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05-2433
~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA CIVIL DIVISION TOWNE MANOR EAST, Plaintiff, CASE No: ()5 - ;J'-IJJ (J U;(." ~ f/L~ TYPE OF PLEADING: COMPLAINT IN CIVIL ACTION YS, JEFFREY MILLA WAY AND SUSAN MILLA WAY SHIPE, Defendants , FILED ON BEHALF OF: Plaintiff COUNSEL OF RECORD FOR THIS PARTY: Benjamin R Bibler, Esquire PA 1.0.# 93598 Weltman, Weinberg & Reis Co., L.P.A. 2718 Koppers Bldg. 436 Seventh A venue Pittsburgh, PA 15219 (412) 434-7955 WWR#03230089 . ';) : IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION TOWNE MANOR EAST, Plaintiff, ~I vs. Jeff'rev (I/:I/c.t.mi SllS 6." /I1;/ltAw<r I/.IIJ SA/fe, Civil Action No. Defendant,s J COMPLAINT IN CIVIL ACTION AND NOTICE TO DEFEND 11'1 You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by an attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMA nON ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. ," CUMBERLAND COUNTY LA WYER REFERRAL SERVICE CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, P A 17013 (717) 249-3166 2 ill " 11.1 II ! IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION TOWNE MANOR EAST, CASE No: oS- -p(<i33 C"QLY~ Plaintiff, vs. J e frre y m;1 {,",way SI).SCln f/:IIIAWi\Y (AAJ Sh.fe / Defendants ) COMPLAINT IN CIVIL ACTION AND NOW, comes Plaintiff, by and through its counsel, WELTMAN, WEINBERG & REIS, CO" L.P.A., and hereby files this Complaint against Defendant. In support thereof, Plaintiff avers as follows: 1. The Plaintiff, Towne Manor East, is a corporation with offices located at 111 W. Michigan St., Milwaukee, WI 53203, 2, The Defendant, Jeffrey Millaway (hereinafter "Millaway"), is an individual with a last known address of2004 Old Arch Road, Norristown, PA 19401. 3. The Defendant, Susan MiIlaway Shipe (hereinafter "Shipe"), is an individual with an address of 1330 Doubling Gap Road, Newville, P A 17241. 3 ,. Breach of Contract as to Jeffrey Millaway I 4. On or about November 26, 2001, Defendant MilJaway was admitted into Plaintiffs nursing care facility. Attached hereto is the pertinent part of the admission agreement indicating 'I same and marked Exhibit 'A' and made a part hereof. 5. Pursuant to said agreement, Plaintiff provided nursing care services to Millaway from November 26, 2001 to September 27, 2003, 6. Plaintiff avers that as of September 27, 2003, Plaintiff's services totaled $57,703.55. Attached hereto is the invoice indicating same and marked Exhibit 'B' and made a part hereof. 7. Although requested to do so by Plaintiff, Defendant MilJaway has willfully failed and/or refused to pay the principle balance, finance charges or any part thereof to Plaintiff. WHEREFORE, Plaintiff demands judgment against Jeffrey MilIaway in the amount of $57,703.55 with legal interest of 6% per annum from September 27,2003 plus costs. ',,1 Breach of Contract as to Susan Millaway Shipe II 8. On or about November 26, 2001, Defendant Shipe admitted Defendant Millaway into Plaintiff's nursing care facility acting as MilJaway's agent. 9. Pursuant to said agreement, Plaintiff provided nursing care services to MilIaway totaling 57,703.55 from November 26, 2001 to September 27,2003. See Exhibit "B." 10. Defendant Shipe was obligated to use Defendant MiIlaway's assets to pay this debt. See Exhibit A. 4 , ,. I II. Defendant Shipe was in possession of resources and/or assets of Defendant MiIlaway including real property, which she was responsible for liquidating to pay for MiIlaway's nursing home stay and/or services. 12. Defendant Shipe has failed to remit those resources and as a result is indebted to Plaintiff in the amount of$57,703,55. 13. Plaintiff claims interest at the legal rate of 6% per annum from July 31,2002. 14. Defendant Shipe has willfully failed and/or refused to pay the aforementioned balance, or any part thereof to Plaintiff. "If WHEREFORE, Plaintiff demands judgment against Susan Millaway Shipe in the amount of $57,703.55 with legal interest of 6% per annum from September 27, 2003 plus costs. " NECESSITIES III 15. Between November 2001 and July 2002, Plaintiff, while in the process of operating a medical Health and Rehab Clinic, provided medical services for the husband of defendant, Jeffrey H Millway. See "B." 16. The services provided to Defendant MilIway by plaintiff constituted necessary medical expenses pursuant to 23 Pa.C.S,A. 9 4102, 17, Defendant Shipe was married to Defendant Millway at all times from the initial medical treatment on November 26,2001 to July 31, 2002. 5 ,. 18. Plaintiff was unable to collect the balance due on the account, which is the subject of this action, from Defendant MiIlway because he is without sufficient property to reimburse I Plaintiff. 19. Plaintiffrendered a statement to defendant, Susan MilIaway Shipe, on or about October 15,2003 and several times subsequent thereto. !'I' WHEREFORE, Plaintiff demands judgment against Susan MiIlaway Shipe in the amount of $2,989.60 with legal interest of 6% per annum from July 31,2002 plus costs, THIS FIRM IS ATTEMPTING TO COLLECT A DEBT FROM yOU. ANY INFORMATION OBTAINED FROM YOU WILL BE USED FOR THAT PURPOSE. Respectfully Submitted: I~I ~ ::~~O'LPA Benjafnin R Bibler, Esquire P ALD. # 93598 2718 Koppers Building 436 Seventh Avenue Pittsburgh, PA 15219 (412) 434-7955 WWR# 03230089 6 PA YOR AGREEMENT 11 is Facilily policy Ihatthis form must be presented to and signed hy someone olher rhanthe residem. Resident/Patient Name: cfeJ!f.er; IiJ, 7/atif..ar, Facility Name JQtlLIU.i-lr2l1{J(" d1J f- Information Regarding a Personal Guarantee of Payment Tht Facility docs not require a third party guarantee of paymenl to the facibty a~ a condItion of admIssion or expedited admission or continued std.Y in the faciliry. The Facility does require an individual who has legal access to a resIdent's 1l1comc Or H:SO\.\rCes a.vailable to pay for facility care to sign a contract, wlthout incurring per5onalliabihty, to pro\'lde ftlci1iry payment from the resident's income or resources. Seleer one of rhe fol/owlng by tn"toling rhe appropri(Jre box Agree Decline o ~ I agree to voluntarily guarantee payment to the above-name facility for services provlded to the resident/pallent. I understand that I am not reqUlred, by law or by rhe facility, to personally guor.ntee payment; however, J choose to do thi, on a voluntary baSIS. [aglee volunlarily to be Ilable along with and in addit;ol1to tne resldent for all chargeS Inturred by the rcsldcnt for items and service's provided by the facUity as specified in the Adml'S"\lon Agreement and anachment5. ~.. Individual having access to residcnt funds must agree ro Ihe.!ollowfIlg for admission as aUrhf)rized by fedem I law [(the alJOve statemenT is decbned. I agree \"0 pay resldentlpanem's fund" ro tne facIlIty for goods .and servIces provided to the resident/pallent under the Admlsslon Agreement. ] understand that 1 am not assuming peI'sonalliabiJity [or any payment exctPI up Lo the' amoum of the income or assets bdongmg to the re51dentlpatlent ove.r which I had, have, or will have authorized control I agree 10 nOlify the f.cllity promptly when j anticipate th.t the funds aV'II.ble will be mst\fficlenl to meet the reSldenl!pal1enl's financial obligations as they come due. 1 have authOrized tontrol oVer lht' followmg funds oftht rcsldem (specltIc dolla.r <-\mounts arC listed in the Incomi: and AS5l-tS s(;ctions of the AdmlSS\On Appli(ation) for the follOWing rl'(I~on::.: (C;u:ck all rltar apply; Income and ASSets: o SocIal Security member o Pe-nslOru'Annuitics o Savings o Stacks/Bonds o Home or other real pl'openy o Life insurance Rea:son:s: o You are a spouse or other family o You are i1sred on jOlntly held .ccounts o You are the resident's legal reprcS~ntati\le o Other: Prim Name EXHIBIT. A 'g,a,",< (MU~ b(r#trJ~'!!.Cfytn ,."d"" ti:dt)/ {Dc. not Ut;e 'mles such i:l::> POA O:rdlrdian when sighii'lgJ T'V813' d Pf59~9~9fCf 01 SfP6 66C OT9 19,3 dOUtJlJ 3rWI0l d=i OS : 6 f [OOC SC d3S J :;Vhlte COpy - Facility Yellow Cop V . Volunrary GUo5lrJf1tor or Persf)/7 Hav;ng Access TO ResidenT'S Funds H ,.......' ........,.. ..... . _ . '_. _.J ADMISSION AGREEMENT ResidentlPatient Name: :JL-ff (' ~ m ; II o.Wa 'i Facility Name: Tow n e... , mOJ)o r E ClS-t Requifed by Stale Law A. Facility agrees: 1. To provide DC'l:>i<.: room and board, genent) nursing care, sOClal services, dietary services, and activities as required by I. w. 2. To assist, provide or "btain, as requir~d by law, the services of providers of Resident's chOlce for necessary care. The following pro"",,,ns "re applicable to all re,idents. The Resident and/or Legal Representative agree: 1. Tn giv~ Facility five (5) days written notice of intent to v~cate and to vacate ,^,'ithin this t1m€' or the tlme given in a notiCE: of di~,(harge l!'sucd by Facillty. 