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Home My WebLink About08-19-15 �+,�� ennsylvania 1505618403 J !il �.«...ma...."'�x(as-ial REV-1500 OFFICIAL IISE ONLY BureauoflntlivitlualTaxes CounryGotle Year FueNumeer aoBOx2easoi INHERITANCETAXRETURN C� n � o Pn i�i28-os0i RESIDENTDECEDENT �� L�� ENTER DECEOENT INFORMATION 6ELOW $oci21$pGu/ity NUmbef Ddt2 Of D2d�h MM��YYYY p2t2 Of BIRh MM�DVYVY 03 08 2015 04 15 1933 DecetlenPs Las�Name SUHix Decetlenfs First Name MI RUNKLE CLARA D (If Applicable)Enler Surviving Spouse's Information Below Spouse's last Name Suffix Spouse's Firs[Name MI THIS RETURN MUST BE FILEO IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O 1. OriginalReWm � 2. Supplemen�alReWm � 3. P`I�maontlZ�1382'n(tlateofOeatM1 � p, Agncul�ural Exemplion(tlale ot � 5. FUWre In�eresl Compmmise(tlate ot � 6. FeOeral Es�ate Tv ReNm Requiretl tleatM1onorafler]4-2012) Oea(�afier1242-82) O ]. Decetlen�Dietl Testate � B. DeceOent Main�aine�a Living Tms� 0 9. To�al NumOe�o�Safe Deposi�Boxes (AVach copy of wll� (AI�ecM1 copy of VusL) � iQ Lplgalion Pmceeds Receivetl �X H. NorvPwbate Trareferee ReWrn � 12 DefertallEledlon of Spousal Trusis (Sc�etlule F antl G Asse�s Only) � 13. 9u51nessAssets � 10. Spouse is Sole Benefciary (No�ms�Imolvetl) CORRESPONOENT-THIS SECTION MUST BE COMPLEiEO.ALl LORRESi0N0ENCE AN�CONFIDENIIAL TAX MFOHMATION SHOULO BE DIftEGTEU T0: Name OaytimeTelephoneNumber STEVEN E GRIJBB ESQ 717 234 4161 Firs�Line of Atltlress 4250 CRUMS MILL ROAD ST SeconC Line of Atltlress 6991 CityorPostOHice SWte ZIPCode HARRISBURG PA 17112 CorrespondenPsemailaddress: seA(a�aa�dberqkatzman.com p I FEGISTER OF WILLS USE OlyLY_ CJ REGISiEROfWILL5U5E0NLV _ � �� OATE FILEO MMODYYYY �. '�� Cil 7 � �-J I l � � . OATERLEO$TAMP � !.l fl> �� Side 1 I IIIIII IIIII IIIII IIIII III�I IIIII II'll I�III�I�II IIIII IIII IIII L 1505618403 1505618403 � '� � 1505618411 REV-1500 EX DecedenPs Social5ecurity Number oeceaem�sName� Runkle, Clare D. RECAPITULATION 1. RealEstate(ScheduleA�.... .......... ...____ .............. 1. 2. StocksantlBonds(SchetluleB) ._._._ .....___ ...........__. �� 3. Closely Held Corporation,Patlnership or Sole-Pmp�ie�orship(Schedule C).__.... 3. 4. MortgagesandNotesReceivable(Schetlule�)............................_____.............. 4. 5. Cash.Bank Deposits and Miscellaneous Personal Property(Schedule E).._..__ 5. 6. Join�lyOwnetlPropetly(ScheduleF) ��_ SeparateBillingReques�ed..._...._. 6. 67.804 • 97 ]. In[er-Vivos 7ransfers&Miscellaneous N,�n-Pmbate Property (Schedule G) �_ Separa�e Billing Reques�ed............ 7. 8. TotalGrossAssets(rotalLinesithrough])........_...... __..................._ 8. 67 .804 . 97 -"" _ 9. FuneralExpensesandAdministrativeCosts(ScheduleH)_._.................._..___... 9. 13,186• 40 10. Debisof0ecetlent,MotlgageLiabilitiesantlLiens(Schedulel)...............______. 10. 2,352 • 96 11. TotalDeductions(�otalLines9antl10)..._.. .......... .____. �1. 15.539 • 36 12. NetValueofESWte(LineBminusLinellj_ .......... .____ 12. 52,265 • 61 13. Charitable antl Govemmenlal Bequesls/Sec 9113 Tmsls for which an election to tax has not been matle(Schedule J).................._.._..._________.. 13. 14. NelValueSubjec[toTax(Linel2minusLinel3).............._.._.._.......,.._.,.___.. 14. $2 +265 • 61 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Nmoun[ofLinel4taxable at ihe spousal tax rate,or transfers untler Sec.9116 (a)I12)X.00 15. 0 . 0 0 16. Amaunt of Line 14 taxable at lineal rate % .OaS 5 2�2 6 5 • 61 16. 2�3 51 . 9 5 17. Amount of Line 14 taxable a�sibfing rata %.12 � • �� »- 0 • Q� 18. Amount of Line 14 taxable a�collateralrateX.15 0 • OU �8. � • 00 t9. rrJCDUe. _........... ._....... ....._.. .......... is. 2 ,351 . 95 20. FILL IN THE OVAL IF VOU ARE REOUESTING A REFUND OF AN OVERPAVMENT � Under penal(ies of peQury,I tleclare I M1ave examine0�M1ls reWm,intlutling aaompanying sc�etlules anC sla�emen�s and�o�M1e best oi my knowledge antl Gelie( i�Is trua,corzect antl complele.Declaration ot preparer oNer Nan�M1e person responaible br filing�M1e reNm Is DaseJ on all'mformation of w�lc�preparer�as any knowletlge. sicnn�gEo�so�sPotis�,�RFaiHCRE�uRN DeborahL. Runkle /E /s �� nooREss 28 Fargreen Road Camp Hill PA 17011 scHnzugEo/aj�E�yagryEa*HnNReaaESEHrnnvE Steven E. GrubbEsq. �^TE s yY /7 S!