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HomeMy WebLinkAbout09-22-05 . Neo Financial Systems, Inc. 140 Sprint Dr. Blountville, Tn. 37617 ,800-295-3884 Ext. 2407 ~Q~~ ~ wJLlo 1- (I",6lAA"t ~ 4 ~~ ~o~ ~ PI1 17013 e~~: ) ) Name: fhO~(1A.jLL,(. D-UVL ; Address: .:1.4-*0. /Ltm ~ it ~ ;.() /I. ) A . . A ) ~11JL~ Pit ,?cJ/3 ' ) , ) Creditor: COlLJ-t.;'fOJ R~~oJl ) ) Date of Service: 4 -/3 - 0 ~- ) ) ) ) Current Balance: J1 028.51/.33 , ~.J)' -:J:1 CJ.?() 7 9 9 .5- DECEASED. 4 - I 3 -o.s-" 1~{t My 'J Case No.: ~/-05- 3S-Q Proof Of Claim against Estate \\\\1111111/1111 \\ II "", ~S C. S 11/// ~' b..~ .......... Co // ;2 y-.... .... 'J' ~ ~ ..' STATE "',)< ~ ~ / OF .... ~ ~ f TENNESSEE ~ ~ ~ i:. ". NOTARY ..= ~ ~'Y~"" PUBLIC ....~t'! ~('Jt........ ......&~.$" <,'T/~ ....... O'V" ////11 GrON C """ 111'1/" /I" \,,\\\ II :-2 "'.> ~ ('"~ (./' ;.'1 -- 4J r.\) t'p :I~ :.) " ~l:; ., c ~'} .. .."",, I I I \ 'r1 ~ 1'-'1 (~-I-~ I I i I ~'3o-0~ I '1./J~/L {l. iJA. n.I>vtV.L- T~ I Date: J'''l , , Dewanna Palmer Legal Forwarding Assistant Please file a claim against the listed estate. - 1 ~ Account:48417402 window: U Disp:4DEC REVIEW DECEASED INFO ~ Name:BEAR MARGARET L Rp: Adr:24 HARMONY HALL DR Poe: Ad r : Ad r : Cty:CARLISLE Cty: St:PA zip:17013 St: zip: Clt:H85803 CARLISLE REGIONAL MEDICAL CENTER Lst:06/07/05 Srv:04/13/05 Ltrs:1 Time:O Ssn: Ssn: Time:NONE cont:O -396 Cbr:N ph:717 243-1170 Rp ph: Lgl:1 Poe ph: Freq: Pay: 0.00 Canc:UNC Born:09/19/1940 I COf:N Sal: CARLISLE 9307995 org: Atmps:O ~ ~. worked:O---- Int: 28511.33 .J:t.'W.~ o. 09/01/05 PAGE 001 HEALTH 1lARAGEKElft' ASSOC:IATES CARL:ISLE REG:IORAL MED CENTER PAT:IERT: BEAR, MARGARET L F/C: P P/T::I A/C: 9307995 ADM:ISS:IOH: 04/09/05 DA17 COID: 858 AS OF 08/31/05 DSC CODE# 20 D:ISCRARGE: 04/13/05 -----------------------------------------------------------------------~------- CHG DATE DPT REV BAT# BCPC M1M2 CHGeD DESCR:IPT:IOH QTY ~ORT -----------------------------------------------------------------------+------- 04/08/05 428 320 04/08/05 444 730 04/08/05 480 307 04/09/05 350 200 04/09/05 412 250 04/09/05 412 250 04/09/05 412 250 04/09/05 412 250 04/09/05 412 250 04/09/05 412 250 04/09/05 412 250 04/09/05 412 250 04/09/05 412 250 04/09/05 412 250 SELECT: REV- * CMD:l-DAR,2-PAT 8 71010 6 93005 6 81005 4 5200 5200 5200 5200 5200 5200 5200 5200 5200 5200 11180 CHEST lV 00033 ELECTROCARD:IOGRAIII 10447 UR:IHE D:IPST:ICK 00026 0005A:ICCU PR:IVATE 04610 CALC:IUM ACETATE 667M 04610 CALC:IUM ACETATE 667M 12451 :IHSUL:IH REG HOllAR RE 27960 OXYMETAZOL:IHE 0.05% 34470 SOD:IUM B:ICARB 650MG 34470 SOD:IUM B:ICARB 650MG 34490 SOD:IUM B:ICARB 8.4% S 34490 SOD:IUM B:ICARB 8.4% S 34490 SOD:IUM B:ICARB 8.4% S 34490 SOD:IUM B:ICARB 8.4% S DEPT- * CHGeD- * DATE/MDCY- * 4-SUMMARY,5-TOP,6-EHD,7-RETURH,8-BACKWARD 1 ~92.65 1 ~90.66 1 138.12 1 1,~80.00 2 7.60 2 7.60 1 14.55 1 22.77 2 7.60 2 7.60 2 214.18 2 ~14.18 2 ~14.18 1 ~07.09 CORT:II.I1UED. . ~ TO/MDCY- * : I ENTER-~RWARD I 1 I \l\lS lS A.N AllEMP'1I 10 COl.LECT A DEB~. . ANY INFORMA liON oaT AINEO WILL B USED FOR THAT PURP. SE J? ,; ". , -~\~ ), . ; 09/01/05 PAGE 002 HEALTH MARAGEMENT ASSOC:IATES CARL:ISLE REG:IORAL MED CERTER PAT:IERT: BEAR, MARGARET L F/C: