HomeMy WebLinkAbout07-29-05
REV-1500 EX + (6-00)
+,
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OFFICIAL USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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[l1. Original Return 0 2. Supplemental Return
o 4. Limited Estate LJ
~ 6. Decedent Died Testate (Attach 0
copy of Will)
09. Litigation Proceeds Received L::l 10 Spousal Povertv Credit (dalaof dea\hbelween 0 11.Election to tax under See 9113(A)(Atlach Sch 0)
.. 12-31-91 and 1-,-95)
THIS SECTION MUST BE'COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIA\..TAA INfORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
Jennifer B. Hipp
FIRM NAME (If applicable)
Bogar and Hipp Law Offices
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Brougher, Sarah E.
DATE OF DEATH (MM-DD-YEAR) --roATE OF BIRTH (MM-DD-YEAR)
01-07-2005 I 06-07-1909
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST AND MIDDLE INITIAL)
FILE NUMBER
II
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COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
NUMBER
201.18.4177
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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3. Remainder Return (date of death prior to 12-13-82)
4a. Future Interest Compromise (date of death atter
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
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TELEPHONE NUMBER
717-737-8761
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L) 0 Separate Billing Requested
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
1 West Main Street
Shiremanstown, PA 17011
(1)
(2)
(3)
(4)
(5)
(6)
(7)
OFFICI~ USE O~~ Y
None
None
None
None
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--1
749.40
318.89
None
N
(8)
1,068.29
(9)
(10)
385.00
124,220.95
(11)
124,605.95
(12)
insolvent
(13)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has
not been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
0.00
(14)
0.00
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
20.0
0.00
0.00
0.00
0.00
0.00
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
"" BE SURE 10 ANSWER At\.. QUfSTIONS ON REVERSE SIDE AND RECHECK MATH <<
Copyright 2002 form software only The Lackner Group, Inc.
15. Amount of Line 14 taxable at the spousal tax rate, 0.00 x .00 (15)
z or transfers under Sec. 9116(a)(1.2)
0 (16)
i= 16. Amount of Line 14 taxable at lineal rate 0.00 x .045
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... 17. Amount of Line 14 taxable at sibling rate 0.00 x .12 (17)
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0
u 18. Amount of Line 14 taxable at collateral rate 0.00 .15 (18)
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I- 19. Tax Due
(19)
Form REV-1500 EX (Rev. 6-00:
J
Oecedent's Complete Address:
STREET ADDRESS
Church of God Home
801 N. Hanover Street
CITY Carlisle
ISTATE PA
!ZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
0.00
0.00
Total Credits (A + B + C)
(2)
0.00
3. Interest'Penalty if applicable
D. I nte rest
E. Penalty
A. Enter the interest on the tax due.
6. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
(5) 0.00
(5A)
(56) 0.00
Totallnterest'Penalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enterthe difference. This is the TAX DUE.
Make Check
to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;................................................................................ D 0x
b. retain the right to designate who shall use the property transferred or its income;................................... [J 0
c. retain a reversionary interest; or............................................................................................................... D 0x
d. receive the promise for life of either payments, benefits or care? ...............................-............................. D 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ." '" ..... .... ...... ... ..... ..... ............... ..... ... ..... ... ... '" ...... ... ... ... ................ .............. D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ......... D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ................................................................................................................... LJ [XJ
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of pe~ury, I c1eclaro that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and
complete. Decl~ration of preparer other than the persOf1al representative is based on all information 01 which preparer has any know\~dge.
SIGN. ATUR.E OF PERSON RESPONSIBLE F[L1NG RETURN ADORESS
Y'itlla S. Bro ghe 633 B Street
ak. ~( Enola, PA 17025
SIGNATURE OF PERSON RESP R FILING RETURN AOORESS
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OATE
'-Vd?;b.5~
.oA TE
OTHER THAN REPRESENTATIVE
AOORESS
"'127) O<S"
OATE
1 West Main Street
Shiremanstown, PA 17011
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. s9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. s9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and fiiing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a
natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. S9116 (a) (1.2)J.
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P .S.
S9116 1.2) [72 P.S. s9116 (a) (1)].
The lax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P .5. s9116 (a) (1.3)]. A sibling is
detined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
Rev-15D8 EX+ (6-98)
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETUAN
RESIDENT DECEDENT
Brougher, Sarah E.
FILE NUMBER
21--
ESTATE OF
Include the proceeds of litigation and the date the proceeds were rec~ived by the estate.
All property jointly-owned wnh the right of survivorship must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION
1 Church of God Home - Resident Trust Fund Account. Account No. 2184, date of
death balance $776.53, final deduction $127.13 (medical and personal care not
covered by Medicaid)
VALUE AT DATE
OF DEATH
649.40
2 Personal Property - Clothing and Chair
100.00
TOTAL (Also enter on Line 5, Recapitulation)
749.40
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule E (Rev. 6-98)
Rev-1509 EX+(6-98)
SCHEDULE F
JOINTL V-OWNED PROPERTV
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Brougher, Sarah E.
FILE NUMBER
21--
ESTATE OF
If an asset wa. made joint within one year of the decedent's date of death, It must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME
A. William S. Brougher
ADDRESS
RELATIONSHIP TO DECEDENT
633 B Street
Enola, PA 17025
Son
B.
C.
JOINTLY OWNED PROPERTY:
DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
LETTER
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT NUMBER OR SIMILAR IDENTIFYING NUMBER ATTACH DEED FOR VALUE OF ASSET INTEREST DECEDENT'S INTEREST
JOINTLY-HELD REAL ESTATE.
1 M&T Bank - Checking Account - Account 637.77 50.000% 318.89
No. 17944481, jointly owned with William
S. Brougher
TOTAL (Also enter on Line 6, Recapitulation) 318.89
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule F (Rev. 6-98)
m1M&fBank
499 Mitchell Road, MilIsboro, DE 19966 Mail Code DE-MB-12
Phone (888) 502-4349
Fax (302) 934-2955
February 8, 2005
James D Bogar
Attorney At Law
One West Main Street
Shiremanstown, Pennsylvania 17011
Re: Estate of Sarah E Brougher
Social Security: 201-18-4177
Date of Death: January 07, 2005
Dear Sir or Madam:
Per your inquiry dated January 25, 2005, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
1.
Type of Account
Checking Account
Account Number
17944481
Ownership (Names oj)
Sarah E Brougher, Joint Owners
William S Brougher, Joint Owners
Opening Date
11/28/80
Balance on Date of Death
$637.77
Accrued Interest
$ 0.00
Total
$637.77
Please be advised, there was no safe deposit box found for the above decedent.
For further account information, regarding ownership, closures and/or reimbursement of funds, etc., please call the
Summerdale Plaza Office # 717-255-2261.
Sincerely,
--:r~~,e-
Nancy Clagett
Records Management
REV-1151 EX+ (12-99)
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SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Brougher, Sarah E.
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21--
ESTATE OF
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
B. ADMINISTRATIVE COSTS:
1. Persona) Representative's Commissions
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Add ress
City State Zip
-
Year(s) Commission paid
2. Attorney's Fees 370.00
See continuation schedule(s) attached
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Retum Preparer's Fees
7. Other Administrative Costs 15.00
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 385.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Scheduie H (Rev. 6-98)
Rev-1M2 EX+ (6-98)
SCHEDULE H-B2
ATTORNEY'S FEES
continued
COMMONWEAL..TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Brougher, Sarah E.
FILE NUMBER
21..
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Jennifer B. Hipp, Esquire - Attorney fees for representation of Estate per agreement
370.00
Subtotal
370.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B2 (Rev. 6-98)
Rev.1502 EX+ (S...gS)
*'
SCHEDULE H.B7
OTHER
ADMINISTRATIVE COSTS
continued
COMMONWEAL.TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Brougher, Sarah E.
FILE NUMBER
21.-
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Register of Wills. filing fee, Pa. Inheritance Tax Return
15.00
Subtotal
15.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B7 (Rev. 6-98)
Rev-1512 EX+ (6-98)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEAl.. TN OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Brougher, Sarah E.
FILE NUMBER
21-.