/ 7// nooa ss 4250 Crums Mill Road Ste 301 Harrisburg PA II��I�IIIIIIIIIIIIIIIIIIIII�II�III�IIIIIIIIIIIIIIIIIII�II��I Side2 L1505618411 1505618411 � REV-150�EX Page 3 File Number Decedent's Complete Adtlress: DECEDENT'S NAME Runkle, Clara D. ..._ STREETADDRESS CITY � �� STATE I,ZIP � � PA Tax Payments and Credits: L Tax Due(Page 2,Line 19) (17 2,351.85 2. CreditslPaymenis A. PriorPayments B. �iscount 0.00 To[al Gretlits(A +B) (2) 0.00 3. Interest (3) �-� 4. If�ine 2 is grealer than Line 7 +Line 3,enter ihe tlifference. This is the OVERPAVMENT. (4) _ Chack boz on Page 3,Line 20 to request a refuntl 5. If Line 7 i Line 3 is greaterthan Line 2,en�erthe tliHerence. This is Ihe TAX DUE. (5) 2�.3$�.9$ Make Check Payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Ditltlecedentmakeatransferantl'. Vas No a. retain the use or inwme otlhe property lransterred _......,. __ __ _ ❑z b. retain lhe righ��o designate who shall use ihe property iransferred or its mcome ._. __ ` O c. re�ainareversionaryinleres�:or.... ____. ._... ..._ ._. . x tl. receivethepromiseforlifeoteitherpaymenls.benefisorcare� ...... ....... ...... �'� 0 2. If tlea[h ocwrretl afte� Dec. 12, 1982, tlitl tlecetlen� transfer pmpehy wi�hin one yea� of tleath withou� r rewivingatle9ualeconsitleration?......._ ..........._.. ...._.... ........__ .......... u � 3. Ditl decedent awn an"in tmst foT or payable upon tlea�h bank account or sewrity at his or her tlea�h?..__ [J '�� 4. Ditl decetlent own an indivitlual re�irement accoun�,annuity,oro�hernon-probate propehy which ❑ r� containsabeneficiarytlesiqnation?........ ............_.. ............. ._.......__ ........._. IJ IF THE ANSWER TO ANV OF THE ABOVE pUESTIONS IS VES,VOII MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of Oeath on or atter July 1,1994 and before Jan.1,1995,t�e tax rate imposeG on Ihe net value of iransfers to or for the use of ihe surviving spouse is 3 percent[72 Pb-§9118(a)(1-1)(ip. For dales of death on or afler January 1,1995,the tax rate imposed on ihe net value of t2nsfers to or Por the use of Ihe surviving spouse is 0 percent �]2 P.S.§9116(a)(1.7)(ii)]. The staNte does not exempt a Iransfer�o a surviving spouse from�ax,antl��e sta�Wory requiremenR for OiSGowre ot asse�s and fling a�ax reWm are still applicable even it t�e surviving spouse is the onty beneficiary. for dates of tleath on or after July 1.400P. . ThetaxreteimposetlonihenetvaWeoflransferslmmadeceaseGchiltl2l earsofageoryoungeraltleathtoorforiheuseofanaWrelparenl,an adop�ive parent,oro step-parenlollhe chilE is 0 percent�l2 P.S.§9716(a)�1 2)�. • The tax rote imposetl on�M1e net value of Uans�ers�o ar for Iha use o(ihe decedenfs lineal beneficiaries is 4.5 percent,except as notetl in�]2 P.S.§9116(a)(1��. . The tax rale imposeG on the ne�value of Vansfers to or for the use o��he decetlenfs siblings Is 12 percent[72 P8.§9116(a)(1.3)]. A sibling is defined under Setlion 9102,as an individual wha has at least one parent in wmmon wi�h the dewdent,whether by Clootl or adoption. n...+¢oe ex.laino� I pennsylvania SCNEDULE F oePnarmervroraeveNuc ,JOINTLY-OWNED PROPERTY INHERITANLE TPX RETURN ESTATE OF FILE NUMBER Runkle Clara D n.n..w�w.:m.a.l��•nmm un.r..�onn.a.caaenr.e,�.a aean,rz mue�e...cen.a an xn.aui.s. SURVNINGJOINTTENANT(5)NAME A�DRESS REL4TIONSHIPTODECEDENT A. Deborah L. Runkle 28 Fargreen Road Daughter Camp Hill, PA 17011 B. C. JOINTLY OWNED PROPERTY: �ESCRIPTION OF PROPERN ��p oare oF oenrrv ITEM �ETTER OATE irvcwoEHun[oFFiw.�+cv.�insniuiioNaHoeauKaccaurvr pATE0F0EATH DEC�'S oEceo[rvisiNrEacsi NUMBER FORJOIN MADE uumaeaoasimivameHnFviuveumaea.nnaceoeeoroa VALUEOFASSE INTEREST TENANT JOINT �ownr-He�oaeuesinie 1 A 08/23/7988 PSECU -Savings account entling in 4029. 5,985.81 50.000% 2.992.97 Owned jointly with daughler, Deborah L. Runkle. y A OB/23/1988 PSECU-Checkingaccountendingin4029. 35,757.30 50.000% 17.875.65 Ownetl jointly with tlaughter, Deborah L. Runkle. 3 A 02/24/1984 PSECU -Checkingaccountendingin4859. 29.637.70 50.000% 14.818.55 Owned jointly with dauqhter,Deboreh L. Runkle. 4 A 02/24/1984 PSECU-Savingsaccountendingin4859. 5,931.40 50.000% 2.965.70 Owned joinUy with daughteq Deboroh L. Runkle. 5 A 02/24H984 PSECU-Moneymarketaccountendingin 58,304.37 50.000% 29,152.16 4859. Owned jointly with tlaughter, �eborah L.Runkle. TOTAL IAlso enter on Line 6,Recapitulation) 67,804.97 (If more space Is needed,atltli�ional pages of I�e sama size) Copyright(c)20ID form softwara only The Lackner Gmup, Inc Fortn PA-0500 Schetlule F(Rev.0140) 0.EV151E%.`��," gCHEDULE H pennsylvania oePnRrrnexroFaeveH�e FUNERALEXPENSESAND wNereirnNcerr�zaeruaN qDMINISTRATIVE COSTS ESTATE OF FILE NUMBER Runkle, Clara D. Decedent's debts must be reported on Schetlule I. ITEM DESCRIPTION AMOUNT q. FUNERALEXPENSES: See continuation schedule�s) attached 71,677.a0 B. ADMINISTRATIVE COSTS: 1. PersonalRepresentative'sCommissions Name ot Personal Represenlafive(s) Slreet Address City State _ Zio Year(s)Commission Paid z, anoroeysFees GoldbergKatzman, P.C. 7,sao.00 3_ Family Exemption: Qf tlecedenfs atlEress is not Ihe same as claimanfs,attach explanation) Claiman� SVeetACtlress Ciry State _ Zio Relalionshio o(Claiman�to Decetlenl 0. Pro�ate Fees 5. AccountanfsFees 6. Tax ReWm Preparers Fees ]. OtherAdminis�ralive Cos�s 15.00 See continuation schedule�s) attached TOTAL(Also enter on line 9, Recapitulation) 13,186.40 CopyrigM(c)2�13 form sokware only The Lackner Group, Ina Farm PA-1500 Schetlule H(Rev. OB-13J SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Runkle, Clara D. ITEM DESCRIPTION nMOUNT NUMBER Fnneral Exoense=_ 1 Fackler-Weideman Funerel Home-Funeral Bill 11,611.40 H-A 77.671.40 OtherAdm'n'strativeG sta 2 Cumberland County Register of Wills-Fee to tile inheritance Wx return. 