2. To hilV€, an attending physician Zlnd <llternate pnysic:ia.n \vho arc available and who \yi11 visit the .Resident ri'g.lJ.larly and in em cmcq:;t'ncy according to the policies of the FC'ciIity, state and federal law ). To the admlni~lrati~m of such s~rvic('~ as are required to carry out the Resident's plan of care as Resident, Focllit)', and R~sld.nt', attending physician deem approprIate, except where the resident has mdicated in writins to the Facility 'lOd Rc"dent', physician that a particular service is refused to the extcnt permitted by taw. ~. To abide by ,,\\ rules, regulation., policies and procedures as Me from time to time established by Facility. ,. To initiate and mai.nlain a proceeding in state court to appoint a Guardian or Conservator for the Resident within thirty (30) days of a written request by Fnci1ity to do so. 6. To provide Facility WIth a copy of any written document indicating the Resident's choices lor treatment of terminallllnes< and/or u,e of life-sustaining medical treatment such as a Living Will, Directive to Physicians or a Dur"ble POhler of l\ttom€v for Health Care. 7. That custody of the re;ident ,hall be assumed by the Resident or Legal Representative upon discharge, if thl> IS medically appropriate as certified by the Facility's medical director, and if this is not in violation of statE.' Or {"deraJ laY>'. S. The right of a tv1fdicaid reCipIent/resident to facility services lS not contingent upon past or future contributions. The following prOVision,. Me applic,ble to all Residents and Voluntary Guarantors, d someone has agreed to ~crv€, as. ~uch. ThI2 Rel".idE'nt and Voluntary Guarantor agree: 1. To be financially rc'punsiblc, Jointly and severally. for all charges accruing under this Agreement. The Voluntary Guarantor agn:.'e~ to ~atisfy the' R('sident',S account i.n the event that Resident's OWn funds are insufficient to COver any and all charge, 2. To pay. monthly. in advance, the Basic D"ily Rate (refened to as "BDR" throughout this Agreement), as adjusted, in effect ot the time the services are provided Or to pay for items and services provided but not paid for by Medicare, MedicaId, or any other third-party payor. 3. To acr,no",ledgo receIpt 01 the following written information on which the charges for items and services provided by Facility as of the admission date are based: a. Charges for item> and services provided by Facility and: 1) Included or excluded Irom the BDR. 2) Not covered by Medicaid or Medicare, respechvely, or the BDR. b. Items and serVIce, provided by Facility ilrtd paid lor by Medicaid Or Medicare, respectively. c. Acuity chargE' system or method of adjustmg the BDR depending on the complexity of care re- quired by the Resident. To acknowledge that the foregoing arc subject to change upon rNsonable notice. .. To pay promptly ",hen billed. 5. T" pay the established rate for holding a vacant bed, if bed hold is requested, in compliance with Facility's policy on bod hold and readmission unlESS payment is made by Med,cald or another third-party payor. 6. To ,ettle all lKwunts ,,'ith Facility, in full, at the time of discharge, to the satisfaction of the Administrator Or designee. 7 Reside!1t and Voluntarv Guarantor agree to assume Imanci,) responsibility for any legal charges related to proceedU1gs to appoint a GuardlM or COn5Cl'Vator lor the resident. The 10U"wing provisIOns are applicable to privole pay reslcents only: (excludes Meclicare & Medicaid residents) J. TI,e Resident and! Or Legal Representative agree: a. That the mformatwn gJ\'en to enable the F"cdity to assi,t the Resident to apply for beneflts under Titles XVIII and XIX of Ihe Social Security Act is correct; further, that Facility is hereby authoril,cd and directed to relea~,c: infurmation concerning: Resident to insurance companies, federal intermediaries and/or state Cl.gendes, t\l1d reguJatory bodies, in cOMectlon with care rendered or to be rendered to the Resident to the extent necessary lor the facility to assist the Resident in obtaining payment and otherwise comply with applicable laws. . b. Except where prohibited by law, to agree to the following assignment of benefits: Except where Resident's health care benefit plan(s) provides for automatic payment of benefits to the provider of services, Resident and/or Legal Representative authorize payment of benefits, otherwise B c D LJHFC1J7DD.6 11/99 (AR,fL,IO. IN,KY,OH. PA, TXi \?T/90'd \?T69[9[9TGT 01 ST\?~ 66G 0T9 151:'3 <O,I:'I.J 31,('101 d::J B\? : 6 T [DOG SG d35 payable 10 Resident, for services rendered by Facility and/or", indicated On an accompanying bill or claim. Until revok~d in writing by the Residi?1\t or Legal Representative, this assignment 01 benefits shall remain valid and in force for the Facility and/ or as indicated on an accompanying bill Or claim. 2. The Resident and Voluntary Guarantor agree: a. Upon admissIon, payment shall be made lor the day 01 admission and for any remaming days of the current m(mth plus an adnnCQayment for th~ following monlh. The Facility w"l charge a one-time admission processing fee nf $ . b. To pay lhe BDR iI,; "djusted, for t e day "f dLschilfge. faJ!ure w give five (5) days written notice of in.tent 10 vacate wiJI r~sultlI\ liquidated damages being charged to the re,ident', account m an amount equal to tive (5) days ilt tIle BDR as adJLlsled. Within 30 days 01 dischorgf'. or whatever period is r~quired by state law, FacUity shall rdll.nd to the Resident the prepaid portion of ti,e mcmthly rill~ prorated on a da.lty basis after dedL\ctlon of all applic<ible charges. 1f discharge occllr~ wilhin le55 thi\!"i five (5) day::; of admission, n minimum chnrgc: for five (5) dilYs stay ~h'lU bE' retained <llong V\'ith the admis$ion proccssjn~ f€:~. c. fo be fin"I1cblly rC'spon$iblC' to faolity for <:111 cnargc5 nnt c0vcrr:'d by Rtsid€nt'~ bendit plan and to pay, upon F1cditys reql..te~t, the C'-;tHTHlted non-col'('red c.hilrhL'~ pnor to the compk-t\on of WI insuran(~, bill Or claim. d If poymo.nt IS not "'<Ide wlthen len (10) d,'ys, Ihe FacililY may add a lole charge, not to exceed the maximum percentage r<.'\tE' permitted by Jaw, to the payment du~ until h.\H payment IS r('ce-ived by Facility. A f(lil"Llre to mi'lke iull payment within ten (10) d~lY~ m~}' be' trci;'ll'cd by lhe Fadlity a:-; grounds for tem1inatlOn of this Agreement where merited under applicable law. In the event that this "ccount become, delinquent arid past dLte, the patient's account wilI be assigned to a collection agency. The patient agrees to pay all costs of collections including interest, ctlurt costs, sheriffs fees, attorney kes arid collection fees as may be necessary. In additIOn to the above, a 30'Y, collection cost will be added to the outstanding balance upon assignment to the collecteon agency. fOr which the patient will be responsible. E. General Agreements' 1. In the event the Resident knowingly leaves the FacilHy or is temporarily away from the F"cihty und"'f the care of any person not directly employed by Ihe """lilY. all re;ponsibUity of the fadity for the Resident's welfare shall terminate. 2. The Facilitv shall not be hablE.' to the ReSldf..'nt nr l.E.'gal Repre~c..nt;ltlvc or Voluntarv Guar~ntor. Or his Of her heirs: a.ssigns, nT represE.'ntntivC's, or E'$tntt' for ~InY dama8~s w(vrred by th~ I~e5ident ~xcept if said damag~s. arc: G\\.ls.~'d by the $o\e- negligence of the Fi\(jHty, jt~ emplcJYccs, or ~gellt~ acting within the scope of their employment Of agency. It is undE'!$to(.)d and agreed tJ"iill the facility is not in ~ny millU1er to be conSIdered an in~urcr of th~ he?\lth, ~Zlfcty, Or welfare of the Resident or the R('sid~:I'tt's prop~rty. 3. 1l"i€ Facility ~,h;dl nt)t be responsible for the In~$ of money i;md In!>$ or dil.mag€ to jewelry, documents, or other per~on211 property ret;tio'2d in Resident'$ poss€8Sit>n unless olherwl~e requirC'd undu statE: law, 4. All medical COre provided to Resident by the Medicol Director or any other physician" a part of the physJCian's independent modiol practrce and IS not provided by or on beh"jf of facility. 5. Thi~ agreement represents ~ll of the undcrsta.ndings between the parties and there are no conditions, terms, or proVISions affecting thiS Agreement which are not specificaUy contained herein. Tim Agreement shall not be modified, altered, or otherWISe subie<:t to ,my oral statements or representahon.s not incorporated in writing in this Agreement. 6. The Facility operates und.r and in compliance With Ihe terms of Tille VI of the Civil Rights Act of 1964. No distinctIon will be mil.d~ un the grounds of [(H.:i:.', color, ct"€'€'d, national ongin, age, Or handicap in t.he admission nnd tt('atrnent (l{ Re~_ident$, the accommodations: pwvidcd, the use of equipment and other facilities, ,,-nd/or the i;lssignment of personnel to provjde ~rvi("e5. 7. If any terms or condition.:; (If this Agreen1ent .<:Ire invalid or unenforceable by reason of any rule of law, federal or state slotute. or regulatIOn, thi, Agreement ,hall be d~emed amended to comply with the rclcvilJ1t law, statute, or regulation i\I\d ,hall remain in full fNce <lnd effect. I have read and understood rhis entire Agreemenr. My signatu'e on Acknowledgement of Receipt of Admission Information (UHFG 13 70 0-15) designates my :,cceptance of the terms and conditions of rhis Agreement. .U/Qiifl;vt----, ..--- Dare .- (1I00/-_ t{!ik . D,'!\e I( Legal Repfe"wntau 's Tl Ie \~_g" O\lall;;lian. Con$€rvafor, Power 01 Altorney} If resident signs with an "X" Or mark, two witIiesse~ must ~lso sign. For all Ohio Jdrrussions, one witness must sign regardless of how the resident signs. The Ohio witness may not be connected in any mnMer with the facility or the administr<<tor, Witness 1 Dale Witness 2 '-.----..- Dai~- Sl/Jnature. !=a.d1i\y ReDrescn\:1liY'~ D-at;-~ ~;~,;..:~7 Origim1j - R!,f;id~ntl A'.lthorizt~d A..-;:el)f 1"1/",0'd 1"159Z9Z91C1 01 S11"", ~~c 019 15"3 dOU"rJ 31~~101 d.:l 51" : ~ 1 D30c SC d35 EXTENDICARE Health Services, Inc. Pavor Tvpe 1 "Private Pay 2"Medicare A 3"Medicaid 5"VA 6"lnsurance 7"HMO-A 8"Hospice 12"Medicare B 17"HMO B Pavor 1 1 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 c/yy/mmldd From To Q!y 1011126 1011130 0 1011130 1011130 0 1011123 1011130 8 1011123 1011123 1 1011123 1011123 7 1011123 1011123 11 1011123 1011123 11 1011123 1011123 3 1011123 1011123 3 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011124 1011124 1 1011125 1011125 1 1011125 1011125 1 1011126 1011126 1 1011126 1011126 2 Statement of Account Dated 2/18/05 Jeff Millaway Account # 357-21155 Description MEDICARE B COINSURANCE COINSURANCE ADJUSTMENT 8 CARE DAYS AT $ 200.00 ADMISSION KIT, MALE GAUZE STRETCH 3" NS GAUZE ABD PAD 5X9 ST DRESS TELFA IS 2X3.5 ST DRESS ADAPTIC 3X3 ST GAUZE SPG 4X4 NS PKl200 PRESCRIPTION DRUGS PRESCRIPTION DRUGS PRESCRIPTION DRUGS PRESCRIPTION DRUGS PRESCRIPTION DRUGS PRESCRIPTION DRUGS PRESCRIPTION DRUGS PRESCRIPTION DRUGS PRESCRIPTION DRUGS PRESCRIPTION DRUGS PRESCRIPTION DRUGS OVER THE COUNTER(OTC) PRESCRIPTION DRUGS PRESCRIPTION DRUGS PRESCRIPTION DRUGS PRESCRIPTION DRUGS OVER THE COUNTER(OTC) PRESCRIPTION DRUGS OT EVALUATION 97003 AR6104 OT THERAPEUTIC ACT 97530AR6104 EXHiBiT ~ Amount ($163.79) $163.79 $1,600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $000 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $000 $0.00 Referred to 3rd Party . 