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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 05
COUNTY COJ)E YEAR
SOCIAL SECURITY NUMBER
00626
NUMBER
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128.0601
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DECEDENT'S NAME (LAST. FIRST. AND MIDDLE INITIAL)
McCoy, Marlin L.
THIS RETURN MUST BE FILED IN UPLICATE WITH THE
174-20-2235
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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3. Remainder Return (date of death priorto 12-13-82)
5 Federal Estate Tax Return equired
D
8. Total Number of Safe Depo it Boxes
11 . Election to tax under Sec. 9 13(A} (Attach Sch 0)
2100 Longs Gap Road
Carlisle, PA 17013
(1 ) None
(2) None
(3) None
(4) None
(5) 15,624.94
(6) None
(7) 58,342.81
(9) 12,376.07
(10) 5,157.12
13, Charitable and Governmental Bequests/Sec 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)
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o 2. Supplemental Return
D 4a. Future Interest Compromise (dale 01 death alter
12-12-82)
D 7. Decedent Maintained a living Trust (Attach
copy 01 Trust)
D 10. Spousal Poverty Credit (date 01 death between
12-31 -9Landl-1-95)
LTl-m~ ~EC!I()N MUST I3,E C;QMPL~E,D,AL.L. 9911J!E~f)()f'!P,EN9E: I\~P_COf\lFIDE:NTIALJ:~~ I.N~ORMA TION~1:I0\JI"Q.I3IU>.LRE:QTE:DI(); .
f'lAME ,COMPLETE MAILING ADDRESS
Stephen L. Bloom
i DATE OF DEATH (MM-DD-YEAR)
DATE OF BIRTH (MM-DD-YEAR)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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(8)
73,967.75
06/14/2005
01/12/1926
(11 )
17,533.19
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
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1. Original Return
4. limited Estate
6 Decedent Died Testate (Attach copy
01 Will)
9. litigation Proceeds Received
(12)
56,434.56
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F'RM NAME (If applicable)
Stephen L. Bloom, Esquire
~ELEPHONE NUMBER
717/249-7717
(13)
(14)
56,434.56
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
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)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a)(1.2)
z 56,434.56 .045 (16)
0 16.Amount of Line 14 taxable at lineal rate x
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n. 17.Amount of Line 14 taxable at sibling rate x .12 (17)
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19. Tax Due (19)
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)
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
2,539.56
2,539.56
>> BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH <<
Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
51 Mountain Street
Lot 6
CITY
Mt. Holly Springs
STATE PA
ZIP 17065
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
2,539.56
Total Credits (A + B + C)
(2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (0 + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPA VMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
0.00
(5)
(5A)
(5B)
2,539.56
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes N
a. retain the use or income of the property transferred;.................................................................................. ~
~: ~::::~ ~h;e~;~~i:~~~s:~~~~s~~~. .~~~~ ~. ~~~. ~~~. :'~.~~.~.~:. .t.~~.~.~.~~:~~~. ~.~ .i.t.~. :~~~~~;:::::::::::::: ::::::::::::::........
d. receive the promise for life of either payments, benefits or care?..............................................................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?................................. ..................................................................................... D
D
~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.........
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ................................ ........................... ............................. ..........................
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART 0 THE RETURN.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct a d complete. Declaration of
preparer other than the personal representative is based on all )nfo~lttion()f ~ich P~l!P~~t:!_r_hlt:S _a~y knowlE!~g_e.
SIGNA TURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
R"/C~J
SI~~~SP( N
DATE
] 4] Horseshoe Road
Carlisle, PA ]70]3
ADDRESS
ADDRESS
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 us
surviving spouse is 3% [72 P.S. g9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value O'
[72 P.S. g9116 (a) (1.1) (ii)). The statute does not exempt a transfer to a surviving SpOI
of assets and filing a tax return are still applicable even if the surviving spouse is the or
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 YE
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. g9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lir
1.2) [72 P.S. g9116 (a) (1)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's si 3. ~us::T
under Section 9102, as an individual who has at least one parent in common with the ac~uc"" ""c,,,c, "1 ,,'VVV VI ClVVf'lIVII.
NAT> D
g spousE! is 0%
nts for difclosure
I
1e use o~ ell natural
din 72 ~.S s9116
\ sibling ii defined,
ESTATE OF
*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
2 I - 05 - 00626
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with he right of
survivorship must be disclosed on schedule F.
ITEM
NUMBER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
McCoy, Marlin L.
DESCRIPTION
M&T Bank - Checking Account #9835405342
1973 Liberty Trailer and Appliances - Actual Sale Price
1989 Ford Ranger Truck - Actual Sale Price
1990 Sachi Moped (non-operable)
1968 Sea King l2-Foot Rowboat and Accessories
Household /terns - Actual Sale Price
Masland Industries, Inc. - Final Pension Payment
Fraternal Order of Eagles Aerie No. 1299 - Death Benefit
White Circle Club - Death Benefit
American Legion Post 674 - Death Benefit
Cumberland County - Death Benefit
State Farm Insurance - Premium Refund
Comcast Cable TV - Refund
Carlisle Propane - Refund
The Sentinel - Refund
TOTAL (Also enter on Line 5, Recapitulation)
ALUE AT DATE OF
DEATH
11,443.01
1,500.00
500.00
50.00
100.00
200.00
221. 10
500.00
200.00
350.00
100.00
105.29
114.98
117.04
123.52
15,624.94
II
*'
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
McCoy, Marlin L.
1 FILE NUMBER
21 - 05 - 0062~
ESTATE OF
ITEM
NUMBER
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is y s.
I DESCRIPTION OF PROPERTY , T % OF i,
, Include the name or the transferee, their relaltonship to decedent and the dale ot Iranster ; DA E OF DEATH, DECO'S 'I' EXCLUSION TA ABLE VALUE
Attach a copy ot the deed tor real estate IV ALUE OF ASSET I (IF APPLICABLE)
, · INTEREST
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M&T Bank - Individual Retirement Account
#35004200214481
58,342.811
100%
58,342.81
TOTAL (Also enter on line 7, Recapitulation)
58,342.81
ESTATE OF
ITEM
NUMBER
A.
B.
4.
*'
SCHEDULE H
FUNERAL EXPENSES &
ADMINlSTRA11VE COSlS
II
8,545.00
60.00
2,873.05
10 1. 00
15.00
\ ' 75.00
\ ,
: '
I' 137.03
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\ 569.99
12,376.07
I
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COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
McCoy, Marlin L.
FILE NUMBER ,
21 - 05 - 0062f
Debts of decedent must be reported on Schedule I.
DESCRIPTION
AMO NT
FUNERAL EXPENSES:
Hollinger Funeral Home & Crematory, Inc.
2
Rev. Richard L. Reese - Pastoral Stipend
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City
Year(s) Commission paid
State
Zip
2.
Attorney's Fees
Stephen L. Bloom, Attorney and Counsellor at Law
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
Probate Fees
Cumberland County - Register of Wills - Probate
Cumberland County - Register of Wills - Inventory
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
I Cumberland Law Journal - Legal Notices
2 The Sentinel - Legal Notices
Total of Continuation Schedule(s)
TOTAL (Also enter on line 9, Recapitulation)
ESTATE OF
3
4
5
6
7
.
Schedule H
FlIleraI Expenses &
Amlinislrative Cos1s cootinued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
McCoy, Marlin L.
Earl Lawn Maintenance - Decedent's Trailer Residence Prior to Sale
Sprint - Telephone Service for Decedent's Trailer Residence Prior to Sale
Met Ed - Electric Service for Decedent's Trailer Residence Prior to Sale
Lot Rent (July & August) - Decedent's Trailer Residence Prior to Sale
Gas Reimbursement - Robert L. McCoy
II
i
: FILE NUMBER 1
. 21 - 05 - 006i6
Page 2 of Schedu e H
80.00
13.90
46.09
380.00
50.00
ESTATE OF
.
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DeCEDENT
McCoy, Marlin L.
Include unreimbursed medical expenses.