ESTATE OF
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1 Department of Public Welfare - Claim for restitution of medical assistance per
attached letter
VALUE AT DATE
OF DEATH
124,220.95
TOTAL (Also enter on Line 10, Recapitulation)
124,220.95
(If more space is needed, additional pages of the same size)
Copyright (e) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-98)
.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARi:
BUREAU OF FINANCIAL OPERATIONS
DNlSION OF THIRD PARTY LIABILITY
ESTATE Ri:COVi:RY PROGRAM
PO BOX 8466
HARRISBURG. PA 1T105-84B6
February 1, 2005
JAMES D BOGAR ATTORNEY AT LAW
JENNIFER B HIPP ESQ
ONE WEST MAIN ST
SHIREMANSTOWN PA 17011
Re: SARAH BROUGHER
CIS #: 360157654
SSN: 201-16-4177
Date of Death: 01/07/2005
Dear Attorney Hipp:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $124,220.95 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense, namely $25,215.78, was incurred
during the last six months of the decedent's life; therefore, it is a Class 3
claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $99,005.17, is
to be entered as a priority Class 6 claim against the estate.
please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. If the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sincerely,
f~.-~~
patricia Nace
Claims Investigation Agent
717-772-6616
717-705-8150 FAX
Enclosure
W
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION - CASUAL TV UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
February 1, 2005
STATEMENT OF CLAIM SUMMARY
NAME
ID
Estate of BROUGHER, SARAH
380 157 654
MEDICAL CLASS 3 CLASS 6 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 23,094.96 93,046.48 116,141.44
DRUG 2,120.82 5,958.69 8,079.51
'"
REIMBURSEMENT TO DPW, 25,215.78 99,005.17 124,220.95
"
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN - 23-6003113
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
CHURCH OF GOD HOME INC
801 N HANOVER ST
PA 17013
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN USUAL CHARGES
05/01/02 - 05/31/02 08/12/02 40022214092660001 3,520.18 3,520.18
DIAGNOSIS 1: 3310 ALZHEIMER'S DISEASE
DIAGNOSIS 2: 3625 DEGENERATION OF MACULA
PROC CODE: 000000
06/01/02 - 06/30/02 08/12/02 40022214092670001 3,384.32 3,384.32
DIAGNOSIS 1: 3310 ALZHEIMER'S DISEASE
DIAGNOSIS 2: 3625 DEGENERATION OF MACULA
PROC CODE: 000000
07/01/02 - 07/31/02 11/09/02 60023134673330001 3,520.18 3,486.70
DIAGNOSIS 1: 3310 ALZHEIMER'S DISEASE
DIAGNOSIS 2: 3625 DEGENERATION OF MACULA
PROC CODE: 000000
08/01/02 - 08/31/02 11/09/02 60023134673340001 3,520.18 3,486.70
DIAGNOSIS 1: 3310 ALZHEIMER'S DISEASE
DIAGNOSIS 2: 3625 DEGENERATION OF MACULA
PROC CODE: 000000
09/01/02 - 09/30/02 10/07/02 40022774311260001 3,351.92 3,351.92
DIAGNOSIS 1: 3310 ALZHEIMER'S DISEASE
DIAGNOSIS 2: 3625 DEGENERATION OF MACULA
PROC CODe: 000000
10/01/02 - 10/31/02 11/11/02 40023124172240001 3,608.22 3,608.22
DIAGNOSIS 1: 3310 ALZHEIMER'S DISEASE
DIAGNOSIS 2: 3625 DEGENERATION OF MACULA
PROC CODe: 000000
11/01/02 . 11/30/02 04/14/03 60031014021070001 3,469.52 3,469.52
DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE
DIAGNOSIS 2 : 3625 DEGENERATION OF MACULA
PROC CODE: 000000
12/01/02 - 12/31/02 01/20/03 40030144039840001 3,608.22 3,608.22
DIAGNOSIS 1: 3310 ALZHEIMER'S DISEASE
DIAGNOSIS 2: 3625 DEGENERATION OF MACULA
PROC CODE: 000000
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
CHURCH OF GOD HOME INC
801 N HANOVER ST
01/01/03 - 01/31/03
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
02/01/03 - 02/28/03
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
03/01/03 - 03131/03
DIAGNOSIS 1: 3310
DIAGNOSIS 2; 3625
PROC CODE: 000000
04/01/03 - 04/30/03
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE; 000000
05/01/03 - 05/31/03
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
06/01/03 - 06130/03
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
07/01/03 - 07/31/03
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
08/01/03 - 08/31/03
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODe: 000000
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
PA 17013
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVeD
02/10/03 40030384180190001
AlZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,655.07
3,655.07
03/10/03 40030654106470001
AlZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,205.22
3,205.22
04107/03 40030944231440001
AlZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,621.32
3,621.32
05/12/03 40031284109500001
AlZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,529.72
3,529.72
06/09/03 40031574154440001
AlZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,669.99
3,669.99
07/07/03 40031854177270001
AlZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,529.72
3,529.72
09/13/04 55042514086420001
AlZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,669.99
3,856.30
09/13/04 55042514086890001
AlZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,669.99
3,856.30
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
CHURCH OF GOD HOME INC
801 N HANOVER ST
ARLISLE
DATE OF SERVICE
09/01/03 - 09/30/03
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
10/01/03 - 10/31/03
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
11/01/03 - 11/30/03
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
12/01/03 - 12/31/03
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
01/01/04 - 01/31/04
DIAGNOSIS 1; 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
02/01/04 - 02/29/04
DIAGNOSIS 1: 3310
DIAGNOSIS 2; 3625
PROC CODe: 000000
03/01/04 - 03/31/04
DIAGNOSIS 1 ; 3310
DIAGNOSIS 2: 3625
PROC CODE; 000000
04101/04 . 04/30/04
DIAGNOSIS 1: 3310
DIAGNOSIS 2; 3625
PROC CODe: 000000
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
ID 380 151 654
PA
11013
PAYMENT DATE
ORIGINAL CRN
USUAL CHARGES AMOUNT APPROVED
ADJUSTED eRN
09/13/04 55042514081440001
ALZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,529.12
3,110.02
09/20/04 55042584128610001
ALZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,669.99
3,856.30
09/20/04 55042584129010001
ALZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,126.12
3,901.02
09/20/04 55042584129510001
ALZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,669.99
3,856.30
09/21/04 55042644122800001
ALZHEIMER'S DISEASE
DEGENERATION OF MACULA
3,661.93
3,198.02
09/21/04 55042644123110001
ALZHEIMER'S DISEASE
DEGENERATION OF MACULA
4,061.83
3,508.10
09/21/04 55042644123610001
ALZHEIMER'S DISEASE
DEGENERATION OF MACULA
4,348.31
3,198.02
10/04104 55042694191710001
AL2HEIMER'S DISEASE
DEGENERATION OF MACULA