7 1011126 1011126 1 PT EVALUATION 97001 AR6104 $0.00 7 1011126 1011126 2 PT THER ACT 97530 AR6104 $0.00 7 1011126 1011126 1 ST SPEECH EVAL 92506 AR6104 $0.00 7 1011127 1011127 1 OT THERAPEUTIC EX 97110 AR6104 $0.00 7 1011127 1011127 1 OT THERAPEUTIC ACT 97530AR6104 $0.00 7 1011127 1011127 2 OT ADL 97535 AR6104 $0.00 7 1011127 1011127 1 PTTHER EX 97110 AR6104 $0.00 7 1011127 1011127 0 PT THER ACT 97530 AR6104 $0.00 7 1011128 1011128 2 OT THERAPEUTIC ACT 97530AR6104 $0.00 7 1011128 1011128 1 PTTHER EX 97110 AR6104 $0.00 7 1011128 1011128 1 PT THER ACT 97530 AR6104 $0.00 7 1011129 1011129 1 OT THERAPEUTIC EX 97110 AR61 04 $0.00 7 1011129 1011129 2 OT THERAPEUTIC ACT 97530AR6104 $0.00 7 1011129 1011129 1 PT NEUROM REED 97112 AR6104 $0.00 7 1011129 1011129 1 PT THER ACT 97530 AR6104 $0.00 7 1011129 1011129 1 PRESCRIPTION DRUGS $0.00 7 1011130 1011130 1 OT THERAPEUTIC EX 97110 AR61 04 $0.00 7 1011130 1011130 1 OT THERAPEUTIC ACT 97530AR6104 $0.00 7 1011130 1011130 1 PT THER EX 97110 AR6104 $0.00 7 1011130 1011130 1 PT THER ACT 97530 AR6104 $0.00 7 1020115 1020115 0 PAYMENT 01/15/02 THANK YOU ($1,600.00) 12 1011126 1011130 0 MEDICARE B COINS OFFSET $163.79 12 1011130 1011130 0 COINSURANCE ADJUSTMENT ($163.79) 7 1011201 1011203 3 3 CARE DAYS AT $ 200.00 $600.00 7 1011201 1011201 3 ZINC OXIDE 10Z $0.00 7 1011201 1011201 2 GAUZE STRETCH 3" NS $0.00 7 1011201 1011201 9 DRESS TELFA IS 2X3.5 ST $000 7 1011201 1011201 3 GAUZE TRACH SPG 4X4 6PL Y $0.00 7 1011201 1011201 3 GAUZE STRETCH 3" NS $0.00 7 1011201 1011201 1 OXYGEN CONCENTRATOR $0.00 7 1011201 1011201 4 NASAL CANNULA OVER EAR $0.00 7 1011203 1011203 1 PRESCRIPTION DRUGS $0.00 7 1011203 1011203 1 PRESCRIPTION DRUGS $0.00 7 1011207 1011218 12 12 CARE DAYS AT $ 200.00 $2,400.00 7 1011208 1011208 1 PRESCRIPTION DRUGS $0.00 7 1011208 1011208 1 PRESCRIPTION DRUGS $0.00 7 1011208 1011208 1 OVER THE COUNTER(OTC) $0.00 7 1011210 1011210 1 PRESCRIPTION DRUGS $0.00 7 1011211 1011211 1 ST SWALLOWING EVAL G0195 $0.00 7 1011212 1011212 1 OT REEVALUATION 97004 $0.00 7 1011212 1011212 2 OT THERAPEUTIC ACT 97530 $0.00 7 1011212 1011212 1 PT REEVALUATION 97002 $0.00 7 1011212 1011212 2 PT THER ACT 97530 $0.00 7 1011212 1011212 1 ST SWALLOWING TX 92526 $0.00 7 1011213 1011213 1 OT THERAPEUTIC EX 97110 $0.00 7 1011213 1011213 2 OT THERAPEUTIC ACT 97530 $0.00 7 1011213 1011213 1 PT GAIT TRAINING 97116 $0.00 7 1011213 1011213 1 PT THER ACT 97530 $0.00 7 1011213 1011213 1 ST SWALLOWING TX 92526 $0.00 7 1011213 1011213 1 OVER THE COUNTER(OTC) $0.00 7 1011213 1011213 1 PRESCRIPTION DRUGS $0.00 7 1011214 1011214 1 OT THERAPEUTIC EX 97110 $0.00 7 1011214 1011214 1 OT THERAPEUTIC ACT 97530 $0.00 7 1011214 1011214 1 PT THER EX 97110 $0.00 7 1011214 1011214 1 PT GAIT TRAINING 97116 $0.00 7 1011214 1011214 0 PT THER ACT 97530 $0.00 7 1011214 1011214 1 ST SWALLOWING TX 92526 $0.00 7 1011217 1011217 1 OT THERAPEUTIC ACT 97530 $0.00 7 1011217 1011217 1 PT THER ACT 97530 $0.00 7 1011217 10t1217 1 ST SWALLOWING TX 92526 $0.00 7 1011217 1011217 1 PRESCRIPTION DRUGS $0.00 7 1011217 1011217 1 LABORATORY $0.00 7 1011217 1011217 1 LABORATORY $0.00 7 1011218 1011218 1 OT THERAPEUTIC EX 97110 $0.00 7 1011218 1011218 1 OT THERAPEUTIC ACT 97530 $0.00 7 1011218 1011218 1 PT GAIT TRAINING 97116 $0.00 7 1011218 1011218 0 PT THER ACT 97530 $0.00 7 1011219 1011219 1 OT THERAPEUTIC ACT 97530 $0.00 7 1011219 1011219 1 PT THER ACT 97530 $0.00 7 1020221 1020221 0 PAYMENT 02/21/02 THANK YOU ($600.00) 7 1020328 1020328 0 PAYMENT 03/28/02 THANK YOU ($2.40000) 7 1020411 1020411 0 PAYMENT 04/11/02 THANK YOU ($4,600.00) 7 1020629 1020629 0 PAYMENT 04/11/02 $4,600.00 1 1020126 1020131 6 6 CARE DAYS AT $ 166.00 $996.00 1 1020219 1020219 0 PAYMENT 02/19/02 THANK YOU ($832.21) 1 1020415 1020415 0 PAYMENT 04/15/02 THANK YOU ($163.79) 7 1020101 1020101 1 OT EVALUATION 97003 $0.00 7 1020101 1020101 2 OT THERAPEUTIC ACT 97530 $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $000 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $000 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 PRESCRIPTION DRUGS $0.00 7 1020101 1020101 1 OVER THE COUNTER(OTC) $0.00 7 1020101 1020125 25 25 CARE DAYS AT $ 200.00 $5,000.00 7 1020101 1020101 1 OXYGEN CONCENTRATOR $000 7 1020101 1020101 4 NASAL CANNULA OVER EAR $0.00 7 1020101 1020101 1 ADMISSION KIT, MALE $0.00 7 1020101 1020101 12 GAUZE ABD PAD 5X9 ST $0.00 7 1020101 1020101 19 GAUZE STRETCH 3" NS $0.00 7 1020101 1020101 16 DRESS TELFA IS 2X3.5 ST $0.00 7 1020101 1020101 23 GAUZE VERSALON SPG 4X4 ST $0.00 7 1020102 1020102 1 PT EVALUATION 97001 $0.00 . 7 1020102 1020102 2 PT THER ACT 97530 $0.00 7 1020102 1020102 1 PRESCRIPTION DRUGS $0.00 7 1020103 1020103 0 PT THER EX 97110 $0.00 7 1020103 1020103 1 PT NEUROM REED 97112 $0.00 7 1020103 1020103 1 PT THER ACT 97530 $0.00 7 1020103 1020103 1 OT THERAPEUTIC EX 97110 $0.00 7 1020103 1020103 1 OT THERAPEUTIC ACT 97530 $0.00 7 1020104 1020104 0 PT THER EX 97110 $0.00 7 1020104 1020104 1 PT NEUROM REED 97112 $0.00 7 1020104 1020104 1 PT THER ACT 97530 $0.00 7 1020104 1020104 2 OT ADL 97535 $0.00 7 1020107 1020107 1 PRESCRIPTION DRUGS $0.00 7 1020107 1020107 1 PRESCRIPTION DRUGS $0.00 7 1020108 1020108 0 PT THER EX 97110 $0.00 7 1020108 1020108 1 PT NEUROM REED 97112 $0.00 7 1020108 1020108 1 PT THER ACT 97530 $0.00 7 1020108 1020108 1 OT THERAPEUTIC EX 97110 $0.00 7 1020108 1020108 1 OT THERAPEUTIC ACT 97530 $0.00 7 1020108 1020108 1 XRAY CHEST ONE VIEW FRONT $0.00 7 1020108 1020108 1 XRAY SET-UP PORTABLE $0.00 7 1020108 1020108 1 XRAY TRANSP EQUIP >1 PAT $0.00 7 1020109 1020109 1 LABORATORY $0.00 7 1020110 1020110 1 PT THER EX 97110 $0.00 7 1020110 1020110 1 OT THERAPEUTIC EX 97110 $0.00 7 1020110 1020110 1 OT ADL 97535 $0.00 7 1020111 1020111 1 PT THER EX 97110 $0.00 7 1020111 1020111 1 PT THER ACT 97530 $0.00 7 1020111 1020111 1 OT THERAPEUTIC EX 97110 $0.00 7 1020111 1020111 1 OT THERAPEUTIC ACT 97530 $0.00 7 1020112 1020112 1 PRESCRIPTION DRUGS $0.00 7 1020112 1020112 1 OVER THE COUNTER(OTC) $0.00 7 1020114 1020114 0 PT THER EX 97110 $0.00 7 1020114 1020114 1 PT NEUROM REED 97112 $0.00 7 1020114 1020114 1 PT THER ACT 97530 $0.00 7 1020114 1020114 1 OT THERAPEUTIC EX 97110 $0.00 7 1020114 1020114 1 OT THERAPEUTIC ACT 97530 $0.00 7 1020115 1020115 1 OT THERAPEUTIC ACT 97530 $0.00 7 1020115 1020115 1 PRESCRIPTION DRUGS $0.00 7 1020116 1020116 0 PT THER EX 97110 $0.00 7 1020116 1020116 1 PT NEUROM REED 97112 $000 7 1020116 1020116 1 PT THER ACT 97530 $0.00 7 1020116 1020116 1 OT THERAPEUTIC EX 97110 $0.00 7 1020116 1020116 1 OT THERAPEUTIC ACT 97530 $0.00 7 1020116 1020116 1 OT ADL 97535 $0.00 7 1020117 1020117 0 PT THER EX 97110 $0.00 7 1020117 1020117 1 PT NEUROM REED 97112 $0.00 7 1020117 1020117 1 PT THER ACT 97530 $0.00 7 1020117 1020117 1 OT THERAPEUTIC EX 97110 $0.00 7 1020117 1020117 1 OT THERAPEUTIC ACT 97530 $0.00 7 1020118 1020118 1 PT THER EX 97110 $0.00 7 1020118 1020118 0 PT GAIT TRAINING 97116 $0.00 7 1020118 1020118 1 PT THER ACT 97530 $0.00 . 7 1020118 1020118 1 OT THERAPEUTIC EX 97110 $0.00 7 1020118 1020118 1 OT THERAPEUTIC ACT 97530 $0.00 7 1020118 1020118 1 PRESCRIPTION DRUGS $0.00 7 1020121 1020121 1 OT THERAPEUTIC EX 97110 $0.00 7 1020121 1020121 1 OT THERAPEUTIC ACT 97530 $0.00 7 1020121 1020121 0 PT THER EX 97110 $0.00 7 1020121 1020121 1 PT NEUROM REED 97112 $0.00 7 1020121 1020121 1 PT THER ACT 97530 $0.00 7 1020122 1020122 1 OT THERAPEUTIC EX 97110 $0.00 7 1020122 1020122 1 OT THERAPEUTIC ACT 97530 $0.00 7 1020122 1020122 1 PT THER EX 97110 $0.00 7 1020122 1020122 1 PT THER ACT 97530 $000 7 1020123 1020123 1 OT THERAPEUTIC EX 97110 $0.00 7 1020123 1020123 1 OT THERAPEUTIC ACT 97530 $000 7 1020123 1020123 0 PT THER EX 97110 $0.00 7 1020123 1020123 1 PT NEUROM REED 97112 $0.00 7 1020123 1020123 1 PT THER ACT 97530 $0.00 7 1020124 1020124 1 OT THERAPEUTIC ACT 97530 $0.00 7 1020124 1020124 2 OT ADL 97535 $0.00 7 1020124 1020124 0 PT THER EX 97110 $0.00 7 1020124 1020124 1 PT NEUROM REED 97112 $0.00 7 1020124 1020124 1 PT THER ACT 97530 $0.00 7 1020124 1020124 0 WIO - NO PRIOR AUTHORIZATION ($400.00) 7 1020125 1020125 1 OT THERAPEUTIC EX 97110 $0.00 7 1020125 1020125 1 OT THERAPEUTIC ACT 97530 $0.00 7 1020125 1020125 0 PT THER EX 97110 $0.00 7 1020125 1020125 1 PT NEUROM REED 97112 $0.00 7 1020125 1020125 1 PT THER ACT 97530 $0.00 7 1020629 1020629 0 PAYMENT 04/11/02 ($4,600.00) 1 1020201 1020228 28 28 CARE DAYS AT $166.00 $4,648.00 1 1020201 1020201 4 SYR INS 1-1/2CC 27GX1/2 $200 1 1020201 1020201 9 GAUZE ABD PAD 5X9 ST $7.29 1 1020201 1020201 16 GAUZE VERSALON SPG 4X4 ST $8.00 1 1020201 1020201 3 DRESS ADAPTIC 3X3 ST $5.46 1 1020201 1020201 8 GAUZE STRETCH 3" NS $5.28 1 1020201 1020201 1 OXYGEN CONCENTRATOR $65.00 1 1020201 1020201 4 NASAL CANNULA OVER EAR $5.40 1 1020219 1020219 0 PAYMENT 02/19/02 THANK YOU ($4,648.00) 1 1020227 1020227 1 BARBER & BEAUTY SHOP $10.00 1 1020228 1020228 1 LAUNDRY $20.00 1 1020314 1020314 0 PAYMENT 03/14/02 THANK YOU ($20.00) 1 1020415 1020415 0 PAYMENT 04/15/02 THANK YOU ($108.43) 1 1020301 1020331 31 31 CARE DAYS AT $ 166.00 $5,146.00 1 1020301 1020331 1 LAUNDRY $20.00 1 1020301 1020301 9 DRESS ADAPTIC 3X3 ST $16.38 1 1020301 1020301 12 GAUZE ABD PAD 5X9 ST $9.72 1 1020301 1020301 12 GAUZE STRETCH 3" NS $7.92 1 1020314 1020314 0 PAYMENT 03/14/02 THANK YOU ($5,146.00) 1 1020415 1020415 0 PAYMENT 04/15/02 THANK YOU ($20.00) 1 1020530 1020530 0 PAYMENT 05/30/02 THANK YOU ($34.02) 1 1020401 1020430 30 30 CARE DAYS AT $ 166.00 $4,980.00 1 1020401 1020430 1 LAUNDRY $20.00 . 