75.00 H-67 15.00 Copyright(c)2002 torm software only The Lackner Gmup.Inc Fortn PA-0500 Schetlule H(Rev.6-98) Rev-0SIIES��R-02) SCHEDULE 1 pennsylvania DEBTS OF DECEDENT, oePaa.Mer+roFaeve�+ue MORTGAGE LIABILITIES AND LIENS INHERITANLE TP%RETORN RESIpENiDECE�ENT ESTATE OF FILE NUMBER Runkle Clara D n.von a.m.m��.a ey�n.m�.a.m vno,io e..m mn..ma�w��n.ia.�a.a.i.oi aa.m,iMimmv��reime�n.a mmem.i..c.�,... ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Camp Hill Emergency Physicians-Medical Bill. 34.84 2 Charlas R. Inner,MD-Medical Bill. �4Z.�3 3 Health5outhRehabilitationHospiWlMechanicsburg-MetlicalBill. 1.260.00 4 Internisls of Central PA-Medical Bill. 132.70 5 Internists of Centrel PA-Medical Bill. 40.75 6 Internists of Centrel PA-Medical Bill. 30539 7 Orthopedic Inslitute of PA-Medical Bill. 14.30 8 Phys of Rehab,Ind 8 Spine Medicine,PC-Medical Bill. 76.43 9 Phys oF Rehab, Ind 8 Spine Medicine, PC -Medical Bill. �38.48 70 Physicians Mobile X-roy,Inc. -Medical Bill. 20.44 17 Pinnacle Health Medical Group-Medical Bill. 39.35 12 Pinnacle Health Medical Group-Metlical Bill. 45.z9 73 PinnacleHealthMedicalGroup-MedicalBill. 20.19 14 Pulmonary and Critieal Care Medicine Associates-Medical Bill. 39.55 15 Quantum Imaging and Therepeutic Associates-Metlical Bill. 8.<9 i6 �uantumlmagingandTherapeuticAssociates-MetlicalBill. �3.8$ 77 Smith Ratliology, Inc. -Medical Bill. 6.85 Total of Continuation Schedule See attachetl page TOTAL(Also enter on Line 10, Recapitulation) 2,352.96 Qf more space Is neeOeJ,adCllional pages oi iM1e same size) Copyright(c)2o12 torm soNware only The lackner Group, Ina Form PA-0500 Schedule I(Rev. 1242) Fev-0SII E%�(II�41 SCHEDULE 1 pennsylvania DEBTS OF DECEDENT, oePuerMeHroFReveuuE ,„„EA„aN�Er�aE,�ax MORTGAGE LIABILITIES AND LIENS aesioewroeceoEr�r eontinued ESTATE OF FILE NUMBER Runkle, Clara D. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 18 Smith Radiology, Inc. -Medical Bill. 14.60 TOTAL(Also enter on Line 70, Recapitulalion� 2.352.96 Copyright(c)2012 form soRware onty The Lackne�Gmup,Ina Fortn PA-0500 Schedule I(Rev. 1242) LAST WILL AND TESTAMENT OF GLARA D. RUNICLE I, GLARA D. RUIDBLE, of 2458 Brookwood Street, Harzisburg, Dassphin Gounty, Pemsylrevia, beivg of sound a�d dispocing mind and memory, do make, publish and declare this my Last Will and Testrment� hereby revoking and mak- ing void any and all Wills by me herem£ore made. ITEM I: I direct that all my legally owing debte aM funezal espenses, adxnix�istratton expevaes and any fazes payable on account of my death, be paid from my residuary estate ae soon as pracHcable after my decease. ITEM II: it ic my desire to be interred in the Woodlawn Memorial Gardens on Londondexry Road� Harrisburg� Dauphin Gounty, Peansylvania. ITEM III: 1 give, devise and bequeath all ot rhe residue of my estrLe, of whatever }a.Nze and wherever aiNaLe� to my daughter� Deborah L. Runkle� oi 2458 Bxookvsood Street, Harriaburg, Dauphin Gowty, Pennsylvania. Shwld my daughter predecease me, or should she fail to survive me for a peziod of thirTy (30) days, then I gire, deviee and bequeath all of the residue o£my es�ate to my es-husband, Ralph Runkle. ITEM IV: I nomiiate, consritute and appoint my said daughter, Deborah Runkle� to be the Execuirix of this, my Laet Will and Tesfament. Should my said daughter for any reason reEuse or be u�ble m serve as such /) t ��..q � ,�� ' ,.. � k.t, (Seal) CLARA D. R[1NKLE � Page one of two typewritten pages Executrix, thev I nominate, conarimte and appoiat my said ex-husband, Ralph Runkle, to be the Alter�te Executor of ffiis, my I.ast Will and Tesbmeat. I direct Na[ ehe/hc eLall not be required to enter bond or furvish sureriea in any jurisdictlon, and that she/Le shall be empowered to act in any and all jur- isdicnons, without bond or mretlea, w the extent necessary for the c mplete admiNstration of my esfate. ITEM V: My peraonal representative shall, in addition [o all powers and avNozity conierred upon her/him by ]aw and by any provisiona hereinabove, have authority to reWin asseta, sell, mortgage, leaee, repair and improve any property, c mpromise daims, make distriburion in Idnd, borrow money, and in 6eneral to exerciae all powers in the management of my assets wNch I could Aave ezercased, upoa such terma and conditionc as m her/him seem best, and to ezecute and delivez all inatrvments and do all- acts which she/he deema neo- essary or propex to carry out the purposee of this Will. IN WI TNE55 WHEREOF� I 6ave hereunto set my hand and eeal to this, my Lasc Will and Testament, this .^ 5- day of 19'/4. ✓ � `: l� ..