4,208.10
3,150.56
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
CHURCH OF GOO HOME INC
801 N HANOVER ST
ARLISLE
DATE OF SERVICE
05/12/04 - 05/31/04
DIAGNOSIS 1: 3310
DIAGNOSIS 2; 3625
PROC CODE; 000000
06101/04 - 06/30/04
DIAGNOSIS 1 : 3310
DIAGNOSIS 2: 3625
PROC CODE; 000000
07/01/04 - 07/31/04
DIAGNOSIS 1; 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
08/01/04 - 08/31/04
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
09/01/04 . 09/30/04
DIAGNOSIS 1; 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
10/01/04 - 10/31/04
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE; 000000
11/01/04 - 11/30/04
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODE: 000000
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
PA
17013
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
10/04104 55042694192150001
AUHEIMER'S DISEASE
DEGENERATION OF MACULA
2,805.40
2,271.56
10/04104 55042694192620001
AUHEIMER'S DISEASE
DEGENERATION OF MACULA
4,208.10
3,750.56
10/04104 55042694193120001
AUHEIMER'S DISEASE
DEGENERATION OF MACULA
4,348.37
3,898.46
10/04104 55042694193580001
AUHEIMER'S DISEASE
DEGENERATION OF MACULA
4,348.37
3,898.46
10/04104 20042754044490001
AUHEIMER'S DISEASE
DEGENERATION OF MACULA
4,437.00
3,750.56
11/08/04 20043094076550001
AUHEIMER'S DISEASE
DEGENERATION OF MACULA
4,584.90
3,898.46
12/06/04 20043374173030001
AUHEIMER'S DISEASE
DEGENERATION OF MACULA
4,437.00
3,750.56
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF PUBLIC WELFARE
I
I
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
CHURCH OF GOD HOME (NC
801 N HANOVER ST
ARLISLE
PA
17013
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
AMOUNT APPROVED
12/01/04 - 12/31/04
DIAGNOSIS 1: 3310
DIAGNOSIS 2: 3625
PROC CODe: 000000
01/10/05 20050064089340001
ALZHEIMER'S DISEASE
DEGENERATION OF MACULA
4,584.90
3,898.46
PROVIDER SUB TOTAL CHURCH OF GOD HOME INC 121,170.45 116,141.44
03 000747604 0001
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
CONTINUING CARE RX
28 SOUTH SECOND STREET
EWPORT
DATE OF SERVICE
09/23/04 - 09/23/04
DIAGNOSIS 1: 0
NDC CODE: 50458030250
09/23/04 - 09/23/04
DIAGNOSIS 1 : 0
NDC CODE: 00591024010
09/25/04 - 09/25/04
DIAGNOSIS 1: 0
NDC CODE: 50458030050
09/25/04 - 09/25/04
DIAGNOSIS 1: 0
NDC CODE: 00591024010
10/01/04 - 10/01104
DIAGNOSIS 1: 0
NDC CODE: 50458003305
10/06/04 - 10/06/04
DIAGNOSIS 1 : 0
NDC CODE: 50458003305
10/25/04 - 10/25/04
DIAGNOSIS 1 : 0
NDC CODE: 50458030250
11108/04 - 11/08/04
DIAGNOSIS 1: 0
NDC CODE: 50458003305
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
ID 380157654
PA
17074
PAYMENT DATE
ORIGINAL eRN
ADJUSTED CRN
10/18/04
25042675691890001
185.53
189.53
RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
10/18/04
25042675709580001
21.28
17.05
LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
10/25/04
25042695340910001
188.08
184.08
RISPERDAL 1 MG TABLET - ATARACTICS-TRANQUILIZERS
10/25/04
25042715782040001
12.64
6.53
LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
10/25/04
25042755888080001
32.87
32.87
DURAGESIC 25 MCG/HR PATCH . NARCOTIC ANALGESICS
11/01/04
25042805424000001
148.34
148.34
DURAGESIC 25 MCGIHR PATCH . NARCOTIC ANALGESICS
11/22/04
25042995508590001
177.16
177.16
RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
12/06/04
25043136056650001
18.44
18.43
DURAGESIC 25 MCG/HR PATCH . NARCOTIC ANALGESICS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
CONTINUING CARE RX
28 SOUTH SECOND STREET
EWPORT
DATE OF SERVICE
11/10/04 - 11/10/04
DIAGNOSIS 1: 0
NDC CODE: 50458003305
11118/04 . 11/18/04
DIAGNOSIS 1: 0
NDC CODE: 50458030150
11118/04 - 11/18/04
DIAGNOSIS 1: 0
NDC CODE: 50458030250
11/22104 - 11/22/04
DIAGNOSIS 1: 0
NDC CODE: 50458030150
11/22/04 - 11/22/04
DIAGNOSIS 1: 0
NDC CODE: 50458030250
12/08/04 - 12/08/04
DIAGNOSIS 1: 0
NDC CODE: 50458003305
12/16/04 - 12/16104
DIAGNOSIS 1 : 0
NDC CODE: 00591024010
12/20/04 - 12/20/04
DIAGNOSIS 1: 0
NDC CODE: 00054465029
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
ID 380157654
PA
17074
PAYMENT DATE
ORIGINAL CRN
USUAL CHARGES AMOUNT APPROVED
ADJUSTED CRN
12/06/04
25043155633060001
148.34
148.34
DURAGESIC 25 MCG/HR PATCH - NARCOTIC ANALGESICS
12/13/04
25043235751800001
27.42
27.42
RISPERDAL 0.25 MG TABLET . ATARACTICS-TRANQUILIZERS
12/13/04
25043235754540001
28.74
24.74
RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
12/20104
25043285998980001
179.63
175.63
RISPERDAL 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
12/20104
25043285999040001
189.53
185.53
RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
01103/05
25043435616510001
148.34
148.34
DURAGESIC 25 MCGIHR PATCH - NARCOTIC ANALGESICS
01110105
25043515465320001
12.64
10.53
LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
01117105
25043556411390001
11.03
6.15
ROXICET 5/325 TABLET - NARCOTIC ANALGESICS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
CONTINUING CARE RX
28 SOUTH SECOND STREET
EWPORT
PA
17074
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
12/22/04 - 12/22104
DIAGNOSIS 1: 0
01117105
25043575923910001
8.69
5.43
NDC CODE: 00054465029
ROXICET 5/325 TABLET - NARCOTIC ANALGESICS
12/22/04 - 12/22/04
DIAGNOSIS 1: 0
01/17/05
25043585661100001
184.72
184.72
NDC CODE: 50458030150
RISPERDAL 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
12/22/04 - 12/22104
DIAGNOSIS 1; 0
01/17/05
25043585661150001
202.32
202.32
NDC CODE: 50458030250
RISPERDAL 0.5 MG TABLET - ATARACTICS.TRANQUILIZERS
12/24/04 - 12/24/04
DIAGNOSIS 1: 0
01/17/05
25043595435800001
50.89
18.30
NDC CODE: 00054465029
ROXICET 5/325 TABLET - NARCOTIC ANALGESICS
PROVIDER SUB TOTAL CONTINUING CARE RX
24 100731447 0011
1,980.63
1,907.44
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
ID 380 157 654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
05101/02 . 05/01/02
DIAGNOSIS 1: 0
09/02102
40022195521520001
76.57
66.48
NDC CODe: 00456402001
CELEXA 20 MG TABLET - PSVCHOSTIMULANTS-ANTlDEPRESSANTS
05/06/02 . 05/06/02
DIAGNOSIS 1: 0
09/02102
40022195522100001
48.99
43.02
NDC CODe: 00228257709
DILTlAZEM HCL 180 MG CAP SA . OTHER CARDIOVASCULAR PREPS
05/06/02 . 05/06/02
DIAGNOSIS 1: 0
09/02102
40022195523050001
8.82
4.08
NDC CODe: 00904188380
OYSTER SHELL CAL 500 MG TAB . ELECTROLYTES & MISCELLANEOUS NUTRIENTS
05106102 . 05/06/02
DIAGNOSIS 1: 0
09/02102
40022195532740001
51.04
38.47
NDC CODE: 00378022101
TfMOLOL MALEATE 10 MG TABLET OTHER CARDIOVASCULAR PREPS
05/18/02 . 05/18/02
DIAGNOSIS 1: 0
09/02102
40022195527840001
8.09
5.68
NDC CODe: 00378020801
FUROSEMIDE 20 MG TABLET . DIURETICS
OS/28/02 . OS/28/02
DIAGNOSIS 1: 0
