROUP NUMBER a .EMPLOYMENT? (Current or Previous) a.INSUREWYAI1 SEX YES NO M 22 rrt�p 11 �XJJ�rbb M F b. OTHER INSURED'S SATE OF BIRTH SEX b. AUTO ACC ENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME M[] F YES NO Z J Z c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR (PROGRAM NAME ~ �ves NO PROGRESSIVE INSURANCE w a d. INSURANCE PLAN NAME OR PROGRAM NAME 70d. RESERVED FOR LOCAL USE d. IS THERE ANO R HEALTH BENEFIT PLAN? a I YES NO /f yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other infor necessary payment of medical benefits to the undersigned physician or supplier for to process th)�clafroJ 81.SRI�gtl est pAymqpt�Lgrmment benefits either to myself or to the party OS / O 1 / 13 sslgnmant services descdl�sl T URE ON FILE below. S1CiNli'1'1JYCk 51 SIGNED DATE SIGNED 3A.A V C%bJ1 RENT: ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION t5 MLl H ! L YY INJURY (Accident) OR GIVE FIRST DATE MM ; DD ; YY MM DD YY MM DD YY PREGNANCY(LMP) FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a 18: HOSPITALIZATION DATES RELATED TO CURRENT SERVICES - --- - - -- ^-` --- ` - =--- - ---- - -- °-- _ MM DO ; YY MM DD ; YY 17b. NPI FROM TO ; I 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? X $ CHARGES YES FIND 21 \DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or to Item 24E by Line) 22. MEDICAID RESUBMISSION 8 4 7 0 8 4 0 4 CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 724 4 739 7 2. L.� . 4. I-_ . 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. Z From To RPLEOF (Explain Unusual Circumstances) DIAGNOSIS Y Fa�mnyr 10. RENDERING O OR MM DO YY MM DO YY SM CE EC. CPT /HCPCS MODIFIER POINTER S CHARGES UNITS Plan OUAL PROVIDER 10. # Q 1 3..22_...13_ . 03. 22- ..13.. 9.8.94.0.__ ... T _ __.12 3,4 _. . ._70,.00.1._..:._ --------- 1 NPI 0 Z 2 3...2.2 ...1,3- ....03- :-2.2.._� 3___..__11_.. __ 1: 98943" . - _ :....L-2-34 - 7.5 _ 0:0 l ___. >_ _ `... � :.L:J-(j ti'LS fitf:__- NPI 71 32 2 _ 13_1 1 .03. 2 2 1.3 .....11._:_.._. 9.7.110.. _...,._ -._ -1_ .23.4 1.50 0,0 2 a. i NP d 4 3 22-.13... 1 -2..3 4 60 00 .1 --------- a NP 0 Z t 3 22 13- ..- 03 - -22 7 3 -- -11- _. 97124.x..- 59. ------- 1--2- :....0.0..1. - - -- - NPI V N } 6 3 27 13 03 ,27 13 11 98940 .. .. _,....- ._..,._._._.... 1- 2.3. -4 _._. _._....._.70,. 00 .1...._...._... NPI a. 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. ' 27.CCEPT ASSIGN vt IE 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE 00081670 [1] OOJE000 12060 YES ele' ❑NO $ 495 ;.00 $ $ 495.0 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INF 33. BILLING PROVIDER INFO & PH # ( INCLUDING DEGREES OR CREDENTIALS I RON HAVEN GYM CHIROPRACTIC MATTHEW M NICAST`20 D (I certify I that billandare ma ea part e t 90 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 IRK UREONre � CARLISLE PA 17013 CARLISLE PA 17013 05/01/13 SIGNED DATE e. b. a. h NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05) r PROGRESSIVE INSURANCE ' PO BOX 512926 ` a 1 50 LOS ANGELES CA 90051 Lu FHEALTH INSURANCE CLAIM FORM a APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105 V PICA PICA �r 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a]1y._gfjg (For Program in Item 1) CHAMPUS HEALTH PLAN BLK LUNG (Medicare #) ❑ (Medicaid #) ❑ (Sponsor's SSN) ❑ (Member 10 #) ❑ (SSN or /D) ❑ (SSN) (f0) T'S r Firs Name, Middle Initial) 3. ®!KI 1E4�TiS pTg1 - D�TE SEX 4. �� NAN�� First Name, Middle Initial) AMM 'D M F f- 1 TI R ) ST 6. PATIENT RELAT(OIXSHIP TO INSURED 7. "Q It EtE ,ftSIr!T J Self❑ Spouse❑Child❑ Other❑ ITY TE 8. PATIENT STATUS CI LE STATPj; Z Single ❑ Married ❑ Other ❑ gg �yD Q IIO��E Tl�-fppon"111e��a Code) Zl i 1 U i 3 rELEPHOpf J� nclyLd Fir Cgdg) Full -Time Part-me ( Employed ❑ Student ❑ Ti Student ❑ 0 LL 9. OTHER INSURED's NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED's POLICY GROUP OR FECA NUMBER Z a LU