ITEM
NUMBER
1
DESCRIPTION
State Farm Insurance Companies - Manufactured Home Policy Premium
2
Miscellaneous Unreimbursed Medical Expenses (itemized statements attached)
FILE NUMBER i
I
21 - 05 - 00626
TOTAL (Also enter on Line 10, Recapitulation)
11
AMOUNT
133.00
4,833.53
34.99
19.17
32.12
28.29
17.64
24.19
34.19
5,157.12
3
Met Ed - Electric Bill
4
Real Estate Taxes
5
Three Springs Family Practice - Medical Bill
6
Carlisle Pathology - Medical Bill
7
Appalachian Orthropedic - Medical Bill
8
Family Home Medical - Medical Bill
9
Walnut Bottom Radiology - Medical Bill
11
REV.1513 EX+ (9.o0)
.
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
,
I
FILE NUMBER l
21 - 05 - 0062r
RELATIONSHIP TO ! A OUNT OR SHARE
DECEDENT OF ESTATE
00 No\. Lilt Trultee(l)
Ben e fi c fi8}3tt.fuE 1
f Probate Estate
ESTATE OF
McCoy, Marlin L.
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
Susan D. Lebo
19 W. Oakwood Drive
Carlisle, P A 17013
Daughter
2
Michael L. McCoy
5955 Wilson Street
Marshall, VA 20115
Son
1/3 f Probate Estate
3
Robert L. McCoy
141 Horseshoe Road
Carlisle, PA 17013
$0'1
1(3 [,.f ~J~~"[s,t~C:
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!
II
!IM&rBank
499 Mitchell Street, Millsboro, DE 19966
August 15, 2005
Stephen L. Bloom
Attorney and Counsellor At Law
2100 Longs Gap Road
Carlisle, PA 17013
RE: Estate of Marlin L. McCoy
Date of Death: June 14, 2005
Social Security Number: 174-20-2235
Dear Mr. Bloom:
In response to your request, please be advised that at the time of death, the abov -
named decedent had on deposit with this bank the following accounts.
1. Account Type..... .................. .... Checking Account
Account Number....................... 9835405342
Ownership (Names oj).............. Marlin L. McCoy
Opening Date.......................... .03/02/04 (account closed 07/14/05)
Balance on Date ofDeath.........$11,442.63
Accrued Interest
$
0.38
Total................. ..... ....... ..... .....$11,443.01
2. Account Type.. ............ ....... ...... Individual Retirement Account
Account Number....................... 35004200214481
Ownership (Names oj).............. Marlin McCoy
Opening Date......................... ..02/22/99 (account closed 07/13/05)
Balance on Date ofDeath.........$58,190.25
Accrued Interest
$ 152.56
Total................................... ....$58,342.81
The above named decedent did not have a safe deposit box with this bank.
II
. Page 2
August 15,2Q05
For any additional information on this account please contact our Mount Ho y
Springs branch at 717-486-3038.
Sincerely,
(floWn0 ~~
Charlene Warrington, Records Management
1-888-502-4349
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Offic Phone:
(717) 49-2711
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26 East High Street
P.O. Box 571
Carlisle, PA 17013
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SOUTH MOUNTAIN POST 674
AMERICAN LEGION
DEA TH BENEFIT FUND FOR REGULAR MEMBERS
JUNE 10, 1985
YEARS OF MEMBERSHIP
BENEFIT' PAID
One Year
Two - Three Years
Four Years and More
$ 50.00
$100.00
$200.00
A copy of the Death Certificate must be provided to Post 674 before
payment is made.
~
PLEASE PUT THIS WITH YOUR INSURANCE PAPERS.
(5;D I (,u. ~h e 5f_
(If. {-t1j ~% - 75150
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REORDER 805. U.S. PATENT NO. 553'290. 5575508. 5641183. 57F15353. 5964364, 1)1
999003455 ROBERT MCCOY
INVOICE NUMBER
DATE
CHECKNUMBER 610641 DATE. 07/08/05
DESCRIPTION GROSS AMT. DISCOUNT ET AMOUNT
62305VA
06/23/05 M. McCoy - Buri
100.00
0.00
100.00
County of Cumberland
TOTALS
100.00
0.00
100.00
PLEASE ADDRESS ANY CORRESPONDENCE REGARDING THIS VOUCHER OR TRANSACTION TO THE OFICE OF THE CONTROLLER. CUMBERLAND COUNTY COURT HOUSE. CA LISLE. PA. 1701l.
'OENERALACCOuNT
CARLISLE,PENNSYL VANIA
CHECK NO.
610641
60. 7269 ~31 3
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CO~T~~~0UMBERLAND
Sovereign Bank
PAY ONE HUNDRED AND 00}100------------------------------------------------- \ DOLLARS I
TO THE
ORDER OF
ROBER'!' MCCOY
141 HORSESHOE RD
qARLTSLE
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AU HORJZEDSIGN T AE ~~
II' b ~ 07 ~ ~ ';~3117 2 b -;j ~ .: -17 ~ lD ~"{~'5'~ I.:"'" 00'''"' ::.'6"6 ~'6'6;~(J"65'o~;^;
PA 17013
Hollinger Funeral Home & Crematory, Inc.
Eric L. Hollinger, Supervisor
501 North ~Baltimore Avenue
Mount Holly SpIlings, Pennsylvania 17065
sTATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any Items, we will
explain the reason in writing below.
If you selected a funeral that may require embalming, such as a funeral viewing, you may have to pay for embalming. You do not have to pay for embalm-
ing you did not approve if selected such' . n or lnunediate burial. If we charged for embalming, we lain !why ow.
Par the Service of C1 Date of Death
CIuu1Je to.
A. CllAB.GE POR. SEaVlCES SELECl'JID;
1. PROFESSIONAL SERVICES
Services of Funeral DlrectorlStaff . . . . . . $
Embalming ..................... $
Other prepa",tion of body
Other clothing
----
'-""'"
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i
$ I
I
TOTAL MERCHANDISE SI!lECTJ!I) . . .$. . . . . . . . . . . . . .B I $a770
c. SPECIAL CHARGES: I
Porwarding of remains to $ I'
(Funeral Home)
Receiving of remains from
I
I
I
Direct ere .. .. .. . .. .. .. . .. . $ I
OF SPIIOALCllAB.GI!S ..~............ .cl $
I
D'~~V~~/~.......$h,M !
CemeteryEquipment .............. $ 77r1
Lot and Deed :...... .Q..J'~' '-'~ u~ -7
Newspaper NOl1Ce&-~.(~$ ~
Newspaper Noticeo-Out-of-town ...... $ ,
Telephone II: Telegrams ............ $ !
~"""""""""","$ d I
Qe Offering .............. $ /0_ I
allbeareno ............ "ii{.'jO . $ --../ ,-tS
Certified Copies of the Death U'I;' .... $ ~ ~
Ce~e ...................... $
~~:~H~MY::::: : /:S-I'J
Vault Service Charge . . . . . . . . . . . . . . . $
$
$
: I 11-55
$ I
SUB-TOTALOFADVANCES .......................0 $~
Cremation urn .. . . .
(Description)
. . $
OTHER
..............................$ ~
SUB- TOTAL OF I'ROFIISSIONAL SERVICES . . . . . . . . . .Al $
2. FAClLlTIBS AND Sl!RVlCl!S
u.., of facilities and services for, .I~ / L
viewi~ake) rr-~~$
Use off~servic~/~
for funeral ceremony ~ ~ /-T. . . $
Use of facilities and services for
Memorial Service ............... $
Use of equipment and services. / /.../. ./'
for graveslde servt~7:"~~ $ ~
Other use of facilities ~~~
. . . . . . . . . . . . . . . . . . . . . . . .. .. . . . $
SUB-TOTAL OF FACILITII!SIEQUIPMENT . . . . . . . . . . .A2 $
3. AUTOMOTIVE EQtnPMENT
Vehicle to transfer remains to Funeral Home
loc3l.........................$
Hearse (Casket Coach)
Local ......................... $
LlmousIne
Local ......................... $
Family car
Local ......................... $
Plower car or /Ioral disposition
loc31 ......................... $
Lead carl clergy car
Local ........
