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HomeMy WebLinkAbout03-03-15 (2) r 1505610149 REV-1500 Extol-t 1>pennst ania OFFICIAL USE ONLY PA Department of Revenue "` Countv Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 21 14 0972 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 02 07 2014 11 03 1927 Decedent's Last Name Suffix Decedent's First Name MI Garland Mona F (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1.Original Return Q 2. Supplemental Return Q 3. Remainder Return(Date of Death Prior to 12-13-82) Q 4.Limited Estate Q 4a. Future Interest Compromise(date of Q 5. Federal Estate Tax Return Required death after 12-12-82) Q 6.Decedent Died Testate Q 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) Q 9.Litigation Proceeds Received Q 10. Spousal Poverty Credit(Date of Death Q 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT—THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number John A . Feichtel , Esquire 717 612 5803 REGISTER OF WILLS USE ONLY C770 First Line of Address C__ Saidis , Sullivan 8 Rogers o , ' t _ _.t C:'J Second Line of Address ;=' ^w 1— W r-, 635 North 12th Street, Suite 400 �A C� DATE FILM "T1 TI City or Post Office State ZIP Code Lemoyne PA 17043 ' =''i N r - rrn tom_ �I1 Uo c7. C U T1 Correspondent's e-mail address: jfeichtel@SSr-attorneyS.com Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGN "OFSON,RESPO���LE yO�R FILING URN ©DATLx7t/5 ADDR 29 C Urt Lane v/1.1J Car le SIG RE OF PREPA. SENTA OTH T IV DATE _ ADDRESS 35 North 72th Ute 400 Lemoyne, PA 17043 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610149 1505610149 J 1505618296 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: Mona F Gar 1 and RECAPITULATION 1. Real Estate(Schedule A) ... ... . . . ... . . . . . . . .. . .... . . .... . .. . ..... 1. 0 . 00 2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. ... . . 2. 0 - 00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . . . . 3. 0 - 00 4. Mortgages and Notes Receivable Schedule D 4. 0 . 00 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E) . . . . . 5. 10,733 - 20 6. Jointly Owned Property(Schedule F) O Separate Billing Requested . . . . . 6. 0 - DO 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested . . . . . 7. 0 - 00 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . .. ..... . . . . .. . . . . . 8. 101733 . 20 9. Funeral Expenses and Administrative Costs(Schedule H) . .. .. . . . . . . . . . . . 9. 6 -1647 - 14 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1) . . . .... ...... 10. 3481990 - 27 11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . .. . . . . . . . . 11. 355 ,637 - 41 12. Net Value of Estate(Line 8 minus Line 11) ............... .. .. ... ... .. 12. 0 - 00 13. Charitable and Governmental Bequests/Sec.9113 Trusts for which an election to tax has not been made(Schedule J) ... ... . . . . . . . .. . .. . . . . 13. 0 - 00 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . ... . . . . . 14. 0 - 00 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec. 9116 (a)(1.2)X.0 0 0 . 00 15. 0 . 00 16. Amount of Line 14 taxable at lineal rate X.0 45 0 . 00 16. 0 . 00 17. Amount of Line 14 taxable at sibling rate X.12 0 . 00 17. 0 . 00 18. Amount of Line 14 taxable at collateral rate X.15 0 . 00 18. 0 . 00 19. TAX DUE . .. . ...... .. . .. . .. . ....... . . .. . . . . . . . . . . . . . .. .. . . . . 19. 0 . 00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Q Under penalties of perjury,I declare I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete. Declaration of preparer other than the person responsible for filing the return is based on all information of which preparer has any knowledge. SIGNATU OF PE SON R PONSIBI,E FOyi©ILING RETPDATE ADDRES 29 rt Lane Carlis e PA SIGNATURE OF -REPARER OT AN PERSON RESP0 IB FOR FILING THE RETURN DAT ADDRESS 63 orth 12t t e , e 400 Lemoyne, PA 17043 I I��I�I II��I�IIII"I'I 1III1 1II1I ILII 1I1I1 IIT ILII IN Side 2 1505618296 1505618296 REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: 21 140972 DECEDENT'S NAME Mona F. Garland STREET ADDRESS 29 Court Lane CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments 0.00 B.Discount 0.00 (See instructions.) Total Credits(A+B) (2) 0.00 3. Interest (3) 0.00 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred ... ... . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . ❑ b. retain the right to designate who shall use the property transferred or its income . . . . . . . . . . . . . . . . . . ❑ 91 c. retain a reversionary interest. .. . .. . .. . ... ... ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ d. receive the promise for fife of either payments,benefits or care? . . . . . . . . . .. ... . . . . .... . . . . . .. ❑ 2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ..................... . . . . . ..... .. . . .... . . . .... ❑ 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?. . .. .. ❑ 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?. .. ... ... ..... ...... .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994,and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent or a step-parent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)). • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-7.508 EX+ (08-12) rx Pennsylvania SCHEDULE E k DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE EDENAX TURN PERSONAL PROPERTY RESIDENT DECEDENT ,. ESTATE OF: FILE NUMBER: Mona F. Garland 21 140972 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH 1 Wells Fargo Checking Account 8,601.84 Per 10/30/14 letter 2 2013 Form 1040 Refund 2,131.36 ($2,103 plus $28.36 interest) TOTAL (Also enter on Line 5, Recapitulation) 10,733.20 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (08-13) ;t A„,. pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND TAX RESIDENTNCE DEC DENTTURN ADMINSTRATIVE COSTS ESTATE OF FILE NUMBER Mona F. Garland 21 140972 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: 1 Hoffman-Roth Funeral Home & Crematory, Inc. 5,232.42 r B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. Attorney Fees: 1,000.00 3. Family Exemption: (If decedent's address is not the same as clalmant's, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 130.