a.OTHER INSURED's POLICY OR GROUP NUMBER a.EMPLOYMENT? (Current or revious) a. INSUREQ S DA E OF B {RTH SEX cc Ml�1 I 16 9 M[j F❑ Z YES NO LJ b.OMMER INSURED' YDATE OF BIRTH SEX b. AUTO AC ENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME 0 DO ME] F YES ❑NO c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME (- PROGRESSIVE INSURANCE w ❑ YES NO d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOT R HEALTH BENEFIT PLAN? a 1:1 YES InNO if yes, return to and complete item 9 a -d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED's OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process i � � �� a mgt+ g benefits either to myself or to the party wt oo accepts 1 � services descriS bed g @Igw ATURE ON FILE below. 1(71V SIGNED DATE SIGNED 4 ❑AS�E �P ENT: ILLNESS (First symptom) OR 15, IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNF BLE TO WORK IN CURRENT OCCUPATION YY ' INJURY (Accident) OR GIVE FIRST DATE MM , DO ; YY MM ; DD , YY MM ; DD YY PREGNANCY(LMP) FROM ; ; TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 7.7a: 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES _ -_ . --`-_- MM , DD , YY MM ; OO , YY 17b. NPI --` -- - -- -- - FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? X $ CHARGES ❑ YES ❑NO 2��tTNGISIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 8 or 4 2 4E by Line) 22. MEDICAID RESUBMISSION ORIGINAL REF. NO. 1. 1- . 3, 1� . 23. PRIOR AUTHORIZATION NUMBER 724 4 739 7 2. 1- . 4. 1-. 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J• Z From To RP1 EOF (Explain Unusual Circumstances) DIAGNOSIS � p 0 j y {D. RENDERING O MM DD YY MM DD YY SfffJa EMG CPT /HCPCS MODIFIER POINTER $ CHARGES LMS Wan Qu PROVIDER ID. S Q 3 27 13 03 27 13 11_ 1.2.34' _...75..,.0 -0- ..1 1Ubt31S�bki_ -- LL 3 27 13 03 27 13 11 97035_ _ - -._ 1.2._3.4 _ ..60 - .0..0...1 -__ . __JU_6fi LSSbki z - - -1 - .. NPI W i 3 27 13 _... 03 27 _.. ._11 .._.__ 9711_0 .._._ ... ........ 1.5.0.. 2_.__..._.. 136)b55b�i - -- a a N _.. _ _ '... NPI 0 4- Z NPI Q _.. - -- --------------- -- - - - - -- N a - PI X I.D. NUMBER SS EIN II 6 PATI NT ACCOUNT NO. 27.60CE t cpI GNM NT? 2B. TOTAL CHARGE 29. AMOUNT PAID L3O. BALANCE DUE 8 � t "t�f M�GJEMR 12060 ves ❑NO $ 285 00 s 285.0 31. INCLUDING SIGNATUR DEGREES O RCRED E CREDENTIALS I � EF�!(IMF_F GILITYIOCATIOiLINFQRNiNT1QN 33. BILLING I NICAST O DC� INCLUDING DEREES R CREDNTIALS nr1V 1V C� Y lv1 C:H 1 L�U L'L�i ( I certify t that b the statements on the reverse 2 0 E POMFRET ST SUITE 3 290 E POMFRET ST SUITE 3 S Gl ' V KC, III and arwaad,f part thereof.) U1V �1L CARLISLE PA 17013 CARLISLE PA 17013 05/01/13 q;;rr,7qQ&0- 125557 1 894 SIGNED DATE I ` NUCC Instruction Manual available at: www.nucc.org APPROVED OMB - 0938 -0999 FORM CMS -1500 (08/05. Law Offices of Hubshman & Flood By: Lynn A Zikoski, Esquire Attorney ID #80242 5165 Campus Drive, Suite 200 Plymouth Meeting, PA 19462 Telephone #(610) 276-4978 Lynn_A_Zikoski@Progressive.com Our File #123838246-001 Attorney for Defendant Progressive Preferred Insurance Company IRON HAVEN GYM & CHIROPRACTIC, : COURT OF COMMON PLEAS P.C. : CUMBERLAND COUNTY c, • V. • PROGRESSIVE PREFERRED INSURANCE : : 14-228 ENTRY OF APPEARANCE 4�d C- 811W 'it OZ r>" C.51 (2:s rr rl cD TO THE PROTHONOTARY: Kindly enter my appearance on behalf of Defendant, Progressive Preferred Insurance Company, in the above-captioned matter. Law Offices of Hubshman & Flood By: Lynn A Zikoski, Esquire Attorney for Defendant NOTICE TO PLEAD TO: Plaintiff You are hereby notified to file a written response to the enclosed Answer with New Matter within twenty (20) days from service hereof -or a judgment may be entered against you. Lynn AZikoski sq. Attorney for Defendant I, • 1. Law Offices of Hubshman & Flood By: Lynn A Zikoski; Esquire Attorney ID #8o242 5i65 Campus Drive, Suite,2oo, Plymouth Meeting, PA 19462 Telephone #(61o) 276 :4978 Our File #1238-382461601' Iron Haven Gyrii'& Chiropractic, P.C. CERTIFICATE OF SERVICE I hereby certify that I have served a copy of the attached pleading upon all other parties or their attorneys by: _xf.L, a,regularmail certified mail other , :13y. Lynn A Z. oski, Esq. Attorney for Defendant fTl ci3 Fri Attorney;for,Defendant., wr Progressive Preferred Insurance Co i py P 3- n : ' Court of Common Pleas : Cumberland County Progressive Preferred Insurance 14 -228 DEFENDANTS:ANSWER AND,NEW MATT. ATTER -TO PLAINTIFF'S COMPLAINT 1. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 2..-Denied. The-allegations -contained ih this paragraph are conclusions of law, and no response :is required. ;After reasonable investigation; answering:defendantis without knowledge --c cwa CD or information-sufficient to form'abelief as to: the truth of the averments'contained in this paragraph,. and strict Proof thereof ldernanded at the'time of trial. 3. Admitted. 4. .Denied. , tThe allegations c °oritained in this paragraph are conclusions of law, and no responseis required.' tAfter reasonable investigation; answering defendant is without.knowledge or information- sufficient to form .ma belief asto,the truth':of the averments :contained in this paragraph; and-strict: proof thereofis demanded atthe time of ;trial 5. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 6. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 7. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 8. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. The answering defendant has no independent knowledge of what, if any, injuries or damages the plaintiff sustained. Further, it is denied that the alleged injuries, if truthful, are serious, permanent or causally related to the incident set forth in plaintiffs Complaint. Furthermore, all averments are denied, and strict proof thereof is demanded at the time of trial. 9. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. The answering defendant has no independent knowledge of what, if any, injuries or damages the plaintiff sustained. Further, it is denied that the alleged injuries, if truthful, are serious, permanent or causally related to the incident set forth in plaintiffs Complaint. Furthermore, all averments are denied, and strict proof thereof is demanded at the time of trial. 10. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 11. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 12. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 13. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 14. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 15. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. i6. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 17. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 18. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 19. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 20. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 21. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 22. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 23. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 24. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 25. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 26. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 27. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 28. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 29. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 3o. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 31. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 32. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 33. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. 