P P/T::I A/C: 9307995 .ADII:ISS:IOR: 04/09/05 DA17 CO:ID: 858 AS OF 08/31/05 DSC CODE: 20 D:ISCHARGE: 04/13/05 ------------------------------------------------------------------------------- , CRG DATE DPT REV BAT' RCPC 111112 CaGeD DESCR:IPT:IOR Q'l'Y ~mrr -----------------------------------------------------------------------~------- 04/09/05 412 250 04/09/05 416 258 04/09/05 416 258 04/09/05 416 258 04/09/05 416 258 04/09/05 416 258 04/09/05 416 258 04/09/05 416 258 04/09/05 416 258 04/09/05 416 258 04/09/05 416 258 04/09/05 416 258 04/09/05 418 270 04/09/05 418 270 SELECT: REV- * CIID:1-DAR,2-PAT 5200 5400 5400 5200 5400 5400 5400 5400 5400 6 5200 5200 6 5400 SOD:IUII POLYSTYRERE S 2 t25.24 D5 1/2 rv SOL 100011L 1 ~27.41 D5 RS rv SOL 100011L 1 104.64 D5W rv SOL 100011L 1 100.85 D5W rv SOL 100011L 1 ~00.85 SOD:IUII CBLOR:IDE 0.9% 194.02 I SOD:IUII CBLOR:IDE 0.9% 2 ~73.62 SOD:IUII CBLOR:IDE 0.9% 1 !93.65 SOD:IUII CBLOR:IDE 0.9% 1 93.65 SOD:IUII CBLOR:IDE 0.9% 1 71.03 DOPAII:IRE 1.6I1G/IIL/D5 1 ~69.65 DOPAII:IRE 1.6I1G/IIL/D5 1 ~69.65 SET CORT:IRO FLO 0.22 1 !37.97 SET CORT:IRO FLO 0.22 1 :37.97 CORT:IROED. . .: TO/IIDCY- * ERTER-!'ORWARD 34940 00750 00800 00960 00960 02750 02760 02770 02770 02820 78791 78791 00493 00493 DEPT- * caGeD- * DATE/IIDCY- * 4-SUllMARY,5-TOP,6-ERD,7-RETURR,8-BACKWARD TH!S IS AN ATiEMPT lO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE 09/01/05 PAGE 003 HEALTH KARAGEIIERT ASSOCZATES CARLJ:SLE REGJ:ORAL NED CEIlITER PATJ:ERT: BEAR, MARGARET L F/C: P PIT: J: A/C: 9307995 ADIIJ:SSJ:OH: 04/09/05 DA17 COJ:D: 858 AS OF 08/31/0~ DSC CODE; 20 DJ:SCBARGE: 04/13/05 -----------------------------------------------------------------------~------- I CHG DATE DPT REV BAT# HCPC 111112 CHGCD DESCRJ:PTJ:OH QTY ~01JHT ~~~~;~~~-~~;-;;~-~~~~------------~~~;;-;;;-~~;;~~-~-~~;;----~-------i;;~;;-- 5400 00493 SET CORTJ:HO FLO 0.22 1 !37.97 5400 00493 SET CORTJ:HO FLO 0.22 1 137.97 6 01811 TRAY CATH FOLEY 18FR 1 ~03.76 6 03430 KJ:T J:V START 1! 57 .89 5400 03430 KJ:T J:V START 1 !57.89 I 5400 08369 OJ:RTIIERT PROTBCTJ:VE 1 !37.97 5400 11312 DRESSJ:HG SPLJ:T 2X2B 10 ~68.80 5400 12654 CUFF B/P ADULT SJ:HGL 1 48.52 5400 17366 CUFF B/P ADULT SMALL 1 48.52 5400 25858 PERJ:HEAL CARE COIIFOR 1 16.88 6 28187 CORTAJ:HER TRANS SPEC 1 16.88 5400 28220 KJ:T READY BATH 2 46.42 5400 28220 KJ:T READY BATH 1 23.21 CORTJ:HOED. . ~ DEPT- * CHGCD- * DATE/IIDCY- * TO/IIDCY- * i 4aSUllllARY, 5-TOP, 6-EHD, 7.RETtJRR, 8-BACKWARD EHTER-+>RWARD 04/09/05 418 270 04/09/05 418 270 04/09/05 418 270 04/09/05 418 272 04/09/05 418 272 04/09/05 418 250 04/09/05 418 270 04/09/05 418 270 04/09/05 418 270 04/09/05 418 272 04/09/05 418 270 04/09/05 418 270 04/09/05 418 270 SELECT: REV- * CIID:l-DAR,2-PAT 'p-'... . f;- t THIS IS AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE 09/01/05 PAGE 004 BEALTB KARAGEKENT ASSOCLATES DA17 COID: 858 CARLXSLE REGXORAL MED CERTBR AS OF 08/31/05 PATXENT: BEAR, MARGARET L F/C: P PIT: X DSC CODE: 20 A/C: 9307995 ADMXSSXOR: 04/09/05 DXSCBARGE: 04/13/05 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~: 04/09/05 418 270 5400 28220 KXT READY BATH 1 ,23.21 04/09/05 418 272 6 31258 SET XV ADMXR EXT SET 1 129.55 I 04/09/05 418 