09/02102
40022195518480001
51.04
38.47
NDC CODE: 00378022101
TIMOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
OS/28/02 - OS/28/02
DIAGNOSIS 1: 0
09/02/02
40022195530010001
76.57
66.48
NDC CODe: 00456402001
CELEXA 20 MG TABLET . PSYCHOSTfMULANTS-ANTIOEPRESSANTS
06103/02 - 06/03/02
DIAGNOSIS 1: 0
09/02102
40022195523590001
48.99
43.02
NOC CODE: 00228257709
OflTIAZEM HCL 180 MG CAP SA - OTHER CARDIOVASCULAR PREPS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380 157 654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
USUAL CHARGES AMOUNT APPROVED
06111/02 - 06/11/02
DIAGNOSIS 1: 0
09/02102
40022195523690001
8.82
4.08
NDC CODE: 00904188380
OYSTER SHELL CAI. 500 MG TAB . ELECTROLYTES & MISCELLANEOUS NUTRIENTS
06/17/02 - 06117/02
DIAGNOSIS 1: 0
09/02102
40022195532110001
8.09
5.68
NDC CODe: 00378020801
FUROSEMIDE 20 MG TABLET - DIURETICS
06120/02 - 06/20/02
DIAGNOSIS 1: 0
09/02102
40022195530640001
51.04
38.47
NDC CODE: 00378022101
TIMOLOL MAl.EATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
06129/02 - 06129/02
DIAGNOSIS 1: 0
09/02102
40022195527690001
76.57
66.48
NDC CODE: 00456402001
CELEXA 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
07102102 . 07/02102
DIAGNOSIS 1; 0
09/02102
40022195528990001
25.99
20.08
NDC CODe: 00172480460
OXAZEPAM 10 MG CAPSULE . ATARACTICS.TRANQUILlZERS
07/02102 . 07/02102
DIAGNOSIS 1: 0
09/02102
40022195534400001
67.34
67.34
NDC CODe; 00052010530
REMERON 15 MG TABLET . PSYCHOSTIMULANTS-ANTIDEPRESSANTS
07/03/02 - 07/03/02
DIAGNOSIS 1: 0
09/02102
40022195522090001
48.99
43.02
NDC CODE: 00228257709
DILTlAZEM HCL180 MG CAP SA . OTHER CARDIOVASCULAR PREPS
07/10/02 - 07/10/02
DIAGNOSIS 1: 0
09102102
40022205388340001
8.82
4.08
NDC CODe; 00904188380
OYSTER SHELL CAI. 500 MG TAB - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
ID 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
07/10/02 - 07/10/02
DIAGNOSIS 1: 0
NDC CODE: 52544024010
07/15/02 - 07/15/02
DIAGNOSIS 1: 0
NDC CODE: 00378020801
07/16/02 - 07/16/02
DIAGNOSIS 1: 0
NDC CODE: 00378022101
07/24/02 - 07/24/02
DIAGNOSIS 1: 0
NDC CODE: 00052010530
07/29/02 - 07/29/02
DIAGNOSIS 1 : 0
NDC CODE: 00071080324
07/29/02 - 07129102
DIAGNOSIS 1: 0
NDC CODE: 52544024010
07/29102 - 07/29102
DIAGNOSIS 1: 0
NDC CODE: 00456402001
08105102 - 08105102
DIAGNOSIS 1: 0
NDC CODE: 00904188380
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
09102102
40022205388950001
16.12
10.52
LORAZEPAM 0.5MG TABLET - ATARACTICS.TRANQUILIZERS
09/02102
40022195528950001
8.09
5.68
FUROSEMIDE 20 MG TABLET . DIURETICS
09102102
40022195521040001
51.04
38.47
T1MOLOL MALEATE 10 MG TABLET . OTHER CARDIOVASCULAR PREPS
09102102
40022195528170001
77.32
77.32
REMERON 15 MG TABLET - PSYCHOSTIMULANTS-ANTlDEPRESSANTS
09102102
40022195520630001
27.04
17.87
NEURONTIN 100 MG CAPSULE - ANTICONVULSANTS
09/02102
40022195521000001
31.88
17.05
LORAZEPAM 0.5MG TABLET - ATARACTICS.TRANQUILlZERS
09102102
40022195528160001
76.57
66.48
CELEXA20 MG TABLET - PSYCHOSTIMUlANTS.ANTlDEPRESSANTS
09102102
40022195520000001
8.82
4.08
OYSTER SHELL CAL 500 MG TAB - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
I
I
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380 157 654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
08/06/02 - 08/06/02
DIAGNOSIS 1: 0
NDC CODE: 00228257709
08/12/02 - 08/12/02
DIAGNOSIS 1 : 0
NDC CODE: 00378022101
08112/02 - 08/12/02
DIAGNOSIS 1: 0
NDC CODE: 00054429731
08122/02 . 08/22/02
DIAGNOSIS 1: 0
NDC CODE: 00071080324
08126/02 - 08/26/02
DIAGNOSIS 1: 0
NDC CODE: 00456402001
09/03/02 - 09/03/02
DIAGNOSIS 1 : 0
NDC CODE: 00378022101
09/03/02 - 09/03102
DIAGNOSIS 1: 0
NDC CODE: 00904188380
09/03/02 - 09/03/02
DIAGNOSIS 1. 0
NDC CODE: 00052010530
PAYMENT DATE
ORIGINAL CRN
USUAL CHARGES AMOUNT APPROVED
ADJUSTED CRN
09/02/02
40022195522080001
48.99
43.02
DILTIAZEM HCL 180 MG CAP SA - OTHER CARDIOVASCULAR PREPS
09/09/02
40022245263810001
51.04
38.47
TIMOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
09/09/02
40022245275350001
8.09
5.68
FUROSEMIDE 20 MG TABLET - DIURETICS
09/16/02
40022345322250001
27.04
18.29
NEURONTIN 100 MG CAPSULE . ANTICONVULSANTS
09/23/02
40022385273050001
76.57
66.48
CELEXA20 MG TABLET - PSYCHOSTIMULANTS-ANTfDEPRESSANTS
09/30/02
40022465311840001
45.36
61.22
TIMOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
09/30/02
40022465313530001
8.82
4.08
OYSTER SHELL CAL 500 MG TAB
ELECTROLYTES & MISCELLANEOUS NUTRIENTS
09/30/02
40022465318810001
77.32
77.32
REMERON 15 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
09/03/02 - 09/03/02
DIAGNOSIS 1: 0
09/30/02
40022465483990001
48.99
43.02
NOC CODE: 00228257709
DILTIAZEM HCL 180 MG CAP SA OTHER CARDIOVASCULAR PREPS
09/09/02 - 09/09/02
DIAGNOSIS 1: 0
10/07/02
40022525458630001
1.69
.69
NDC CODE: 00904770480
ASPIR-LOW 81 MG TABLET EC - NON-NARCOTIC ANALGESICS
09/16/02 - 09/16/02
DIAGNOSIS 1: 0
10/14/02
40022595608200001
8.09
5.68
NDC CODE: 00054429731
FUROSEMIDE 20 MG TABLET - DIURETICS
09/23/02 - 09/23/02
DIAGNOSIS 1: 0
10/21/02
40022675383010001
27.04
18.29
NDC CODE: 00071080324
NEURONTIN 100 MG CAPSULE - ANTICONVULSANTS
09/25/02 - 09/25/02
DIAGNOSIS 1: 0
10/21/02
40022685352380001
76.57
66.48
NDC CODE: 00456402001
CELEXA20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
10/01/02 - 10/01102
DIAGNOSIS 1: 0
10128/02
40022745355020001
77.32
77.32
NDC CODE: 00052010530
REMERON 15 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
10/01/02 - 10101102
DIAGNOSIS 1: 0
10/28/02
40022745355250001
48.99
43.02
NDC CODE: 00228257709
DILTIAZEM HCL 180 MG CAP SA - OTHER CARDIOVASCULAR PREPS
10/04/02 - 10104102
DIAGNOSIS 1. 0
10/28/02
40022775286490001
1.69
.69
NDC CODE: 00904770480
ASPIR-LOW 81 MG TABLET EC - NON-NARCOTIC ANALGESICS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
ID 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
10/05/02 - 10/05/02
DIAGNOSIS 1: 0
NDC CODE: 00378022101
10/07/02 . 10/07/02
DIAGNOSIS 1 : 0
NDC CODE: 00904188380
10/14/02 . 10/14/02
DIAGNOSIS 1 : 0
NDC CODE: 00172290860
10/14/02 . 10/14/02
DIAGNOSIS 1: 0
NDC CODE: 00071080324
10/28/02 - 10/28/02
DIAGNOSIS 1 : 0
NDC CODE: 00071080324
10/28/02 - 10/28/02
DIAGNOSIS 1 : 0
NDC CODE: 00052010530
10/30/02 - 10/30/02
DIAGNOSIS 1 : 0
NDG CODE: 00378022101
11101/02 - 11/01/02
DIAGNOSIS 1: 0
NDC CODE : 00456402001
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
10/28/02
40022785295700001
61.22
45.36
TlMOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
11/04102
40022805293760001
8.82
4.08
OYSTER SHELL CAL 500 MG TAB - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
11/11/02