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 7 Harland Clarke, check order 24.92 8 Saidis, Sullivan & Rogers, out of pocket expenses ($75.00 Cumberland Law 244.30 Journal, $169.30 The Sentinel) 9 Register of Wills, additional probate fee 15.00 TOTAL (Also enter on Line 9, Recapitulation) 6,647.14 If more space is needed, use additional sheets of paper of the same size. a REV-1512 EX+ (12-12) r�; Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Mona F. Garland 21 140972 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,induding unreimbursed medical expenses. ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH 1 DCM Services Claim 1,216.00 Per 11/4/14 Notice of Claim 2 Forest Park Health Center 39.70 3 PA Department of.Public Welfare 347,734.57 TOTAL (Also enter on Line 10, Recapitulation) 348,990.27 If more space is needed, insert additional sheets of the same size Kelly Howell From: Kelly Howell Sent: Thursday, October 16, 2014 1:54 PM To: 'RA-InheritanceTaxExt@pa.gov' Cc: Feichtel,John Ofeichtel@ssr-attorneys.com); Cayle Swindler Subject: Estate of Mona Fern Garland - Request for Extension This e-mail will serve as our request for a six(6) month extension of time to file the PA inheritance tax return due to the unavailability of records for the following decedent: Mona Fern Garland Date of Death: 02/07/2014 SSN: File No.: 2014-00972 At the time of her death, Mrs. Garland was a resident of Cumberland County. If you have any questions or require additional information, please do not hesitate to contact me. Kelly Saidis,Sullivan&Rogers - Trust Matters Kelly R.Howell I Legal Assistant 635 N.12th Street I Suite 400 1 Lemoyne,PA 17043 Phone(717)612.5800 1 Fax(717)612.5805 1 Email khowell a ssr attorneys.com This e-mail may contain privileged,confidential,copyrighted,or other legally protected information. If you are not the intended recipient(even if the e-mail address above is yours),you may not use,copy or retransmit this e-mail. If you have received this by mistake please notify us by return.e-mail,then delete. Thank you. Saidis,Sullivan&Rogers'web site is maw.ssr-attorneys.com We advise you that any discussion of federal tax issues in this e-mail is not to be used,and cannot be relied upon by you(i) to avoid any penalty imposed under the Internal Revenue Code,or(ii) to promote, market or recommend to another party any transaction or matter addressed in this e-mail. 1 a� v $ K ,fl8W y a o asQ"oa�, aj o . U tt r�:x. a• n, o+ ky' N O � a IM 6s, -zt Ck co � o us •C A a �,. m y Oo o 'a" M . O p ,a toPC cu p„:: °y o W to ev Cr n cz v o 0 • O v 0.0 0 STATEMENT Forest Park Health Center Resident: Garland, Mona (22665) 700 Walnut Bottom Road Location: - Carlisle, PA 17013-3699 Statement Date: 3/1/2014 (888) 880-7090 ALL TRANSACTIONS PROCESSED AFTER Feb 28, 2014 WILL APPEAR ON YOUR NEXT STATEMENT Erik Kochert 3470 Harrowgate Road York, PA 17402 Amount Due $83.00 PLEASE DETACH AND RETURN WITH YOUR PAYMENT Amount Enclosed $ Forest Park Health Center Resident: Garland, Mona (22665) 700 Walnut Bottom Road Location: - Carlisle, PA 17013-3699 Statement Date: 3/1/2014 (888) 880-7090 Effective Date Description Units Unit Amount Amount BALANCE FORWARD $47.00 2/1/2014 Telephone SNF 1 $36.00 $36.00 BALANCE DUE $83.00 QUESTIONS REGARDING BILL? PLEASE CALL 888-880-7090/NIKKI EXT 807 Nikki.ppbilling@guardianeldercare.net WE ACCEPT MOST MAJOR CREDIT CARDS (SEE BACK OF BILL) I/ o/ �(h - a /y 1 )r &/a che0 ba�I� Ftm-t ParV Qnj (z rn orP U),i � Gt l l �e n� v� WA l PAYMENT IN FULL IS DUE BY THE 15th OF THE MONTH Please make check payable to facility listed above in upper left or complete credit card payment information on back of this form. This is an attempt to collect debt.Any information provided will be used for that purpose. i Oki 7601 PENN AVENUE SOUTH,SUITE A600 MINNEAPOLIS, MINNESOTA 55423-5004 TELEPHONE 612-243-8640 Hours(CT): 7:00 am-7:00 pm M-TH FAX 877-326-8784 7:00 am-5:00 pm F TOLL-FREE(877) 326-1533 NOVEMBER 04, 2014 I IIIIIII III III II I II III VII I VIII VIII VIII III I I I II CL603631 JOHN A FEICHTEL 635 N 12TH ST STE 400 LEMOYNE, PA 17043-1247 Estate of: MONA FERN GARLAND Total Unpaid Balance PF Reference No Probate Case No Date of Death $1,216.00 CL603631 2014-00972 2/7/2014 Dear Sir or Madam: Enclosed herewith is a copy of the Creditor's Claim by DCM Services on behalf of CARLISE HMA, LLC, D/B/A CARLISE REGIONAL MEDICAL CENTER for the above referenced estate. Responses are requested to be returned to the address of DCM Services. If you have any questions or if this is a duplicate claim, please call our company toll free at 1-(877) 326-1533. Cordially, DCM Services, LLC Enclosures This company is a debt collector. We are attempting to collect a balance due from the assets of the estate and any information obtained will be used for that purpose. Calls may be monitored or recorded for quality assurance purposes. NOTICE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION NOTICE: SEE ATTACHED PAGE(S) FOR CLAIM DETAIL Attomey_Cover_Letter_DCM_R20140729 u 6 � Pennsylvania DEPARTMENT O:F PUB'LI'C WELF T*k ARE November 14, 2014 SAIDIS SULLIVAN & ROGERS PC JOHN A FEICHTEL ESQUIRE STE 400 635 N 12TH ST LEMOYNE PA 17043 Re: Mona Garland CIS #: 640206476 SSN: ###-##- Date of Death: 02/07/2014 ESTATE RECOVERY STATEMENT OF CLAIM Dear Mr. Feichtel: Under State and Federal law, the Department of Public Welfare (the Department) is required to recover medical assistance (MA) reimbursement from the probate estates of deceased individuals who were over age 55 when such assistance was received. 