270 5400 33801 'rOO'l'BBRUSB 1 110.56 · 04/09/05 418 270 5400 33900 'l'OOTHPASTE 1 110.56 04/09/05 418 270 5 42052 OXYGER DAXLY 1 ~93.71 04/09/05 418 272 5400 50748 TRAY XRRXGATXOR PXST 1 116.88 04/09/05 418 270 5400 53155 TOOTHETTES 10/PK 2 121.12 04/09/05 418 270 5400 53155 TOOTHETTES 10/PK 1 110.56 04/09/05 418 270 5400 70320 BUKXDXFXER BUBBLE 1 123.21 04/09/05 418 270 5400 72885 BABY WXPES (40 COURT 1 123.21 , 04/09/05 418 272 5400 87793 SET XV SECORDARY V19 1 : 6.33 04/09/05 429 352 8 71260 71260 CT THORAX W/CONTRAST 1 1,~41.48 04/09/05 429 352 8 72193 72193 CT PELVXS W/CONTRAST 1 1,~19.56 04/09/05 429 352 8 74160 74160 CT ABDOMER W/CONTRAS 1 1,~19.56 CONTXl!iUED. . ~ SELECT: REV- * DEPT- * CHGCD- * DATE/MDCY- * TO/MDCY- * CKD:l-DAR,2-PAT 4-8OKMARY,5-TOP,6-ERD,7-RETURR,8-BACKWARD ERTBR- RWARD TH\S \S AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE \ I 09/01/05 PAGB 005 HEALTH IlARAGBKBN'l' ASSOC:IATES CAJU.:ISLB RBG:IORAL JlBD CBN'l'BR PAT:IERT: BEAR, MARGARET L F/C: P P/T::I A/C: 9307995 ADM:ISS:IOR: 04/09/05 DA17 COlD: 858 AS OF 08/31/05 DSC CODE: 20 D:ISCBARGB: 04/13/05 -----------------------------------------------------------------------~------- CRG DATE DPT REV BAT' BCPC 111112 CRGCD DESCR:IPT:IOR QTY ~URT -----------------------------------------------------------------------~------- 04/09/05 431 402 04/09/05 436 305 04/09/05 436 306 04/08/05 436 301 04/09/05 436 301 04/09/05 436 301 04/09/05 436 301 04/09/05 436 301 04/09/05 436 301 04/09/05 436 301 04/08/05 436 301 04/09/05 436 301 04/09/05 436 301 04/09/05 436 301 SBLBCT: REV- * CIID:1-DAR,2-PAT 8 76700 30 85007 30 87046 30 82962 30 82962 30 82962 30 82962 30 82962 30 82962 30 80048 30 80053 30 80053 30 80053 30 80074 76700 U/S ABDOMEN COMPLETE 1 ~75.65 00719 WBC D:IFF OBLY 1 !20.97 10024 CULTURE V:IBR:IO STOOL 1 :36.70 10306 GLUCOSB BEDS:IDB 1 '12.60 10306 GLUCOSB BEDS:IDB 112.60 10306 GLUCOSB BBDS:IDE 1 12.60 10306 GLUCOSB BEDS:IDE 1 12.60 10306 GLUCOSE BEDS:IDE 1 12.60 10306 GLUCOSB BEDS:IDZ 1 12.60 10606 BAS:IC JlBTABOL:IC PARE 1 66.39 10607 COKPRBBBRS:IVB KBTABO 1 78.90 10607 COKPRBBBRS:IVB JlBTABO 1 78.90 10607 COKPRBBBRS:IVB KETABO 1 78.90 10694 ACUTE BBPAT:IT:IS PARE 1 t62.95 CON'l':IRtJED. . 4 TO /IIDCY- * i ERTBR-'~RWARD DEPT- * CBGCD- * DATE/KDCY- * 4_S1JIOIARY,5-TOP,6-ZRD,7-U'1'URR,S-BACJtWARD ~ · 2HiS \S AN A'TTEMPT 10 COLLECT A DEBT. ANY' INFORMATION QmA~NEO WILL 8~ USE/) FOR THAT PWirOSE 09/01/05 PAGE 006 HEALTH MARAGEMERT ASSOC~TES DA17 COlD: 858 CARLISLE REGIORAL KED CENTER AS OF 08/31/0$ PATIERT: BEAR, MARGARET L F/C: P PIT: I DSC CODE: 20 A/C: 9307995 ADMISSION: 04/09/05 DISCHARGE: 04/13/05 -----------------------------------------------------------------------t------- CHG DATE DPT REV BAT# HCPC 111M2 CHGCD DESCRIPTION Q'l'Y ~omrr I -----------------------------------------------------------------------+------- 04/09/05 436 309 30 89055 17059 LEUKOCYTE COURT FECA 1 155.90 04/09/05 436 301 30 82105 20060 ALPHA-FETOPROTEIN SE 1 ~29.28 04/09/05 436 306 30 87040 20132 CULTURE BLOOD 1 ~14.87 04/09/05 436 306 30 87040 20132 CULTURE BLOOD 1 ~14.87 04/08/05 436 301 30 82140 21402 AIIMONIA BLOOD 1 ~18.80 04/09/05 436 305 30 85027 25254 HEIIOGRAII/PLATELET AU 