1 1020401 1020401 16 GAUZE STRETCH 3" NS $10.56 1 1020401 1020401 12 GAUZE ABD PAD 5X9 ST $9.72 1 1020401 1020401 26 GAUZE VERSALON SPG 4X4 ST $13.00 1 1020401 1020401 0 INTEREST ADJUSTMENT ($4.08) 1 1020415 1020415 0 PAYMENT 04/15/02 THANK YOU ($4,707.78) 1 1020418 1020418 1 BARBER & BEAUTY SHOP $10.00 1 1020430 1020430 0 INTEREST ON BAL OF 272.22 $4.08 1 1020520 1020520 0 PAYMENT OS/20/02 THANK YOU ($20.00) 1 1020530 1020530 0 PAYMENT 05/30/02 THANK YOU ($30.00) 1 1020923 1020923 0 PAYMENT 09/23/02 THANK YOU ($285.50) 17 1020415 1020415 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020415 1020415 1 ST TEST APHASIAlHR 961 05AR61 04 $86.24 17 1020418 1020418 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020419 1020419 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020422 1020422 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020424 1020424 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020425 1020425 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020426 1020426 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020429 1020429 1 ST SP/COMM TX 92507 AR61 04 $81.15 1 1020501 1020531 31 31 CARE DAYS AT $ 166.00 $5,146.00 1 1020501 1020531 1 LAUNDRY $20.00 1 1020501 1020501 9 DRESS TELFA IS 2X3.5 ST $4.50 1 1020501 1020501 19 GAUZE VERSALON SPG 4X4 ST $9.50 1 1020501 1020501 9 GAUZE STRETCH 3" NS $5.94 1 1020501 1020501 2 TAPE CLOTH 1" $3.54 1 1020501 1020531 0 INTEREST ADJUSTMENT ($14.81) 1 1020520 1020520 0 PAYMENT OS/20/02 THANK YOU ($5,146.00) 1 1020531 1020531 0 INTEREST ON BAL OF 987.66 $14.81 1 1020628 1020628 0 PAYMENT 06/28/02 THANK YOU ($20.00) 1 1020923 1020923 0 PAYMENT 09/23f02 THANK YOU ($23.48) 17 1020502 1020502 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020503 1020503 1 ST SP/COMM TX 92507 AR61 04 $81.15 17 1020506 1020506 1 ST SPfCOMM TX 92507 AR6104 $81.15 17 1020507 1020507 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020508 1020508 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020509 1020509 1 ST SP/COMM TX 92507 AR61 04 $81.15 17 1020510 1020510 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020513 1020513 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020514 1020514 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020515 1020515 1 ST SP/COMM TX 92507 AR61 04 $81.15 17 1020516 1020516 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020517 1020517 1 ST SP/COMM TX 92507 AR61 04 $81.15 17 1020520 1020520 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020521 1020521 1 ST SP/COMM TX 92507 AR61 04 $81.15 17 1020522 1020522 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020523 1020523 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020528 1020528 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020529 1020529 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020530 1020530 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020531 1020531 1 ST SPfCOMM TX 92507 AR61 04 $81.15 1 1020601 1020630 30 30 CARE DAYS AT $ 166.00 $4,980.00 1 1020601 1020630 1 LAUNDRY $20.00 . 1 1020601 1020601 12 GAUZE STRETCH 3" NS $7.92 1 1020601 1020601 3 ZINC OXIDE 10Z $7.26 1 1020601 1020601 11 GAUZE VERSALON SPG 4X4 ST $5.50 1 1020601 1020601 9 GAUZE ABD PAD 5X9 ST $7.29 1 1020601 1020601 0 INTEREST ADJUSTMENT ($40.01) 1 1020611 1020611 1 BARBER & BEAUTY SHOP $10.00 1 1020628 1020628 0 PAYMENT 06/28/02 THANK YOU ($4,980.00) 1 1020630 1020630 0 INTEREST ON BAL. OF 2667.42 $40.01 1 1020705 1020705 0 PAYMENT 07/05/02 THANK YOU ($56.76) 1 1020923 1020923 0 PAYMENT 09/23/02 THANK YOU ($1.21) 17 1020603 1020603 1 ST SP/COMM TX 92507 AR6104 $81.15 17 1020604 1020604 1 ST SP/COMM TX 92507 AR6104 $8115 17 1020605 1020605 1 ST SP/COMM TX 92507 AR6104 $8115 17 1020606 1020606 1 ST SP/COMM TX 92507 AR6104 $8115 17 1020607 1020607 1 ST SP/COMM TX 92507 AR6104 $8115 1 1020701 1020731 31 31 CARE DAYS AT $ 166.00 $5,146.00 1 1020701 1020731 1 LAUNDRY $20.00 1 1020701 1020701 2 TAPE CLOTH 1" $3.54 1 1020701 1020701 12 GAUZE STRETCH 3" NS $7.92 1 1020701 1020701 13 GAUZE VERSALON SPG 4X4 ST $6.50 1 1020701 1020701 8 DRESS TELFA IS 2X3.5 ST $4.00 1 1020701 1020701 3 ZINC OXIDE 10Z $7.26 1 1020701 1020701 0 INTEREST ADJUSTMENT ($81.42) 1 1020701 1020701 0 COINSURANCE ADJUSTMENT $20.00 1 1020731 1020731 0 INTEREST ON BAL. OF 5428.22 $81.42 1 1020923 1020923 0 PAYMENT 09/23/02 THANK YOU ($4,78981 ) 1 1030407 1030407 0 PAYMENT 04/07/03 THANK YOU ($100.00) 1 1040106 1040106 0 PAYMENT 01/06/04 THANK YOU ($100.00) 17 1020701 1020701 0 COINSURANCE ADJUSTMENT ($20.00) 17 1020701 1020701 0 C/A-PHYSICAL THERAPY-HMO ($49.43) 17 1020731 1020731 1 OT EVALUATION 97003 $78.21 17 1020731 1020731 1 PT EVALUATION 97001 $77.34 17 1020731 1020731 1 PTTHER EX 97110 $28.08 17 1020731 1020731 1 PT GAIT TRAINING 97116 $28.88 17 1031029 1031029 0 PAYMENT 10/29/03 THANK YOU ($143.08) Amount prior to 8102 $2,989,60 1 1020801 1020801 0 INTEREST ADJUSTMENT ($159.77) 1 1020801 1020801 0 PRIVATE B PREMIUM DEDUCTION ($54.00) 1 1020801 1020831 0 AVAILABLE INCOME FOR 08/02 $1,360.00 1 1020831 1020831 0 INTEREST ON BAL. OF 10651.41 $159.77 3 1020801 1020831 1 LAUNDRY AR6104 $0.00 3 1020801 1020801 16 GAUZE VERSALON SPG 4X4 SAR610' $000 3 1020801 1020801 12 GAUZE ABD PAD 5X9 ST AR6104 $0.00 3 1020801 1020801 9 DRESS ADAPTIC 3X3 ST AR61 04 $0.00 3 1020801 1020801 16 GAUZE STRETCH 3" NS AR6104 $0.00 3 1020801 1020830 0 MEDICARE B COINSURANCE $494.73 3 1020801 1020801 0 MEDICAID B PREMIUM DEDUCTION $54.00 3 1020801 1020801 1 211CF -INTERMEDIATE CARE FAC $129.74 3 1020802 1020831 30 21 ICF - INTERMEDIATE CARE FAC $3,892.20 3 1020831 1020831 0 All MEDICAID OFFSET ($1,360.00) 12 1020801 1020801 1 PT THER EX 97110 AR6104 $28.08 12 1020801 1020801 1 PT NEUROM REED 97112 AR6104 $29.15 . 12 1020801 1020801 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020801 1020801 0 W/O-NO lONGER COST EFFECTIVE ($0.05) 12 1020801 1020830 0 MEDICARE B COINS OFFSET ($494.73) 12 1020802 1020802 1 PT THER EX 97110 AR6104 $28.08 12 1020802 1020802 1 PT NEUROM REED 97112 AR6104 $29.15 12 1020802 1020802 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020802 1020802 2 OT THERAPEUTIC ACT 97530AR6104 $70.22 12 1020805 1020805 1 OT THERAPEUTIC EX 97110 AR6104 $28.08 12 1020805 1020805 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020805 1020805 1 PT THER EX 97110 AR6104 $28.08 12 1020805 1020805 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020805 1020805 1 PT THER ACT 97530 AR6104 $35.11 12 1020806 1020806 1 OT THERAPEUTIC EX 97110 AR6104 $28.08 12 1020806 1020806 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020806 1020806 0 PT THER EX 97110 AR6104 $000 12 1020806 1020806 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020806 1020806 1 PT THER ACT 97530 AR6104 $35.11 12 1020807 1020807 1 OT THERAPEUTIC EX 97110 AR6104 $28.08 12 1020807 1020807 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020807 1020807 1 PT THER EX 97110 AR6104 $28.08 12 1020807 1020807 0 PT GAIT TRAINING 97116 AR6104 $0.00 12 1020807 1020807 1 PT THER ACT 97530 AR6104 $35.11 12 1020808 1020808 0 OT THERAPEUTIC EX 97110 AR6104 $0.00 12 1020808 1020808 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020808 1020808 1 OT ADl 97535 AR6104 $31.52 12 1020808 1020808 1 PT THER EX 97110 AR6104 $28.08 12 1020808 1020808 0 PT NEUROM REED 97112 AR6104 $0.00 12 1020808 1020808 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020809 1020809 2 OT THERAPEUTIC ACT 97530AR6104 $70.22 12 1020809 1020809 0 PT THER EX 97110 AR6104 $0.00 12 1020809 1020809 1 PT NEUROM REED 97112 AR6104 $29.15 12 1020809 1020809 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020812 1020812 1 OT THERAPEUTIC EX 97110 AR61 04 $28.08 12 1020812 1020812 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020812 1020812 1 PT THER EX 97110 AR6104 $28.08 12 1020812 1020812 0 PT NEUROM REED 97112 AR6104 $0.00 12 1020812 1020812 1 PT THER ACT 97530 AR6104 $35.11 12 1020813 1020813 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020815 1020815 2 OT THERAPEUTIC EX 97110 AR61 04 $56.16 12 1020815 1020815 1 PT THER EX 97110 AR6104 $28.08 12 1020816 1020816 2 OT THERAPEUTIC EX 97110 AR61 04 $56.16 12 1020819 1020819 1 OT THERAPEUTIC EX 97110 AR6104 $28.08 12 1020819 1020819 1 OT ADl 97535 AR6104 $31.52 12 1020819 1020819 1 PT THER EX 97110 AR6104 $28.08 12 1020819 1020819 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020820 1020820 1 OT THERAPEUTIC EX 97110 AR6104 $28.08 12 1020820 1020820 1 OT ADl 97535 AR6104 $31.52 12 1020820 1020820 1 PT THER EX 97110 AR61 04 $28.08 12 1020820 1020820 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020821 1020821 0 OT THERAPEUTIC EX 97110 AR6104 $0.00 12 1020821 1020821 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020821 1020821 1 PT THER EX 97110 AR6104 $28.08 12 1020821 1020821 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020822 1020822 1 OT THERAPEUTIC EX 97110 AR61 04 $28.08 12 1020822 1020822 1 OT ADL 97535 AR6104 $31.52 12 1020822 1020822 1 PT THER EX 97110 AR61 04 $28.08 12 1020822 1020822 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020823 1020823 2 OT THERAPEUTIC EX 97110 AR6104 $56.16 12 1020823 1020823 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020823 1020823 1 PT THER EX 97110 AR6104 $28.08 12 1020823 1020823 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020826 1020826 1 OT THERAPEUTIC EX 97110 AR6104 $28.08 12 1020826 1020826 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020826 1020826 1 OT ADL 97535 AR6104 $31.52 12 1020827 1020827 1 OT THERAPEUTIC EX 97110 AR6104 $28.08 12 1020827 1020827 1 OT ADL 97535 AR6104 $31.52 12 1020827 1020827 1 PT THER EX 97110 AR6104 $28.08 12 1020827 1020827 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020828 1020828 2 OT ADL 97535 AR6104 $63.04 12 1020828 1020828 1 PT THER EX 97110 