40022875315180001
8.09
5.68
FUROSEMIDE 20 MG TABLET - DIURETICS
11/11/02
40022885383660001
27.04
18.29
NEURONTlN 100 MG CAPSULE - ANTlCONVULSANTS
11/25/02
40023015255910001
53.56
32.59
NEURONTIN 100 MG CAPSULE . ANTICONVULSANTS
11/25/02
40023015256990001
77.32
n.32
REMERON 15 MG TABLET - PSYCHOSTIMULANTS-ANTlDEPRESSANTS
11/25/02
40023035229070001
61.22
45.36
T1MOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
12/09/02
40023155440410001
79.76
69.09
CELEXA 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1. 2005
STATEMENT OF CLAIM
NAME BROUGHER, SARAH
10 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
11/04102 - 11/04102
DIAGNOSIS 1: 0
12/02/02
40023085258560001
8.82
4.08
NDC CODE; 00904188380
OYSTER SHELL CAL 500 MG TAB ELECTROLYTES & MISCELLANEOUS NUTRIENTS
11 /04/02 - 11/04102
DIAGNOSIS 1: 0
12/02/02
40023085264610001
48.99
43.02
NDC CODE: 00228257709
OIL T1AZEM HCL 180 MG CAP SA - OTHER CARDIOVASCULAR PREPS
11/04102 - 11/04102
DIAGNOSIS 1; 0
12/02/02
40023085265950001
3.07
2.07
NDC CODE: 00904770480
ASPIR-LOW 81 MG TABLET EC . NON-NARCOTIC ANALGESICS
11/06/02 . 11/06/02
DIAGNOSIS 1: 0
12/02/02
40023105304920001
19.78
17.05
NDC CODE: 52544024010
LORAZEPAM 0.5MG TABLET. ATARACTICS-TRANQUILIZERS
11/12/02 . 11/12/02
DIAGNOSIS 1: 0
12/09/02
40023165352440001
8.09
5.68
NDC CODE: 00781181801
FUROSEMIDE 20 MG TABLET - DIURETICS
11/25/02 - 11/25/02
DIAGNOSIS 1: 0
12/23/02
40023295246460001
53.56
32.59
NDC CODE: 00071080324
NEURONTlN 100 MG CAPSULE . ANTICONVULSANTS
11/26/02 - 11/26102
DIAGNOSIS 1: 0
12/23/02
40023305293610001
83.96
78.82
NDC CODE: 00052010530
REMERON 15 MG TABLET . PSYCHOSTIMULANTS-ANTIDEPRESSANTS
11/26/02 - 11/26/02
DIAGNOSIS 1 : 0
12/23/02
40023305293620001
79.76
69.09
NDC CODE: 00456402001
CELEXA 20 MG TABLET . PSYCHOSTlMULANTS-ANTlDEPRESSANTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380 157 654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
12105/02 . 12105/02
DIAGNOSIS 1: 0
NDC CODE: 00228257709
12105/02 . 12105/02
DIAGNOSIS 1: 0
NDC CODe: 00904188380
12105/02 . 12105/02
DIAGNOSIS 1: 0
NDC CODE: 00904770480
12105/02 . 12105/02
DIAGNOSIS 1: 0
NDC CODE: 00378022101
12110/02 . 12110/02
DIAGNOSIS 1: 0
NDC CODE: 00781181801
12127/02 . 12127/02
DIAGNOSIS 1: 0
NDC CODe: 00052010530
12127/02 . 12127/02
DIAGNOSIS 1: 0
NDC CODE: 00456402001
12130/02 . 12130/02
DIAGNOSIS 1: 0
NDC CODE: 00904188380
PAYMENT DATE
ORIGINAL CRN
USUAL CHARGES AMOUNT APPROVED
ADJUSTED CRN
12130/02
40023395330240001
48.99
43.02
DILTIAZEM HCL 180 MG CAP SA - OTHER CARDIOVASCULAR PREPS
12130/02
40023395333780001
8.82
4.08
OYSTER SHELL CAL 500 MG TAB - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
12130/02
40023395334790001
2.07
3.07
ASPIR.LOW 81 MG TABLET EC - NON-NARCOTIC ANALGESICS
12130/02
40023395335280001
45.36
61.22
TIMOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
01/06/03
40023445559400001
5.68
8.09
FUROSEMIDE 20 MG TABLET - DIURETICS
01/20/03
40023615363840001
83.96
18.82
REMERON 15 MG TABLET . PSYCHOSTIMULANTS.ANTIDEPRESSANTS
01/20/03
40023615388210001
79.76
69.09
CELEXA 20 MG TABLET . PSYCHOSTlMULANTS.ANTlDEPRESSANTS
01/21/03
40023645244000001
8.82
4.08
OYSTER SHELL CAL 500 MG TAB . ELECTROLYTES & MISCELLANEOUS NUTRIENTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
12/30/02 - 12/30/02
DIAGNOSIS 1: 0
01/27/03
40023645250260001
61.22
45.36
NDC CODE: 00378022101
TIMOLOL MALEATE 10 MG TABLET OTHER CARDIOVASCULAR PREPS
12/31/02 . 12/31/02
DIAGNOSIS 1: 0
01/27/03
40023655251190001
53.56
32.59
NDC CODE: 00071080324
NEURONTIN 100 MG CAPSULE - ANTICONVULSANTS
01/02/03 - 01/02/03
DIAGNOSIS 1: 0
01/27/03
40030025319230001
3.07
2.07
NDC CODE: 00904770480
ASPIR-LOW 81 MG TABLET EC - NON-NARCOTIC ANALGESICS
01/02103 - 01/02103
DIAGNOSIS 1: 0
01/27/03
40030025422140001
48.99
43.02
NDC CODE: 00228257709
OIL TlAZEM HCL 180 MG CAP SA - OTHER CARDIOVASCULAR PREPS
01/13/03 - 01/13/03
DIAGNOSIS 1: 0
02110/03
40030135280270001
8.64
5.68
NDC CODE: 00781181801
FUROSEMIDE 20 MG TABLET - DIURETICS
01/20/03 - 01/20/03
DIAGNOSIS 1: 0
02/17/03
40030205592850001
19.78
17.05
NDC CODE: 52544024010
LORAZEPAM 0.5MG TABLET - ATARACTICS-TRANQUILIZERS
01/27/03 - 01/27/03
DIAGNOSIS 1: 0
02/24/03
40030275321220001
55.24
49.03
NDC CODE: 00071080324
NEURONTIN 100 MG CAPSULE - ANTICONVULSANTS
01/27/03 - 01/27/03
DIAGNOSIS 1: 0
02/24/03
40030275321260001
79.76
69.09
NDC CODE: 00456402001
CELEXA 20 MG TABLET - PSYCHOSTIMULANTS.ANTlDEPRESSANTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 11405
DATE OF SERVICE
01127103 - 01127103
DIAGNOSIS 1: 0
NDC CODE: 00052010530
01129103 - 01129103
DIAGNOSIS 1: 0
NDC CODE: 00228251709
01131/03 - 01131/03
DIAGNOSIS 1: 0
NDC CODE: 00904770480
01131103 . 01131/03
DIAGNOSIS 1: 0
NDC CODE: 00378022101
02110103 - 02110/03
DIAGNOSIS 1: 0
NDC CODE: 00378020810
02124103 - 02124103
DIAGNOSIS 1: 0
NDC CODE: 00904188380
02124103 - 02124103
DIAGNOSIS 1: 0
NDC CODE: 00071080324
02124103 - 02124103
DIAGNOSIS 1: 0
NDC CODE: 00093720656
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
02124103
40030275342760001
83.96
18.82
REMERON 15 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
02124103
40030295400670001
41.53
41.53
DIL TlAZEM HCL 180 MG CAP SA - OTHER CARDIOVASCULAR PREPS
02124103
40030315242840001
3.07
2.01
ASPIR-LOW 81 MG TABLET EC - NON-NARCOTIC ANALGESICS
02124103
40030315326160001
61.22
45.36
T1MOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
03110103
40030415315410001
8.64
5.68
FUROSEMIDE 20 MG TABLET - DIURETICS
03124103
40030555468510001
8.82
4.08
OYSTER SHELL CAL 500 MG TAB
ELECTROLYTES & MISCELLANEOUS NUTRIENTS
03124103
40030555410700001
55.24
49.03
NEURONTlN 100 MG CAPSULE - ANTICONVULSANTS
03124103
40030555669960001
75.81
75.81
MIRTAZAPINE 15 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
ID 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERViCe
02/28/03 - 02/28/03
DIAGNOSIS 1 : 0
NDC CODE: 00456402001
03/03/03 - 03/03/03
DIAGNOSIS 1: 0
NDC CODE: 00904770480
03/03/03 - 03/03/03
DIAGNOSIS 1: 0
NDC CODe: 00228257709
03/03/03 - 03/03/03
DIAGNOSIS 1: 0
NDC CODE: 00378022101
03/12/03 - 03/12/03
DIAGNOSIS 1 : 0
NDC CODE: 00054429731
03113/03 - 03/13/03
DIAGNOSIS 1: 0
NDC CODE: 00093720656
03/24/03 - 03/24/03
DIAGNOSIS 1: 0
NDC CODE: 00904188380
03/26/03 - 03/26/03
DIAGNOSIS 1 : 0
NDC CODE: 00071080324
PAYMENT DATE
ORIGINAL CRN
USUAL CHARGES AMOUNT APPROVED
ADJUSTED CRN
03/24/03
40030595501600001
79.76
69.09
CELEXA 20 MG TABLET - PSYCHOSTIMULANTS-ANTJDEPRESSANTS
03/31/03
40030625293570001
3.07
2.07
ASPIR-LOW 81 MG TABLET EC - NON-NARCOTIC ANALGESICS
03/31/03