Car for paUbearers
Local......................... $
Oul of town transportation .......... $
$
SUB-TOTAL OF AuroMO'I1VE I!QU1PMENT . . . . . . . . .A3 $
TOTAL OF I'ROFESSIONAL SERVICES,
~~~~UV)C~.... A t:?r"~1J
8. CHAIlGI!~SEI.BCI'ED; .;?~<;.
Casket .., ~~~ es.Jh_
~~~-.r~~
Other Receptacle ............'.... $
(Deocriptlon) ~ t- '7r
ri'~~~~~~
.A~~gemenrcards............$ c"....-"'"
Memory folders::::: :~7:-:-:-;::: :: ~:..
Pr.tyer cards .............,...... $ ___If any law, metery. or aernstory uin:menlS have ired the
Tempocat}' grave marker . . . . . . . . . . . . $ L..-' ~y of the items I~bove, the law or requin:~1s exp,lained ~low.
Burial clothing.. .. . . . . . . . . . . . . . . . $ ~~ ~J/~ltl ~ /5ck/"" ,
;; I agree that I have examined the ilemS of goods and services selecled above and found them to be correct and according to the anangemenlS I have requC$ted. ~Cknowledge
receipt of a copy of thio Statement of Funeral Goods and Services Selected. I represent thaI I have sufficlenl funds available for payment of the cash price fOr the goods
and oervices selected. I also agree to rnske payment of $ within days. I agree 10 be joinlIy and severally Uable with an ne else who
signs below. A late chaIge of per month amounting to per year will be applied 10 the unpaJd balance beginning ~ days
from the date of thio agreement. 1 will also pay to the Funeral Director all reasonable costS paid by the Funeral DIrector to collect amounts 1 owe under l\1lI' agreement.
Those COOlS may . s' ~ ,court OOIS other costs. Any additional services or merchandise ordered or requested after the dale of thio ~llreement will
be consl p wtU on the 6nal bill or statement. __ I
(Seal)
c Penooy\Yatlla ......... Ol>.-. __
form . 600 R.cvlscd 1/04
~
t .-/'
~
t~
. . . $
..-/'
L,./
We chaIge you for our services in obtaining,
($JJ<<IIY ClUb a4tN1OICtIS tINrt "... ~)
SUMMARY OF CHARGES
A. Professional Services, Pacililies and
Equipment, and Automotive
B.~;;~~~'::::::::::::::::::::!~ t C7~~~~
c. Special Charges .................. ~ .I/; ()J"'ft;,J.'-
D.CashAdvances ............ ...... $ ~~
TOTALOFALLSJlCl10NS .......................~ P
PAID AT 11ME OF OR ~ TO I
~~~:...:~iI-::lA~r.::::: tJ;~
~
STEPHEN L. BLOOM
ATTORNEY AND COUNSELLOR AT LAW
WWW i'RACTICALCOIINSEL COM
2100 LONCS GAl' ROAD
CARLISLE, PENNSYLVANIA 17013
SIll.OOM@I'RACTICAI ( ()\'NSFl. COM
Invoice submitted to:
McCoy, Marlin L. Estate
c/o Robert L. McCoy, Administrator
141 Horseshoe Road
Carlisle, PA 17013
July 13, 2005
In Reference To: Estate Administration - Initial Interim Billing Statement
Invoice #1602
Professional Services
7/5/2005 Preliminary matters and preparation for administration of estate;
Conference with Administrator; Prepare, execute and acknowledge
Renunciation
7/13/2005 Estate matters and preparations for Probate, including preparation of
Petition for Grant of Letters of Administration, Oath of Personal
Representative and Exhibits, Estate Information Document, IRS Form
SS-4; Correspondence with IRS re FEIN; Appearance at Register of
Wills for presentation of Petition/conference with Personal
Representative; Review Letters of Administration and Short Certificates
Reserve for remaining initial phase of administrative and estate
matters: Preparation of required Estate Legal Notices for publication
and correspondence with legal journal and newspaper re same; Review
and filing of Proofs of Publication re same; Preparation of required
Notices of Beneficial Interest in Estate and correspondence re same;
Preparation and filing of required Certificate of Notice re same at
Register of Wills; Correspondence with financial institution re
confirmation of date of death account information; Required
correspondence with Department of Public Welfare Estate Recovery
Section; Preliminary matters re confirmation of assets and liabilities
For professional services rendered
Balance due
PRACTICAL COUNSEL + CHRISTIAN PERSPECTIVE
TEL E I' 1-[ 0 N E 7 1 7 - 2 4 9 - 7 7 1 7
FAeSIMILI- 717-249-7757
TOl.l.FREF 877-548-9(,02
Hrs/Rate
Amount
1.62 323.94
200.00/ r
2.81 561.06
200.00/ r
3.17 633.33
200.00/ r
7.60 $1,518.33
$1,518.33
McCoy, Marlin L Estate
PAYABLE UPON RECEIPT - THANK YOU
PRACTICAL COUNSEL 4< CHRISTIAN PERSPECTIVE
II
Page
2
STEPHEN L. BLOOM
ATTORNEY AND COUNSELLOR AT LAW
WWW PRACTICALCOUNSEl COM
2100 L(),,-:c;s GAl' R()AI)
CARLISLF, PF"i"-:SYLVAi\IA 1701.\
SIILOOM@PRACTICALCOlll\:SFL COM
Invoice submitted to:
McCoy, Marlin L. Estate
c/o Robert L. McCoy, Administrator
141 Horseshoe Road
Carlisle, PA 17013
October 06,2005
In Reference To: Estate Administration - 2nd Interim Billing Statement
Invoice #1649
Professional Services
8/8/2005 Telephone consultation with client; Administrative matters and file
memorandum
8/16/2005 Correspondence
9/29/2005 Administrative matters; Correspondence
10/5/2005 Administrative and estate matters; Review correspondence from
Department of Public Welfare; Review account documentation from
M& T Bank; Preliminary evaluation of assets and liabilities for
Inheritance Tax purposes; Correspondence with Executor
10/6/2005 Administrative and estate matters; Correspondence; Preparation of
Pennsylvania Inheritance Tax Return and Schedules; Inheritance Tax
Calculation; Preparation of Inventory
Reserve for final administrative and estate matters: Conference with
Personal Representative for Review, execution and assembly of
Pennsylvania Inheritance Tax Return, Schedules and Exhibits, and for
Review and execution of Inventory; Appearance at Register of Wills for
filing of same; Preparation, review and execution of Reciept, Release
and Refunding Agreements/Proposed Distribution Schedules; Review
and file Official Receipt and Notice of Appraisement from Department
of Revenue; Prepare and file Notice of Status of Administration at
Register of Wills; Correspondence
For professional services rendered
TEL E P liON F 7 I 7 - 2 4 9 - 7 7 I 7
FACSIMILE 717-249-7757
TOI.LFRFF 877-54R-9(,02
Hrs/Rate Amount
0.07 13.50
200.00/ r
0.08 16.67
200.00/ r
0.17 33.33
200.00/ r
0.70 139.78
200.00/ r
2.51
200.00/ If
501.44
3.25
200.00/r
650.00
6.78
$1,354.72
PRACTICAL COUNSEl. >I< CHRISTIAN PERSPECTIVE
McCoy, Marlin L. Estate
Additional Charges:
9/6/2005 Publishing Fee - Legal Notice - The Sentinel
Total costs
Total amount of this bill
Previous balance
7/14/2005 Payment - thank you
Total payments and adjustments
Balance due
PAYABLE UPON RECEIPT - THANK YOU
PRACTICAL COUNSEL + CHRISTIAN PERSPECTIVE
Page
2
Amount
137.03
$137.03
$1.491.75
$1,518.33
($1,518.33)
($1,518.33)
$1,49175
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
MCCOY MARLIN L
Estate File No. :
Paid By Remarks:
2005-00626
ROBERT L MCCOY
RSK
Receipt Date:
Rece~pt Time:
Recelpt No.:
7613/2005
]5:24:26
[1041273
------------------------ Receipt Distribution ---------------- -------
Fee/Tax Description PaYment Amount Payee Name
PETITION LTRS ADM
RENUNCIATION
SHORT CERTIFICATE
JCP FEE
AUTOMATION FEE
Check# 1060
Total Received.........