\ (Seal) GLARA D. RONKLE THIS INSTRLMEST, c isting of two (2) typewritten pages, each page bearing the eignature of Ne above Tesfatrix, CLARA D. RUNKLE, was by her n the date hereof signed, published and declared by her ro be her Las! Will and Teatrment, in ur presence, whq at her request and in the presence of each other, w , believing her to be of swnd and disposing mind and memory, have hereuntoesubsczibed wr names as Hie witnesses. �I \ \ ��'. \� LIl residing at�\^h\� i"�P �� -�� n �(j � , siaingat lN-"+�) �"" t2 Page two of nvo typewritten pages PSEC� � 04/02/2015 Debocah L Runkle � � 28 Fargreen Rtl. � � - Camp Hill, Pa 1701 I � Re: CLA1tAD RUNKlh'., Deceasetl.� -- � PSBCU Reference ft 67 83 82 8524029 � Dear Yls.Rwkie The above eeferenced person has an accoun[wilh P56CU which was opened on OS/23/88. The S6are accounte weeejointly held by GLARA D HiJNKLE and D6BORAH L RUNKLP. I'he following are the Deta of Death Balances for CLARA D RiJNKLE's aceo�ui with PSECU: Acmunt Date of Dezth Balanecs Iuterest—March P`-8ih Savings (S7) $, 5,985BL $ 020 - Chccldng (54) $35,75130 $ 0]8 � Please provide us ins[ructions ou closing the decedenPs accou¢t. � Ifyou have any questious,please con[act our departmen[mll-free at(800)237-7328,pcess 6,extension 3120 or email accouniserdces(dosecu.com. Siucerely, ��a,Uv��- Da�a Willard � Membec Service Representative PSF.CU � � P. O. BO% 6I013 HARRISBURG, PA 1I106�]013 800.237J326 -�-psecu.rnm � � . . _ __.- - _.____ _. —. _ ____._ .. iH6(RE�Ii0NI0NI5FE�EAALLVINSUAEDBYiHFPIAiIONAL(AEUIi0NI0NA�MINISiRATION EQUBLOPPONiONIiYIEN�ER. PSEC� � �,��ra�s Debocah L. Ru�kle � - �- � 28 Fargceen RA. - �- � - - . Camp Hill, PA 1701 I-261> Re: DEBORAH L RUNKLE PSECU ReFece¢ce#4002SR4394859 Dear Ms.Rwklc: � The above referenced pers'on has an flcwunt witl� PSECU which was opened on 0212d/I984. The Share accou�ts arejoinHy held by DEBORAH L RUNKLE ftV D CLAR4 D RONKLE. The followiug are Ihe Date of Death Dzlances for DPBORAH RU�KLE's account with PSECU. As of CLARA D R[JNKLEs DOD of MARCII 8,2015: Account DateofDeathBalances interest-Marchl-Sth Savings (S7) 5 5,931.40 $4�� Chccking i (S4) $29,63Z10 $0.65 MoneyMerket (S7) 558,30431 � ��6 lf you have auy questions,please contac[oar departmenC toll-ftee at(800)237-7328,press'6,e#ension � 3120 or email accounl�ervfces n osccu.com . � Sincerely, ` �u�u,u,,;u� Dana Willard � Membec Service Represen[ative PSECU � � P. O. BG% 6I013 HARRISHURG, PA I ]lOG�7013 SOO.'137.7038z>psecamm _ _.. . ___._ ._ . ._- -. . . . . _ __ _. � � iH6CRE�1i111JI0NI5FE�EANLIYINSIIPEOBYiHENAiIONALCREDIi0NI0NA�MINISiRAiION.EQOALOPPOAiUN17YlEN�EN. STATEMENT OF ACCOl1NT (1) CAMP HILL EMERGENCY PHYSICIANS 5latement Date� MarchOG,2m5 � PO BOX 13693 ACCOUNT NUMBER: HYP49639616 PHILADELPHIA, PA1 91 01 36 93 (PatientName:CLAfthDRUNKI.E r�io x: zoass�sao Pccount 8alaiwe: E34.84 AmouM Pentling Insurance'. $0.00 I I I 11111 I I I I I I , I� I I I Amoun�Due Fmm r b �I Ilrl i ^ 'i ihl�rill� � �i I il li n Ir ihli P,�;Qm�aR��: asaea 082516-000�049B39616-06 AmouniDueFrom #BWNJFDB Paaent(Past oue)�. So 00 � � � #OOOOOOHYP9518469# PayThisAmounF. 534.81 CLAR4 D RUNKLE 28 FARGREEN RD PLEASE REMIT PHYMENT BY'PHYMEN' CAMP HILL PA 1707 7-2615 DUE BY"DATE.THANK YOu. Please refe [o coupon below for payment instmctions. Pay your bill securely online anytime a[www.MyMedicalPayments.com pale 0 Descriplion Cha`ge Frstllns. Olherl�ns. PaeeB� Adusletl I�nsura w BATIANCE � 0]NNS 1 88395EMERGINJURYEVAL6MGXR-LVLS f131J00 OXBi800ft.lEPPIGMGLY SPIRR XOSPRBL � OiR]tli MEUIG�RECOMaXQWLhLLGWPNCE 511d0B1 � 0]2]I15 MEOiCPRESEOIlESlIiRNNJ�REOVCiIONMFEDERn 5��9 SPENDWG 0]ll]tl5 MEqCPREPAVMENi f135. 534& GG�F_l=SLa. y�rp� �.,.:r�.i/,�r TOTALS: s�3ze.00 s�se.w som s000 t>>s.so woo s3a.ea Important Messages: � mi:e�stem�m is mru.m,xi vezMem,�emi:uv�m.m�m�.,�w��q«^^n�e�.'�a wm.��ae=oov ann�o�,�.�rvory srrn nmptii me�ees mi�ms>,.+re ' p�yamn^arcGllledupanlelyhomanyM1ospAalcnaryeso�o�httprofmsionel/eezlorwM1w�pumayalsobem[panAGle. T�eMore,aMUlEyourtterveaElllLomMe h prtalo�oNnp�ys¢iansbrca�BesnconnaY�mx+MP�sna[i�wlllno�incluEeNe�emslw�eEonUleeGkment "Payment Plans"Accep[ed Duestions about this statement?/Llame de Lunes a Viernes? Call tA00-355-2470 Monday through Friday 9:30AM-4:OOPM. � Your automated system access code is 0801-49839616, or you can send email to � bi Ilin g_q uestio ns@emcare.com. a„�,a,.,ua, yy Please detach and return bottom portion with your remittance. 'I"I' DATE DR PATIENT OESCRIPTION �CHARGES CREDITS ��. OS!o/15 Ad�:AL!uscment - Metltcere -3��U � Oi/o6/'S c3 L1ai�a H3P'U-I.eve15 _85.00 i c3!�3i15 Plen ?ayment:69o1LC829 - necScere -45�i6 '� 03/=3/�5 AG,]:Medicare AcJcstmerL - Mecicane -63�53 � E4o.5P �emsurar�ce � �� I �s I ' (�/,e,c�s�i �s�� is'a.o3 � �u a3ja�,r5- 'Amounts pending with insurance a2 nol inGuded in the balance tlue. You will be billed once your insurence responds�o our daim. ACCT: 084700-00 CURRENT 30-60 DAVS 60-90 DAYS 90-120 DAYS OVER 120 DAVS INS BALANCE O.GO 0.00 0.00 0.00 0.00 GATIENTBALANGE 192. 