1 154.16 04/08/05 436 300 30 36415 36111 VENIPUNCTURE ROUTINE 1 9.00 04/09/05 436 300 30 36415 36111 VENIPUNCTURE ROUTINE 1 9.00 04/09/05 436 300 30 36415 36111 VENIPUNCTURE ROUTINE 1 9.00 04/09/05 436 300 30 36415 36111 VENIPUNCTURE ROUTINE 1 9.00 04/09/05 436 300 30 36415 36111 VENIPUNCTURE ROUTINE 1 9.00 04/09/05 436 300 30 36415 36111 VENIPUNCTURE ROUTINE 1 9.00 04/08/05 436 300 30 80100 75235 DRUG SCREER URINE 1 ~26.49 04/09/05 436 301 30 82150 82150 AllYLASE 1 154.16 COftIHUED. . .i SELECT: REV- * DEPT- * CHGCD- * DATE/IIDCY- * TO/IIDCY- * 1 CIID:l-DAR,2-PAT 4-SUllllARY,5-TOP,6-EHD,7-RETORH,8-BACXWARD ENTER-~RWARD f~' :::,.... ,. r TH1S IS AN ArrEMPT TO COllECT A DEBT. ANY tNFORMA TION OBTAINED WilL BE USED FOR THAT PURPOSE 09/01/05 PAGE 007 HEALTH MARAGEMERT ASSOCIATES CARLISLE REGIONAL lIED CERTER PATIENT: BEAR, MARGARET L F/C: P PIT: I A/C: 9307995 ADMISSION: 04/09/05 DA17 COID: 858 AS OF 08/31/0$ DSC CODE; 20 DISCHARGE: 04113/05 -----------------------------------------------------------------------.------- I CHG DATE DPT REV BAT# HCPC M1M2 CaGeD DESCRIPTION QTY ~OUHT -----------------------------------------------------------------------~------- 04/08/05 436 301 30 83690 83690 LIPASE 1 i81.68 04/09/05 436 301 30 83690 83690 LIPASE 1 ~81.68 04/09/05 436 301 30 83735 83735 MAGNESIUM 1 82.11 04/09/05 436 301 30 84100 84100 PHOSPHORUS 1 38.44 04/08/05 436 305 30 85025 85028 CBC COMPLETE AUTOMAT 1 57.66 04/08/05 436 305 30 85730 85341 PTT 1 50.67 04/08/05 436 300 30 85610 85610 PROTHROMBIN TIllE 1 38.44 04/09/05 436 301 30 83605 91001 LACTIC ACID 1 78.62 04/09/05 458 302 30 86900 33131 ABa GROUP 1 25.14 04/09/05 458 302 30 86850 33132 ANTIBODY SCREER SIII 1 62.85 04/09/05 458 302 30 86901 33134 BLOOD TYPING RB (D) 1 25.14 04/09/05 480 450 6 99285 00520 ER DEPT MAJOR VISIT 1 *81.08 04/08/05 480 307 5 81005 10447 URINE DIPSTICK 1- j38.12- 04/09/05 480 260 6 90780 33425 IV INFUSION THERAPY 1 ~89.00 I CONTINUED. . 1 SELECT: REV- * DEPT- * CHGeD- * DATE/MDCY- * TO/MDCY- * ! CMD:1-DAR,2-PAT 4-SUMMARY,5-TOP,6-EHD,7-RETORH,8-BACKWARD ERTER.~RWARD THIS IS AN ATTEMPT TO COLLECT A DEBT. ANY INFORMA T/ON OBr A/NED W/LL BE USED FOR THAT PURPOSE 09/01/05 PAGE 008 HEALTH IlARAGEllER'l' ASSOCI:ATES CARLI:SLE REGI:ORAL lIED CENTER PATI:ER'!': BEAR, MARGARET L F/C: P PIT: I: A/C: 9307995 ADIII:SSI:OR: 04/09/05 DA17 COI:D: 858 AS OF 08/31/0$ DSC CODE: 20 DI:SCBARGE: 04113/05 -----------------------------------------------------------------------~------- CHG DATE DPT REV BATt HCPC M1M2 CHGCD DESCRI:PTI:OR QT'Y l.omrr -----------------------------------------------------------------------~------- 04/09/05 480 260 6 90781 33426 I:V I:RFOSI:OR, ADDI:TI:O 6 1,~00.00 04/09/05 480 450 6 97000 ER PROCED MI:R'OR 1 $67.07 04/10/05 350 200 4 00026 0005AI:CCO PRI:VATE 1 1,~80.00 04/10/05 412 250 5202 15170 GER'l'AMI:CI:R SUL 40MG/ 4 160.12 04/10/05 412 250 5202 16810 HEPARI:R SODI:um 100U/ 2 61.96 04/10/05 412 250 5202 20150 LACTULOSE 10GM/15ML 1 14.67 04/10/05 412 250 5202 25000 MORPHI:R'E SULFATE 10M 1 5.44 04/09/05 412 250 5202 30410 PHYTORADI:OR'E 5MG TAB 1 4.12 04/10/05 412 250 5202 30410 PHYTORADI:OR'E 5MG TAB 1 4.12 04/10/05 412 250 5202 34470 SODI:um BI:CARB 650MG 2 7.60 04/10/05 412 250 5202 34470 SODI:um BI:CARB 650MG 2 I 7.60 04/10/05 412 250 5202 34490 SODI:um BI:CARB 8.4% S 3 a21.27 04/10/05 412 250 5202 34490 SODI:um BI:CARB 8.4% S 2 ~14.18 04/10/05 412 250 5202 34490 SODI:um BI:CARB 8.4% S 1 ~07.09 COR'l'I:R'tJED. . ~ SELECT: REV- * DEPT- * CHGCD- * DATE/MDCY- * TO/MDCY- * i CMD:1-DAR,2-PAT 4-SUIOIAR.Y,5-TOP,6-E&D,7-UTURR',8-BACKWARD ENTER.