60.00
10.00
16.00
10.00
5.00
----------------
$101.00
$101.00
CUMBERLAND COUNTY GEN
CUMBERLAND COUNTY GEN
CUMBERLAND COUNTY GEN
BUREAU OF RECEIPTS &
CUMBERLAND COUNTY GEN
FUN
FUN
FUN
M.D
FUN
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, P A 17013
September 2, 2005
Cumberland Law Journal is published every Friday by the Cumberland County Bar
Association and is designated by the Court of Common Pleas as the official legal publicatio for
Cumberland County and the legal newspaper for publication of legal notices.
TO:
Stephen L. Bloom, ESQUIRE
RE:
Marlin L. McCoy, ESTATE
Legal advertisements must be received by Friday Noon. All legal advertising must e
paid in advance. Make all checks payable to: Cumberland Law Journal.
-----------------------------------------------------------------
----------------------------------------------------------------- ---
Advertisement inserted on following dates:
August 19, 26, September 2, 2005
Advertising Cost
Proof of Publication
Second Proof Request
Payment Received
Total Amount Due
Payment received August 15. 2005
by Becky H. Morgenthal/Executive Director
$ 75.00
$ 0.00
$ 0.00
$ 75.00
-------------
$
0.00
---------
---------
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STATE FARM INSURANCE COMPANIES
State Farm Fire and Casualty Company
One State Farm Dr.
Concordville, PA 19339-0001
C-13- 2627-F382 FT
DATE DUE
JUN 30 2005
MC COY. MARLIN L
51 MOUNTAIN ST LOT 6
MT HOLLY SPGS PA 17065-1431
111111111111111111111111111111111111111111111111111111111I1111
Coverages and Limits
Section I
A Dwelling
Dwelling Extension
B Personal Property
C Loss of Use
$5,000
500
4,000
Actual Loss
Sustained
Deductibles - Section I
All Losses
500
Location: Same as Mailing Address
Section "
L Personal Liability
Damage to Property of Others
M Medical Payments to Others
(Each Person)
$100,000
500
1,000
Forms, Options, and Endorsements
Manufactured Home Policy
Earth Movement
Amendatory Endorsement
Fungus (Including Mold) Excl
Motor Vehicle Endorsement
FP-7933.1
OPT EM
FE-7238.4
FE-5901
* FE-5452
Annual Premium
Amount Due
$133.00
$133.00
*Effective: JUN 30 2005
Premium Reductions
Your premium has already been red ped
by the following:
Renewal Discount
24.00
Description: LIBERTY
Serial No: P-7790
NOTICE: Information concerning changes in your policy language is included. Please call your agent if
you have any questions.
~p~~~ Iq~L{
u.~9- oS"
! I
II
h J 3402 9603
See reverse side for imp~rtant information.
Please keep this part for tour record.
Tkir f&.. ~tJS~ p. lIJe,~tkJIC!otrj(vf1(~.
Agent JOHN iAMpELLI J~
/717\ 1).040_11::01)
APPALACHIAN ORTHOPEDIC CENTER, LTD
1 DUNWOODY DR
CARLISLE, PA 17013
Forwarding Service Requested
*******AUTO**3-DIGIT 170
MARLIN L MCCOY
151 MOUNTAIN ST LOT 6
MT HOLLY SPNGS PA 17065-1409
I". /I I,,, /I 1,11.11,111.1111111.1,11/1" .1.111.1.11'11 /I 11.1 /I
275 63
LTD
;'::. :~~;~:tf';;~;1~
*,'0', Prornpt::~avment is appreciat'ed"f;orjb1i-l':rin2"~"'c:J'O~'~
,~ ,'d'd,,', ,~,', ,~,',,, * * ".M,~,,~ ,', ,',~, ~d, * ,', fd'ob'( * * ~(***,\'* *:*-**~(,,~*,~~~.'1f,'It;.i!?t~
. Ins uran.ce. c;n.a. r;g.lj!.s. ,p'en.. .0:....1..n.... &. .f..o...:'J.~,.'.t:V;:~~
.'>;:~;! Ins PaylA.dlt_aga1.',n's:t",;::r;h:sY~'p':e'i:i~d1:n.'
Og44411;'22bl,~.'o';~"',., HOS~;a~~;~~~~'~~~~~
U/5 v Accep...t.;.A:.S'S1.;~.. n. .i'.;.:A:d..1""'~'."'" ..':', ,"
OS/20/0:5;'. "'~' PHCS!7A'SSUR'~C'tPa~~n't' ,,::
OS/20t05' Accept Ass1.gnAd].
04/05l~0:5; X-RAY P.ELV-IS.AP ONLY
04[26,%05'.: Medi't:.: ar.e' P.aym' ent
04Z26;~Cr ".
05../.....2. '.P', p....!' Ac.c e p..t ",A. '.5..,.5. i.. g. .n. . AcLj;."
,P PHCS7::ASSQREC;~~.aymerit
, ,;.. _,.,';'~.'.:.._dllol;..~:_-. ,'.I.~:",. .<,
.~:i4\1im:O:'
';'ti~f\~f'::'
..':l.";';':-;.
'2r.i6'9'~(
.' .~;:'{'.~..".,. .
,.q'd .'
,l "~::; ~:j~
',/:. ":'~i.~ ~:;I'
"Ylf~ .'"X~
.... ....,-J,.~...,v~~
.\~~~~ -.?(:-.""' ,~'~J!
'. ~?;E .;.:~. ?J~
','
AP PAIiA€HIAN " ORTHOPEDIC
]:'DUNWOODYDR
..CAR-LIS'LE, PA 17013
PATI! T-MARLINLMCCOY
I
717) -249..,6112
IF: 19890
: '06/07105
Il'aste 1 of 1
~ 4050 Hunsackcr Drive
Suite 110
East Lansing, MI 48823
200)()(.09l)OO
Address Sen'ice Requested
Questions? Contact us ~lt
(517) 351-6616 or (800) 968-6616
3-DIGIT 170
Enrollee:MARLIN
Patient: MARLIN MCCOY
Soc See #: XXX-XX-2235
Group: LEAR RETIREES
Group #: REI
Claim #: 58034399-01
Patient #: 7490267
Date: 06/08/2005
MCCOY
25860 0.5824 AT 0.292
'11111111111111111111.1.1111111.1111'11111111111 .... 111..11111
MARLIN MCCOY 98
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
Explanation of Benefits for Services Provided By:
CARLISLE REGIONAL MED CENT
II DatCll of Service Service
Code
104f28-04f28f2005 13
TOTALS
Totol
Charge
215.26
215.26
con Ineligible -Reason
Paid Code
43.15 0.0004
43.15 0.0
Dbeount
Amount
Con red Dy Deductible
Plan Amount
67.43 O.OC
67.43 a.oc
.Co-PIlY
Amount
0.00
0.00
Ballince
Pili
At
8 to
147.83
147.83
67.43
67.43
Total Net Paym .t
Patient Responslbll ~
Accumulators
Your 2005 deductible has been satisfied
Sen'ice Code
113 hospital outpatient
Payment To:
CARLISLE REGIONAL MED CEN
Reason Code Description
I I 04 Benefits coordinated with Medicare.
Check No.
00218626
j mount
10.79
Messages
... IF YOUR CLAIM WAS DENIED. IN WHOLE OR IN PART, YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE THE RlIOHT TO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITTEN COMM NTS,
DOCUMENTS, RECORDS OR INFORMATION ABOUT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF CH }..RGE,
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTL Y OF THE INITIAI_ DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF YO iJR DENIAL
WAS BASED IN WHOLE OR IN PART ON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFESS C1>NAL ON
YOUR APPEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACTIO iUNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WILT BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
... For eligibility and claim status information, please visit our website at www.assurecare.com.