03 O.00 C.09 0.00 0.00 CHAftLES P INNERS MD I PATIEN�E il ] STERLING GLEN WAV 717-249-2482 $142.03 MECHANICSBURG, PA V0502]09 16E66-V93)'Tfl4�VLDIPo00019 I'��„�I��'ll HealthSouth Rehabilitatlon Hospital Mechanicsburg HFe►TMS�TM 175 LANCASTER BLVD MECHANICSBURG, PA 17055 � � w.: � Temp-Retum Service Requested BILLING INVOICE Page 1 of 2 ODD281-000001-000001-000281241211]36705T0113 patientName CLARADRUNKLE CLARA D RUNKLE AccounW 031-768699 28 FARGREEN ROAD Invoice Date _ 03/19/2015 CAMP HILL, PA 17011 Invoice# 031-768699-150319 u;: Payment Due Please Pa This Amoun[ U on Recei t E7 260.00 � Th ae mounf shown below is your payment responsibilify on your account to date. Payment is due upon receipt of invoice. If lyou have any quesf ons regarding your acwunt please contact a representative at(877)298-1066. The statement provides the payment details[o date on your account. Please note the patien[responsibility amount and send payment in full. We accept oniine payments al www healthsouth.com/patien[pavment with your Visa, MasterCard, American Ezpress, or Discover or you can pay online with your bank account information. If you choose to pay by mail, please return your check payment wi[h the de[achable coupon below. __ _ DATE DESCRIPTION � AMOl1NT 02/06/2015-02/77/2015 'InpatientRehabilitationCare _ $ 1�,655.35 03/77/2015 Medicare a ment _ 5 16,326.54 _ 03/17/2015 IAd�ustment 5 6820 Pentlin Insurance Pa ment $ _ 0.61 � Amount due from Patient $ 1,260.00 .�p: .�C�.�^*� �tr4�mv- ,6�.�i� 7r� JCO/) BSoo- ,9i�3G �L-i i.a� �lo /9/7B— �G3G _.........�y ��cS7a l�....—rY"...=�-: �h'Go,�o ,dJvz �� , 3-��/Y Our hospital offers charity care,fnancial assistance and payment plans subject to approval of a financial need application. Please call (677)298-1086 or visit the hospital's website at http:Ohealthsouthpa.com/if you are in[eres[ed in leaming more about these.options. DeGch Nis poNon and mall with paymeM-Thank Vou .,�� _ . . 02l25/15 1 10 L HOSPITAL SUBSEQIIENT CARE 99233 486 135.00 09I27(15 MEDICARE PA Payment 80.77 03/27I15 Accept Assign Adj . -31.98 03I27115 Accept Assign Ad� . -1.65 20.60= 02�26�15 1 19 L HOSPITAL SI7BSEQIIENT CARE 99232 486 100.00 03/27� 15 MEDICARE PA Payment 47.64 03127� 15 Accept Assign Adj . -39.24 03I27�15 Accept Assign Ad� . -0.97 12. 15* 02/27/15 1 10 L HOSPITAL SUBSEQUENT CARE 99233 486 135.00 03/27/15 MEDICARE PA Payment 80 J7 03127�15 Accept Assign Adj . -31.98 03/27/15 Accept Assign Ad7 . -1.65 20.60= ��C.P<c 3�>0�/6 L��e4f S73 G?-.n-a- %.�., m��a,�� a'�- �-: 'f��/6 L-The 'PLEASE PAY' includes unpaid co-pay or m-ins. Please make payment. JATELASTPAID AMOUNT � ' � • ' � " '� oolooloo o.00 i3z.�o o.00 o.00 o.00 o.00 zazs.00 o.00 zss�.�o INTERNISTS OF CENTAAL PA , � "KF 108 LOWfHER STREET VELK �raa�ero: LEMOYNE, PA 17043 Payment Due llpon Rec 132J0* Ph: (717)-774-1366 Acet9: 77311 PATB 1-CIARA D RONRLE PRVd 8-LEHMAN, DEAN, PA-C Date: 03f30/15 PRVB 10-MIRARCHI, DOMINIC, D.O. Page 2 of 2 PRV6 19-RUMAR� VINAYSHREE, PA-C . . . . . . , INTERNISTS OF CENTRAL PA 06/OS/15 77311 $ �y1,�$' 108 LOWT�R STREET LEMOYNE, PA 17043 � 40.15* Forwarding Service Requested MC VISA Disc Security � Card$ Code Sign Exp _� � CLARA D RUNRLE INTERNISTS OF CENTRAL PA 28 FARGREEN RD 108 LOWTHER STREET CAME HILL PA 170ll LEMOYNE, PA 17043 � • .. - � . _ '._.___———_"_— MESSAGESE%PLAINED � BELOW � . - " � _ � - - - 03/30/15 • MEDICARE PA Payment 56.04 • 03/30/15 Accept Assign Ad�. -28.52 03/30/15 Accept Assign Ad�. -1.14 OS/12/15 Check-Personal Pay�ent 14.30 0.00 03/07/15 1 19 HOSPITAL SUBSEQOENT CARE 99232 486 100.00 03/30/15 MEDICARE PA Payment 47.64 03/30/15 Accept Assign Adj. . -39.24 03/30/15 Accept Assign Ad,7 . -0.97 OS/12/15 Check-Personal Payment 12.15 0.00 ,Q.w,Q.P� %P/iU- G�.r,< .n9 �.+w.�z�.u.a ; •5�e..u' ,�(� �i,.<' aG�ii�js' L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make paymeni. MTE LAST PAIO AMOUNT • - � � . .� � . •i • . � os/iz/is 305.39 ao.is o.00 o.00 o.00 o.00 o.oa o.00 co.is INTERNISTS OF CENTRAL YA � +ecK 308 LOWT�R STREET naeiero: LEMOYNE, PA ll043 Payment Due Upon Rec 40.15* Ph: (717)-774-1366 Acct#: 77311 PATQ 1-CLARA D RUNIQ.E PRVp 2-MICHAEL L. GLUCR, M.D. Date: 06/08/15 PRV; 3-TYNDALL, JAMES A. , M.D. Page 5 of 5 PRV$ 8-LEHMAN, DEAN, PA-C PRV4 10-MIRARCHI, DOMINIC, D.O. MESSAGES EXPLAINED�:,' 6ELOW,.. � � . .� . � . � __ . ..� - . . � ' � . . - •, - ' � - � . . - 03/30)'-1•5 Accept Assign Adj. � � -1.65 20.60* 03/03/33 1 19 L HOSPITAL SUBSEt�UENT CARE 99233 486 135.00 03y30/;15 MEDICARE PA Payment 68.66 03�301�i5 Accept Assign Adj. -47.43 03/30�,i5 Acceyt Assi n Ad,7. -1.40 17.51* 03/04�+i!5 1 2 L 90SPITAL SllBSE�IIENf CARE 99233 486 135.00 03�.