AR6104 $28.08 12 1020828 1020828 0 PT GAIT TRAINING 97116 AR6104 $0.00 12 1020828 1020828 1 PT THER ACT 97530 AR61 04 $35.11 12 1020829 1020829 1 OT THERAPEUTIC EX 97110 AR61 04 $28.08 12 1020829 1020829 2 OT THERAPEUTIC ACT 97530AR6104 $70.22 12 1020829 1020829 0 PT NEUROM REED 97112 AR61 04 $0.00 12 1020829 1020829 1 PT THER ACT 97530 AR6104 $35.11 12 1020830 1020830 1 OT NEUROM USC REED 97112AR610. $29.15 12 1020830 1020830 2 OT COG SKILLS DEV 97532 AR6104 $47.06 12 1020830 1020830 1 PT THER EX 97110 AR61 04 $28.08 12 1020830 1020830 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020830 1020830 1 ST SWALLOWING EVAL G0195AR610, $136.21 12 1021121 1021121 0 PMT 11/21/02 000000000000485 ($1,978.86) 1 1020901 1020901 0 INTEREST ADJUSTMENT ($158.27) 1 1020901 1020901 0 PRIVATE B PREMIUM DEDUCTION ($54.00) 1 1020901 1020930 0 AVAILABLE INCOME FOR 09102 $1,360.00 1 1020905 1020905 1 BARBER & BEAUTY SHOP AR6104 $10.00 1 1020930 1020930 0 INTEREST ON BAL. OF 10551.41 $158.27 1 1030515 1030515 0 PAYMENT 05/15/03 THANK YOU ($100.00) 3 1020901 1020930 1 LAUNDRY AR6104 $0.00 3 1020901 1020901 9 DRESS TELFA IS 2X3.5 ST AR6104 $0.00 3 1020901 1020901 26 GAUZE STRETCH 3" NS AR6104 $000 3 1020901 1020901 2 TAPE CLOTH 1" AR6104 $0.00 3 1020901 1020901 16 GAUZE VERSALON SPG 4X4 SAR610' $0.00 3 1020901 1020901 3 IRR SALINE SOL 240ML AR6104 $0.00 3 1020901 1020901 0 MEDICAID B PREMIUM DEDUCTION $54.00 3 1020901 1020930 30 211CF -INTERMEDIATE CARE FAC $3,89220 3 1020903 1020927 0 MEDICARE B COINSURANCE $287.30 3 1020930 1020930 0 All MEDICAID OFFSET ($1,360.00) 12 1020901 1020901 0 W/O-NO LONGER COST EFFECTIVE $0.01 12 1020903 1020903 1 PT THER EX 97110 AR6104 $28.08 12 1020903 1020903 1 PT NEUROM REED 97112 AR61 04 $29.15 12 1020903 1020903 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020903 1020903 1 ST SWALLOWING TX 92526 AR6104 $82.66 12 1020903 1020927 0 MEDICARE B COINS OFFSET ($287.30) 12 1020904 1020904 1 OT NEUROM USC REED 97112AR610, $29.15 12 1020904 1020904 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020904 1020904 1 ST SWALLOWING TX 92526 AR6104 $82.66 12 1020905 1020905 1 OT THERAPEUTIC EX 97110 AR61 04 $28.08 12 1020905 1020905 1 OT NEUROM USC REED 97112AR610, $29.15 12 1020905 1020905 1 PT THER EX 97110 AR6104 $28.08 12 1020905 1020905 0 PT GAIT TRAINING 97116 AR6104 $0.00 12 1020906 1020906 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020906 1020906 2 OT COG SKILLS DEV 97532 AR61 04 $47.06 12 1020906 1020906 1 PT THER EX 97110 AR6104 $28.08 12 1020906 1020906 1 PT GAIT TRAINING 97116 AR6104 $24.14 12 1020906 1020906 1 ST SWALLOWING TX 92526 AR6104 $82.66 12 1020909 1020909 1 OT THERAPEUTIC EX 97110 AR6104 $28.08 12 1020909 1020909 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020909 1020909 1 ST SWALLOWING TX 92526 AR6104 $82.66 12 1020910 1020910 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1020910 1020910 1 ST SWALLOWING TX 92526 AR6104 $82.66 12 1020912 1020912 1 ST SWALLOWING TX 92526 AR6104 $82.66 12 1020918 1020918 2 OT ORTHOTIC FITITMG 9750AR6104 $56.16 12 1020919 1020919 2 OT NEUROM USC REED 97112AR610, $58 30 12 1020920 1020920 2 OT NEUROM USC REED 97112AR610, $58.30 12 1020924 1020924 2 OT ORTHOTIC FITITMG 9750AR6104 $56.16 12 1020925 1020925 1 ST SWALLOWING TX 92526 AR6104 $82.66 12 1020926 1020926 1 ST SWALLOWING TX 92526 AR6104 $82.66 12 1020927 1020927 1 ST SWALLOWING TX 92526 AR6104 $82.66 12 1021212 1021212 0 PMT 12/12/02 000000000000490 ($1,149.20) 1 1021001 1021001 0 INTEREST ADJUSTMENT ($237.20) 1 1021001 1021001 0 PRIVATE B PREMIUM DEDUCTION ($54.00) 1 1021001 1021031 0 AVAILABLE INCOME FOR 10/02 $1,36000 1 1021031 1021031 0 INTEREST ON BAL. OF 15813.52 $237.20 1 1030804 1030804 0 PAYMENT 08/04/03 THANK YOU ($100.00) 1 1031002 1031002 0 PAYMENT 10/02/03 THANK YOU ($100.00) 3 1021001 1021031 1 LAUNDRY AR6104 $0.00 3 1021001 1021001 3 ZINC OXIDE 10Z AR6104 $000 3 1021001 1021001 0 MEDICAID B PREMIUM DEDUCTION $54.00 3 1021001 1021031 31 211CF -INTERMEDIATE CARE FAC $4,13850 3 1021002 1021031 0 MEDICARE B COINSURANCE $170.91 3 1021031 1021031 0 All MEDICAID OFFSET ($1,360.00) 12 1021001 1021001 0 W/O-NO LONGER COST EFFECTIVE $0.01 12 1021002 1021002 1 ST SWALLOWING TX 92526 AR6104 $82.66 12 1021002 1021031 0 MEDICARE B COINS OFFSET ($170.91) 12 1021004 1021004 1 ST SWALLOWING TX 92526 AR6104 $82.66 12 1021010 1021010 1 OT ORTHOTIC FITITMG 9750AR6104 $28.08 12 1021014 1021014 2 OT NEUROM USC REED 97112AR610' $58.30 12 1021016 1021016 2 OT NEUROM USC REED 97112AR610, $58.30 12 1021017 1021017 2 OT NEUROM USC REED 97112AR610, $58.30 12 1021018 1021018 1 OT NEUROM USC REED 97112AR610' $29.15 12 1021018 1021018 1 OT ORTHOTIC FITITMG 9750AR6104 $28.08 12 1021022 1021022 2 OT THERAPEUTIC ACT 97530AR6104 $70.22 12 1021024 1021024 2 OT NEUROM USC REED 97112AR61 0, $58.30 12 1021024 1021024 1 OT THERAPEUTIC ACT 97530AR6104 $35.11 12 1021025 1021025 2 OT THERAPEUTIC ACT 97530AR6104 $70.22 . 12 1021029 1021029 2 OT NEUROM USC REED 97112AR61Q. $58.30 12 1021029 1021029 1 OT ADL 97535 AR6104 $31.52 12 1021031 1021031 3 OT THERAPEUTIC ACT 97530AR6104 $105.33 12 1021202 1021202 0 PMT 12/02/02 000000000000488 ($683.63) 1 1021101 1021101 0 PRIVATE B PREMIUM DEDUCTION ($5400) 1 1021101 1021130 0 AVAILABLE INCOME FOR 11102 $1,360.00 1 1030325 1030325 0 PAYMENT 03/25/03 THANK YOU ($100.00) 1 1030430 1030430 0 PAYMENT 04/30/03 THANK YOU ($100.00) 1 1030602 1030602 0 PAYMENT 06/02/03 THANK YOU ($100.00) 1 1030728 1030728 0 PAYMENT 07/28/03 THANK YOU ($100.00) 1 1030829 1030829 0 PAYMENT 08/29/03 THANK YOU ($100.00) 3 1021101 1021101 0 BAD DEBT - NON REIMB T18B ($46.64) 3 1021101 1021101 0 MEDICAID B PREMIUM DEDUCTION $54.00 3 1021101 1021130 30 21 ICF - INTERMEDIATE CARE FAC $4,005.00 3 1021108 1021121 0 MEDICARE B COINSURANCE $46.64 3 1021130 1021130 0 All MEDICAID OFFSET ($1,360.00) 12 1021108 1021108 2 OT NEUROM USC REED 97112 $5830 12 1021108 1021121 0 MEDICARE B COINS OFFSET ($46.64) 12 1021113 1021113 2 OT NEUROM USC REED 97112 $58.30 12 1021115 1021115 2 OT NEUROM USC REED 97112 $58.30 12 1021121 1021121 2 OT NEUROM USC REED 97112 $58.30 12 1021220 1021220 0 PMT 12/20/02 000000000000494 ($186.56) 1 1021201 1021201 0 PRIVATE B PREMIUM DEDUCTION ($54.00) 1 1021201 1021231 0 AVAILABLE INCOME FOR 12/02 $1,434.00 1 1021203 1021203 0 PAYMENT 12/03/02 THANK YOU ($1,380.00) 1 1030707 1030707 0 PAYMENT 07/07/03 THANK YOU ($100.00) 3 1021201 1021201 1 PRESCRIPTION DRUGS $0.00 3 1021201 1021201 1 PRESCRIPTION DRUGS $0.00 3 1021201 1021201 0 BAD DEBT - NON REIMB T18B ($241.96) 3 1021201 1021201 0 MEDICAID B PREMIUM DEDUCTION $54.00 3 1021201 1021201 1 PRESCRIPTION DRUGS $0.00 3 1021201 1021201 1 PRESCRIPTION DRUGS $000 3 1021201 1021231 31 211CF -INTERMEDIATE CARE FAC $4,138.50 3 1021206 1021206 1 PRESCRIPTION DRUGS $0.00 3 1021206 1021206 1 PRESCRIPTION DRUGS $0.00 3 1021209 1021209 1 PRESCRIPTION DRUGS $0.00 3 1021209 1021209 1 PRESCRIPTION DRUGS $0.00 3 1021210 1021210 1 PRESCRIPTION DRUGS $0.00 3 1021210 1021210 1 PRESCRIPTION DRUGS $000 3 1021210 1021231 0 MEDICARE B COINSURANCE $241.96 3 1021214 1021214 1 PRESCRIPTION DRUGS $000 3 1021214 1021214 1 PRESCRIPTION DRUGS $0.00 3 1021214 1021214 1 PRESCRIPTION DRUGS $000 3 1021214 1021214 1 PRESCRIPTION DRUGS $0.00 3 1021214 1021214 1 PRESCRIPTION DRUGS $000 3 1021214 1021214 1 PRESCRIPTION DRUGS $0.00 3 1021215 1021215 1 PRESCRIPTION DRUGS $0.00 3 1021215 1021215 1 PRESCRIPTION DRUGS $0.00 3 1021215 1021215 1 PRESCRIPTION DRUGS $0.00 3 1021215 1021215 1 PRESCRIPTION DRUGS $0.00 3 1021218 1021218 1 PRESCRIPTION DRUGS $0.00 3 1021218 1021218 1 PRESCRIPTION DRUGS $0.00 . 3 1021218 1021218 1 PRESCRIPTION DRUGS $0.00 3 1021218 1021218 1 PRESCRIPTION DRUGS $0.00 3 1021218 1021218 1 PRESCRIPTION DRUGS $0.00 3 1021218 1021218 1 PRESCRIPTION DRUGS $0.00 3 1021219 1021219 1 PRESCRIPTION DRUGS $0.00 3 1021219 1021219 1 PRESCRIPTION DRUGS $0.00 3 1021219 1021219 1 PRESCRIPTION DRUGS $0.00 3 1021219 1021219 1 PRESCRIPTION DRUGS $0.00 3 1021231 1021231 1 PRESCRIPTION DRUGS $0.00 3 1021231 1021231 1 PRESCRIPTION DRUGS $0.00 3 1021231 1021231 0 All MEDICAID OFFSET ($1,434.00) 12 1021210 1021210 1 ST TEST APHASIAlHR 96105 $73.69 12 1021210 1021231 0 MEDICARE B COINS OFFSET ($241.96) 12 1021211 1021211 1 ST SP/COMM TX 92507 $81.15 12 1021212 1021212 1 ST SP/COMM TX 92507 $81.15 12 1021213 1021213 1 ST SP/COMM TX 92507 $81.15 12 1021216 1021216 1 ST SP/COMM TX 92507 $81.15 12 1021217 1021217 1 ST SP/COMM TX 92507 $81.15 12 1021219 1021219 1 ST SP/COMM TX 92507 $81.15 12 1021220 1021220 1 ST SP/COMM TX 92507 $81.15 12 1021222 1021222 1 ST SP/COMM TX 92507 $81.15 12 1021223 1021223 1 ST SP/COMM TX 92507 $81.15 12 1021226 1021226 1 ST SP/COMM TX 92507 $81.15 12 1021227 1021227 1 ST SP/COMM TX 92507 $81.15 12 1021228 1021228 1 ST SP/COMM TX 92507 $81.15 12 1021230 1021230 1 ST SP/COMM TX 92507 $81.15 12 1021231 1021231 1 ST SP/COMM TX 92507 $81.15 12 1030120 1030120 0 PMT 01/20/03 000000000000499 ($967.83) 1 1030101 1030101 0 PRIVATE B PREMIUM DEDUCTION ($58.70) 1 1030101 1030131 0 AVAILABLE INCOME FOR 01/03 $1,454.70 1 1030103 1030103 0 PAYMENT 01/03/03 THANK YOU ($1,396.00) 3 1030101 1030101 0 BAD DEBT - NON REIMB T18B ($33008) 3 1030101 1030101 0 WRITE-OFF REIMB. MEDICARE B ($26.50) 3 1030101 1030101 0 MEDICAID B PREMIUM DEDUCTION $58.70 3 1030101 1030101 0 COINSURANCE ADJUSTMENT ($19.98) 3 1030101 1030131 31 20 SNF - SKILLED NURSING FAC $4,255.06 3 1030102 1030102 3 ZINC OXIDE 10Z $000 3 1030102 1030102 14 DRESS ADAPTIC 3X3 ST $0.00 3 1030102 1030102 12 GAUZE ABD PAD 5X9 ST $000 3 1030102 1030102 12 GAUZE STRETCH 3" NS $0.00 3 1030102 1030102 5 GAUZE VERSALON SPG 4X4 ST $0.00 3 1030102 1030127 0 MEDICARE B DEDUCTIBLE $100.00 3 1030102 1030127 0 MEDICARE B DEDUCTIBLE ($100.00) 3 1030102 1030127 0 MEDICARE B DEDUCTIBLE $100.00 3 1030102 1030127 0 MEDICARE B COINSURANCE $276.58 3 1030106 1030106 1 PRESCRIPTION DRUGS $0.00 3 1030106 