P862900~OOO
!~
;<0
;(
~
l'ayrril!/ll
Amount
53.94
53.94
10.79
13.49
~ 4050 Hunsacker Drive
Suite 110
East Lansing, MI 48823
200~0609JJOO
Address Service Requested
I Questions? Contact us at
l~17) 351-6616 or (800) 968-6616
3-DIGIT 170
Enrollee:MARLIN
Patient:MARLIN MCCOY
Soe See #: XX.X-XX-2235
Group: LEAR RETIREES
Group #: REI
Claim #: 58035385-01
Patient #: 043431 20232
Date: 06/08/2005
MCCOY
25860 0.5824 AT 0.292
111111111111111111111.111111111.111111111111111111111111111111
MARLIN MCCOY 98
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
Explanation of Benefits for Services Provided By:
BLUE MOUNTAIN ANESTHESIA ASSOC
-vates or 1Servlce Service
Code
04107-0410712005 22
TOT ALS
COB Ineligible Reason
Paid Code
62.83 0.0004
62.83 O.O!
Total
Charge
591.50
591.50
Discount
Amount
493.32
493.32
Cove,'ed By
Plan
98.18
98.18
Co-Pay
Amount
0.00
0.00
Balance Pal !
A
98.18 8~%
98.18
Total Net Paym nt
Patient Responslb~ .y
Deductible
Amount
0.00
0.00
Accumula.ors
Your 2005 deductible has been satisfied
Service Code
122 anesthesiologist
Payment To:
BLUE MOUNTAIN ANESTHESIA
Reason Code Description
I I 04 Benefits coordinated with Medicare.
Check No.
00218632
mount
15.71
Messages
... IF YOUR CLAIM WAS DENIED, IN WHOLE OR IN PART, YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE THE IIGHTTO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITIEN COMM tITS,
DOCUMENTS, RECORDS OR INFORMATION ABOUT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF CH \RGE,
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF THE INITIAL DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF YO R DENIAL
W AS BASED IN WHOLE OR IN PART ON A MEDICAL ruDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFESSlDNAL ON
YOUR APPEAL, AND PROVIDE YOU WITH TIiEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACTIer UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WILL BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
... For eligibility and claim status information, please visit our website at www.assurecare.com.
1'8629(JO.'WOO
~;;:
r~
~
Payment
Amount
78.54
78.54
15.71
19.64
_J
STATEMENT
BLUE MOUNTAIN ANESTHESIA ASSOC
POBOX 947
CHAMBERSBURG PA 17201
DIAL EXT 406
SHOW AMOUNT $
PAID HERE
(800)827-3458
OFFICE PHONE NUMBER
09/14/05
CLOSING DATE
20232
YOUR ACCOUNT NUMBER
01
PAGE NO.
CONTINUED
NEW BALANCE
MARLIN L MCCOY
141 HORSESHOE RD
CARLISLE PA 17013
11..111...11111....11..11.1.1...1.1'11111111.1.11.1"111...111
....
....
-0
BLUE MOUNTAIN ANESTHESIA ASSOC
PO BOX 947
CHAMBERSBURG PA 17201
1,,1111...1111.111,,1111111111.111,,111.111,11.11.111,111..111
NOTE: Charges and payments not appearing on this
statement will appear on next month's statement. RETURN THIS PORTION WITH PAYMENT
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT
, I I I PATIENT NAME/I CHARGES I PAYMENTS
~ATE DOCTOR NAME EXPLANATION OF ACTIVITY CLAIM ACTIVITY AND DEBITS AND CREDITS
040705 "SOtA 'SERVICES RENDERED MARLIN !in.!iO
04250!i BILlED:HGS ADMINISTRATORS
04250!i' BILLED,:ASSURE CARE PHCS
04280!i,KAPOOR SERVICES' ,RENDERED MARLIN 16!i.00
0!i040!i'KAPOOR SERVICES RENDERED MARLIN 65.00
050905 BIllED:HGS ADMINISTRATORS
050905 BILlED:ASSURE CARE PHCS
051205 BILLED:HGS ADMINISTRATORS
051205 BILLED:ASSURE CARE PHCS
051305 KAPOOR SERVICES RENDERED MARLIN 6!i.00
051605 MEDICARE PAYMENT 62.83-
051605, MEDICARE ADJUSTMENT '512.96-
051605 Me CO-INS U5.71 0.00
051605 BILLED:ASSURE CARE PHCS
052305 BILlED:HGS' ADMINISTRATORS
052305 BILLED:ASSURE CARE PHCS
053105 MEDICARE PAYMENT 63.18-
PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE:
NEW BALANCE OVER BALANCE OVER' BALANCE OVER BALANCEOVER NEW BALANCE
CHARGES 30 DAYS 60 DAYS 90 DAYS 120 DAYS PAY THIS AMOUNT
0.00 882.33- 886.50
SEND INQUIRIES TO:
(800)827-3458
BLUE MOUNTAIN ANESTHESIA ASSOC
P 0 B~X}947
CHAHlERSB4RGiPA17201
0.00
4.17
0.,00
0.00 CONTINUED
STATEMENT
BLUE MOUNTAIN ANESTHESIA ASSOC
POBOX 947
CHAMBERSBURG PA 17201
DIAL EXT 406
SHOW AMOUNT $
PAID HERE
(800)827-3458
OFFICE PHONE NUMBER
09/14/05
CLOSING DATE
20232
YOUR ACCOUNT NUMBER
02
PAGE NO.
CONTINUED
NEW BALANCE
BLUE MOUNTAIN ANESTHESIA ASSOC
PO BOX 947
CHAMBERSBURG PA 17201
MARLIN L MCCOY
1,1111111I1 i .1.111......11111111.1'111..11'111.1111111I11..1.1
NOTE: Charges and payments not appearing on this
statement will appear on next month's statement. RETURN THIS PORTION WITH PAYMENT
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT
,. I I I PATIENT NAME/I CHARGES I PAYMENTS
DATE DOCTOR NAME EXPLANATION OF ACTIVITY CLAIM ACTIVITY AND DEBITS AND CREDITS
053105 MEDICARE, ADJUSTMENT 86.03-
053105 'HCCO~INS $15.79 0.00
053105 BILLED,:ASSURE CARE PHCS
060705 I1EDICARE.PAYHENT 29.38-
060705 MEDICARE ADJUSTMENT 28.28-
060705 HCCO-INS.7.34 0.00
060705 BILLED:ASSURE CARE PHCS
061005 MEDICARE PAYMENT 29.38-
061005 MEDICARE ADJUSTMENT 28.28-
061005 MC'CO~INS' .,7.34 0.00
06.1005 ' BILLED,: ASSURE CARE PHCS
061405 COI1MERCIAL PHT 15.71-
061405 ASSURECARE 0.00
071205 COMMERCIAL PHT 11.62-
071205 ASSUURECO-INS $4.17 0.00
071205 COHMERCIAL PMT 7.34-
071205 ASSURECARE 0.00
PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE:
NEW BALANCE OVER BALANCE OVER BALANCE OVER BALANCE,OVER
CHARGES 30 DAYS 60 DAYS 90 DAYS 120 DAYS
20232
NEW BALANCE
PAY THIS AMOUNT
0.00 882.33- 886.50
SEND INQUIRIES TO:
(800)827-3458
BLUE MOUNTAIN ANESTHESIA ASSOC
PO;BOX,947
CHAHBERSBURGPA' 17201
0,.00
0.00 CONTINUED
0.00
4.17
. .