40030625297630001
41.53
41.53
DILTIAZEM HCL 180 MG CAP SA - OTHER CARDIOVASCULAR PREPS
03/31/03
40030625297640001
61.22
45.36
TIMOLOL MALEATE 10 MG TABLET OTHER CARDIOVASCULAR PREPS
04/14/03
40030715275600001
8.64
5.68
FUROSEMIDE 20 MG TABLET - DIURETICS
04/14/03
40030725276100001
75.81
75.81
MIRTAZAPINE 15 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
04/21/03
40030835326650001
8.82
4.08
OYSTER SHELL CAL 500 MG TAB
ELECTROLYTES & MISCELLANEOUS NUTRIENTS
04121/03
40030855295250001
55.24
49.03
NEURONTIN 100 MG CAPSULE - ANTICONVULSANTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF ClAIM
NAME BROUGHER,SARAH
10 380 157 654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
03127103 - 03127103
DIAGNOSIS 1: 0
04121103
40030865289630001
82.94
69.09
NDC CODE: 00456402001
CELEXA20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
03131/03 - 03/31103
DIAGNOSIS 1: 0
04/28103
40030905445830001
41.53
41.53
NDC CODE: 00228257709
DILTlAZEM HCL 180 MG CAP SA - OTHER CARDIOVASCULAR PREPS
03131103 - 03131103
DIAGNOSIS 1: 0
04128/03
40030905484590001
3.07
2.07
NDC CODE: 00904770480
ASPIR-lOW 81 MG TABLET EC - NON-NARCOTIC ANALGESICS
04103103 - 04103/03
DIAGNOSIS 1 : 0
04128103
40030935478850001
61.22
45.36
NDC CODE: 00378022101
TIMOLOL MALEATE 10 MG TABLET OTHER CARDIOVASCULAR PREPS
04109103 - 04109/03
DIAGNOSIS 1: 0
05/05/03
40030995318710001
8.64
5.68
NDC CODE: 00054429731
FUROSEMIDE 20 MG TABLET - DIURETICS
04118103 - 04118/03
DIAGNOSIS 1 : 0
05112/03
40031085267780001
73.59
64.04
NDC CODE: 00071080324
NEURONTlN 100 MG CAPSULE - ANTICONVULSANTS
04123103 . 04/23/03
DIAGNOSIS 1 : 0
05/19/03
40031135303130001
8.82
4.08
NDC CODE: 00904188380
OYSTER SHELL CAL 500 MG T AS ELECTROLYTES & MISCELLANEOUS NUTRIENTS
04129/03 . 04129/03
DIAGNOSIS 1 : 0
05126/03
40031195376080001
82.94
71.69
NDC CODE; 00456402001
CELEXA 20 MG TABLET . PSYCHOSTIMULANTS-ANTIDEPRESSANTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
04130/03 - 04/30/03
DIAGNOSIS 1: 0
OS/26/03
40031205315000001
75.81
75.81
NDC CODE: 00093720656
MIRTAZAPINE 15 MG TABLET - PSYCHOSTIMULANTS-ANTlDEPRESSANTS
05/02103 - 05/02103
DIAGNOSIS 1: 0
OS/26/03
40031225485970001
3.07
2.07
NDC CODE: 00904770480
ASPIR-LOW 81 MG TABLET EC . NON-NARCOTIC ANALGESICS
05/02103 . 05/02103
DIAGNOSIS 1: 0
05126/03
40031225506520001
41.53
41.53
NDC CODE: 00228257709
OIL T1AZEM HCL 180 MG CAP SA - OTHER CARDIOVASCUlAR PREPS
05/05/03 . 05105/03
DIAGNOSIS 1: 0
06/02103
40031255481010001
61.22
45.36
NDC CODE: 00378022101
T1MOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
05/12103 - 05/12103
DIAGNOSIS l' 0
06/09/03
40031325293030001
8.64
5.68
NDC CODe: 00054429731
FUROSEMIDE 20 MG TABLET - DIURETICS
OS/20/03 - OS/20/03
DIAGNOSIS l' 0
06/16/03
40031405261260001
8.82
4.29
NDC CODE: 00904188380
OYSTER SHELL CAL 500 MG TAB ELECTROLYTES & MISCELLANEOUS NUTRIENTS
OS/20/03 - OS/20/03
DIAGNOSIS 1 . 0
06/16/03
40031405272890001
73.59
64.04
NDC CODe: 00071080324
NEURONTIN 100 MG CAPSULE - ANTlCONVULSANTS
OS/27/03 - OS/27/03
DIAGNOSIS 1 . 0
06/23/03
40031475519760001
75.81
75.81
NDC CODE: 00093720656
MIRTAZAPINE 15 MG TABLET - PSYCHOSTlMULANTS-ANTIDEPRESSANTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
ID 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
PAYMENT DATE ORIGINAL CRN
ADJUSTED CRN AMOUNT APPROVED
05127/03 - OS/27/03
DIAGNOSIS 1: 0
06/23/03 40031475522450001
82.94 71.69
NDC CODE: 00456402001
CELEXA 20 MG TABLET - PSYCHOSTlMUlANTS-ANTlDEPRESSANTS
06102103 - 06/02103
DIAGNOSIS 1: 0
06130/03
40031535260280001
3.07
2.07
NDC CODE: 00904770480
ASPIR-LOW 81 MG TABLET EC - NON-NARCOTIC ANALGESICS
06102103 - 06/02103
DIAGNOSIS 1: 0
06/30/03
40031535260320001
61.22
45.36
NDC CODE: 00378022101
T1MOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
06102103 - 06/02103
DIAGNOSIS 1: 0
06130/03
40031535268820001
41.53
41.53
NDC CODE: 00228257709
DILTlAZEM HCL 180 MG CAP SA - OTHER CARDIOVASCULAR PREPS
06109/03 - 06109/03
DIAGNOSIS 1 : 0
07/07/03
40031605620160001
8.64
5.68
NDC CODE: 00054429731
FUROSEMIDE 20 MG TABLET - DIURETICS
06/19/03 . 06119/03
DIAGNOSIS 1 : 0
07/14/03
40031705461220001
34.84
34.84
NDC CODE: 00228258809
DILTlAZEM HCL 120 MG CAP SA - OTHER CARDIOVASCULAR PREPS
06/23/03 - 06123/03
DIAGNOSIS 1 : 0
07/21/03
40031745323770001
75.81
75.81
NDC CODE: 00093720656
MIRTAZAPINE 15 MG TABLET PSYCHOSTIMULANTS-ANTIDEPRESSANTS
06/23/03 - 06123103
DIAGNOSIS 1. 0
07/21/03
40031745327040001
73.59
64.04
NDC CODE: 00071080324
NEURONTlN 100 MG CAPSULE . ANTlCONVULSANTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
ID 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK 17405
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
06124103 - 06/24103
DIAGNOSIS 1: 0
07/21/03
40031755381960001
82.94
71.69
NDC CODE: 00456402001
CELEXA 20 MG TABL.ET . PSYCHOSTIMULANTS.ANTIDEPRESSANTS
06/30103 - 06/30/03
DIAGNOSIS 1: 0
07/28/03
40031815316020001
43.86
43.86
NDC CODE: 00378022101
TIMOLOL MALEATE 10 MG TABLET . OTHER CARDIOVASCULAR PREPS
07/02103 - 07/02103
DIAGNOSIS 1: 0
07/28/03
40031835366770001
3.07
2.07
NDC CODE: 00904770480
ASPIR-LOW 81 MG TABLET EC - NON-NARCOTIC ANALGESICS
07/14103 - 07/14103
DIAGNOSIS 1: 0
08/11/03
40031955380390001
8.82
4.29
NDC CODE: 00904188380
OYSTER SHELL CAL 500 MG TAB . ELECTROLYTES & MISCELLANEOUS NUTRIENTS
07/14103 - 07/14103
DIAGNOSIS 1: 0
08/11/03
40031955404150001
8.64
5.68
NDC CODE: 00054429731
FUROSEMIDE 20 MG TABLET - DIURETICS
08/01/03 - 08101/03
DIAGNOSIS 1: 0
08/25/03
40032135490940001
75.81
75.81
NDC CODE: 00591111730
MIRTAZAPINE 15 MG TABLET - PSYCHOSTlMULANTS-ANTlDEPRESSANTS
08/01/03 - 08/01/03
DIAGNOSIS 1 : 0
08/25/03
40032135491920001
34.84
34.84
NDC CODE: 00228258809
D1lTtAZEM HCL 120 MG CAP SA - OTHER CARDIOVASCULAR PREPS
08/02103 - 08/02103
DIAGNOSIS 1: 0
08/25/03
40032145343730001
82.94
71.69
NDC CODE: 00456402001
CELEXA 20 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
08/03/03 - 08/03/03
DIAGNOSIS 1: 0
08/25/03
40032155291160001
43.86
43.86
NDC CODE: 00378022101
T1MOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
08104103 - 08104/03
DIAGNOSIS 1 : 0
09/01/03
40032165267740001
3.07
2.07
NDC CODE: 00904770480
ASPIR-LOW 81 MG TABLET EC . NON-NARCOTIC ANALGESICS
08107/03 - 08107/03
DIAGNOSIS 1: 0
09/01/03
40032195331540001
8.82
4.29
NDC CODE: 00904188380
OYSTER SHELL CAL 500 MG TAB - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
08108103 - 08108103
DIAGNOSIS 1: 0
09/01/03
40032205261750001
6.58
5.68
NDC CODE: 00054429731
FUROSEMIDE 20 MG TABLET - DIURETICS
08115/03 - 08/15/03
DIAGNOSIS 1: 0
09/08103
40032275520500001
11.85
11.80