34. Denied. The allegations contained in this paragraph are conclusions of law, and no response is required. After reasonable investigation, answering defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph, and strict proof thereof is demanded at the time of trial. WHEREFORE, answering defendant demands judgment in his favor and dismissal of plaintiff's complaint with prejudice. NEW MATTER 1. Plaintiffs failed to cooperate in the investigation and or claims process. 2. Plaintiffs failed to provide proof of entitlement to benefits. 3. Plaintiffs failed to comply with applicable sections of the Pennsylvania Motor Vehicle Financial Responsibility Law. 4. Defendant was at all times relevant hereto reasonable in its actions and further has, at all times relevant hereto, acted reasonably and with reasonable foundations as to any and all claims made by the plaintiffs including its decision to deny medical payments. 5. The Plaintiffs are not entitled to interest, punitive damages, court costs or attorney fees of any kind or in any way as defendant acted with reasonable foundation at all times relevant hereto. 6. In the event defendant is found liable for any unpaid medical bills, which liability is strictly denied, such bills are subject to reduction in accordance with the requirements of the PMVFRL. 7. Plaintiffs' Complaint fails to state a cause of action upon which relief may be granted. 8. Plaintiffs' claims are barred by the applicable Statute of Limitations. 9. Plaintiffs' claims are barred in whole or in part by the doctrine of res judicata and /or the doctrine of collateral estoppel. 10. Defendant does not owe benefits to plaintiffs. WHEREFORE, answering Defendant demands judgment in its favor, together with costs, and against all parties, along with such other relief as this Honorable Court deems appropriate. BY: DATE: April 11, 2014 HUBSHMAN & FLOOD Lynn'A ikoski, Es uire Attorney for Defendant VERIFICATION I, Lynn A Zikoski, Esquire, aver that I am the attorney for the answering Defendant in this case, and I aver that the averments contained in the foregoing pleadings are true and correct to the best of my knowledge, information and belief; and that the statements therein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities. w Lynn A ikoski, squire Andrew C. Spears (PA 87737) HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road, Suite 2 Harrisburg, PA 17110 Ph. 717.238.2000 Fax 717.233.3029 spears@hhrlaw.com :HONllO ZO I !i i' r 'i _ 5 P CLJt1F3EPLAND COUNTY PENHSYLVANIA IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IRON HAVEN GYM & CHIROPRACTIC, P.C. V. PROGRESSIVE PREFERRED INSURANCE COMPANY. CO. Defendant CIVIL ACTION NO: 14-228 Attorneys for Plaintiff PLAINTIFF'S REPLY TO NEW MATTER AND NOW, comes the Plaintiff, Jennifer Moore, by and through her attorney, HANDLER, HENNING & ROSENBERG, LLP, by Andrew C. Spears, Esq., and responds to the Defendant's allegations of New Matter as follows: 1. The averments in this paragraph constitute conclusions of law to which no response is required. If a response is required, the averments in this New Matter appear to be directed to a motor vehicle Plaintiff. If any response is required, any and all allegations and/or insinuations of wrongdoing on the part of Plaintiff are hereby denied. 2. The averments in this paragraph constitute conclusions of law to which no response is required. If a response is required, the averments in this New Matter appear to be directed to a motor vehicle Plaintiff. If any response is required, any and all allegations and/or insinuations of wrongdoing on the part of Plaintiff are hereby denied. 1 • 3. The averments in this paragraph constitute conclusions of law to which no response is required. If a response is required, the averments in this New Matter appear to be directed to a motor vehicle Plaintiff. If any response is required, any and all allegations and/or insinuations of wrongdoing on the part of Plaintiff are hereby denied. 