STATEMENT
BLUE MOUNTAIN ANESTHESIA ASSOC
POBOX 947
CHAMBERSBURG PA 17201
DIAL EXT 406
SHOW AMOUNT $
PAID HERE
(800)827-3458
OFFICE PHONE NUMBER
09/14/05
CLOSING DATE
20232
YOUR ACCOUNT NUMBER
03
PAGE NO,
4.17
NEW BALANCE
BLUE MOUNTAIN ANESTHESIA ASSOC
POBOX947
CHAMBERSBURG PA 17201
MARLIN L MCCOY
1...111...1..1.111......1111'111.1...1..11...1.11.11...11..1.1
NOTE: Charges and payments not appearing on this
statement will appear on next month's statement. RETURN THIS PORTION WITH PAYMENT
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT
I I . I PATIENT NAME!I CHARGES I PAYMENTS
DATE DOCTOR NAME EXPLANATION OF ACTIVITY , CLAIM ACTIVITY AND DEBITS AND CREDITS
071205
071205
COtfl1ERCIAl PI1T
ASSURECARE
7.34-
0.00
PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE:
NEW BALANCE OVER BALANCE OVER BALANCE OVER 'BALANCE,OVER
CHARGES 30 DAYS eo DAYS 90 DAYS 120 DAYS
20232
NEW BALANCE
PAY THIS AMOUNT
4.17
0.00 882.33- 886.50
SEND INQUIRIES TO:
(800)827-3458
BLUE 110UNTAIN ANESTHESIA ASSOC
POBOX 947
CHAI1BERSBURG PA 17201
0.00
4.17
0.00
0.00
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141 HORSESHOE ROAD
CARLISLE, PA 17013-9562
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MARLIN L MCCOY
Office Phone Number
717 519-0753
Statement Date
09/11/05
Your Account Number
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New Balance
CONTINUED
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--------------------------------------------------------------------------------------------------------------------
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141 HORSESHOE ROAD
CARLISLE, PA 17013-9562
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09/11/05
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Page No.
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MARLIN L MCCOY
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141 HORSESHOE ROAD
CARLISLE, PA 17013-9562
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Office Phone Number
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08/11/05
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Statement Date
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MARLIN L MCCOY
51 MOUNTAIN ST LOT 6
MT HOLLY SPRG, PA 17065-1431
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EAST PETERSBUR, PA 17520-0619
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New Balance
Office Phone Number
717 519-0753
Statement Date
07/13/05
Your Account Number
23.90
----------------------------------------------------------------------------------------------------~-----------------
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEME r
'. . . .' EXPLANATION OF ACTIVITY: :. . . .... :'
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~ 4050 Hunsacker Drive
Suite 110
East Lansing, MI 48823
wo\n7t..II.IO(l
Address Scn'ice Requested
1----~estionS? -Cont;ct~;-i~t I - ...
i
(517) 351-6616 or (800) 968-66 6
~
SINGLE PIECE
~ -
Enrollce:MARLIN
1 Patient: MARLIN MCCOY
Soc Sec #: XXX-XX-2235
Group: LEAR. RETIREES
Groul) #: RET
Claim #: 58042]94-01
Pnticnt #: 7486016
Date: 07/13/2005
. I.. -..
MCCO
1069 2.0176 SP 0.830
1,111111/1111111111,,11.1111111111111.11111111111111111111111I
MARLIN MCCOY 7
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
-n"tes of Sen' ce Service
Code
04l12-O412912005 45
TOT ALS
Total CO
Charge Pili
31,744.88 3,881.41
31,744.883,881.41
EXI)lanation of Benefits for Services PI'ovidcd By:
CARLISLE REGIONAL MED CENT
------
n IneUglble Reason Discowlt
d Code Amount
Cove,'ed Dy
Plnn
Deductible
Amowlt
0.0004
O.O(
24,812.14
24,812.14
6,932.74
6,932.74
0.00
0.00
---- -------- --: -+:-:--~. -
Co-Pa)' Balance "id Payment
Alnowlt At Amount
0.00 6,9~~= 80%- 5.546.19
0.00 6,932.74 5,546.19
Total Net Pll'~\ent - 1,664.78
Pntlellt Respollslllllity 1-- 1.386.55
Accumulators
Payment To:
CARLISLE REGIONAL MED CEN
Reason Code Description
~enefits coordinated with Medicare.
Check No.
00222683
Amount
"--
1.664.78
Y o1ll2005 deductible has b.:ell slIlisfied
Sen'ice Code
[45 ~~yllab leslillg---------------.J
.___.-1
Messages
... IF YOUR CLAIM WAS DENIED, IN WHOLE OR IN PAIn. YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE TH iRIGHTTO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITI'EN COM '(~NTS,
DOCUMENTS. RECORDS OR INFORMATION ABOUT THE CLAlM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF C ~i'\RGE,
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF THE INITIAL DENIAL, PERfORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF Y( tJR DENIAL
W AS BASED IN WHOLE OR IN PART ON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFES ION AI. ON
YOUR APPEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACTI( hl UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AfTER REVIEW. AN APPEAL DETERMINATION wn L BE MADE
WITHIN 30 CALENJ)AI~ DAYS FROM RECEIPT OF THE APPEAL
...
For eligibility and claim status infOlmalioll, please visil our website al \vww.as.~lIrecare.com.
VK~1lX\\\'I"li'
~AU" 4050 Hunsackcr Drivc
Suite 110
East Lansing, M! 48823
0,
~~
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c:
Qucstions? Contact us at
B~~
~
::lUO~071.11.jOO
Address Scn'icc Requcsted
(517) 351-6616 or (SOO) 968~6616
SINGLE PIECE
En rollcc: MARLIN
Patient: MARLIN MCCOY
Soc See #: XXX-XX-2235
GroU!): LEAR RETIREES
GroUI) #: RET
Claim #: 58042591-01
Patient #: 4653722
Date: 0711 3/2005
MCCO
1069 2.0176 SP 0.830
11111111111111111111.1111.1111111.11111111111111111111111111.1
MARLIN MCCOY 7
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
~ateS(I(SerVrce Service
Code
05/16-05/1612005 42
TOT ALS
Total
Charge
]82,92
]82.92
Explanl\tion of Benefits for Sen'ices Pro"ided B)':
WALLACE A LONGTON MD
con Ineligible Reason Discount Covered nY~eductible C';-i'ay' -D~I;'~~~ 1'. i"ll-- "I)'l~ymelit
Paid Code Amount Plan Amowlt Amount e Amowlt
___ ___ __" ._.___~n_.____
133.94 0.0004 0.00 18292 O. 0.00 ]82.92 14634
--- .,-- -.--.. ---..--.-"
133.94 0.0 _ ~.5!c.QQ ___._ 182.92 0.00 0 00 .,_I82.9~ . _~~63~
Totnl Net I'll) (lit 12.40
------~-
1'lItlent RC5ponslb lit)' 36.58
WALLACE A LONGTON MD
Check No,
00222689
mount
Accumulators
PlI)'mcnt To:
-- ------.----- - -- -,-_._._~~..._--- -.-.--.--
Your 2005 deductible has been satisfied
12.40
Sen'ice Code
[42.~dintjon services
Reason Code Description
--=,-=~_~_._~,:___._) L~~_ Belle~~c~ordinat~d with Medicare. _____
~ '--'-1
j
Messages
------_._- ~----- - --~-------~-- --~-_.- ------
... IF YOUR CLAIM WAS DENIED, IN WHOLE OR IN PART, YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE THE IGHTTO
APPEAL THIS BENEFIT DECISION W]THlN 180 DAYS or RECEIPT OF TH]S NOTICE. YOU MAY SUBMIT WRrITEN COMM NTS.
DOCUMENTS, RECORDS OR INFORMATION Al30UT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF CH (WE,
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF THE INITIAL DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF YOl It DENiAl.
W AS BASED IN WHOLE OR IN PART ON A MEDICAL JtJDGEMENT, WE WILL CONSULT WITH A HEAI_TH CARE PROFESS I NAL ON
YOUR APPEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACTION ~lNDER
ERISA 502(A) IF YOU fiLE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WILL E MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
...
For eligibility and claim status infonn<ltion, pI case visit our websile at w\\w.assllrecare.COlll.