~RWARD I I -1.I'S I::' r'}.l .\Trq.\r\PT 1 f' t .,;; J'U' ;.),~. 1 I.... . . " I I" ~T '" ;,'~n'" 10 C()L.I..cL i j-. vL~q. A! "',' ~~i';::1~.P!.,1ll Tln!~ f',f,j. \I 'it I ....J, ll'J'~." '. 1 :::.: ... 0'"'1' ~ 0',17' n I..U" j I',l- .)...5il-\,!;~c.:-J .t"""... ,J._ USED fOR THAT PUfWOSE \ I 09/01/05 PAGE 009 HEALTH 1lARAGEDlfi' ASSOCIATES CARLISLE REGIOHAL OD CBHTBR PATIERT: BEAR, MARGARET L F/C: P PIT: I A/C: 9307995 ADMISSION: 04/09/05 DA17 COID: 858 AS OF 08/31/05 DSC coma 20 DISCHARGB: 04/13/05 -----------------------------------------------------------------------.------- I CRG DATE DPT REV BATI RCPC 111112 caGeD DBSCRIPTION Q'I'Y ",-0tJH'1' -----------------------------------------------------------------------+------- 04/10/05 412 250 5202 34490 SODroM BICARB 8.4% S 2- ~14.18- 04/10/05 412 250 5202 69999 ZOSYH 2/.25 OM 2 ~40.80 04/10/05 412 250 5202 69999 ZOSYH 2/.25 OM 1 \70.40 04/10/05 412 250 5202 69999 ZOSYW 2/.25 GII 1 '70.40 04/10/05 412 250 5202 97289 DOPAMINE 4001lG/l011L 8 74.88 04/10/05 416 258 5202 00920 D5W IV SOL 5011L 2 188.04 04/10/05 416 258 5202 00920 D5W IV SOL 5011L 1 94.02 04/10/05 416 258 5202 00940 D5W IV SOL 25011L 4 320.40 04/10/05 416 258 5202 00960 D5W IV SOL 100011L 1 100.85 04/10/05 416 258 5202 00960 D5W IV SOL 100011L 1 100.85 04/10/05 416 258 5202 00960 D5W IV SOL 100011L 1- 100.85- 04/10/05 416 258 5400 02770 SODIUM CHLORIDE 0.9% 2 187.30 04/10/05 416 258 5400 02820 SODIUM CHLORIDE 0.9% 1 71.03 04/10/05 416 258 5202 44556 HEPARIN 10000 .9% NS 1 27.03 COHTIHUBD. . ~ TO/KDCY. * BHTBR-~ORWARD SBLECT: REV- * CIID:l-DAR,2-PAT DEPT- * caGeD- * DATE/KDCY- * 4_SUMKARY,5-TOP,6-BHD,7-RETURH,8-BACKWARD ~ ~ THIS IS AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION OST A/NED WILL BE USED FOR THAT PURPOSE - II 09/01/05 PAGE 010 HEALTH JlARAGEllER'l' ASSOC:IATES CARL:ISLE REG:IORAL lIED CEN'l'ER PAT:IER'l': BEAR, MARGARET L F/C: P P/T::I A/C: 9307995 ADII:ISS:IOIf: 04/09/05 DA17 CO:ID: 858 AS OF 08/31/05 DSC CODE: 20 D:ISCBARGE: 04/13/05 -----------------------------------------------------------------------~------- CHG DATE DPT REV BATI HCPC M1M2 CHGCD DESCR:IPT:IOIf QTY ~UIfT -----------------------------------------------------------------------~------- 04/10/05 416 258 5202 78791 DOPAM:I1fE 1.6HG/ML/D5 1 ~69.65 04/10/05 416 258 5202 78791 DOPAM:I1fE 1. 6MG/ML/D5 1 .169.65 04/10/05 416 258 5202 78791 DOPAM:I1fE 1.6HG/ML/D5 1 ~69.65 04/10/05 418 270 5400 00173 K:IT DIUI",I;ud CARE 1 16.88 04/10/05 418 270 5400 00493 SET COR'l':I1fU FLO 0.22 3 .1(13.91 04/10/05 418 270 5400 01859 tJR:IIlETER 1 i.97 . 