42 U.S.C. §1396p(b)(1). 62 P.S. § 1412. This letter sets forth the amount of the Department's claim against the estate of the above referenced individual and explains the obligations of executors, administrators, and persons receiving estate property. Although the amount in the estate may be considerably less than that which is owed to the Department, our claim is against the estate, no one else. Statement of Claim Amount The Department maintains a claim in the amount of $347,734.57 against the above-mentioned estate. This claim is for repayment of MA granted on behalf of the decedent. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $30,168.68, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $317,565.89, is to be entered as a priority Class 5.1 claim against the estate. You should refer to Section 3392 for a more complete explanation of the priority rules. If a lawsuit is filed for injuries sustained by the decedent prior to death, then the Department may also have a lien against the personal injury action. A statement of claim for that injury-related lien must be requested separately. Bureau of Program Integrity i Division of Third Party Liability I Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 T 0 +� pennsyLvania . - IIDEPARTMENT OF PUBL3C WELFARE Your Responsibility to Provide Information to the Department Please acknowledge receipt of this letter and advise whether the Department's claim is admitted and when payment may be expected. When the estate accounting is complete, please provide a copy. The Department audits all estate recovery claims and therefore we require documentation to substantiate all deductions from the gross estate. The regulations governing how the Department computes its estate recovery claim are found in 55 Pa. Code Chapter 258. These regulations are readily available on the Internet, in addition to being carried in most local law libraries. In order to accurately compute the amount due the Department, the following items should be submitted to the address below: 1. For real estate: a. Copy of the deed b. Copy of the latest tax assessment c. Copy of a current appraisal, if available 2. Copy of the funeral bill 3. Copy of the statement of the burial account if one existed 4. Copy of the statement of the personal care account balance at date of death, if the decedent was in a nursing home 5. Copies of original and updated life insurance policy forms naming beneficiaries 6. Copies of any and all stocks and bonds 7. Copies of bank statements showing balances on the date of death 8. Copies of signature cards or other proof of when accounts were made joint 9. A list of any gifts or other transfers for less than fair market value made by the decedent (personally or under a power of attorney) Your Responsibilities to the Department Under State law, executors or administrators may be personally liable to pay the Department's estate recovery claim if they transfer estate property without the Department's claim being paid. Persons who receive that property without paying valuable and adequate consideration to the estate may also be personally liable. The responsibilities of the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to ensure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. Accordingly, you must ensure the Department's claim is satisfied before making distribution of assets to heirs. Bureau of Program Integrity I Division of Third Party Liability i Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 M. n. pennsy.vanial _ DEPARTMENT OF PUBLIC WELFARE Insolvent Estates and the Fiduciary Responsibility to Creditors If there are not enough estate assets to pay the claims of all creditors in full, then the executor or administrator has a duty to act in the best interest of creditors when administering the estate. If you must spend the estate's money to administer it, you must act prudently and make purchases as if the money were coming out of your own pocket. The Department's approval is required if you expect the legal fees to exceed more than the greater of 6% of the estate assets or $1,000. Contingent fees for estate administration will generally not be approved. If you do not obtain approval, the Department may consider the excessive fees to be a transfer for less than valuable and adequate consideration. Sincerely, Tina M. Wise TPL Program Investigator 717-214-1204 717-772-6553 FAX Enclosure Bureau of Program Integrity Division of Third Party Liability Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 n „ COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG,PA 17105-8486 November 3,2014 STATEMENT OF CLAIM SUMMARY r NAME_;::, Estate of GARLAND,MONA 640 206 476 jMEDICAL t CLASS 3 CLASS 5 1 { ` TOTAL f INPATIENT .00 .00 .00 OUTPATIENT 00 .00 .00 LONG TERM CARE 30,168.68 316,952.95 347,121.63 DRUG .00 612.94 612.94 REIMBURSEMENT TO DPWtS30,168.68 317,565.89 347,734.57 x ° ' COMMONWEALTH OF PiNNSYLVANIAt' A ti DEPAR MENT OF PUBLIC WELFARE,�O Q" r Page 1 of 24 �� N° � .; r� 4 ,, � COMMONIIVEALTNOFPENNSYLVANIA x<,f ,� � fi �� � November 3,2014 STATEMENT OF CLAIM GARLAND,MONA 1D 640 206 476 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OFSERVJCE aPAYIJIENT DATE �' ORIGINAL CRN k ADJUSTED CRNF " USUAL CHARGES ; AMOUNT,APPROVED: 04/09/08 - 04/30/08 07/14/08 