1030106 1 PRESCRIPTION DRUGS $0.00 3 1030106 1030106 1 PRESCRIPTION DRUGS $0.00 3 1030106 1030106 1 PRESCRIPTION DRUGS $0.00 3 1030112 1030112 1 PRESCRIPTION DRUGS $0.00 3 1030112 1030112 1 PRESCRIPTION DRUGS $0.00 3 1030113 1030113 1 PRESCRIPTION DRUGS $0.00 3 1030113 1030113 1 PRESCRIPTION DRUGS $0.00 3 1030115 1030115 1 PRESCRIPTION DRUGS $0.00 3 1030115 1030115 1 PRESCRIPTION DRUGS $0.00 3 1030117 1030117 1 PRESCRIPTION DRUGS $0.00 3 1030117 1030117 1 PRESCRIPTION DRUGS $0.00 3 1030117 1030117 1 PRESCRIPTION DRUGS $0.00 3 1030117 1030117 1 PRESCRIPTION DRUGS $0.00 3 1030120 1030120 1 PRESCRIPTION DRUGS $0.00 3 1030120 1030120 1 PRESCRIPTION DRUGS $0.00 3 1030120 1030120 1 PRESCRIPTION DRUGS $0.00 3 1030120 1030120 1 PRESCRIPTION DRUGS $0.00 3 1030120 1030120 1 PRESCRIPTION DRUGS $0.00 3 1030120 1030120 1 PRESCRIPTION DRUGS $0.00 3 1030120 1030120 1 PRESCRIPTION DRUGS $0.00 3 1030120 1030120 1 PRESCRIPTION DRUGS $0.00 3 1030122 1030122 1 PRESCRIPTION DRUGS $0.00 3 1030122 1030122 1 PRESCRIPTION DRUGS $0.00 3 1030122 1030122 1 PRESCRIPTION DRUGS $0.00 3 1030122 1030122 1 PRESCRIPTION DRUGS $0.00 3 1030123 1030123 1 PRESCRIPTION DRUGS $0.00 3 1030123 1030123 1 PRESCRIPTION DRUGS $0.00 3 1030124 1030124 1 PRESCRIPTION DRUGS $000 3 1030124 1030124 1 PRESCRIPTION DRUGS $0.00 3 1030125 1030125 1 PRESCRIPTION DRUGS $0.00 3 1030125 1030125 1 PRESCRIPTION DRUGS $0.00 3 1030126 1030126 1 PRESCRIPTION DRUGS $0.00 3 1030131 1030131 0 All MEDICAID OFFSET ($1,454.70) 12 1030101 1030101 0 PART 8 CIA ADJUSTMENT ($46.38) 12 1030101 1030101 0 C/A-X-RAY - T188 ($24.63) 12 1030101 1030101 0 COINSURANCE ADJUSTMENT $19.98 12 1030101 1030101 0 CIA-X. RAY - T188 $24.63 12 1030102 1030102 1 ST SP/COMM TX 92507 $81.15 12 1030102 1030127 1 MEDICARE 8 DEDUCT OFFSET ($100.00) 12 1030102 1030127 1 MEDICARE 8 DEDUCT OFFSET $100.00 12 1030102 1030127 1 MEDICARE 8 DEDUCT OFFSET ($100.00) 12 1030102 1030127 0 MEDICARE 8 COINS OFFSET ($276.58) 12 1030103 1030103 1 ST SP/COMM TX 92507 $81.15 12 1030106 1030106 1 ST SPfCOMM TX 92507 $81.15 12 1030107 1030107 1 ST SP/COMM TX 92507 $81.15 12 1030109 1030109 1 ST SP/COMM TX 92507 $81.15 12 1030110 1030110 1 ST SP/COMM TX 92507 $81.15 12 1030113 1030113 1 ST SP/COMM TX 92507 $81.15 12 1030114 1030114 1 ST SP/COMM TX 92507 $81.15 12 1030115 1030115 1 ST SP/COMM TX 92507 $81.15 12 1030116 1030116 1 ST SP/COMM TX 92507 $81.15 12 1030121 1030121 1 ST SP/COMM TX 92507 $81.15 12 1030122 1030122 1 ST SP/COMM TX 92507 $81.15 12 1030123 1030123 1 ST SP/COMM TX 92507 $81.15 12 1030123 1030123 1 XRAY HCPC 74000 $20.79 12 1030123 1030123 1 XRAY SET-UP HCPC 00092 $12.37 12 1030123 1030123 1 XRAY TRANSP HCPC R0070 $132.51 12 1030124 1030124 1 ST SP/COMM TX 92507 $81.15 . 12 1030127 1030127 1 ST SP/COMM TX 92507 $81.15 12 1030220 1030220 0 PMT 02/20/03 000000000000505 ($893.80) 12 1030226 1030226 0 PMT 02/26/03 000000000000508 $893.80 12 1030226 1030226 0 PMT 02126/03 000000000000508 ($979.94) 1 1030201 1030201 0 PRIVATE B PREMIUM DEDUCTION ($58.70) 1 1030201 1030228 0 AVAILABLE INCOME FOR 02/03 $1,454.70 1 1030203 1030203 0 PAYMENT 02/03/03 THANK YOU ($1,396.00) 3 1030201 1030201 3 DRESS ADAPTIC 3X3 ST $0.00 3 1030201 1030201 6 GAUZE STRETCH 3" NS $0.00 3 1030201 1030201 6 GAUZE VERSALON SPG 4X4 ST $0.00 3 1030201 1030201 8 GAUZE ABD PAD 5X9 ST $0.00 3 1030201 1030201 0 BAD DEBT - NON REIMB T18B ($48.69) 3 1030201 1030201 0 MEDICAID B PREMIUM DEDUCTION $58.70 3 1030201 1030228 28 20 SNF - SKILLED NURSING FAC $3,843.28 3 1030201 1030205 0 MEDICARE B COINSURANCE $48.69 3 1030204 1030204 1 PRESCRIPTION DRUGS $0.00 3 1030205 1030205 1 PRESCRIPTION DRUGS $0.00 3 1030209 1030209 1 PRESCRIPTION DRUGS $0.00 3 1030209 1030209 1 PRESCRIPTION DRUGS $0.00 3 1030210 1030210 1 PRESCRIPTION DRUGS $0.00 3 1030218 1030218 1 PRESCRIPTION DRUGS $0.00 3 1030219 1030219 1 PRESCRIPTION DRUGS $0.00 3 1030219 1030219 1 PRESCRIPTION DRUGS $0.00 3 1030220 1030220 1 PRESCRIPTION DRUGS $0.00 3 1030220 1030220 1 PRESCRIPTION DRUGS $0.00 3 1030221 1030221 1 PRESCRIPTION DRUGS $000 3 1030224 1030224 1 PRESCRIPTION DRUGS $0.00 3 1030228 1030228 0 All MEDICAID OFFSET ($1,454.70) 12 1030201 1030201 1 ST SP/COMM TX 92507 $81.15 12 1030201 1030205 0 MEDICARE B COINS OFFSET ($48.69) 12 1030202 1030202 1 ST SP/COMM TX 92507 $81.15 12 1030205 1030205 1 ST SP/COMM TX 92507 $81.15 12 1030320 1030320 0 PMT 03/20/03 000000000000514 ($194.76) 1 1030301 1030301 0 PRIVATE B PREMIUM DEDUCTION ($58.70) 1 1030301 1030331 0 AVAILABLE INCOME FOR 03/03 $1,454.70 1 1030303 1030303 0 PAYMENT 03/03/03 THANK YOU ($1,396.00) 3 1030301 1030301 0 MEDICAID B PREMIUM DEDUCTION $58.70 3 1030301 1030316 16 20 SNF - SKILLED NURSING FAC $2,196.16 3 1030302 1030302 1 PRESCRIPTION DRUGS $0.00 3 1030304 1030304 1 PRESCRIPTION DRUGS $0.00 3 1030304 1030304 1 PRESCRIPTION DRUGS $0.00 3 1030304 1030304 1 PRESCRIPTION DRUGS $0.00 3 1030306 1030306 1 PRESCRIPTION DRUGS $000 3 1030313 1030313 1 PRESCRIPTION DRUGS $0.00 3 1030315 1030315 1 PRESCRIPTION DRUGS $0.00 3 1030317 1030317 1 PRESCRIPTION DRUGS $0.00 3 1030317 1030318 2 30 SNF - HOSPITAL BED HOLD $91.50 3 1030319 1030331 13 20 SNF - SKILLED NURSING FAC $1,78438 3 1030324 1030324 1 PRESCRIPTION DRUGS $0.00 3 1030324 1030324 1 PRESCRIPTION DRUGS $0.00 3 1030331 1030331 0 All MEDICAID OFFSET ($1,454.70) 1 1030401 1030401 0 PRIVATE B PREMIUM DEDUCTION ($58.70) . . 1 1030401 1030430 0 AVAILABLE INCOME FOR 04/03 $1,454.70 1 1030403 1030403 0 PAYMENT 04/03/03 THANK YOU ($1,396.00) 3 1030401 1030401 0 MEDICAID B PREMIUM DEDUCTION $58.70 3 1030401 1030401 1 PRESCRIPTION DRUGS $0.00 3 1030401 1030401 1 PRESCRIPTION DRUGS $0.00 3 1030401 1030401 1 PRESCRIPTION DRUGS $0.00 3 1030401 1030430 30 20 SNF - SKILLED NURSING FAC $4,095.30 3 1030403 1030403 1 PRESCRIPTION DRUGS $0.00 3 1030408 1030408 1 PRESCRIPTION DRUGS $0.00 3 1030410 1030410 1 PRESCRIPTION DRUGS $0.00 3 1030420 1030420 1 PRESCRIPTION DRUGS $0.00 3 1030421 1030421 1 PRESCRIPTION DRUGS $0.00 3 1030423 1030423 1 PRESCRIPTION DRUGS $0.00 3 1030424 1030424 1 PRESCRIPTION DRUGS $0.00 3 1030425 1030425 1 PRESCRIPTION DRUGS $0.00 3 1030425 1030425 1 PRESCRIPTION DRUGS $0.00 3 1030427 1030427 1 PRESCRIPTION DRUGS $0.00 3 1030430 1030430 0 All MEDICAID OFFSET ($1,454.70) 1 1030501 1030501 0 PRIVATE B PREMIUM DEDUCTION ($58.70) 1 1030501 1030531 0 AVAILABLE INCOME FOR 05/03 $1,454.70 1 1030502 1030502 0 PAYMENT 05/02/03 THANK YOU ($1,39600) 3 1030501 1030501 0 MEDICAID B PREMIUM DEDUCTION $58.70 3 1030501 1030531 31 20 SNF - SKILLED NURSING FAC $4,231.81 3 1030502 1030502 1 PRESCRIPTION DRUGS $0.00 3 1030503 1030503 1 PRESCRIPTION DRUGS $000 3 1030506 1030506 1 PRESCRIPTION DRUGS $0.00 3 1030510 1030510 1 PRESCRIPTION DRUGS $0.00 3 1030510 1030510 1 PRESCRIPTION DRUGS $0.00 3 1030510 1030510 1 PRESCRIPTION DRUGS $0.00 3 1030515 1030515 1 PRESCRIPTION DRUGS $0.00 3 1030516 1030516 1 PRESCRIPTION DRUGS $000 3 1030519 1030519 1 PRESCRIPTION DRUGS $0.00 3 1030520 1030520 1 PRESCRIPTION DRUGS $0.00 3 1030522 1030522 1 PRESCRIPTION DRUGS $0.00 3 1030526 1030526 1 PRESCRIPTION DRUGS $0.00 3 1030526 1030526 1 PRESCRIPTION DRUGS $0.00 3 1030527 1030527 1 PRESCRIPTION DRUGS $0.00 3 1030528 1030528 1 PRESCRIPTION DRUGS $0.00 3 1030528 1030528 1 PRESCRIPTION DRUGS $0.00 3 1030531 1030531 1 PRESCRIPTION DRUGS $0.00 3 1030531 1030531 0 All MEDICAID OFFSET ($1,454.70) 1 1030601 1030601 0 PRIVATE B PREMIUM DEDUCTION ($58.70) 1 1030601 1030630 0 AVAILABLE INCOME FOR 06/03 $1,454.70 1 1030601 1030601 0 INTEREST ADJUSTMENT ($4.58) 1 1030603 1030603 0 PAYMENT 06/03/03 THANK YOU ($1,396.00) 1 1030630 1030630 0 INTEREST ON BAL. OF 305.41 $4.58 2 1030601 1030601 0 W/O - MEDICARE A SMALL BALANCE ($0.03) 2 1030614 1030627 14 MEDICARE FULL DAYS - SE231 $4,306.12 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 . 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 2 1030615 1030615 1 PRESCRIPTION DRUGS $0.00 2 1030616 1030616 1 PRESCRIPTION DRUGS $0.00 2 1030617 1030617 1 PRESCRIPTION DRUGS $0.00 2 1030618 1030618 1 LABORATORY $0.00 2 1030620 1030620 1 PRESCRIPTION DRUGS $0.00 2 1030625 1030625 1 OVER THE COUNTER(OTC) $0.00 2 1030628 1030630 3 MEDICARE FULL DAYS - CA107 $627.39 2 1030629 1030629 1 DRAIN BAG W/ANTI REFLUX $0.00 2 1030721 1030721 0 PMT 07/21/03 000000000000554 ($4,933.48) 3 1030601 1030601 0 MEDICAID B PREMIUM DEDUCTION $58.70 3 1030601 1030606 1 BED RENTAL $0.00 3 1030601 1030608 8 20 SNF - SKILLED NURSING FAC $1,092.08 3 1030603 1030603 1 PRESCRIPTION DRUGS $0.00 3 1030603 1030603 1 PRESCRIPTION DRUGS $0.00 3 1030603 1030603 1 PRESCRIPTION DRUGS $0.00 3 1030603 1030603 1 PRESCRIPTION DRUGS $0.00 3 1030603 1030603 1 PRESCRIPTION DRUGS $0.00 3 1030603 1030603 1 PRESCRIPTION DRUGS $0.00 3 1030603 1030603 1 PRESCRIPTION DRUGS $0.00 3 1030603 1030603 1 PRESCRIPTION DRUGS $0.00 3 1030603 1030606 1 TRAPEZE - RENTAL $0.00 3 1030604 1030604 1 PRESCRIPTION DRUGS $0.00 3 1030605 1030605 1 PRESCRIPTION DRUGS $0.00 3 1030608 1030608 1 PRESCRIPTION DRUGS $0.00 3 1030609 1030613 5 30 SNF - HOSPITAL BED HOLD $227.50 3 1030630 1030630 0 All MEDICAID OFFSET ($1,454.70) 1 1030701 1030731 0 AVAILABLE INCOME FOR 07/03 $1,454.70 1 1030701 1030701 0 AVAILABLE INCOME ADJUSTMENT ($1,454.70) 1 1030701 1030701 0 INTEREST ADJUSTMENT ($4.58) 1 1030701 1030701 0 COINSURANCE ADJUSTMENT $2.753.24 1 1030703 1030703 0 PAYMENT 07/03/03 THANK YOU ($1,396.00) 1 1030731 1030731 0 INTEREST ON BAL. OF 305.41 $4.58 2 1030701 1030701 1 BED RENTAL $0.00 2 1030701 1030701 1 TRAPEZE - RENTAL $0.00 2 1030701 1030701 0 W/O - MEDICARE A SMALL BALANCE ($0.13) 2 1030701 1030703 3 MEDICARE FULL DAYS - CA107 $627.39 2 1030701 1030731 0 MEDICARE A COINS OFFSET ($186.76) 2 1030701 1030731 0 MEDICARE A REIM BAD DEBT ($2,753.24) 2 1030701 1030701 0 WRITE-OFF REIMB. MEDICARE A $2,753.24 2 1030701 1030701 0 COINSURANCE ADJUSTMENT ($2,753.24) 2 1030702 1030702 1 PRESCRIPTION DRUGS $0.00 2 1030704 1030713 10 MEDICARE COIN DAYS - CA107 $2,091.30 2 1030710 1030710 1 PRESCRIPTION DRUGS $0.00 2 1030711 1030711 1 PRESCRIPTION DRUGS $0.00 . . 