42 04/10/05 418 270 5400 07123 K:IT ARTER:IAL MOIf:ITOR 1 63.29 04/10/05 418 270 5400 07123 KIT ARTER:IAL MOIf:ITOR 1 ,63.29 04/10/05 418 270 5400 07125 K:IT IIOIf:ITOR:IIfG D:IAL 1 1126.57 04/10/05 418 270 5400 07125 K:IT MOIf:ITOR:I1fG D:IAL 1 ~26.57 04/09/05 418 270 5 07150 CATH FOLEY 30CC 30F 1 ,37.97 , 04/10/05 418 270 5400 10057 SOLtJT:IOIf BBTAD:I1fE 4 1 6.33 04/09/05 418 272 5 10445 BAG tJR:IIDRY DRA:IRAGE 1 137.97 04/10/05 418 272 5400 18409 K:IT CATH CER'l' VElfOUS 1 4199.94 COR'l':IIfUED. . . I SELECT: REV- * DEPT- * CHGCD- * DATE/IIDCY- * TO /IIDCY- * CIID:l-DAR,2-PAT 4-S1JIIIIARY,5-TOP,6-ElfD,7-UTtJRlf,8-BACKWARD EN'l'ER-FpRWARD \if. ,.HIS IS .~N ATIEMPT TO CCLLECT A DEBT. ANY INFORMA YION OBTAINED WilL BE USED FOR "filA T PURPOSE l' 09/01/05 PAGB 011 HEALTH MARAGZMBRT ASSOCXATES DA17 COID: 858 CARLISLE REGIONAL BED CERTBR AS OF 08/31/05 PATIENT: BEAR, MARGARET L F/C: P PIT: I DSC CODE: 20 A/C: 9307995 ADHISSIOR: 04/09/05 DISCHARGB: 04113/05 ______________________________________________________-----------------t------- CHG DATE DPT REV BATt HCPC M1M2 CHGeD DESCRIPTIOR QTY ..-OtJRT -----------------------------------------------------------------------~------- 04/10/05 418 272 5400 20738 CAP IRJBCTIOR 4 .23.04 04/10/05 418 270 5 42052 OXYGER DAILY 1 ~93.71 04/10/05 418 270 5400 53155 TOO'l'BBTTES 10/PK 1 10.56 04/09/05 418 272 5 74896 STATLOCK MICRO CATB 1 30.00 04/10/05 418 272 5400 87793 SET rv SECORDARY V19 1 6.33 04/10/05 428 320 8 71010 11180 CHBST 1 V 1 292.65 04/10/05 436 301 30 80069 10610 RENAL I'OHCTIOR PAm!:L 1 72.04 04/10/05 436 300 30 36415 36111 VBRIPURCTO'RE ROU'l'IRB 1 9.00 04/08/05 436 300 30 80100 75235 DRUG SCREER tJRIRB 1- ~26.49- 04/10/05 436 300 30 85610 85610 PRO'l'BROIIBIR TIllE 1 38.44 04/11/05 350 200 4 00026 0005AICCtJ PRrvATE 1 1,a80.00 04/11/05 412 250 5201 04610 CALCIUM ACBTATE 667M 2 7.60 04/11/05 412 250 5201 04610 CALCIUM ACBTATE 667M 2 7.60 04/11/05 412 250 5201 10286 LIDOCAIRB HCL 1% MPF 1 34.86 CORTIRtJED. . .! SBLECT: REV- * DBPT- * CHGeD- * DATE/MDCY- * TO/MDCY- * CMD:1-DAR,2-PAT 4_StJMMARY,S_TOP,6_ERD,7_UTtJRR,8_BACKWARD BRTBR-i!ORWARD THIS IS AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION 08T AINED WILL BE USED FOR THAT PURPOSE l' 09/01./05 PAGE 01.2 HEALTH IlARAGBIIBl'ft ASSOC:rATES CARLJ:SLE UGJ:ORAL aD CBR'l'BR PATJ:ERT: BEAR, MARGARET L F/C: P PIT: J: A/C: 9307995 ADMJ:SSJ:OR: 04/09/05 DA17 COJ:D: 858 AS OF 08/31/05 DSC CODE: 20 DJ:SCBARGE: 04/1.3/05 ------------------------------------------------------------------------------- CRG DATE DPT REV BAT# RCPC 111112 caGeD DBSCRJ:PTJ:OR QTY AIIOURT -----------------------------------------------------------------------~------- 04/1.1./05 41.2 250 5201. 11.100 DJ:PBBRJIYDRAIIJ:RB 2511G 1 3.80 04/1.1./05 41.2 250 5201. 1.11.40 DJ:PHl!:IIIHYDRAIIJ:RB BCL 1. 16.54 04/11/05 412 250 5201 11.1.40 DJ:PBERIIYDRAIIJ:D BCL 1 16.54 04/11/05 412 250 5201 20150 LACTOLOSB 10GII/1511L 1. 1.4.67 04/11/05 412 250 5201 20150 LACTOLOSB 10GII/1511L 1 14.67 04/11/05 412 250 5201 25000 MORPRJ:D SULFATE 1011 1 5.44 04/11./05 412 250 5201 25000 IIORPRJ:D SULFATE 1011 1 5.44 04/09/05 41.2 250 5201. 3041.0 PBY'l'OJlADJ:OD 511G TAB 1 4.12 04/11/05 4.1.2 250 5201. 3041.0 PBY'l'OJlADJ:OD 511G TAB 1. 4.1.2 04/11/05 4.12 250 5201 344.70 SODJ:UII BJ:CARB 65011G 2 7.60 04./11/05 412 250 5201 34.470 SODJ:UII BJ:CARB 650llG 2 7.60 04/11/05 412 250 5201 69999 ZOSYR 2/.25 GII 2 140.80 04./11/05 412 250 5201. 