69081704020010001 69081704020010001 4,576.88 3,744.41 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 0 PROC CODE: 000000 05/01108 - 05/31/08 07/14108 69081704020030001 69081704020030001 6,449.24 5,616.77 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] 'DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 06/01/08 - 06/30/08 07/28/08 20081834092330001 20081834092330001 6,241.20 5,408.73 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 07/01/08 - 07/31/08 03/02/09 55090584089490001 55090584089490001 6,449.24 5,637.54 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 08/01108 - 08/31/08 03/02/09 55090584090250001 55090584090250001 6,449.24 5,637.54 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 09/01/08 - 09/30/08 03/02/09 55090584091140001 55090584091140001 6,241.20 5,428.83 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 Page 2 of 24 - COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE '. November 3,2014 STATEMENT OF CLAIM NAME,: GARLAND,MONA 1D. 640 206 476 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OF SERVICE' PAYMENT DATE ORIGINAL CRN ADJUSTED CRN; USUAL CHARGES AMOUNTAPPROVED 10101/08 - 10/31/08 03/23/09 55090784385010001 55090784385010001 6,449.24 5,666.06 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 11/01/08 - 11/30/08 03/23/09 55090784385760001 55090784385760001 6,241.20 5,456.43 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 12!01/08 - 12/31/08 03/23/09 55090784386460001 55090784386460001 6,449.24 5,666.06 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 01!01109 - 01/31/09 04/13/09 55090994127330001 55090994127330001 6,449.24 5,448.25 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 02/01/09 - 02/28/09 04/13/09 55090994127850001 55090994127850001 5,825.12 4,819.36 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 03/01/09 - 03/31/09 04/20/09 55090994128740001 55090994128740001 6,449.24 5,448.25 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 Page 3 of 24 November 3,.2014 STATEMENT OF CLAIM NWE' GARLAND,MONA ID 640 206 476 .r FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 a,n ''•` ", ,yC':«., --. 2 K � .Ft 5+ �a` XX' f".' kw t✓. '.x DATE OF SERVICE' PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVEDs ,. ;; mow. 04/01/09 - 04/30/09 07/13/09 69091774020350001 69091774020350001 6,344.40 5,622.62 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 05/01/09 - 05/31/09 06/15/09 20091524110260001 20091524110260001 6,273.90 5,223.63 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 06/01/09 - 06/30/09 07/20/09 20091824099460001 20091824099460001 6,344.40 5,294.12 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 07/01/09 - 07/31109 . 11/08/10 55103094559820001 55103094559820001 6,555.88 5,303.17 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 08/01/09 : 08/31/09 11/08/10 55103094560550001 55103094560550001 6,555.88 5,303.17 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 09/01/09 - 09/30/09 11/08/10 55103094561340001 55103094561340001 6,344.40 5,098.22 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 Page 4 of 24 r COMMONWEALTH DF PENNSYLVANIA DEPARTMENT OF„PUBLIGINELFAREs F w November 3,2014 STATEMENT OF CLAIM NAME.` GARLAND,MONA 7D 640 206 476 3 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE y ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED, 10/01/09 - 10/31/09 12/13/10 55103425271880001 55103425271880001 6,555.88 5,357.73 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 11/01/09 - 11/30/09 12/13/10 55103425272530001 55103425272530001 6,344.40 5,151.02 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 12/01/09 - 12/31/09 12/13/10 55103425273460001 55103425273460001 6,555.88 5,432.73 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 01/01/10 - 01/31/10 01/10/11 55110044267380001 55110044267380001 6,555.88 5,385.01 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 02/01/10 - 02/28/10 01/10/11 55110044268010001 55110044268010001 4,300.08 3,170.72 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 06/01/10 - 06/30/10 02/14/11 55110394262880001 55110394262880001 6,344.40 5,177.42 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE : 000000 Page 5 of 24 , Y w COMMONWEALTH OF PENNSYLVANIA,. - ~= DEPARTMENTOF PUBLIC WELFARE November 3,2014 STATEMENT OF CLAIM :NAME< GARLAND,MONA 1D _ 640 206 476 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OF SERVICE, PAYMENT DATE. ORIGINAL CRN, ADJUSTED CRN , USUAL CHARGES. AMOUNT APPROVED 07/01/10 - 07/31/10 10/17/11 55112854568100001 55112854568100001 6,555.88 5,402.41 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 08/01/10 - 08/31/10 10/17/11 55112854568880001 55112854568880001 6,555.88 6,447.41 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 09/01/10 - 09/30/10 10/17111 55112854569660001 55112854569660001 6,344.40 6,139.42 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 10/01/10 - 10/31/10 10/24/11 55112924728010001 55112924728010001 6,555.88 5,487.00 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 11/01/10 - 11/30/10 10/24/11 55112924728770001 55112924728770001 6,227.70 5,276.12 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 12/01/10 - 12/31/10 10/24/11 55112924729540001 55112924729540001 6,435.29 5,487.00 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 Page 6 of 24 COMMONWEALTH'OF PENNSYLVANIA.' L, t S s DEPARTMENT OF PU*96I WELFARE�� November 3,2014 STATEMENT OF CLAIM NAii11E`> GARLAND,MONA F:a 640 206 476 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 "+( .,+ } ' DATE OF SERVICE: z PAYMENT DATE 7 ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED, 01/01/11 - 01131/11 10/31/11 55112994713320001 55112994713320001 6,435.29 5,487.00 DIAGNOSIS 1 : 3315 IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS[INPH] DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 02101/11 - 02128/11 10/31/11 55112994714030001 55112994714030001 4,151.81 3,485.82 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 4409 ATHEROSCLEROSIS NOS PROC CODE: 000000 03/01/11 - 03/31/11 10/31/11 55112994714710001 55112994714710001 3,113.85 2,112.92 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 04/01/11 - 04/30/11 11/07/11 55113054626960001 55113054626960001 6,227.70 5,276.12 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 05/01/11 - 05/31/11 11/07/11 55113054627680001 55113054627680001 6,435.29 5,624.50 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 06/01/11 - 06130/11 11/07/11 55113054628430001 55113054628430001 6,227.70 5,276.12 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE : 000000 Page 7 of 24 COMMONWEALTH:OF PENNSYLVANIA DEPARTMENT OF:PUBLIC WELFARE 11 November 3,2014 STATEMENT OF CLAIM NAME : GARLAND,MONA ID 640 206 476 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OF SERVICE"..., PAYMENT DATE. ORIGINAL CRN ADJUSTED CRN` USUAL CHARGES I OVED 07/01/11 - 07/31111 05/07/12 55121254052410001 55121254052410001 6,020.12 4,866.59 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 08/01/11 - 08/31111 05/07/12 55121254053530001 55121254053530001 6,435.29 5,274.65 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 29040 VASCULAR DEMENTIA,UNCOMPLICATED PROC CODE: 000000 09/01111 - 09/30/11 05/07/12 55121254053950001 55121254053950001 6,227.70 5,070.62 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 10/01/11 - 10/31/11 05/21/12 55121374098390001 55121374098390001 6,537.28 5,353.08 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 11/01/11 - 11/30/11 05/21/12 55121374099100001 55121374099100001 6,326.40 5,146.52 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 12/01/11 - 12/31/11 05/21/12 55121374099870001 55121374099870001 6,537.28 5,353.08 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 Page 8 of 24 COMMONWEALTH OF PENNSYLVANIA ' DEPARTMENT OF PUBLIC WELFARE ' November 3,2014 STATEMENT OF CLAIM NAME: GARLAND,MONA ID 640 206 476 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OF SERVICEPAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED.; 01/01112 - 01/31/12 06/18/12 55121644181760001 55121644181760001 6,537.28 5,413.23 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 02/01/12 - 02/29/12 06/18/12 55121644182440001 55121644182440001 6,115.52 4,994.81 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 03/01/12 - 03/31/12 10/29/12 69122794023110001 69122794023110001 6,537.28 6,151.91 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 04/01/12 - 04/30/12 10/29/12 69122794023150001 69122794023150001 6,290.70 6,290.70 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 05/01/12 - 05/31/12 06/25/12 20121534301780001 20121534301780001 6,500.39 5,428.11 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 06/01112 - 06/30/12 07/30/12 20121854027720001 20121854027720001 6,290.70 5,218.42 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 Page 9 of 24 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 3,2014 STATEMENT OF CLAIM NAME GARLAND,MONA I 640 206 476 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 ,DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES .AMOUNTAP-77 PROVED 07/01/12 - 07/31/12 01/28/13 55130244377250001 55130244377250001 6,500.39 5,062.31 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 08/01/12 - 08/31/12 01/28/13 55130244377950001 55130244377950001 6,500.39 5,062.31 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 09/01/12 - 09130/12 01/28/13 55130244378830001 55130244378830001 6,290.70 4,864.42 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 10/01112 - 10/31/12 02/18/13 55130444303460001 55130444303460001 6,500.39 5,062.31 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 11101/12 - 11/30/12 02118/13 55130444304220001 55130444304220001 6,290.70 4,864.42 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 12/01112 - 12/31/12 02/18/13 55130444304970001 55130444304970001 6,500.39 5,062.31 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 Page 10 of 24 �COMMON1NEAtT}i OF PENNSYLI/AyNiA< _ • November 3,2014 STATEMENT OF CLAIM NAME` GARLAND,MONA 640 206 476 ~r: FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 � � •v� t r4' �- �. ; :.. y ..;` � - . { "Y� g x HATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED: 01/01/13 - 01/31/13 02/25/13 20130354051340001 20130354051340001 6,500.39 5,207.21 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 02/01/13 - 02/28/13 03/25/13 20130634044490001 20130634044490001 5,678.12 4,598.84 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 03/01113 - 03/31/13 04/22/13 20130914120410001 20130914120410001 6,286.49 5,207.21 'DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED) PROC CODE: 000000 04/01/13 - 04/30/13 05/27/13 20131214104470001 20131214104470001 6,083.70 5,079.72 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 41400 CORONARY ATHEROSCLEROSIS UNSPEC VESSEL PROC CODE: 000000 05/01/13 - 05/31/13 06/24/13 20131544077620001 20131544077620001 6,364.30 5,285.02 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 41400 CORONARY ATHEROSCLEROSIS UNSPEC VESSEL PROC CODE: 000000 06/01/13 - 06/30/13 07/22/13 20131824177620001 20131824177620001 6,159.00 5,079.72 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 41400 CORONARY ATHEROSCLEROSIS UNSPEC VESSEL PROC CODE: OOOODO Page 11 of 24 COMMONWEALTH OF PENNSYLVANIA r ,.. - r"� a h 4-1 -..�r 7 a. M 3+':a. L [ 7t ?F 1 .