NDC CODE: 00054329446
FUROSEMIDE 10 MG/ML SOLUTION - DIURETICS
08/15/03 - 08/15/03
DIAGNOSIS 1 : 0
09/08/03
40032275525600001
9.41
8.41
NDC CODE: 00054311763
CALCIUM CARB 1,250 MG/S ML SUS - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
08/15/03 - 08115/03
DIAGNOSIS 1: 0
09/08/03
40032275526290001
126.73
107.48
NDC CODE: 00456413008
CELEXA 10 MG/5 ML SOLUTION - PSYCHOSTlMULANTS.ANTIDEPRESSANTS
08/29/03 - 08129/03
DIAGNOSIS 1: 0
09/22/03
40032415476180001
43.86
43.86
NDC CODE: 00378022101
TIMOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380 157 654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAl CHARGES AMOUNT APPROVED
08/30l03 - 08l30l03
DIAGNOSIS 1: 0
09l22l03
40032425332940001
70.30
70.30
NDC CODE: 00052010630
REMERON 15 MG SOLTAB - PSYCHOSTlMULANTS-ANTIDEPRESSANTS
09l02l03 - 09l02l03
DIAGNOSIS 1: 0
09l29l03
40032455316860001
3.07
2.07
NDC CODE: 00904770480
ASPIR-LOW 81 MG TABLET EC - NON-NARCOTIC ANALGESICS
09l04l03 - 09l04l03
DIAGNOSIS 1: 0
09l29l03
40032475458080001
126.73
107.48
NDC CODE: 00456413008
CELEXA 10 MGl5 ML SOLUTION PSYCHOSTlMULANTS-ANTlDEPRESSANTS
09l26l03 - 09l28/03
DIAGNOSIS 1: 0
10l20l03
40032695361460001
73.33
71.79
NDC CODE: 00052010630
REMERON 15 MG SOLTAB - PSYCHOSTIMULANTS-ANTlDEPRESSANTS
09129103 - 09/29l03
DIAGNOSIS 1: 0
10l27l03
40032725365090001
43.86
43.86
NDC CODE: 00378022101
TIMOLOL MALEATE 10 MG TABLET . OTHER CARDIOVASCULAR PREPS
09l29l03 - 09/29/03
DIAGNOSIS 1: 0
10l27l03
40032725368860001
3.07
2.07
NDC CODE: 00904770480
ASPIR-LOW 81 MG TABLET EC . NON-NARCOTIC ANALGESICS
10106103 - 10l06l03
DIAGNOSIS 1: 0
11l03l03
40032795401410001
126.73
107.48
NDC CODE: 00456413008
CELEXA 10 MGl5 ML SOLUTION
PSYCHOSTlMULANTS.ANTIDEPRESSANTS
10l06l03 - 10l06l03
DIAGNOSIS 1: 0
11/03/03
40032795401460001
11.49
9.66
NDC CODE: 00054311763
CAlCIUM CARB 1,250 MGl5 ML SUS . ANTI-ULCER PREPSlGASTROINTESTINAL PREPS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
10/06/03 - 10/06/03
DIAGNOSIS 1: 0
11/03/03
40032795403300001
14.04
11.05
NDC CODE: 00054329450
FUROSEMIDE 10 MG/ML SOLUTION - DIURETICS
10/23/03 - 10/23/03
DIAGNOSIS 1: 0
11/17/03
40032965288470001
86.77
74.83
NDC CODE: 00052010630
REMERON 15 MG SOLTAB - PSYCHOSTIMULANTS-ANTlDEPRESSANTS
11/03/03 - 11/03/03
DIAGNOSIS 1 : 0
12/01/03
40033075423400001
131.78
107.48
NDC CODE: 00456413008
CELEXA 10 MG/5 ML SOLUTION - PSYCHOSTlMULANTS.ANTIDEPRESSANTS
11/14/03 - 11/14/03
DIAGNOSIS 1: 0
12/08/03
40033185632230001
11.49
9.66
NDC CODE: 00054311763
CALCIUM CARB 1,250 MG/5 ML SUS ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
11/24/03 - 11/24/03
DIAGNOSIS 1 : 0
12/22/03
40033285301560001
86.77
74.83
NDC CODE: 00052010630
REMERON 15 MG SOLTAB . PSYCHOSTIMULANTS-ANTlDEPRESSANTS
11/28/03 - 11/28/03
DIAGNOSIS 1: 0
12/22/03
40033325383470001
60.47
44.61
NDC CODE: 00378022101
TIMOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
12/09/03 . 12/09/03
DIAGNOSIS 1: 0
01/05/04
40033445318840001
11.49
9.66
NDC CODE: 00054311763
CALCIUM CARB 1,250 MG/5 ML SUS - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
12/09/03 . 12/09/03
DIAGNOSIS 1: 0
01/05/04
40033445320570001
82.44
71.27
NDC CODE: 00456413008
CELEXA 10 MG/5 ML SOLUTION . PSYCHOSTIMULANTS-ANTlDEPRESSANTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380151654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5041
ORK PA 11405
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
12/11103 - 12/11/03
DIAGNOSIS 1 : 0
01/05104
40033455365910001
14.04
11.05
NDC CODE: 00054329446
FUROSEMIDE 10 MGIML SOLUTION - DIURETICS
12/18/03 - 12/18/03
DIAGNOSIS 1: 0
01/12/04
40033525369810001
86.11
14.83
NDC CODE: 00052010630
REMERON 15 MG SOLTAB - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
12/29/03 - 12/29/03
DIAGNOSIS 1 : 0
01/26/04
40033635291060001
60.41
44.61
NDC CODE: 00318022101
TlMOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
01/01/04 - 01/01/04
DIAGNOSIS 1: 0
02/02/04
40040015483930001
82.44
11.21
NDC CODE: 00456413008
CELEXA 10 MG/5 ML SOLUTION - PSYCHOSTIMULANTS.ANTlDEPRESSANTS
01/01/04 . 01/07/04
DIAGNOSIS 1: 0
02/02/04
40040075628300001
11.49
10.66
NDC CODE: 00054311163
CALCIUM CARB 1,250 MG/5 ML SUS - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
01/22/04 . 01/22/04
DIAGNOSIS 1 : 0
02/16/04
40040225321110001
14.04
11.05
NDC CODe: 00054329446
FUROSEMIDE 10 MG/ML SOLUTION - DIURETICS
01/30/04 - 01/30/04
DIAGNOSIS 1: 0
02/23/04
40040305261660001
60.47
44.61
NDC CODe: 00378022101
TlMOLOL MALEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
02/04/04 - 02104104
DIAGNOSIS 1: 0
02123/04
40040355272640001
82.44
71.27
NDC CODe: 00456413008
CELEXA 10 MG/5 ML SOLUTION - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
02/04104 - 02/04104
DIAGNOSIS 1 : 0
02/23/04
40040355273930001
11.49
10.66
NDC CODe: 00054311763
CAlCIUM CARB 1,250 MG/5 ML SUS - ANTI-ULCER PREPS/GASTROINTESTINAl PREPS
02/09/04 - 02/09/04
DIAGNOSIS 1: 0
02/23/04
40040405488960001
63.40
39.90
NDC CODE: 00591111730
MIRTAZAPINE 15 MG TABLET - PSYCHOSTIMULANTS.ANTlDEPRESSANTS
02/23/04 - 02/23/04
DIAGNOSIS 1: 0
03/08104
25040545344390001
61.22
45.36
NDC CODe: 00378022101
TIMOLOL MAlEATE 10 MG TABLET - OTHER CARDIOVASCULAR PREPS
02/23/04 - 02/23/04
DIAGNOSIS 1: 0
03/08104
25040545504050001
14.79
11.80
NDC CODE: 00054329446
FUROSEMIDE 10 MG/ML SOLUTION - DIURETICS
03/08/04 - 03/08/04
DIAGNOSIS 1 : 0
03/15/04
25040685366430001
64.15
39.91
NDC CODE: 00591111730
MIRTAZAPINE 15 MG TABLET . PSYCHOSTlMULANTS.ANTIDEPRESSANTS
03/12/04 - 03/12/04
DIAGNOSIS 1 . 0
03/15/04
25040725623240001
11.49
10.66
NDC CODE: 00054311763
CAlCIUM CARB 1,250 MG/5 ML SUS - ANTI-ULCER PREPS/GASTROINTESTINAl PREPS
03/15104 - 03/15104
DIAGNOSIS 1. 0
03/22/04
25040755395120001
82.44
71.28
NDG CODE. 00456413008
CELEXA 10 MG/5 ML SOLUTION PSYCHOSTIMULANTS-ANTIDEPRESSANTS
03/27/04 - 03/27/04
DIAGNOSIS 1 0
04112/04
25040875409410001
61.22
44.61
NDC CODE: 00378022101
TlMOLOL MALEATE 10 MG TABLET . OTHER CARDIOVASCULAR PREPS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1, 2005
STATEMENT OF CLAIM
NAME BROUGHER,SARAH
10 380157654
BROCKIE PHARMATECH
209 NORTH BEAVER STREET
POBOX 5047
ORK PA 17405
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
05/11/04 - 05111104
DIAGNOSIS 1; 0
06107104
25041335843550001
6.40
6.40
NOC CODE: 00168001231
TRIPLE ANTIBIOTIC OINTMENT . OTHER ANTIBIOTICS
05/12/04 - 05/12/04
DIAGNOSIS 1; 0
06107/04
25041335836130001
33.14
16.55
NDG CODE; 00591024010
LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
0811 0104 - 08/10104
DIAGNOSIS 1; 0
09/06/04
25042235759290001
2.92
2.92
NDG CODE: 00713028031