2 1030714 1030731 18 MEDICARE COIN DAYS - SSA02 $4,484.34 2 1030724 1030724 1 PRESCRIPTION DRUGS $0.00 2 1030818 1030818 0 PMT 08/18/03 000000000000564 ($4,262.90) 3 1030701 1030731 0 MEDICARE A COINSURANCE $186.76 1 1030801 1030801 0 PAYMENT 08/01/03 THANK YOU ($1,396.00) 1 1030801 1030801 0 PRIVATE B PREMIUM DEDUCTION ($58.70) 1 1030801 1030801 0 AVAILABLE INCOME ADJUSTMENT $1,454.70 1 1030801 1030831 0 AVAILABLE INCOME FOR 08103 $1,454.70 1 1030801 1030801 0 AVAILABLE INCOME ADJUSTMENT ($1,454.70) 1 1030801 1030801 0 COINSURANCE ADJUSTMENT $2,513.28 2 1030801 1030801 1 PRESCRIPTION DRUGS $0.00 2 1030801 1030801 1 URINARY LEG BAG MEDIUM $0.00 2 1030801 1030812 12 MEDICARE COIN DAYS - SSA02 $2,989.56 2 1030801 1030831 0 MEDICARE A COINS OFFSET ($426.72) 2 1030801 1030831 0 MEDICARE A REIM BAD DEBT ($2,513.28) 2 1030801 1030801 0 W/O - MEDICARE A SMALL BALANCE ($0.16) 2 1030801 1030801 0 WRITE-OFF REIMB. MEDICARE A $2,513.28 2 1030801 1030801 0 COINSURANCE ADJUSTMENT ($2,51328) 2 1030806 1030806 1 LABORATORY $0.00 2 1030808 1030808 1 PRESCRIPTION DRUGS $0.00 2 1030809 1030809 1 PRESCRIPTION DRUGS $0.00 2 1030809 1030809 1 PRESCRIPTION DRUGS $0.00 2 1030811 1030811 1 PRESCRIPTION DRUGS $0.00 2 1030811 1030811 1 PRESCRIPTION DRUGS $0.00 2 1030811 1030811 1 PRESCRIPTION DRUGS $0.00 2 1030811 1030811 1 PRESCRIPTION DRUGS $0.00 2 1030811 1030811 1 PRESCRIPTION DRUGS $0.00 2 1030811 1030811 1 LABORATORY $000 2 1030813 1030813 1 LABORATORY $0.00 2 1030813 1030828 16 MEDICARE COIN DAYS - CA103 $3,34608 2 1030819 1030819 1 PRESCRIPTION DRUGS $0.00 2 1030822 1030822 1 PRESCRIPTION DRUGS $0.00 2 1030822 1030822 1 PRESCRIPTION DRUGS $0.00 2 1030822 1030822 1 PRESCRIPTION DRUGS $0.00 2 1030822 1030822 1 PRESCRIPTION DRUGS $0.00 2 1030822 1030822 1 PRESCRIPTION DRUGS $000 2 1030822 1030822 1 PRESCRIPTION DRUGS $0.00 2 1030822 1030822 1 PRESCRIPTION DRUGS $0.00 2 1030930 1030930 0 PMT 09/30/03 000000000000588 ($3,395.48) 3 1030801 1030801 0 MEDICAID B PREMIUM DEDUCTION $58.70 3 1030801 1030828 0 MEDICARE A COINSURANCE $426.72 3 1030829 1030831 3 20 SNF - SKILLED NURSING FAC $409.53 3 1030831 1030831 0 All MEDICAID OFFSET ($1,454.70) 1 1030901 1030901 0 PRIVATE B PREMIUM DEDUCTION ($58.70) 1 1030901 1030930 0 AVAILABLE INCOME FOR 09/03 $1,454.70 1 1030903 1030903 0 PAYMENT 09/03/03 THANK YOU ($1,396.00) 3 1030901 1030901 0 MEDICAID B PREMIUM DEDUCTION $58.70 3 1030901 1030930 30 20 SNF - SKILLED NURSING FAC $4,095.30 3 1030901 1030901 0 BAD DEBT - NON REIMB T18B ($327.95) 3 1030915 1030930 0 MEDICARE B COINSURANCE $327.95 3 1030930 1030930 0 All MEDICAID OFFSET ($1,454.70) 3 1030930 1030930 1 STOCKING JOBST KNEE HIGH $0.00 . . 12 1030901 1030901 0 W/O-NO LONGER COST EFFECTIVE ($0.09) 12 1030915 1030915 1 PT EVALUATION 97001 $77.48 12 1030915 1030915 2 PT THER ACT 97530 $60.10 12 1030915 1030930 0 MEDICARE B COINS OFFSET ($327.95) 12 1030916 1030916 1 OT EVALUATION 97003 $82.70 12 1030916 1030916 1 OT THERAPEUTIC ACT 97530 $30.05 12 1030916 1030916 1 OT ADL 97535 $32.43 12 1030916 1030916 1 PT THER EX 97110 $29.74 12 1030916 1030916 1 PT NEUROM REED 97112 $30.43 12 1030916 1030916 1 PT THER ACT 97530 $30.05 12 1030917 1030917 1 OT THERAPEUTIC EX 97110 $29.74 12 1030917 1030917 2 OT NEUROM USC REED 97112 $60.86 12 1030917 1030917 1 OT ADL 97535 $32.43 12 1030918 1030918 1 OT THERAPEUTIC EX 97110 $29.74 12 1030918 1030918 2 OT NEUROM USC REED 97112 $60.86 12 1030918 1030918 1 OT ADL 97535 $32.43 12 1030918 1030918 1 PT THER EX 97110 $29.74 12 1030918 1030918 1 PT THER ACT 97530 $30.05 12 1030919 1030919 1 OT THERAPEUTIC EX 97110 $29.74 12 1030919 1030919 2 OT THERAPEUTIC ACT 97530 $60.10 12 1030922 1030922 1 OT THERAPEUTIC EX 97110 $29.74 12 1030922 1030922 1 OT NEUROM USC REED 97112 $30.43 12 1030922 1030922 1 OT THERAPEUTIC ACT 97530 $30.05 12 1030922 1030922 1 OT ADL 97535 $32.43 12 1030922 1030922 1 PT THER EX 97110 $29.74 12 1030922 1030922 1 PT GAIT TRAINING 97116 $26.13 12 1030922 1030922 1 PT THER ACT 97530 $30.05 12 1030923 1030923 1 PT THER EX 97110 $29.74 12 1030923 1030923 1 PT NEUROM REED 97112 $30.43 12 1030923 1030923 1 PT GAIT TRAINING 97116 $26.13 12 1030924 1030924 1 OT THERAPEUTIC EX 97110 $29.74 12 1030924 1030924 1 OT NEUROM USC REED 97112 $30.43 12 1030924 1030924 1 OT THERAPEUTIC ACT 97530 $30.05 12 1030924 1030924 1 OT ADL 97535 $32.43 12 1030925 1030925 1 PTTHEREX97110 $29.74 12 1030925 1030925 1 PT THER ACT 97530 $30.05 12 1030929 1030929 1 OT THERAPEUTIC EX 97110 $29.74 12 1030929 1030929 1 OT NEUROM USC REED 97112 $30.43 12 1030929 1030929 1 OT THERAPEUTIC ACT 97530 $30.05 12 1030929 1030929 1 OT ADL 97535 $32.43 12 1030929 1030929 1 PT THER EX 97110 $29.74 12 1030929 1030929 1 PT GAIT TRAINING 97116 $26.13 12 1030930 1030930 1 OT THERAPEUTIC EX 97110 $29.74 12 1030930 1030930 1 OT NEUROM USC REED 97112 $30.43 12 1030930 1030930 2 OT ADL 97535 $64.86 12 1030930 1030930 1 PT THER EX 97110 $29.74 12 1030930 1030930 1 PT NEUROM REED 97112 $30.43 12 1030930 1030930 0 PT GAIT TRAINING 97116 $0.00 12 1030930 1030930 1 PT THER ACT 97530 $30.05 12 1031021 1031021 0 PMT 10/21/03 000000000000596 ($1,311.71) 1 1031001 1031031 0 AVAILABLE INCOME FOR 10103 $1,454.70 1 1031001 1031001 0 PRIVATE B PREMIUM DEDUCTION ($58.70) . . 1 1031003 1031003 0 PAYMENT 10/03/03 THANK YOU ($1,39600) 3 1031001 1031031 31 20 SNF - SKILLED NURSING FAC $4,23181 3 1031001 1031001 0 MEDICAID B PREMIUM DEDUCTION $58.70 3 1031001 1031001 0 BAD DEBT - NON REIMB T18B ($219.94) 3 1031001 1031014 0 MEDICARE B COINSURANCE $219.94 3 1031031 1031031 1 CURITY NON-ADH 3X3 $0.00 3 1031031 1031031 1 ENEMA PHOSPHATE GENTL-TIP $0.00 3 1031031 1031031 0 All MEDICAID OFFSET ($1,454.70) 12 1031001 1031001 1 OT THERAPEUTIC EX 97110 $29.74 12 1031001 1031001 2 OT NEUROM USC REED 97112 $60.86 12 1031001 1031001 1 OT THERAPEUTIC ACT 97530 $30.05 12 1031001 1031001 1 OT ADL 97535 $32.43 12 1031001 1031001 0 W/O-NO LONGER COST EFFECTIVE ($0.08) 12 1031001 1031014 0 MEDICARE B COINS OFFSET ($219.94) 12 1031003 1031003 1 PT THER EX 97110 $29.74 12 1031003 1031003 1 PT GAIT TRAINING 97116 $26.13 12 1031003 1031003 1 PT THER ACT 97530 $30.05 12 1031006 1031006 1 PT THER EX 97110 $29.74 12 1031006 1031006 1 PT NEUROM REED 97112 $30.43 12 1031006 1031006 1 PT GAIT TRAINING 97116 $26.13 12 1031007 1031007 1 OT THERAPEUTIC EX 97110 $29.74 12 1031007 1031007 1 OT NEUROM USC REED 97112 $30.43 12 1031007 1031007 1 OT THERAPEUTIC ACT 97530 $30.05 12 1031007 1031007 1 OT ADL 97535 $32.43 12 1031007 1031007 1 PT THER EX 97110 $29.74 12 1031007 1031007 1 PT NEUROM REED 97112 $30.43 12 1031007 1031007 1 PT GAIT TRAINING 97116 $26.13 12 1031009 1031009 1 PT THER EX 97110 $29.74 12 1031009 1031009 1 PT THER ACT 97530 $30.05 12 1031010 1031010 1 OT THERAPEUTIC EX 97110 $29.74 12 1031010 1031010 1 OT NEUROM USC REED 97112 $30.43 12 1031010 1031010 2 OT THERAPEUTIC ACT 97530 $60.10 12 1031013 1031013 1 OT THERAPEUTIC EX 97110 $29.74 12 1031013 1031013 1 OT NEUROM USC REED 97112 $30.43 12 1031013 1031013 1 OT THERAPEUTIC ACT 97530 $30.05 12 1031013 1031013 1 OT ADL 97535 $32.43 12 1031013 1031013 1 PT THER EX 97110 $29.74 12 1031013 1031013 1 PT NEUROM REED 97112 $30.43 12 1031013 1031013 1 PT GAIT TRAINING 97116 $26.13 12 1031013 1031013 1 PT THER ACT 97530 $30.05 12 1031014 1031014 1 OT THERAPEUTIC ACT 97530 $30.05 12 1031014 1031014 1 PT THER EX 97110 $29.74 12 1031014 1031014 1 PT NEUROM REED 97112 $30.43 12 1031014 1031014 1 PT GAIT TRAINING 97116 $26.13 12 1031014 1031014 1 PT THER ACT 97530 $30.05 12 1031121 1031121 0 PMT 11/21/03 000000000000610 ($87969) 1 1030905 1030905 0 PAYMENT 09/05/03 THANK YOU ($150.00) 1 1031101 1031130 0 AVAILABLE INCOME FOR 11/03 $1,454.70 1 1031101 1031101 0 PRIVATE B PREMIUM DEDUCTION ($58.70) 1 1031103 1031103 0 PAYMENT 11/03/03 THANK YOU ($1,396.00) 3 1031101 1031130 30 20 SNF - SKILLED NURSING FAC $4,095.30 3 1031101 1031101 0 MEDICAID B PREMIUM DEDUCTION $58.70 . . 3 1031130 1031130 0 All MEDICAID OFFSET ($1,454.70) 1 1031201 1031231 0 AVAILABLE INCOME FOR 12/03 $1,454.70 1 1031201 1031201 0 PRIVATE B PREMIUM DEDUCTION ($58.70) 1 1031203 1031203 0 PAYMENT 12/03/03 THANK YOU ($1,396.00) 3 1031201 1031231 31 20 SNF - SKILLED NURSING FAC $4,231.81 3 1031201 1031201 0 MEDICAID B PREMIUM DEDUCTION $58.70 3 1031201 1031201 1 GAUZE SPG 4X4 12PL Y ST $000 3 1031201 1031201 3 GAUZE STRETCH 3" ST $0.00 3 1031201 1031201 1 ALOE VEST A ANTIFUNGAL 50Z $0.00 3 1031201 1031201 0 BAD DEBT - NON REIMB T18B ($16.54) 3 1031231 1031231 0 All MEDICAID OFFSET ($1,454.70) 3 1031231 1031231 0 MEDICARE B COINSURANCE $16.54 12 1031231 1031231 1 OT EVALUATION 97003 $82.70 12 1031231 1031231 0 MEDICARE B COINS OFFSET ($16.54) 12 1040122 1040122 0 PMT 01/22/04 000000000000638 ($66.16) 1 1040101 1040131 0 AVAILABLE INCOME FOR 01/04 $1,454.70 1 1040101 1040101 0 PRIVATE B PREMIUM DEDUCTION ($66.60) 1 1040102 1040102 0 PAYMENT 01/02/04 THANK YOU ($1,419.00) 3 1040101 1040131 31 20 SNF - SKILLED NURSING FAC $4,231.81 3 1040101 1040101 0 MEDICAID B PREMIUM DEDUCTION $66.60 3 1040101 1040101 0 BAD DEBT - NON REIMB T18B ($144.82) 3 1040102 1040130 0 MEDICARE B DEDUCTIBLE $59.23 3 1040102 1040130 0 MEDICARE B COINSURANCE $216.51 3 1040131 1040131 0 All MEDICAID OFFSET ($1,454.70) 12 1040101 1040101 0 CIA - T18B OCCUP THERAPY $11.89 12 1040102 1040102 1 OT EVALUATION 97003 $84.04 12 1040102 1040102 1 OT NEUROM USC REED 97112 $30.47 12 1040102 1040130 1 MEDICARE B DEDUCT OFFSET ($59.23) 12 1040102 1040130 0 MEDICARE B COINS OFFSET ($216.51) 12 1040105 1040105 1 OT NEUROM USC REED 97112 $30.47 12 1040105 1040105 1 OT THERAPEUTIC EX 97110 $30.70 12 1040108 1040108 1 OT NEUROM USC REED 97112 $30.47 12 1040108 1040108 1 OT THERAPEUTIC EX 97110 $30.70 12 1040108 1040108 1 OT COG SKILLS DEV 97532 $25.89 12 1040109 1040109 1 OT NEUROM USC REED 97112 $30.47 12 1040109 