✓ 3 3� h S z y c M _DEPARTIJIENT OF PUBLIC WELFARE a<' r November 3,2014 STATEMENT OF CLAIM .a NAME;, GARLAND,MONA 640 206 476. FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 yry DATE OFRSERVICEPAYMENTDATE r tiORIGINAL CRN ADJUSTED CRNr USUAL CHARGES AMOUNTAPPROVED 07/01/13 - 07/31/13. 01/13/14 55140074557380001 55140074557380001 6,364.30 4,955.80 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 41400 CORONARY ATHEROSCLEROSIS UNSPEC VESSEL" PROC CODE: 000000 08/01/13 - 08/31/13 01/13/14 55140074558020001 55140074558020001 6,364.30 4,955.80 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 41400 CORONARY ATHEROSCLEROSIS UNSPEC VESSEL PROC CODE: 000000 09/01/13 - 09/30/13 01/13/14 55140074558790001 55140074558790001 6,159.00 4,761.12 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 41400 CORONARY ATHEROSCLEROSIS UNSPEC VESSEL PROC CODE: 000000 10/01/13 - 10/31/13 01/20/14 55140164088150001 55140164088150001 6,364.30 5,243.79 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 41400 CORONARY ATHEROSCLEROSIS UNSPEC VESSEL PROC CODE: 000000 11/01/13 - 11/30/13 01/20/14 55140164088900001 55140164088900001 6,159.00 5,059.82 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 41400 CORONARY ATHEROSCLEROSIS UNSPEC VESSEL PROC CODE: 000000 12/01/13 - 12/31/13 01/27/14 55140164089640001 55140164089640001 6,364.30 5,243.79 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 41400 CORONARY ATHEROSCLEROSIS UNSPEC VESSEL PROC CODE: 000000 Page 12 of 24 I PENNSYLVANIA 'E LVMIK ', D EPART -OF PUBLIC Wk6Ri November 3,2014 STATEMENT OF CLAIM ,NAME GARLAND,MONA ID. 640 206 476 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OF SERVICEEN ORIGINALCRN ADJUSTED-CRN' - ; USUAL CHARGES' AMOUNT APPROVED 01/01114 01/31/14 04/14/14 69140804021730001 69140804021730001 5,548.80 4,708.52 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 41400 CORONARY ATHEROSCLEROSIS UNSPEC VESSEL PROC CODE: 000000 02101114 - 02/07/14 03131/14 27140634028520001 27140634028520001 195.84 195.84 DIAGNOSIS 1 : 496 CHR AIRWAY OBSTRUCT NEC DIAGNOSIS 2: 41400 CORONARY ATHEROSCLEROSIS UNSPEC VESSEL PROC CODE: 000000 FOREST PARK HEALTH CENTERVTOT 416,143.07 347,121.63 03 101867397 0001 Page 13 of 24 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 3,2014 STATEMENT OF CLAIM NAME GARLAND,MONA ID - 640 206 476 GUARDIAN LONG TERM CARE PHARMACY I 123 BRUBAKER RD BROCKWAY PA 15824 DATE OF SERVICE' PAYMENT'DATE.:' ORIGINAL CRN.,. ADJUSTED.CRN IUSUALCHARGES AMOUNTAPPROVED 04/10/08 - 04/10/08 06/23/08 25081495322940001 25081495322940001 161.69 33.46 DIAGNOSIS 1 : 0 NDC CODE: 0059700754 SPIRIVA 18 MCG CP-HANDIHALER - BRONCHIAL DILATORS 04/12/08 - 04/12/08 06/23/08 25081495323100001 25081495323100001 55.21 12.52 DIAGNOSIS 1 : 0 NDC CODE: 6340205100 XOPENEX HFA 45 MCG INHALER - BRONCHIAL DILATORS 04/16/08 - 04/16/08 06/23/08 25081495323160001 25081495323160001 201.30 41.25 DIAGNOSIS 1 : 0 NDC CODE: 0017307160, ADVAIR HFA 115-21 MCG INHALER - BRONCHIAL DILATORS 04/16/08 - 04/16/08 06/23/08 25081495323280001 25081495323280001 54.42 3.67 DIAGNOSIS 1 : 0 NDC CODE: 0037852090 AMLODIPINE BESYLATE 5 MG TAB - OTHER CARDIOVASCULAR PREPS 04/16/08 - 04/16/08 06/23/08 25081495323330001 25081495323330001 13.07 4.31 DIAGNOSIS 1 : 0 NDC CODE: 0052713421- LEVOTHYROXINE 50 MCG TABLET - THYROID PREPS 04/16/08 - 04/16/08 06/23/08 25081495323440001 25081495323440001 21.24 3.06 DIAGNOSIS 1 : 0 NDC CODE: 0037800321- METOPROLOL TARTRATE 50 MG TAB - OTHER CARDIOVASCULAR PREPS 04/16/08 - 04/16/08 06/23/08 25081495323520001 25081495323520001 12.79 3.19 DIAGNOSIS 1 : 0 NDC CODE: 0037800180 METOPROLOL TARTRATE 25 MG TAB - OTHER CARDIOVASCULAR PREPS Page 14 of 24 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 3,2014 STATEMENT OF CLAIM .NAME GARLAND,MONA ID 640 206 476 GUARDIAN LONG TERM CARE PHARMACY I 123 BRUBAKER RD BROCKWAY PA 15824 DATE OF:SERVICE:. PAYMENT.DATE ORIGiNALCRN ADJUSTED CRN USUAL CHARGES . AMOUNTAPPROVED 04/16/08 - 04/16/08 06/23/08 25081495323630001 25081495323630001 81.94 14.34 DIAGNOSIS 1 : 0 NDC CODE: 5976249000 SERTRALINE HCL 50 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 04/16/08 - 04/16/08 06/23/08 25081495323720001 25081495323720001 133.94 28.01 DIAGNOSIS 1 : 0 NDC CODE: 0007803593. DIOVAN 160 MG TABLET - OTHER ANTIHYPERTENSIVES 04/16/08 - 04/16108 06/23/08 25081495323770001 25081495323770001 9.92 3.45 DIAGNOSIS 1 : 0 NDC CODE: 0037802081- FUROSEMIDE 20 MG TABLET - DIURETICS 04/16/08 - 04/16/08 06/23/08 25081495323810001 25081495323810001 11.23 2.30 DIAGNOSIS 1 : 0 NDC CODE: 6838200540 WARFARIN SODIUM 3 MG TABLET - ANTICOAGULANTS 04/24/08 - 04/24/08 06/23/08 25081495323920001 25081495323920001 110.46 5.79 DIAGNOSIS 1 : 0 NDC CODE: 0047213201, NYSTATIN 100,000 UNITS/ML SUSP - ANTIFUNGALS 04/25/08 - 04/25/08 06/23/08 25081495323950001 25081495323950001 121.79 25.63 DIAGNOSIS 1 : 0 NDC CODE: 0000636283- COSOPT EYE DROPS - OPHTHALMIC PREPARATIONS 05/10/08 - 05/10/08 06/23/08 25081495324090001 25081495324090001 201.30 41.25 DIAGNOSIS 1 : 0 NDC CODE: 0017307160 ADVAIR HFA 115-21 MCG INHALER - BRONCHIAL DILATORS Page 15 of 24 ' ry '� � � COMMONVi/EALTH OF PENNSYLVAfJIA '� , � November 3,2014 STATEMENT OF CLAIM NAME;; GARLAND,MONA ID 640 206 476 GUARDIAN LONG TERM CARE PHARMACY I 123 BRUBAKER RD BROCKWAY PA 15824 DATE OF SERVICEvPAYMENT DATE Ac ORIGINAL CRN f k ADJUSTED CRN USl7AL CHARGES s AMOUNT APPROVE 7-1 05110/08 - 05/10/08 06/23/08 25081495324130001 25081495324130001 161.69 33.46 DIAGNOSIS 1 : 0 NDC CODE: 0059700754 SPIRIVA 18 MCG CP-HANDIHALER - BRONCHIAL DILATORS 05/13/08 - 05/13/08 06/23/08 25081495324200001 25081495324200001 81.27 12.45 DIAGNOSIS 1.: 0 NDC CODE: 0005432709 FLUTICASONE PROP 50 MCG SPRAY - TOPICAL NASAL AND OTIC PREPARATIONS 05/14/08 - 05/14/08 06/23/08 25081495324260001 25081495324260001 54.42 3.67 DIAGNOSIS 1 : 0 NDC CODE: 