97289 DOPAIIJ:D 4.00IlG/l011L 6 56.16 04/1.1./05 41.6 258 5201 00920 D5W xv SOL 5011L 2 188.04 CORTJ:RUBD. . . SBLECT: REV- * DBPT- * CBGeD- * DATE/IIDCY- * TO/IIDCY- * CIID:l-DAR,2-PAT 4._SUllKARY,5_TOP,6_BRD,7_UTORR,a_BACKWARD BHTBR-roRWARD THIS IS f,J~ ATI!:MPT TO COLLECT A DEBT. ANY !NFOHMiHiON OST A1NEDW:U. [it USED rC'B T;.:r~T [.jur;PCS,E \ I 09/01/05 PAGB 013 HEALTH IIA1lIAGBIIBm'1 ASSOC:IA'l'BS CARL:ISLB REG:IORAL DD CBtlITBR PAT:IBRT: BEAR, MARGARET L F/C: P P/T::I A/C: 9307995 ADM:ISS:IOR: 04/09/05 DA17 CO:ID: 858 AS OF 08/31/05 DSC com:: 20 D:ISCBARGB: 04/13/05 -----------------------------------------------------------------------.------- , CHG DA'l'B DPT REV BATI HCPC 111112 CHGeD DESCR:IPT:IOR Q'l"Y AIIOlJRT -----------------------------------------------------------------------+------- 04/11/05 416 258 5201 00940 D5W :IV SOL 25 01lL 3 *40.30 04/11/05 416 258 5400 02770 SOD:I'CII CBLOR:IDB 0.9% 1 93.65 04/11/05 416 258 5400 02770 SOD:I'CII CBLOR:IDE 0.9% 1 93.65 04/11/05 416 258 5400 02820 SODI'CII CHLORIDE 0.9% 1 71.03 04/11/05 416 258 5400 02820 SODI'CII CHLORIDB 0.9% 1 71.03 04/11/05 418 270 5400 17366 CUFF B/P ADULT SMALL 1 48.52 04/11/05 418 272 5400 20738 CAP IHJECTIOH 1 5.76 04/11/05 418 623 5400 A6216 20784 DRESS:IRG SPORGB 4X4 6 30.36 04/11/05 418 270 5400 28220 KIT READY BATH 1 23.21 04/11/05 418 270 5400 28868 CAmmLA ll1A.SAL OXYGER 1 52.74 04/11/05 418 270 5 42052 OXYGER DAILY 1 ~93.71 04/11/05 418 270 5400 73815 BRUSH ORAL EVACUATOR 6 ~89.90 04/11/05 418 270 5400 73815 BRUSH ORAL EVACUATOR 2 i 63.30 04/11/05 428 320 8 71010 11180 caST 1 v 1 292.65 CORT:IHUBD. . ~ SBLBCT: REV- * DEPT- * CHGeD- * DATB/IIDCY- * TO/IIDCY- * CIID:1-DAR,2-PAT 4_SUllllARY,5_TOP,6_EHD,7_RE'l'URJ1',8_BACKWARD BtlITBR-~RWARD THIS IS AN A ITEM!'T TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE 11 09/01/05 PAGE 014, BBALTB JIARAGBIIBlI1'1 ASSOC:IA'l'BS CARL:ISLE UG:IORAL lIED CENTER PAT:IERT: BEAR, MARGARET L F/C: P P/T::I A/C: 9307995 .ADII:ISS:IOR: 04/09/05 DA17 COlD: 858 AS OF 08/31/05 DSC CODE: 20 D:ISCRARGE: 04/13/05 -----------------------------------------------------------------------*------- CRG DA'l'B DPT REV BAT' RCPC 111112 CRGeD DESCR:IPT:IOR Q'1"Y AIIOtJRT -----------------------------------------------------------------------~------- 04/11/05 436 305 30 85007 00719 DC D:IFF OBLY 1 20.97 04/09/05 436 306 30 87046 10024 C'OLTtJRE V:IBR:IO STOOL 1- 36.70- 04/11/05 436 301 30 80076 10608 HEPATIC I'UIIICT:IOR PAR 1 151.99 04/11/05 436 301 30 80069 10610 RBRAL I'UlllCT:IOR PAUL 1 72.04 04/11/05 436 305 30 85027 25254 BEIIOGRAII/PLATELET AU 1 54.16 04/11/05 436 300 30 36415 36111 VER:IPURCTtJRE ROUT:IRE 1 9.00 04/11/05 436 300 30 85610 85610 PROTHROIIB:IR T:IIIE 1 38.44 04/10/05 444 730 5 93005 00033 ELECTROCARD:IOGRAII 1 390.66 04/12/05 311 121 4 00018 03014SEII:I PR:IVATE RO 1 650.00 04/12/05 412 250 5202 11106 IIORPH:IRE DR:IP 2501lG/ 1 253.00 04/12/05 412 250 5202 21540 LORAZEPAII 211G/1IL J:RJ 1 38.53 i 04/12/05 412 250 5202 25000 IIORPB:IRE SULFA'l'B 1011 1 5.44 04/11/05 412 250 5202 69999 ZOSYR 2/.25 GII 1- 70.40- 04/11/05 412 250 5202 97289 DOPAIIJ:RE 4001lG/l011L 2- 18.72- CORTJ:ROBD. . .' SELECT: REV- * DEPT- * CRGeD- * DATE/IIDCY- * TO/IIDCY- * CIID:l-DAR,2-PAT 4_SUllllARY,5_TOP,6_E&D,7_UT01UI,8_BACDARD ENTER-~ORWARD 1~.:~S '~~l t.