�0�15 MEDICARE PA Payment 80 J7 03/3�9i�3=5 Accept Assign Adj. �� -31.98 03/391.15 Accept Assign Ad,7. -1.65 20.60* 03�05/15 1 19 L HOSPITAL SUHSEQUENT CARE 99233 486 135.00 03/30)'d5 MEDICARE PA Payment 6S.bfi 03/30115 Accept Assign Ad�. -47.43 03/30(.15 Accept Assign Ad� . . -1.40 17.51= 03y06A�:15 1 2 L 605PITAL SUBSEt�IIENT CARE 99232 486 100.00 03;�3U1 3 MEDICARE PA Payment 56.04 03�.30)�3 Accept Assign Adj . -28.52 03930/�5 Accept Assign Ad� . -1.14 14.30* 03/OJ/'15 1 19 L HOSPITAL SUBSEI(UENT CARE 99232 486 100.00 03�30/35 MEDICAAE PA Payment � 47.64 03/30{-15 Accept Assign Ad,� . -39.24 03/30)�.15 Accept Assign Ad� . -0.97 12.15* ,({jL ,�Qp.2 OS/O�i/.(S ' �!t S78 11,n....-.c /"...t : ' .�nr,3Y �� . os�ed�/S L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment. NTELASTPWD AMOUNT • - � • ' •� • '� • ' � 04/06/15 132.70 178.42 126.97 0.00 0.00 0.00 245.00 0.00 550.39 KE INTERNISTS OF CEN1'RAL PA � 108 LOWTHER SIREET �rne�ero: LEMOYNE, PA ll043 Paymen[ Dve Ilpon Rec 305.39' Ph: (717)-774-1366 Acct6: 77311 PATb 1-CLAAA D RUNRLE PRV$ 19-KIIMAR, VINAYSHREE, PA-C Date: OS/04/15 Page 4 of 4 . . .- � � 02/03/�5 � H�SPITAL SUBSEQUENT CARE BB.DO ��. �� II �' 02/27/15 �I MEDICARE Payment 3D.24 � 'i i02/27/15 Contract Adjust Adj . � -49.43 ', 102/27115 Contract Adjust Adj . -0.62 �. II 03l�1 /t5 Check-Personal Payment 7.71 �. � 0.00 i 02/O6/�5 HOSPITAL SUBSE�UENT CARE 116.00 . . . '�, 03/OS/'IS MEDICARE Payment 56.04 �. � '�. iO3/OS/�5 Contract Adjust Adj . ' -44.52 �� '� �, 03/�5/15 Contract Adjust Atlj . -1 .t4 � . 94:30 I � ��. i.� !. i I f� � i . I i.x p r '�. I ''. k:° ai.. �I .. . , ,� r.R.4c�. I . ��1 ' ��. yG: _ � 339r .�;..� /P�.c- �l,i I ��, � �� 2 /7oo—`fYa7:. I i ��.. �r.�.�' ' I �� . � ��/3/� . . II I I . � �.aE.-vS7f� �, �. Qi.ea.Y/�i�f� °/S�,3 a i li .1�c4, �..Y, 'f�J�N" � I " � Messages: � $14.30 � � P�eex Gey 1 Amoum � ' �. I Pay Vour Bill Onllne at www.OlP.com � oa�e usc caie 03/11/15 , CLARA D RUNKLE . for Bllling Ouestions call(]1])]6b5530 op�lon 3 pmoum�a:�Paia $�� ' Montlay thmugh Friaay(8:00 ro 430; See back of s�afement for FREOUENTLY '�. 'Paymem mus�be received by Paymem Due Date ASKED BILLING OUESTIONS&ANSWERS 93 i and inbrma�ion on our Injury Clinic. a==o�m Num�� -��----"'---""—'-- -___ssxIIBNI4PPORTION RETAINLOWERPORTION � '___'___ ______ RETt1RN TOP PORTION• �� RETAIN LOWER PORTION �� -�--J--'--"---.-- Appointment Service �escription Charge PaymenY qd 'ust Patient � B2/11/15 - CLARA - LUPINACCI, MICHAEL F, M.D. HOSPITAL SUBSEoUENT CARE 99232 356.9 12L 90 I B3/03/15 hTEDZCARE PA Payment 55.20 14.08 03/03/15 Accept Assign Ada. -50.52 03/03/15 Accept Assign Ad�. -1.13 I The 'PLEASE PAY 3inc4udes unpaidsco paydor co-ins. Please make payment1.07 I ��6-�SG3 � -�l ,J I :au'r ,�,��r- I 'PAYMENTRECENED Current Over30 Over60 Over90 Over120 ie/00 0.a0 76.43 0.00 0.00 e.00 0.00 Patient 76.43 � PHYS OF REHAB, IND & SGINE MEUICINE, PC K[ 4310 LONDONDERRV RD� STE 106 o� HqRRISBURG� Pq 17109 Payment Uue Date 03/19/15 76.43 • Ph:(855)-386-4709 Statement Date: 03/B4/15 A��tit:9020 Page 2 of 2 ME�N1503051i206.@33]3020f]ON00 � � - 11�� 04/02/15 �� 9020 '� S 138.48 PHVS OF REHAB, IND 8 SPINE MEDICINE, PC , 4310 LONDONDERRV RD, STE 106 �` ��, �� .�.w � -..�.'-. � �S� � HARRISBURG� PA 17109 caaoNumeea ,a�rHoaiz.�norcooE-�0❑ :'nas.,o,amgi�o�cae. — � siewau3_ �L.�Fe�n:e , � CLARA D Rl1NKLE 28 FARGREEN RDAD PHVS OF REHAB, IND $ SPINE MEDICINE, PC CAMP HILL PA ll011 4310 LONDONDERRV RD� STE 106 HARRISBl1R6� PA 17109 —^�i alease check boz il above address Is inconM or insurance Plexre check box N nedit rzrd billln6 address iz aNerennhan nate- �-=Alo�ma6onM1ascM1angeG.an0lndirnfe�hange(s)on�eversesi0e. � �mentaddreszanawri�einaddreszonback _ -- __ -- _—___ _- —.— — __ _— — — -- ___—__-- ____ _____- ___'_—__ _.... ._..._.... RETl1RN TOP PORTION•RETAIN L�WER PORTION Appointment Service Description Charge Payment Adjust Patient 03/03/15 - CLARA - LEHMAN, DEAN L, PA-C HOSPZTAL SUBSEoUENT CARE 99231 799.3 102.00 7.60 03/24/15 hiEDICARE PA Payment 29.75 03/24/15 Accept Assign Ada. -63.43 03/24/15 Accept Assign Ad�. -0.61 03/24/15 Accept.Assign Ad7. -0.58 The 'PLEASE PAV' includes unpaid co-pay or co-ins. Please make payment. 03/04/15 - CLARA - LINGENFELTER, REBECCA, PA-C HOSPITAL SUBSE UENT CARE 99231 799.3 102.00 7.60 93/25/15 EDICARE PA Payment 29.78 B3/25/15 Accept Assign Ad� . -63.43 B3/25/15 Accept Assign Ad� . -0.61 03/25/15 Accept.Assign Ad7. -0.58 The 'PLEASE PAY' in�ludes unpaid co-pay or co-ins. Please make payment. �[t/ T< S7S CL�� .�.t "/.��.,�c ,.D.