0037852090 AMLODIPINE BESYLATE 5 MG TAB - OTHER CARDIOVASCULAR PREPS 05/14/08 - 05/14/08 06/23/08 25081495324290001 25081495324290001 13.07 4.31 DIAGNOSIS 1 : 0 NDC CODE: 0052713421- LEVOTHYROXINE 50 MCG TABLET - THYROID PREPS 05/14/08 05/14/08 06/23/08 25081495324330001 25081495324330001 21.24 3.06 DIAGNOSIS 1 : 0 NDC CODE 0037800321, METOPROLOL TARTRATE 50 MG TAB - OTHER CARDIOVASCULAR PREPS 05/14/08 - 05/14/08 06/23/08 25081495324370001 25081495324370001 12.79 3.19 DIAGNOSIS 1 : 0 NDC CODE: 0037800180 METOPROLOL TARTRATE 25 MG TAB - OTHER CARDIOVASCULAR PREPS 05/14/08 - 05/14/08 06/23/08 25081495324480001 25081495324480001 81.94 14.34 DIAGNOSIS 1 : 0 NDC CODE: 5976249000 SERTRALINE HCL 50 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS Page 16 of 24 ' COMMOI�INEALTH,OF PEI1NSYt1/ANIA � ; a � X. ,k, .Kr DEPARTMENT OF�PUBLIC WELFARE � �' November 3,2014 STATEMENT OF CLAIM NAME;, GARLAND,MONA ID 640 206 476 by, _ GUARDIAN LONG TERM CARE PHARMACY I 123 BRUBAKER RD BROCKWAY PA 15824 DATE OF SERVICE; PAYMENT DATE ORIGINAL CRN AQJUSTED CRN USUAt CHARGES PMOUNTAPPROVED 05/14/08 - 05/14/08 06/23/08 25081495324540001 25081495324540001 133.94 28.01 DIAGNOSIS 1 : 0 NDC CODE: 0007803593. DIOVAN 160 MG TABLET - OTHER ANTIHYPERTENSIVES 05/14/08 - 05/14/08 06/23/08 25081495324600001 25081495324600001 9.92 3.45 DIAGNOSIS 1 : 0 NDC CODE: 0037802081- FUROSEMIDE 20 MG TABLET - DIURETICS 05/16/08 - 05/16/08 06/23/08 25081495324680001 25081495324680001 15.16 1.89 DIAGNOSIS 1 : 0 NDC CODE: 6838200540 WARFARIN SODIUM 3 MG TABLET - ANTICOAGULANTS 06/05/08 - 06/05/08 06/30/08 25081575321830001 25081575321830001 196.70 28.33 DIAGNOSIS 1 : 0 NDC CODE: 0017307160- ADVAIR HFA 115-21 MCG INHALER - BRONCHIAL DILATORS 06/05/08 - 06/05/08 06/30/08 25081575375790001 25081575375790001 124.03 18.88 DIAGNOSIS 1 : 0 NDC CODE: 0000636283 COSOPT EYE DROPS - OPHTHALMIC PREPARATIONS 06/05/08 - 06/05/08 06/30/08 25081575560420001 25081575560420001 129.34 15.57 DIAGNOSIS 1 : 0 NDC CODE: 0007803593. DIOVAN 160 MG TABLET - OTHER ANTIHYPERTENSIVES 06/05/08 - 06/05/08 06/30/08 25081575560670001 25081575560670001 7.16 .59 DIAGNOSIS 1 : 0 NDC CODE: 0052713421, LEVOTHYROXINE 50 MCG TABLET - THYROID PREPS Page 17 of 24 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE,, November 3,2014 STATEMENT OF CLAIM NAME GARLAND,MONA ]D:_ 640 206 476 GUARDIAN LONG TERM CARE PHARMACY I 147 OLD NEWPORT ST STE 1 NANTICOKE PA 18634 DATE,OF SERVI11 CE "PAYMENT DATE -: ORIGIN AL.CRN. ADJUSTED CRN USUAL CHARGES ..AMOUNT APPROVED,. 06/10/08 - 06/10/08 07/07/08 25081625343090001 25081625343090001 157.09 23.18 DIAGNOSIS 1 : 0 NDC CODE: 0059700754 SPI RIVA 18 MCG CP-HAN DI HALER - BRONCHIAL DILATORS 06/11/08 - 06/i1/08 07/21/08 25081755378840001 25081755378840001 100.45 20.05 DIAGNOSIS 1 : 0 NDC CODE: 6217501184 OMEPRAZOLE DR 20 MG CAPSULE - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS 06/25/08 - 06/25/08 07/21/08 25081775294290001 25081775294290001 76.37 12.70 DIAGNOSIS 1 : 0 NDC CODE: 0030015413, PREVACID 15 MG CAPSULE DR - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS 06/27/08 - 06/27/08 07/21/08 25081795253760001 25081795253760001 18.14 .05 DIAGNOSIS 1 : 0 NDC CODE: 5976237200 ALPRAZOLAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 07/28/08 - 07/28/08 08/25/08 25082105649000001 25082105649000001 15.32 .22 DIAGNOSIS 1 : 0 NDC CODE: 5976237190 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 05/09109 - 05/09/09 06/08/09 25091315658380001 25091315658380001 20.95 5.10 DIAGNOSIS 1 : 0 NDC CODE: 5976237190• ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS PROVIDER SUBTOTAL , GUARDIAN LONG TERM CARE PHARMACY INC 2,621.29 454.73 24 101506475 0001 Page 18 of 24 COMMONWEALTH OF PENNSYLVANIA" DEPARTMENT-OF PUBLIC WELFARE November 3,2014 STATEMENT OF CLAIM .NAME GARLAND,MONA 11)f 640 206 476 GUARDIAN LONG TERM CARE PHARMACY I 123 BRUBAKER RD BROCKWAY PA 15824 yy DATE OF°SERVICE: `PAYMENT DATE 'w' ORIGINAL CRN '. QDJUSTEO CRN USUALrCHARGES AMOUNTAPPROVED 06/23/09 - 06/23/09 07/20/09 25091745476210001 25091745476210001 20.95 5.10 DIAGNOSIS 1 : 0 NDC CODE: 5976237190• ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 07/27/09 - 07/27/09 08/24/09 25092085261430001 25092085261430001 20.95 5.10 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 08/29/09 - 08/29/09 09/28109 25092415371270001 25092415371270001 20.95 5.10 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 09/26/09 - 09/26/09 10/26/09 25092695234940001 25092695234940001 20.95 5.10 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 10/23/09 - 10/23/09 11/16/09 25092965255400001 25092965255400001 20.95 5.10 DIAGNOSIS 1 : 0 NDC CODE: 5976237190, ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 11/04/09 - 11/04/09 11/30/09 25093085657500001 25093085657500001 14.01 .59 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 11/23/09 - 11/23/09 12/21/09 25093275346590001 25093275346590001 20.95 5.10 DIAGNOSIS 1 : 0 NDC CODE: 5976237190• ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS Page 19 of 24 f COMMONWEALTH OF PENNSYLVANIA 1 7-v E 'DEPARTMENT OF PUBLIC WELFAREh . y` November 3,2014 STATEMENT OF CLAIM NAME GARLAND,MONA ID. _ 640 206 476 GUARDIAN LONG TERM CARE PHARMACY 1 123 BRUBAKER RD BROCKWAY PA 15824 _ DATE OF SERVICE a PAYMENT DATE 4 ORIGINAL CRN ADJUSTED CRN `USUAL'CHARGES AMOUNT APPROVED 11/30/09 11/30/09 12/28/09 25093345300670001 25093345300670001 14.01 .59 DIAGNOSIS 1 : 0 NDC CODE: 5976237190• ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 12/15/09 - 12/15/09 01/11/10 25093495243220001 25093495243220001 14.01 .59 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 12/29/09 - 12/29/09 01/25/10 25093635277120001 25093635277120001 14.01 4.59 