\. ..._,.,~.. -ro COLLECT A ~)::t1 L I;NY ltiFOn!\1lITlON 08T.L\j~.\EO W;U. ElF U.t'ET' "n\".ll'H" }!\ ",' :;;.; \'l)"ln~'- .AtJ urV,"l ~,. wU 'W,,",'4'o l' 09/01/05 PAGE 015 BBALTH 1IAJlIAGJ!:IIJ!:NT ASSOCZATES CARLI:SLE UGI:OHAL lIED CDTBR PATI:ERT: BEAR, MARGARET L F/C: P PIT: I: A/C: 9307995 ADIII:SSI:OR: 04/09/05 DA17 COI:D: 858 AS OF 08/31/05 DSC CODB: 20 DI:SCBARGB: 04/13/05 -----------------------------------------------------------------------.------- CHG DATE DPT REV BATt acpc 111M2 CaGeD DBSCRI:PTI:OR Q'l'Y UQUR"1' -----------------------------------------------------------------------~------- 04/11/05 416 258 5202 00920 D5W xv SOL 5011L 1- 94.02- 04/11/05 416 258 5202 00940 D5W xv SOL 25011L 1- 80.10- 04/12/05 416 258 5400 02770 SODI:tJII CBLORI:DB O. 9% 1 93.65 04/11/05 418 272 5 00521 OXI:SBRSOR 1 126.57 04/12/05 418 270 5400 01073 G:RADlJATE 1 6.33 04/12/05 418 270 5400 03364 SBT xv VENTED 2906 1 16.88 04/12/05 418 270 5400 12654 CUFF B/P ADULT SI:RGL 1 48.52 04/12/05 418 270 5400 14354 CAHRI:STER W/'l'O'BI:RG 1 2 33.76 04/12/05 418 270 5400 17687 'l'O'BE COma:CTI:RG 6_ 2 :12.66 04/12/05 418 623 5400 A6216 20784 DRESS:IRG SPORGE 4X4 3 15.18 04/12/05 418 271 5400 23314 CUFF B/P LG 1 48.52 04/12/05 418 272 5400 38034 DRESSI:RG TEGADBRII 6R 4 74.24 04/12/05 418 270 5 42052 OJCYGBR DAI:LY 1 ~93.71 04/09/05 418 272 5 72950 RBBDLE BI:OPSY 1 2174.46 CORTI:ROBD. . . SBLECT: REV- * DEPT- * caGeD- * DA'1'E/IIDCY- * TO IIIDCY- * CIID:l-DAR,2-PAT 4-SlJIIIIARY,5-TOP,6-B1\1D,7-U'l'O'RR,8-BACKWARD BRTBR-J!'pRWARD v " 1li1S 1S AN ATTEMPT I TO COLLECT A DEBT.I, ANY INFORMATION ! OBr AINED WILL BE ! USEDFORTHAiPURPO~E \ I 09/01/05 PAGE 016 BEAL'l'B IlAHAGZIIEJII'l' ASSOC:IA'l'ES CARL:ISLE REG:IORAL MED CEIlTER PAT:IERT: BEAR, MARGARET L F/C: P P/T::I A/C: 9307995 ADII:ISS:IOR: 04/09/05 DA17 CO:ID: 858 AS 01' 08/31/05 DSC CODE; 20 D:ISCBARGE: 04113/05 -----------------------------------------------------------------------.------- CHG DA'l'E DPT REV BAT# HCPC !l1112 CHGCD DESCR:IPT:IOR Q'l"Y JUroORT -----------------------------------------------------------------------~------- 04/11/05 431 361 8 05725 B:IOPSY L:IVZR PERC 1 230.60 04/11/05 431 402 8 76942 30408 B:IOPSY ECHO 1 ~27.44 04/12/05 436 301 30 80069 10610 RERAL I"D'JICT:IOR PAUL 1 72.04 04/12/05 436 300 30 36415 36111 VZR:IPORCTtJRB ROUT:I_ 1 9.00 04/11/05 437 312 30 88307 88307 PA'l'BOLOGY LEVEL V 1 ~52.82 04/09/05 418 272 5 03430 K:IT :IV START 1 57.89 04/09/05 418 272 5 03430 K:IT :IV START 1 57.89 04/09/05 418 270 5 73912 DRESS:IRG TEGJ\DB1UII 2 1 46.94 04/12/05 418 270 5 73912 DRBSS:IRG TEGJ\DB1UII 2 1 ',46.94 -----------------------------------------------------------------------~------- TOTAL: CASH > SELECT: REV- * CMD:1-DAR,2-PAT TOTAL CHARGES 28,~11.33 0.00 ADJOSTMERTS > 0.00 BALANCB > 28,~11.33 DEPT- * CHGCD- * DATB/KDCY- * TO/KDCY- * 4-SlJIOIARY,5-TOP,6-BRD,7-UTORR,8-BACKKARD EIITER-l!'pRWARD ---r-t.H'T "'I'U\S \C~ A.N A I \ t:w,r Iii,. . -' . or 10 COLLECT ~ DE.., . ANY INFORMJ,\TION. 08T AINEO WILL Bf:: USED FOR IliA T PURPOSE