= f:-=r y��is IASTPAYMENTRECEIVEO I Current Over3B Over60 Over90 Over120 Patient _� 33/16/15 76.43 I 138.48 0.08 0.00 0.00 0.00 138.48 tns[ PHYS OF REHAB� IND 8 SVINE MEDICINE, PC IKECNEt 4310 LONDONDERRV RU, STE 106 � raeuro: HpRRISBURG� PA 17109 Payment Due Date 04/17/15 138.48 \ / Ph:(855)-386-4709 Statement Date: 04/02/35 Acct#:9020 Page 5 of 5 �couiswoaiasos aazass cs os.w0000 IiP�YIN�BY MA51EPC1NU.MBLOVEP OP VISR FlLLQUi BEL-0W PHYSICIANS MOBILE X-RAY, INC =MECN CAqp p51NG FOP PPYMEM 945 EAS7PARKDR; S7'E 102 �� E�,a, �p_" HP.RRISBLRG,PA 1 711 1-2 804 ' «° --� ' ^'"`�''� a� 353a6 �, na Iw.w.. � 06/11/15 � �293387 oazsso pAGE: 1 of 3 '�� 0303 Q A S2�.Y4 � 653MY3�F ADDflESSEE: � REMIiTO: � unnyi��ii�qiqnquq�u��pih�i�I�dPp�r�u��hldl� I�luulhi��n�lh��p,�,p�194�rdnq��q��inpp��pq� CLARA RUNKLE PHYSICL4DIS MO➢ILE X-RAY,INC 28 FARGREEN RD. 945 EAST PARK DA; STE 102 CAMP AII.L,PA 1701]-26]5 HARRISBURG,PA 171 I 1-2804 3s3ae•rnsnz�ievooa;s2 �Please check box if inwrrect or insurance information has changed, and indica�e change(s) on reverse side. � � PLEASE DETACH HERE AND RETURN TOP PORTION WITH YOUR PAYMENT T � � �. . � ' ' �. • � �� For billing inquiries,please contact 1-800-420-XRAY(717-561-4940). 02/16/15 C[,ARA CEiEST 1V READING 71010 786.05 PINSPA 13.50 1.82 Pazient RiJNKL$CLARA -293387 Servicing Providu: Physiciaris Mobile X-rzy � 0326/2015MEDICAREPENNSYLVANIA 7.14 4.54 g 02/18/15 CI.nRA CHEST 1V READING 71010 486 PD�A 13.50 1.92 $ Patimt RI7NKLE,CLARA -293387 Servicing&ovider: Physicians Mobile X-ray > 03/19/2015 MEDICARE PENNSYL.VANLI 7.14 a.54 0220/IS CLARA CIiEST 1 V READING 71010 786.2 PhAPA 1350 1.82 Patient:RUNKLE,CLARA -293387 � Servicing Provider. Physiciaus Mobile X-ray 03/19/2015 MEDICtll2E PEI�`NSYI,VAIVIA 7.14 4.54 0223/15 CLARA I�g UNII,ATERAL 2V 73510 719.45 PNL�CPA I8.50 2.24 Patient:RIJNKLE,CLARA -293387 Servicing Provida:Physicians Mobile X-ray 03/19/2015MEDICAREPENNSYI.VANIA 8.78 7.48 02rz3R5 CLARA CHEST 1V READING 71010 786.05 PNAPA 13.50 1.62 Patient:RUNKLE,CLARA -293387 - Servicing Provider: Physicians Mobile X-rzy 03/19/2015 MEDICARE PENIVSYI,VANLA � 7.14� 4.54 02/26/15 C[,ARA CHEST 1V READING 71010 578.0 PD7XPA 13.50 i.ffi MAKE YOUR P�'SICIANS MOBII,E X-RAY,INC SEE REVERSE SIDE � . CHECKS �� 945 EASTPARKDR; STE l02 � IP AN INSURANCE RkYA6LE TO 11ARRISBURG,PA ]9ll 1-2804 MESSAGE APPEARS CONTINLTED COMMENTS: Pleasepay within 30 deys._thank you � 293387 i � 20.44 � '�� ' � in�er��n�ui�mui�uiA � � Full payment on your account balance is — ' PINNACLEHEALTH nowdue, Hthisbilldoesnotreflectthe correct insurence informatian please contact Medical Group our office immediatety ro resolve the issue. ForaccouM infortnation Please call Qin — 231-6960 or(800)585-fi229 for Out of Area Calls. See tletails on the back ot ihis s[atement. CLAR4 D. RUNKLE If payment has been sent, please disregartl. 28 FARGREEN RD Payment wn be made qnline at: CAMP HILL PA 17011-2815 https:pbilipav.oinnaclehealih.orn or make Checkpayablato: PINNAGL€ HFALTH MEDICALGROIIP � .1�4�,ueL�,�fw.:c,9 �/�'a-/z� Responsible Party: Clara D. Runkle Total Charges: 3389.00 Account ID: 40075 Paymenls antl Adjustmerrts: 5349.65- Bill Date: 03/i6/15 Bill Number. 22860068 P�� Pay This Amt: 639.35 . Medicare B For ques[ions, cail Customer Service ai: 717-231-8960 for local calls or 1-800.5656?29 for Out of Area � � �� 1ri�� Cuslomer Service Hours: " � Mon-Wed-Fn 8:00 AM to 4:30 PM ��svG �'39 3s � dv-is - ' �� - TuesThurs 8:00 AM to 6:00 PM STATEMENT To discuss pa7ment,call: The amount shown below represen2s your � �s[omer Service financial obiigation to: - � PINNACLEHEALTH (868)467-2563 PimacleHealtLHospitaLs Hospi�als (717)221-1294 PO Box 2353 Hartisbwg PA 17105-2353 Reuresentatives Available: For all olliec inquinu: Mon-Thu B:OOAM-6:OOPM Fri 8:OOAM-S:OOPM (717)221-1294 MESSAGE: 7henk you for choosmg Pinnacle Healti�Hospitals.Tt�e baleuce on your accouut is due.Ifyou need assisteuce or Lave inswauce coverage,please call oar cusmmer service depamnrnClf you veed to make enangemrnts for pa�Rnent,we kiave representztives available to essisl you Financial assistance is aveilable for�he uninsured end imderinsured who apply and quzlity.For more'vSonnatioq please call or see our website at www.oivnaclehealth.or¢/billoav. You mayalso p�y anline a(htt�s:/2i/!mv ninnaclehea((h.orY HOSPIIAL SERVICE DA'IE PATIENT NAME ACCOUNL N[JMBER 02f25A5 CLnRADAUNRLE � 2458100 FOR YOUR HOSPITAL SERVICES: Ct Brain W/O Contrast Y 1177.00 original Billed Amount: 411]],00 Total Insuranw Paid: f-]0.40 Total Aa]ustmenu: 4-1061.31 PatlEflt Fdy1020t5: 50.00 Patient Responsibility: 445.29 • � 445.29 �Zs...r.rP� 8l i.s' �._.Y..;� A�� %g�ify Gd 'Fs„�/ 3��'�', � . . � Full paymeM on your account halance is — now due. If this bill does not reflect the PINIVACLEHEALTN corren insurance imormation p�ease comact Medical Cralp our otfice immediarery to resolve the issue. For accourrt infortnation Please call (11� — 231-8980 or(800)565-6229 for Oul of Area Calls. — � See Aetails on[he back of lhis sta[ement. CLARA D. RUNF�E If paymeM has been seM, please disregard. 