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 01/15/10 - 01/15/10 02/08/10 25100155255530001 25100155255530001 14.01 .59 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 02/01/10 - 02/01/10 03/01/10 25100325362290001 25100325362290001 14.01 4.59 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 06/15/10 - 06/15/10 08/16/10 25102015259620001 25102015259620001 72.30 3.54 DIAGNOSIS 1 : 0 NDC CODE: 0048702010 (PRAT-ALBUT 0.5-3(2.5)MG/3 ML - BRONCHIAL DILATORS 06/18/10 - 06/18/10 07/12/10 25101695576490001 25101695576490001 22.02 5.18 DIAGNOSIS 1 : 0 NDC CODE: 5976237190• ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS Page 20 of 24 COMMONWEALTH OF PENNSYLVANIA41 - a i DEPARTMENT OF.PUBLIC WELFARE November 3,2014 STATEMENT OF CLAIM NAME' GARLAND,MONA ID ; - 640 206 476 GUARDIAN LONG TERM CARE PHARMACY I 123 BRUBAKER RD BROCKWAY PA 15824 II DATE OF SERVICE^ PAYMENT DATE .. 'ORIGINAL CRN - .;'.ADJUSTED•CRN .. USUAL CHARGES I VAMOUNTAPPROVED.; - + . .It rx •X_ _ - 06/21/10 - 06/21/10 08/02/10 25101875816740001 25101875816740001 72.30 7.54 DIAGNOSIS 1 : 0 NDC CODE: 0048702010 IPRAT-ALBUT 0.5-3(2.5)MG/3 ML - BRONCHIAL DILATORS 07/17/10 - 07/17/10 08/16/10 25102015259880001 25102015259880001 72.30 7.47 DIAGNOSIS 1 : 0 NDC CODE: 0048702010 IPRAT-ALBUT 0.5-3(2.5)MG/3 ML - BRONCHIAL DILATORS 07/22110 - 07/22/10 08/16/10 25102035274500001 25102035274500001 22.02 5.18 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 08/16/10 - 08/16/10 09/13/10 25102285374360001 25102285374360001 22.02 5.18 DIAGNOSIS 1 : 0 NDC CODE: 5976237190• ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 08/25/10 - 08/25/10 09/20/10 25102385676010001 25102385676010001 72.30 7.47 DIAGNOSIS 1 : 0 NDC CODE: 0048702010 IPRAT-ALBUT 0.5-3(2.5)MG/3 ML - BRONCHIAL DILATORS 09/15/10 - 09115/10 10/11/10 25102585258270001 25102585258270001 22.02 5.18 DIAGNOSIS 1 : 0 NDC CODE: 5976237190• ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 10/15/10 - 10/15/10 11/08/10 .25102885272620001 25102885272620001 22.02 5.18 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS Page 21 of 24 ' � � � f COMMONWEALTH OF PENNSYLVANIA � { ". + ' x November 3,2014 STATEMENT OF CLAIM NAME;' GARLAND,MONA ll)`, _, 640 206 476 GUARDIAN LONG TERM CARE PHARMACY I 123 BRUBAKER RD BROCKWAY PA 15824 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ,' AD LUSTED CRN USUAL CHARGES :4MOUNTAPPROVED: 10/18/10 - 10/18/10 11/15/10 25102915797640001 25102915797640001 71.70 7.28 DIAGNOSIS 1 : 0 NDC CODE: 0048702010 (PRAT-ALBUT 0.5-3(2.5)MG/3 ML - BRONCHIAL DILATORS 11/15110 - 11/15/10 12/13/10 25103195299310001 25103195299310001 22.02 5.18 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 11/26/10 - 11/26/10 12/27/10 25103345556570001 25103345556570001 71.70 3.28 DIAGNOSIS 1 : 0 NDC CODE: 0048702010 IPRAT-ALBUT 0.5-3(2.5)MG/3 ML - BRONCHIAL DILATORS 11/30/10 - 11/30/10 12/27/10 25103345585710001 25103345585710001 71.70 3.28 DIAGNOSIS 1 : 0 NDC CODE: 0048702010. (PRAT-ALBUT 0.5-3(2.5)MG/3 ML - BRONCHIAL DILATORS 12/04/10 - 12/04/10 01/03/11 25103385400510001 25103385400510001 71.70 3.28 DIAGNOSIS 1 : 0 NDC CODE: 0048702010 IPRAT-ALBUT 0.5-3(2.5)MG/3 ML - BRONCHIAL DILATORS 12/13/10 - 12/13/10 01/10/11 25103475292350001 25103475292350001 22.02 5.18 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 01/12111 - 01/12/11 02/07/11 25110125673640001 25110125673640001 22.02 5.18 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS Page 22 of 24 November 3,2014 STATEMENT OF CLAIM NAME,i GARLAND,MONA 640 206 476 GUARDIAN LONG TERM CARE PHARMACY I 123 BRUBAKER RD BROCKWAY PA 15824 DATE OF SERVIbE-� PAYMENT*DATE ORIGINAL CRN, k ADJUSTED CRN U$UAL=CHARGES 'AMOUNTAPPROVED 02/03/11 - 02/03/11 02/28/11 25110345635220001 25110345635220001 14.01 .59 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 03/23/11 - 03/23/11 04/18/11 25110825272210001 25110825272210001 14.01 4.59 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 04/19/11 - 04/19/11 05/16/11 25111095517960001 25111095517960001 14.01 4.52 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 05/26/11 - 05/26/11 07/04/11 25111595421670001 25111595421670001 7.07 4.07 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 05/30/11 - 05/30/11 07/04/11 25111595421760001 25111595421760001 7.27 .07 DIAGNOSIS 1 : 0 NDC CODE: 5107907882, ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 05/31/11 - 05/31/11 07/04111 25111595422050001 25111595422050001 14.01 .52 DIAGNOSIS 1 : 0 NDC CODE: 5976237190• ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 06/24/11 - 06/24/11 07/18/11 25111755268190001 25111755268190001 14.01 4.56 DIAGNOSIS 1 : 0 NDC CODE: 5976237190, ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS Page 23 of 24 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 3,2014 STATEMENT OF CLAIM NAME GARLAND,MONA ID 640 206 476 GUARDIAN LONG TERM CARE PHARMACY I 123 BRUBAKER RD BROCKWAY PA 15824 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 07/19111 - 07119/11 09/26/11 25112415350750001 25112415350750001 6.64 4.04 DIAGNOSIS 1 : 0 NDC CODE: 5107907882- ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 07/21111 - 07/21/11 09/26111 25112435374730001 25112435374730001 6.66 .56 DIAGNOSIS 1 : 0 NDC CODE: 5976237190• ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 08/17/11 - 08117/11 09/26/11 25112435375010001 25112435375010001 15.90 4.56 DIAGNOSIS 1 : 0 NDC CODE: 6725309001 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS 11/21/11 - 11/21/11 02/27/12 25120315695200001 25120315695200001 14.01 3.41 DIAGNOSIS 1 : 0 NDC CODE: 5976237190. ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS PROVIDER SUB TOTAL GUARDIAN LONGTERM CARE PHARMACY INC 1,089.52 158.21 24 102290870 0001 Page 24 of 24