4. The averments in this paragraph constitute conclusions of law to which no response is required. If a response is required, the averments in this New Matter appear to be directed to a motor vehicle Plaintiff. If any response is required, any and all allegations and/or insinuations of wrongdoing on the part of Plaintiff are hereby denied. 5. The averments in this paragraph constitute conclusions of law to which no response is required. If a response is required, the averments in this New Matter appear to be directed to a motor vehicle Plaintiff. If any response is required, any and all allegations and/or insinuations of wrongdoing on the part of Plaintiff are hereby denied. 6. The averments in this paragraph constitute conclusions of law to which no response is required. If a response is required, any and all allegations and/or insinuations of wrongdoing on the part of Plaintiff are hereby denied. 7. The averments in this paragraph constitute conclusions of law to which no response is required. If a response is required, any and all allegations and/or insinuations of wrongdoing on the part of Plaintiff are hereby denied. 8. The averments in this paragraph constitute conclusions of law to which no response is required. If a response is required, any and all allegations and/or insinuations of wrongdoing on the part of Plaintiff are hereby denied. 9. The averments in this paragraph constitute conclusions of law to which no response is required. If a response is required, any and all allegations and/or insinuations of wrongdoing on the part of Plaintiff are hereby denied. 10. The averments in this paragraph constitute conclusions of law to which no response is required. If a response is required, the averments in this New Matter appear to be directed to a motor vehicle Plaintiff. If any response is required, any and all allegations and/or insinuations of wrongdoing on the part of Plaintiff are hereby denied. WHEREFORE, Plaintiffs respectfully requests this Honorable Court dismiss Defendant's New Matter, and enter judgment in its favor and enter such other Orders that are equitable and just. - Respectfully submitted, HANDLER, HENNING & ROSENBERG, LLP By: 3 Andrew C. Spears, Esquire Supreme Court ID#206214 1300 Linglestown Road - Suite 2 Harrisburg, PA 17110 717-238-2000 spears@hhrlaw.com VERIFICATION PURSUANT TO PA R.C.P. NO. 1024 (c) Andrew C. Spears, Esquire, states that he is the attorney for the party filing the foregoing document; that he makes this affidavit as an attorney, because the party he represents Tacks sufficient knowledge or information upon which to make a verification and/or because he has greater personal knowledge of the information and belief than that of the party for whom he makes this affidavit; and that he has sufficient knowledge or information and belief, based upon his investigation of the matters averred or denied in the foregoing document; and that this statement is made subject to the penalties of 18 Pa C.S. §4904 relating to unsworn falsification to authorities. Andrew C. Spears, Esquire Date: 4/30/2014 Andrew C. Spears Attorney ID# 87737 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Fax : (717) 233-3029 E-mail: Spears@hhrlaw.com Attorney for Plaintiff(s) IRON HAVEN GYM & CHIRO IN THE COURT OF COMMON PLEAS Cumberland COUNTY, PENNSYLVANIA Plaintiff(s) PROGRESSIVE PREFERRED INS. Defendant(s) NO. 14-228 . CIVIL ACTION - LAW CERTIFICATE OF SERVICE On, April 30, 2014, I hereby certify that a true and correct copy of Plaintiff's Reply To New Matter was served upon the following by depositing same in the United States Mail, in Harrisburg, Pennsylvania: Lynn A. Zikoski, Esq. Law Offices of Hubshman & Flood 5165 Campus Drive Suite 200 Plymouth Meeting, PA 19462 Attorney for: Progressive Insurance HANDLER, HENNING & ROSENBERG, LLP Andrew C. Spears