28 FARGREEN RD payment can be metle anline at; CAMP HILL PA 17011-2615 httos:ltbilloav.ninnac�ehealth.ora or make Check payable to: PINNACI,E HEALTy MEDlCAL GROUP O O, ,(•G //•z9 �,�., /"/L />/O6—/i.i9 � � Responsi6le Party: Clare D. Runkle Total Charges: 8199.00 Accourrt ID: 40075 Payments and AdjuslmeMs: 4178.81- Bill Date: 04/15/15 8ill Number 24174435 Please Pay This Amt: 52�.19 • . �Medicare B For quesiions, call Cus[omer Service aC 777-231-8960 for local calls or j -�_'1 �. ] �r 1-800-565-fi229 for Out of Aree Cus[omer Service Hours: � ` s7G , j',zaip ,4,tn-� Mon-Wed-Fri 8:00 AM to 4:30 PM TuesThurs 8:00 AM l0 6:00 PM Page Statement Date . Due Date Office Phone Number AccountC Patient Balance 1 of 1 03H9/2015 OM78/2015 (777)2342561 728640 539.55 ' � Da[e VisitOetail EzplanalionofActivity � Gha�ges Insurance Paymenfs Patieni . . � � ' � � BDebifs Pentling BCredits Balance Palient Clara 0 Runkle �� Provitlec Evans;Richartl G � Vauchec ifi91990 @/iB2015 99223 HiPLevel3 $280.00 031102015 89D094138 MedicamPayment -5155.W 03I10/2015 890094138 MetlicareP.tljustmant -58226 0311�/2015 890094138 MetliwreAtljustment -$3.16 031102015 890094138 Medicere Payment $�.00 03110/2015 890094138 Metlicare Transfer This represents the Co-Insurance amount tlue.Please remit payment. Vlsl[Tofal 539.55 Please pay online by visiling httpJAmnv.pccma.net antl click ONLINE BILL PAY �b.�-crG� . Gz.e..-:.rt;�:e: "av,r� .e7rwz /�..��. .J—.ts-/r � � MESSAGE �� . YouracWuntisnowdue.Thankyouforyour �; �A��ount,Number 728640 prompt response. I Billing Inqmries (717)234-25fi1 PULMONNRVANDCRITICALCAREM � 1831 N FRONT ST � HARRISBURG,PA9t02-2435 ' '�,. Amount Due. . . . $39.55 11�:061qtA�t111 z�3e�nusn-eaeosioneaswt-w,siuiee-i-�ma�,ase3io3on;i ranenx: c�nrc.c u rcurvn�c Account. 352289 Services Renderetl At: HARRISBl1RG HOSPITAL � �ate P�� Descri tion Char e • Payments Cotle P 9 Ad"ustments Balance 2/25/2075 70450 CT SCAN BRAIN WIO CONTRAST 198.00 8.49 3262015 PMT MEDIGARE PART B-NOVITAS 33 26 3/2620�5 CRAdjustmentMEDIGAREPARTB-NOVITAS �5625 �n��, J�"��N I i �.".i�3i2 � �.�tF'..a: °6�9 � ,rL'.� 9'..e,- y�3�iJ' �yor (��....s...., -/°.�,y„� a..� .Y�,�,..�- ''a"`---- l/'�p��,�,c4�� G2/Gs %i fn.`� d/1.G5°"d�GS Curtent 37 -60 61 -90 9t -t20 Over 120 BALANCE DUE 58.48 8.49 0.00 0.00 0.00 0.00 PAV BY Due Upon Receipt THIS ACCOUNT BALANCE IS YOUR RESPONSIBILITY. For billing que5li0n5 call: (777)932-5955 PLEASE REMIT PAYMENT W FUII OR CALL OUR OC (877)932-5955 OFFICE IF PAYMENTARRANGEMENTS AND/OR Fax: (717)932-4856 INSURANCE INFORMATION IS NECESSARY. OffiCe HouB: 5:00 AM- 4:30 PM To pay your bill online and register for e5tatement 1N HW g1IIII' STATEMENT please visit us at: www.qita.com I�IWIIIIII�I��BIII��IIII�ItlIIIIIIHUNIIII SEE REVERSE SIDE FOR IMPORTANT BILLING MFORMATION ��ro �� Patient CLARA D RUNKLE Account: 352289 Services Rendered At: HOLY SPIRIT HOSPITAL Proc Payments Date ��e Description Charge ' qd'ustments Balance 2l22075 72770 PELVIS AP 34.00 1.82 225/20t5 PMTMEDICARE-NOVITASSOWTIONS �-�4 2/252015 CRAdjustmentMEDICARE-NOVITASSOWTIONS 25.04 21Y20t5 72t00 SPINE LUMBOSACRQI NJO OR THREE VIEWS A5.00 2.37 2252015 PMT MEDICARENOVITAS SOLUTIONS 9.06 2/292015 CR Adjustment MEDICARE-NOVITAS SOLUTIONS 33.63 2I5/2015 73560 KNEE AP 8 LATERAL 34.00 t.b9 227/2015 PMT MEDICARE-NOVITAS SOLUTIONS 7.4� 2272015 CR Adjustment ME�ICARE-NOVITAS SOLUTIONS 247� 2/5/2075 736D0 XRAY E%AM OF ANKLETWO VIEWS 32.00 7.68 227/2015 PMT MEDICAR6NOVITAS SOLUTIONS 6.59 2/D2015 CR Adjustment ME�ICARE-NOVITAS SOLUTIONS 23.73 2/5/2015 93977 US UUPLEX E%TREM.VEINS UNI '107.D0 4.50 2/272015 PMT ME�ICARE-NOVITAS SOLUTIONS 1762 2/27/2075 CRAdjus[mentMEDICAR6NOVITASSOWTIONS 78.88 2/6/2075 73630 F00T30RMOREVIEWS 35.00 1.68 3/9/20t5 PMTMEDICARENOVITASSOWTIONS 6.61 3/9/2015 CRAdjuslmentMEDICARE-NOVITASSOWTIONS 26.71 2/25/2015 70450 CT SCAN BRAIN W/O CONTRAST 198.00' 198.00 �0:� � �i..�rt.J.:..L�na'u.4: �cc.c..t� PO.� Gt/G� /.�Gc;...s� /�=,w a/dG'f-,�/<.f / �,«•r �. �//�.�20/6 CL..4vr s�v "/a,86 .�f'.,.z .ajr��is Current 31 -60 fi1 -90 91 -720 Over 120 BALANCE DUE 3�3.88 13.88 0.00 0.00 0.00 0.00 PAY BY Due Upon Receipt THIS ACCOUNT BALANCE IS YOUR RESPONSIBILITY. Fo�billing que5tions call: (717)932-5955 PLEASE REMIT PAYMENT IN FULL OR CALL OUR Of: (877)932-595$ OFFICE IF PAYMENTARRANGEMENTS AND/OR Fax: (777)932-4856 INSURANCE INFORMATION IS NECESSARV. OffCe Hours: 8:00 AM-4:30 PM Those charges shown with an""' indicate pending insurance. To pay youf blll online an0 fegister fOf eStatement I��IIII��III�IIIII�II�I��IIIIIIIII�IIIIIIII�IIII STATEMENT please visit us at:www.qita.com SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION ��TO_16z DATE DR. PATIENT PROCEDURE DESCRIPTION qMOUNT CODE ��.,�-c PREVICiUS ERLRNGE----) l. @L t��/i39/L�� ncs Clar�a I] a397f-� 'Jeno�.i=_ ❑�.iplek 147. 1Q� H��;k12;1.� Plan F'ayment :H�ln��91.E.F. 2E. p,i_ 0;;th�!15 Rd.i��.s+,mrnf Mndic'...re llc. ?3" L.-:/�'c,'i� Rd.i�-�etment . Medicare 1. .��-' Bill Halance--) E.. E'.5 i,. r �.�. �� ''.f: �',,. ��;�-�:5;�) . �- � �.� /u�-n�,.�,� �z i>�;•� � ��, ,P.�, o,,.,.r e,.c> ��-i`.� 0��,�r �L.XJ SG� �/9-iS 41E fCCEPf VIS(1, MC f DISCOVER. CRLL OR SEP�D 1'0!ik INFORMR'fTON. 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