1040109 1 OT THERAPEUTIC EX 97110 $30.70 12 1040109 1040109 1 OT COG SKILLS DEV 97532 $25.89 12 1040112 1040112 1 OT THERAPEUTIC EX 97110 $30.70 12 1040112 1040112 1 OT NEUROM USC REED 97112 $30.47 12 1040112 1040112 1 OT COG SKILLS DEV 97532 $25.89 12 1040114 1040114 1 OT THERAPEUTIC EX 97110 $30.70 12 1040114 1040114 1 OT NEUROM USC REED 97112 $30.47 12 1040119 1040119 1 OT NEUROM USC REED 97112 $30.47 12 1040119 1040119 2 OT THERAPEUTIC ACT 97530 $61.80 12 1040120 1040120 2 OT NEUROM USC REED 97112 $60.94 12 1040120 1040120 2 OT THERAPEUTIC ACT 97530 $61.80 12 1040122 1040122 2 OT THERAPEUTIC ACT 97530 $61.80 12 1040126 1040126 3 OT THERAPEUTIC ACT 97530 $92.70 12 1040128 1040128 2 OT NEUROM USC REED 97112 $60.94 12 1040128 1040128 2 OT THERAPEUTIC ACT 97530 $61.80 12 1040130 1040130 1 OT NEUROM USC REED 97112 $30.47 12 1040130 1040130 2 OT THERAPEUTIC ACT 97530 $61.80 . - 12 1040223 1040223 0 PMT 02/23/04 000000000704221 ($818.70) 1 1040201 1040229 0 AVAILABLE INCOME FOR 02/04 $1,454.70 1 1040201 1040201 0 PRIVATE B PREMIUM DEDUCTION ($66.60) 1 1040202 1040202 0 PAYMENT 02/02/04 THANK YOU ($7.00) 1 1040203 1040203 0 PAYMENT 02/03/04 THANK YOU ($1,419.00) 3 1040201 1040229 29 20 SNF - SKILLED NURSING FAC $3,958.79 3 1040201 1040201 0 MEDICAID B PREMIUM DEDUCTION $66.60 3 1040201 1040201 0 BAD DEBT - NON REIMB T18B ($145.54) 3 1040203 1040227 0 MEDICARE B COINSURANCE $145.54 3 1040229 1040229 0 NI MEDICAID OFFSET ($1,454.70) 12 1040203 1040203 2 aT NEUROM USC REED 97112 $60.94 12 1040203 1040227 0 MEDICARE B COINS OFFSET ($145.54) 12 1040204 1040204 2 OT NEUROM USC REED 97112 $60.94 12 1040204 1040204 1 OT COG SKILLS DEV 97532 $25.89 12 1040212 1040212 2 OT NEUROM USC REED 97112 $60.94 12 1040212 1040212 2 OT THERAPEUTIC ACT 97530 $61.80 12 1040216 1040216 1 OT NEUROM USC REED 97112 $30.47 12 1040216 1040216 1 aT THERAPEUTIC ACT 97530 $30.90 12 1040216 1040216 2 OT COG SKILLS DEV 97532 $5178 12 1040219 1040219 1 OT NEUROM USC REED 97112 $30.47 12 1040219 1040219 2 OT THERAPEUTIC ACT 97530 $61.80 12 1040220 1040220 1 OT NEUROM USC REED 97112 $30.47 12 1040220 1040220 1 OT THERAPEUTIC ACT 97530 $30.90 12 1040224 1040224 1 OT NEUROM USC REED 97112 $30.47 12 1040224 1040224 2 OT COG SKILLS DEV 97532 $5178 12 1040225 1040225 1 OT COG SKILLS DEV 97532 $25.89 12 1040227 1040227 1 OT NEUROM USC REED 97112 $30.47 12 1040227 1040227 2 aT COG SKILLS DEV 97532 $5178 12 1040318 1040318 0 PMT 03/18/04 000000007040318 ($582.15) 1 1040301 1040331 0 AVAILABLE INCOME FOR 03/04 $1,454.70 1 1040301 1040301 0 PRIVATE B PREMIUM DEDUCTION ($66.60) 1 1040303 1040303 0 PAYMENT 03/03/04 THANK YOU ($1,419.00) 3 1040301 1040331 31 20 SNF . SKILLED NURSING FAC $4,231.81 3 1040301 1040330 0 MEDICARE B COINSURANCE $129.31 3 1040301 1040301 0 MEDICAID B PREMIUM DEDUCTION $66.60 3 1040301 1040301 0 WRITE-OFF REIMB MEDICARE B ($23.68) 3 1040301 1040301 0 BAD DEBT - NON REIMB T18B ($105.63) 3 1040331 1040331 0 All MEDICAID OFFSET ($1,454.70) 12 1040301 1040301 2 OT NEUROM USC REED 97112 $60.94 12 1040301 1040330 0 MEDICARE B COINS OFFSET ($129.31) 12 1040301 1040301 0 PART B C/AADJUSTMENT ($41.44) 12 1040301 1040301 0 W/O-NO LONGER COST EFFECTIVE ($0.01) 12 1040303 1040303 1 XRAY HCPC 71010 $20.21 12 1040303 1040303 1 XRAY SET-UP HCPC 00092 $13.57 12 1040303 1040303 1 XRA Y TRANSP HCPC R0070 $118.41 12 1040304 1040304 1 OT NEUROM USC REED 97112 $30.47 12 1040304 1040304 2 aT COG SKILLS DEV 97532 $51.78 12 1040308 1040308 1 OT NEUROM USC REED 97112 $30.47 12 1040309 1040309 2 OT COG SKILLS DEV 97532 $5178 12 1040310 1040310 1 OT COG SKILLS DEV 97532 $25.89 12 1040317 1040317 1 OT THERAPEUTIC ACT 97530 $30.90 12 1040319 1040319 1 OT THERAPEUTIC ACT 97530 $30.90 . . 12 1040322 1040322 1 OT COG SKILLS DEV 97532 $25.89 12 1040324 1040324 2 OT COG SKILLS DEV 97532 $51.78 12 1040325 1040325 2 OT COG SKILLS DEV 97532 $51.78 12 1040330 1040330 2 OT COG SKILLS DEV 97532 $51.78 12 1040422 1040422 0 PMT 04/22/04 000000007042204 ($475.79) 1 1040401 1040430 0 AVAILABLE INCOME FOR 04/04 $1,454.70 1 1040401 1040401 0 PRIVATE B PREMIUM DEDUCTION ($66.60) 1 1040402 1040402 0 PAYMENT 04/02/04 THANK YOU ($1,419.00) 3 1040401 1040430 30 20 SNF - SKILLED NURSING FAC $4,095.30 3 1040401 1040401 0 MEDICAID B PREMIUM DEDUCTION $66.60 3 1040430 1040430 0 All MEDICAID OFFSET ($1,454.70) Amount after 8/02 $57,703,55 . , ~ , VERIFICATION The undersigned does hereby verify subject to the penalties of 18 PA. C.S. 4904 relating 1),~;J _S. ~4it P.~5 (NAMI=) . [d{ VlJuAtr'-1? /-kat h/1 ,plaintiff herein, that (COMPANY) to unsworn falsifications to authorities, that he/she is .1 1/, / [f);fjr'lk ~l!eJ/()!1} ~r' of (TITLE) he/she is duly authorized to make this verification, and that the facts set forth in the foregoing Complaint are true and correct to the best of his/her knowledge, in~ on and belief. WWR# 03230089 /' (:) ~ G D ~ ~ 1'-' 0 ,_., -n \t " '." c.'" ,-4 If( , rhE: ~ -'"" ;) - () /-) r ~ ()J -.!::. ) _'.v ...0 W . -'= J r;~? Cr/ b ,) - f"_) " II w t ---..L.. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION TOWNE MANOR EAST Plaintiff No, 05-2433 CIVIL TERM vs. PRAECIPE TO SETTLE, DISCONTINUE AND END WITHOUT PREJUDICE TO REFILE JEFFREY 0 MILLAWAY AND SUSAN MILLAWAY Defendant FILED ON BEHALF OF Plaintiff COUNSEL OF RECORD OF THIS PARTY: James C, Warmbrodt PA 1.0 #42524 WELTMAN, WEINBERG & REIS CO" L.P,A. 2718 Koppers Building 436 Seventh Avenue Pittsburgh, PA 15219 (412) 434-7955 WWR#03230089 . . IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION TOWNE MANOR EAST Plaintiff vs. Civil Action No. 05-2433 CIVIL TERM JEFFREY D MILLAWA Y AND SUSAN MILLAWA Y Defendant PRAECIPE TO SETTLE, DISCONTINUE AND END WITHOUT PREJUDICE TO REFILE TO THE PROTHONOTARY OF CUMBERLAND COUNTY: SIR: Settle, Discontinue and End the above-captioned matter upon the records of the Court without prejudice to refile and mark the costs paid, WELTMAN, WEINBERG & REIS CO., L.P.A. SWORN TO AND SUBSCRIBED this ~ day ,2005 llr'~, t> ".,,,,,;..~n:II:JC-.,,,"",, "~~;',' ;.,..,',,";.-., ;:"t o ~'_-: ,..." = c-::> c.n c_ ~ o .." ~-n n'r -elm -"10 i:l2:') ---{ "4-.i -1: -"'("'I ~,;o OfT! -.; ? :~ w ~ 4~ -" o ';;:" SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2005-02433 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND TOWNE MANOR EAST VS MILLAWAY JEFFREY ET AL R, Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: MILLAWAY JEFFREY but was unable to locate Him in his bailiwick, He therefore deputized the sheriff of MONTGOMERY County, Pennsylvania, to serve the within NOTICE AND COMPLAINT On May 23rd , 2005 , this office was in receipt of the attached return from MONTGOMERY Sheriff's Costs: Docketing Out of County Surcharge Dep Montgomery Co Postage 18.00 9,00 10,00 43,00 ,37 80,37 OS/23/2005 WELTMAN WEINBERG S~. ___"' ~~--'~ -- / -"~~- R, Thomas Kline Sheriff of Cumberland County REIS Sworn and subscribed to before day of 1..,. - /1 (J{2:f A, D , ( _1.0.11 _ (J "'rh~P~L.) J...r' tI I Prothonotary'-=-r"'T me this '" f~ SHERIFF'S RETURN - REGULAR CASE NO: 2005-02433 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND TOWNE MANOR EAST VS MILLAWAY JEFFREY ET AL GERALD WORTHINGTON Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon SHIPE SUSAN MILLAWAY the DEFENDANT at 2000:00 HOURS, on the 13th day of May 2005 at 1330 DOUBLING GAP ROAD NEWVILLE, PA 17241 by handing to SUSAN MILLAWAY SHIPE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof, Sheriff's Costs: Docketing Service Affidavit Surcharge So Answers: 6.00 10,36 ,00 10,00 .00 26,36 .-r-g~~~ R, Thomas Kline OS/23/2005 WELTMAN WEINBERG REIS Sworn and Subscribed to before BY:~~ /A~~' Deputy S riff me this y ~ day of ~~~ ,.J..M}.( A,D, G1;,1.' Q ')rujp,., ~ rothonotary , . ~ In Th~ Court of Common Pleas of Cumberland County, Pennsylvania Towne Manor East VS, Jeffrey Millaway No. 05-2433 civil May 12, 2004 , I, SHERIFF OF CUMBERLAND COUNTY, P A, do Now, hereby deputize the Sheriff of Montganery County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. .."", /" V# .-r'"~~<,~kR Sheriff of Cumberland County, PA Affidavit of Service Now, /8'/1/ V'J l' rfI-1 ~ within I 9rf5 \) v -'<- , ,20.os..-, at /OUCJ o'clock A M. served the upon -:r;;;;.:'/"';?CC-/ r?1 / L {.f3(,./'4/ / ./ at YC ~ v-<::" ae 5J , (17 5' by handing to a copy of the original and made known to / J,rg V ,/,,-- the contents thereof, So answers, ~~ ~CJi/&- Shen fof N~~y County, Sworn and subscribed before me this day of , 20_ COSTS SERVICE MILEAGE AFFIDAVIT $ $ . SHERIFF'S RETURN PROTHONOTARY B- 2043 DEFENDANT: Jeffrey MilIaway DOCUMENT SERVED: Civil INDIVIDUAL SERVED: Jeffrey MilIaway RELATIONSHIP TO DEFENDANT: Defendant DATE AND PREVAILING TIME: May 18,2005 @ 10:00 LOCATION: 2004 Old Arch Rd., Norristown, PA 74e dtwe .ueu"w,e f<UU uwut ~ de Uptt"-<<"t cU flU {+''''dti~" lUtut dtwe "" de ~ ~ ~~",n... e~"''''~''(~'dll' ~ 1J'''''d"trtU{11. ,4UJ-d u4 ~ ~ oM ~ au.w,. 46 d"df<"'l4-, Po4 'P. Zl~ Sheriff of Montgomery County Deputy Sheriff Cavalier NOTARIAL SF l'\l PATRICIA A (,IA^,BIWNE Nolmy Put>l1c NORRISTOWN BOROUGH.MONTGOMERY COUNTY My Commission Expires Dee 13. 2008 MCTIGHE, WEISS, O'ROURKE, TRONCELLITI & MORGAN, P,C, BY: MANRICO A. TRONCELLITI, JR., ESQUIRE ATTORNEY LD. NO.: 31545 II East Airy Street P.O. Box 510 Norristown, PA 19404 (610) 275-8800 Attorney for Defendant Susan MilIaway Shipe TOWNE MANOR EAST COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA v. NO.: 05-2433 CNIL TERM JEFFREY MILLA WAY AND SUSAN MILLA WAY SHIPE JURY TRIAL DEMANDED ENTRY OF APPEARANCE TO THE PROTHONOTARY: Kindly enter my appearance on behalf of Defendant, Susan MilIaway Shipe, in the above-captioned matter. McTIGHE, WEISS, O'ROURKE, TRONCELLITI & MORGAN, P,C. 4 a// BY: ~~ Manrico A, Troncelliti, Jr. Attorney for Defendant Susan Millaway Shipe o C~ r-, ...., = = <.n r (,~ -;; -- o -." 5! ITI.:D r- -"ne :od ~;)Ci -I' -.) ;~~~ ~J --I 5:5 ,< N o -;; 3: .r:- c.n -