II
PRI'o::!C,nrl'llllll
~ 4050 Huns~\ckcr Dl"i\'c
Suile 11 ()
East Lansing, MI 48823
200~O"'/ J -1]-/00
Qucstions? Contnet us at
~
SINGLE PIECE
I-
I
l
~nrOllce:MARLIN
pn:ent:MARL~ M-~~O~
Soe Sec #: XXX-XX-2235
Group: LEAR RETffiEES
I GnlUp #: RET
IlClaim #: 58042592-0 I
Plltient #: 4623709
Datc: 07/1 3/2005
(517) 351-6616 or (800) 968-661
Adtfrcss Service Requested
MCCOY
1069 2.0176 SP 0.830
1."111,"111""11,,.1,1,,,,11.1,,1,,11,.,,111111,,11",11,,1
MARLIN MCCOY 7
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
EXllhmation of Benefits for Services Provided By:
WALLACE A LONGTON MD
182.92
182.92
---~-- l>ayment'
DeductIble Co-Pay Balance
Amount Amount Amount
0.00 0.00 182.92 146.34
0.00 0.00 182.92 146.34
Total Net Pay tnt 12.40
l'lItlent Rcs(lonslb tlty 36.58
~ntes of eM' ce SeM'ice
Code
05/02-05/02/2005 42
TOTALS
Total
Olarge
182.92
182.92
COB IncuglblCJiicason I>iSCOWlt
Paid Codc Amount
13394 00004 0.00
- ----- ~-
133.94 0.0 000
--- - -----
Covel'ed By
Plan
Accumulators
Payment To:
---~
WALLACE A LONGTON MD
Reason Code Description
ro4~_Benefits coordinated with Medicare.
Check No.
00222690
Y ollr 2005 deductible has heen satisfied
12.40
SCr\'ice Code
[42___~adiation "ervic~~=---':=______=~=-=-~~-=_= ====J
~
i
Mcssages
--~--------_..- - -_._~ .---.-------
... IF YOUR CLAIM WAS DENIED. IN WHOLE OR IN PART. YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE THE RIGHTTO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRIITEN COMMENTS,
DOCUMENTS. RECORDS OR INFORMATION ABOUr THE CLAIM. YOU /vIA Y RECEIVE. UPON REQUEST AND FREE OF CH
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF THE INITIAL DENIAL. PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF YO i DENIAL
WAS BASED IN WHOLE OR IN PARTON A MEDICAL JlJDGEMENT. WE WILL CONSULT WlTH A HEALTH CARE PROFESS Cl>NALON
YOUR AI'PEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED YOU HAVE THE RIGHT TO BRING CIVIL ACTIO 1UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WILl BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL
...
For eligibility and claim status infomlation. please visit ollr website at www.nssllrecare.com.
Y1".I':''''';''\<'\>"
~AllE" 4050 Hunsac!{c\' Orivc
Suite 110
East Lansing, MI -lgSD
Qucstions? Contact us at
~
:!(1I)~\l71,11.IO()
Address Sen'ice Requcstcd
(517) 351-6616 or (8()O) 968-6 16
SINGLE PIECE
~
Enrollee:MARLIN
Patient: MARLIN MCCOY
Soc See #: XXX-XX-2235
Groull: LEAR RETIREES
GroUI) #: RET
Claim #: 58042593-0 I
Patient #: 4643273
Date: 07113/2005
MCCOY
1069 2.0176 SP 0.830
111111111111111..11", I .11, "" ,1111'111. 11.111111111111111111
MARLIN MCCOY 7
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
~'lIes-on~l~ccf"e,",~ICef~=- T 01:1'-
Codc Chorge
------- --- ---~-
05/09-05/09/2005 42 182.92
---- -~--
TOTALS 182.92
Explanation of Bcnctits fo)' Scn'iccs Provided By:
WALLACE A LONGTON MD
-('Onfi"~;ligfhj~Tifc~ls.m DiS,CO;;-, ll'tTCov~;;jny Dcducllbk C;;:'-P~;:~ U:lII';'Ce- r- 'It.,ld, Pll)'III,Cnl I
)'lIid 1-- I Code AIIlOUI~lt~ )'llIn Amount Amounl ___ __ _ _ ,~t,_ . Am~\U11 _I
_1J3.~_~--O(~F- _ _ --- _=__~.OO -182'.92 0.00 0.00 _ ....1.~2 92 !O~o. 146.3~~
133.2.'!.l ~ __.2,Q.9 .___ 0.00 __.----'E-n __ 0.00 0.00 J82.92 I 14634
- -- Toh.1 Net 1':1) IItcnl f' -..-I'UO
Pntlcnt Rcspo/lsl JlilY I .' ~61~
Accumullltors
PlIymcnt To:
WALLACE A LONGTON MD
Check No. Amount
-----~.,.- .~---
00222691 12.40
Your 2005 deductible has been satisfied
Sen'icc Code
-------------- -----J
[42 radiation services ,
---- _._._-~---_._-~---~
RCllson Code Description
l,?4 _ Benefits.coordin~ted with Medicare.
Messngcs
-;~IF YOUR CLAIM WAS DENIED. IN WHOLE OR IN I'ART. YOU l-IAVECERTAlN RIGHTS tINDER THE LAW. YOU HAVE;nl main'ro'--
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRIITEN COM tNTS,
DOCUMENTS, RECORDS OR INFORMATION ABOlrr THE CLAIM. YOU tvlA Y RECEIVE. UI'ON REQUEST AND FREE OF CI .~RGE,
ACCESS TO INFORMATION WE REVIEWED IN Mi\.KING TI-/IS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF THE INITIAL DENIAL. PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF Y< {IR DENIAL
WAS BASED IN WHOI.EOR IN PART ON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFESSIONAL ON
YOUR APPEAL, AND PROVmE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACTIO UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFfER REVIEW. AN APPEAL DETERMINATION WIL ,BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF TIlE APPEAl>
...
For eligibility and claim status infonllation. please visit our wehsite at www.l\SS\lrecare.com.
PHr;2'1Il('~"I"
~ 4050 "unsacker Drive
Suite 110
East Lansing, Ml 48823
"'
c
20l)~()71-1 1..11..10
Questions? Contact us at
~..:
..
O'
~.
Addrcss Scrvice Rcqucstcd
(517) 351-6616 or (800) 968-66 6
SINGLE PIECE
Enrollec:MAR.LIN
Paticnt:MARLIN MCCOY
Soc Sec #: XXX-XX-2235
I Group: LEAR RETIREES
I Group #: RET
Claim #: 58042615-0]
Patient #: 7500745
Date: 07/13/2005
MCCO
1069 2.0176 SP 0.830
1111111. 111111111111111111 11.11.1111'11111111111111111111111,1
MARLIN MCCOY 7
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
Exphmation of Benefits for Services Provided By:
CARLISLE REGIONAL MED CENT
1l)3feS,ir sen;iCClsen'ice'rl f(;t,lI- -C61~f- hleUglble - Reas.o n
Code Charge Paid Code
___ _.___ _____~____ ___ ____ __0- ______" _0_.___ ___ __ ___
06/03-06/03/2005 13 10,188.]5 1,045.78 0.0004
L__._____ _____ __ ___ _
TOTALS_~0,188.]5 1,045.78 __ 0.0
Dlscolmt
Amount
Covel'ed B)' Deductible Co-I'ay
Plan Amount Amowlt
~Id
I~t
1,930.86 80%
1,930.86
Total Net ('a '1lent
Patient Responsl Iity
] .544.69
1,544.69
498.91
386.17
Balance
I'aymeni .. ;
Amount
8,257.29 1.930.86 0.00 0.00
--~--_.
__ 8,257.29 __ __l,2]QJli __---.-2.00 0.00
Accumulators
Payment To;
CARLISLE REGIONAL MED CEN
Check No.
00222694
Amount
Your 2005 deductible has been satisfied
498.91
Sen'ice Code
; l:i~~l~spit~~il\pal;en~_==-=~
Reason Code Description
104- Bcndils coordinated wilh Medi~are. .._-~=-=-_.- ---
--- ------l
J
Messages
... IF YOUR CLAIM WAS DENIED. IN WHOLE OR IN PART, YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE Tl- R. RIGHT TO
APPEAL THIS BENEFIT DECISION WITIIIN ISO DAYS OF RECEIPT OF TI-lIS NOTICE. YOU MAY SUBMIT WRITfEN COM fENTS,
DOCUMENTS, RECORDS OR INFORMATION ABOlrr THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF CHARGE.