BACITRACIN OINTMENT - OTHER ANTIBIOTICS
08126104 - 08126104
DIAGNOSIS 1; 0
09/20104
25042405489210001
41.43
30.83
NDC CODE: 00172213060
NITROFURANTOIN MCR 50 MG CAP - URINARY ANTIBACTERIALS
09107104 - 09107104
DIAGNOSIS 1; 0
10104104
25042515661740001
214.85
179.63
NDC CODE: 50458030150
RISPERDAL 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
PROVIDER SUB TOTAL BROCKIE PHARMATECH
24 100750872 0009
7,313.46
6,172.07
REV 1513 EX. (9-00)
*'
SCHEDULE d
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Brougher, Sarah E. 21--
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not List Trustee(s)
I. TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116(a)(1.2)]
1 George E Brougher Son One-sixth (1/6)
1011 Teakwood Lane of rest, residue
Enola, PA 17025 and remainder
2 William S. Brougher Son One-sixth (1/6)
633 B Street of rest, residue
Enola, PA 17025 and remanider
3 Barbara J. Deitch Daughter One-sixth (116)
56 Green Hill Road of rest, residue
Mechanicsburg, PA 17050-1510 and remainder
4 Helen M. Foultz Daughter One-sixth (1/6)
Box 435, RD#1 of rest, residue
Honey Grove, PA 17035 and remainder
5 Patricia A. Gingrich Daughter One-sixth (1/6)
Predeceased of rest, residue
PA and remainder
See continuation schedule attached Continuation
Total
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule J (Rev. 6-98)
SCHEDULE ..
BENEFICIARIES
(Part I, Taxable Distributions)
ESTATE OF:
Sarah E. Brougher 201-18-4177 01/07/2005
Item Name and Address of Person(s) Share of Estate Amount of Estate
Number Receiving Property Relationship (Words) ($$$)
6
Sara J. Simpson
Box 103
Ickesburg, PA 17037-0103
Daughter
One-sixth (1/6) of
rest, residue and
remainder
0.00
Total
1
.
LAST WILL AND TESTAMENT
OF
SARAH E. BROUGHER
I, SARAH E. BROUGHER, of East Pennsboro Township,
Cumberland County, Pennsylvania, make, publish and declare this
as and for my Last Will and Testament, hereby revoking all other
wills and Codicils heretofore made by me.
FIRST: I devise and bequeath all the rest, residue and
remainder of my estate of whatever nature and wherever situate,
including any property over which I hold power of appointment and
together with any insurance policies thereon, in equal shares, to
my children, WILLIAM S. BROUGHER, GEORGE E. BROUGHER, PATRICIA A.
GINGRICH, SARA J. SIMPSON, BARBARA J. DEITCH, and HELEN M.
FOULTZ, provided that should any of my children predecease me, I
give and bequeath such child's share unto his or her issue per
stirpes by representation, and if there be a failure of same,
then I give and bequeath such deceased child's share to my
surviving children as provided herein.
SECOND: In addition to all powers granted to them by
law and by other provisions of this Will, I give the fiduciaries
acting hereunder the following powers, applicable to all proper-
ty, exercisable without court approval and effective until actual
distribution of all property:
(A) To sell at public or private sale, or to lease,
for any period of time, any real or personal property and to give
options for sales, exchanges or leases, for such prices and upon
such terms (including credit, with or without security) or
conditions as are deemed proper. This includes the power to give
legally sufficient instruments for transfer of the property and
to receive the proceeds of any disposition of it.
. .
(B) To partition, subdivide, or improve real estate
and to enter into agreements concerning the partition, subdivi-
sion, improvement, zoning or management of real estate and to
impose or extinguish restrictions on real estate.
(C) To compromise any claim or controversy and to
abandon any property which is of little or no value.
(D) To invest in all forms of property, including
stocks, common trust funds and mortgage investment funds, without
restriction to investments authorized for Pennsylvania fiduci-
aries, as are deemed proper, without regard to any principle of
diversification, risk or productivity.
(E) To exercise any option, right or privilege granted
in insurance policies or in other investments.
(F) To exercise any election or privilege given by the
Federal and other tax laws, including, but not necessarily being
limited to, personal income, gift and estate or inheritance tax
laws.
(G) To make distributions to my herein named benefici-
aries in cash or in kind or partly in each.
(H) To borrow money from themselves or others in order
to pay debts, taxes, or estate or trust administration expenses,
to protect or improve any property held under my will, and for
investment purposes.
(I) To select a mode of payment under any qualified
retirement plan (pension plan, profit sharing plan, employee
stock ownership plan, or any other type of qualified plan) to the
extent the plan or the law permits them to do so, and to exercise
any other rights which they may have under the plan, in whatever
manner they consider advisable.
THIRD: I direct that all inheritance, estate, trans-
fer, succession and death taxes, of any kind whatsoever, which
may be payable by reason of my death, whether or not with respect
to property passing under this Will, shall be paid out of the
principal of my residuary estate.
2
.." "..
FOURTH: All interests hereunder, whether principal or
income, which are undistributed and in the possession of the
fiduciaries acting hereunder, even though vested or distribut-
able, shall not be subject to attachment, execution or sequestra-
tion for any debt, contract, obligation or liability of any
beneficiary, and furthermore, shall not be subject to pledge,
assignment, conveyance or anticipation.
FIFTH: I nominate and appoint WILLIAM S. BROUGHER,
Executor of this, my Last Will and Testament. In the event of
the death, resignation or inability to serve for any reason
whatsoever of the said WILLIAM S. BROUGHER, I nominate and
appoint GEORGE E. BROUGHER, Executor of this, my Last will and
Testament. I direct that my Executor shall not be required to
post security or a bond for the performance of his duties in any
jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal to this, my Last Will and Testament, this /5~' day of
.o.P~
2000.
.,f"'i,'U?~,c- R~.i!-'1..-
SARAH E. BROUG R
(SEAL)
Signed, sealed, published and declared by the above-
named Testatrix as and for her Last will and Testament in our
presence, who, at her request, in her presence and in the
presence of each other, have hereunto subscribed our names as
attesting witnesses.
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Address (j" - I ,~/
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