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF THE INITIM, DENIAL. PERFORMED BY Sm'IEONE NOT INVOLVED IN THE INITI.'\L DENIAL. IF Y lJR DENIAL
WAS BASED IN WHOLE OR IN PART ON A MEDlCM" JUDGEMENT, WE WILL CONSULT WITH A I-IEALTH CARE PROFE SION.'\LON
YOUR APPEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACTI UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW AN APPE.'\L DETERMINATION WI L BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
...
For eligibility and claim status information, please visit our website at www_assurecare.com.
La:Allr 4050 Hunsac!{cl' Dd\'c
Suite 110
East LanslJIg, MI .:1882]
~U(l";1l71.11"'()1l
Addrcss SCI'vicc RC(IUcstcd
SINGLE PIECE
1069 2.0176 SP 0.830
1,1111111,1 II 11,.11".1,1'1" II 11111,,11"1111 1111,,1111,11 III
MARLIN MCCOY 7
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
Questions? Contact liS at
I
(517) 351-6616 or (800) 968-66 6
/'Mt):!?lm"OOll
~~
~ .
~>,.;~
:l- .
'to: .
.. .
EXIJlanntion of Bcnefits for Sen'iccs Provided By:
WALLACE A LONGTON MD
I I),ites oTscn;Jcj'-lse. ..-.-let;I....--.. 'r;;tllIJ.(.':o.n-r~I;..II:iibk1r{('lIS0~t--D-.lS..(.-ount-:t -.C ~OVC-.I'('d llY~- U;'-.I..-UCtlble C.'.~-- P~~---B 1I111~~~C'~1-11..id f. Payment I
I Code: Chlll'ge Paid I C'Hle Amount I'lall Amount Amount ,\t I Amoun' I
04/2-5-04/2 5/20(!5 -1'~ii-I-- '1"&2'92 13i 94 --- () ()cJ\j4'-"-- ------0:00 -- --.-.- u1ii2 92 ------0.00 -o.iw--- -18'2 ~92-80q 01 j
1____ '--Toi:Ai~sr~_I8-i"9~j 1332~L--~(~c2~--' ~~. .. O~O~-~~-==---Lsi92 _-0.00. -- _.JlJ2Q ~_--=-i&2.92 -. "---i--- ;-1~~~1
To'nl Net 1'",' IlI.n./ --'2A01
1'1Itlent Hesponsi (Illy -:16.581
Accumullltors
Your 2005 deduc.ible has been satisfied
Sen'icc Code
[42----;:;;-;ii.;iion services -- __n__ - --.--.
L_________ ._
Messages
"------.----------- -----. J
-
Enrollee:MARLIN
Patient: MARLIN MCCOY
Soc Sec #: XXX-XX-2235
Group: LEAR RETIREES
G"OUI) #: RET
Claim #: 58042617-0 I
Patient #:
Date: 07/13/2005
MCCO
Amount
12.40
I
I
_.~-._--- - ------- -.- <-.---------..---
... IF YOUR CLAIM WAS DENIED, IN WHOLE OR IN PAIn. YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE TII !RIGHTTO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITTEN COM t;NTS,
DOCUMENTS, RECORDS OR INFORMATION Al30UT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF C It\lWE.
ACCESS TO INFORMATION WE REVIEWED IN MAKING TI-I1S DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTL YOI' TIfE INITIAL DENIAL. PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF Y( VR DENIAL
W AS BASED IN WHOLE OR IN l',vn ON A MEDlC,V_ JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFES IONAL ON
YOUR APPEAL, AND PROVIDE YOl r WITH THEIR NAME IF REQUESTED. YOU IIA VE THE RIGHT TO BRING CIVIL ACTI N l fNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENH'ITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WII. L, BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL
...
PlIyment To:
\V ALLACE A LONGTON MD
Check No.
-----.----
00222695
Rellson Code Description
I ~4 _ Bendits coordinated wi.h Medicare.
For eligibili.y llnd claim status infonnation, please visit ollr websile at www.assurecare.colll.
1);;W-~ Poymentl
At Amount
;-'----- -----
80%
80%
80%
.80%
~ 4050 Hunsacker Drive
Suite 110
East Lansing, MI 48823
200'Il"I.114(lO
Address Service RC(IUested
1--- Qucstions?C~ntaet-~-s -;;. -- _n
(517) 351-6616 or (800) 968-6,16
SINGLE PIECE
~-
En roJlec:MARLIN
P.ltient:MARLIN MCCOY
. Soe See #: XXX-XX-2235
GroUI): LEAR RETIREES
Group #: RET
Claim #: 58042696-01
Patient #: 46086] 0
Date: 07/13/2005
-M<X< ;r- -
1069 2.0176 SP 0.830
/",1/1" .11/....1/'111.1....11,1..1..11"111111111.11"111..1
MARLIN MCCOY 7
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
Explanation of Benefits for Sen'ices Provided By:
WALLACE A LONGTON MD
l)lItes o~e Service Total COD IneUglble Re.ason Discount
Code Charge Paid Code Amount
67.61 35.\3 0.0004 18.61
197.43 50.17 0.0004 129.43
1.360.82 184.66 0.0004 1.113.82
174.82 50.18 106.8204 0.00
I 558.16 84.66 0.0004 444.]6
_~_ 182.92 _I~ 0.0004 . _j..-__n_.!.l~
L_3,541. 76 _ ~l~Ji~ 06.8 L_J..:.~06.02 _
Covered Dy
Plan
Deductible Co-Pay
Amount Amount
!laloneI'
0.00
O.OC
0.00
0.00
0.00
0.00
0.00
f-------
0.00 49.00
0.00 68.00
0.00 247.00
0.00 68.00
0.00 J 14.00
0.00 182.92
0.00 728.92
T olul Net Po rlllent -.-
PUllent Respolls ~lUly 1--
04/22-04122/2005 42
04120-04/20/2005 42
04/20-0412012005 42
04/20-04/20/2005 42
04120-04120/2005 42
04/15-04115/2005 42
---~---
TOTALS
49.00
68.00
247.00
68.00
114.00
182.92
728.92
Accumullltors
Sen'ice Code
r:~: .m 'iadiation services -=--==_~~-==~===-~~_~j
Messages
Payment To:
-_.
\V ALLACE A LONGTON MD
Reason Code Description
~ Benefits coordinated with Medicare.
Check No.
00222704
Your 2005 deductible has been satisfied
80%
80%
Amount
I',UiZ"'C)lI"Il'
g
i;
!ii
~
39.20
54.40
I 97. 60
54.40
91.20
146.34
583.14
44.40
252.60
44.40
---~.__._--- ._-
IF YOUR CLAIM \V AS DENIED. IN WHOLE OR IN I' ART, YOU HA VE CERTAIN RIGHTS UNDER THE LAW. YOU HA VE TI e RIGHT TO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITfEN COM ..tENTS,
DOCUMENTS, RECORDS OR INFORMATION ABOUT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF C'lARGE.
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF TilE INITIAL DENIAL. PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF Y DUR DENIAL
W AS BASED IN WHOLE OR IN PART ON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFES 'IONAL ON
YOUR APPEAL. AND PROVIDE YOU WITH TIlEIR NAME IF REQUESTED YOU HAVE THE RIGHT TO BRING CIVIL ACTl< IN UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WII h BE MADE
WITHIN 30 CALENDAR DA YS FROM RECEIPT OF THE APPEAL.
...
'"
For eligibility and claim status information, please visit our website at www.assurecare.COtn.
II
Pl'l6;?900:'>(111O
~. 4050 Hunsacker Drive
Suite 110
East Lansing. MI 48823
~N
',5
~-
mI
lOO.\OS:!f>\\OI
Questions? Contact us at
Address Service Requested
(517) 351-6616 or (800) 968-661)
3-DIGIT 170
---
Enrollec:MARLIN
Paticnt:MARLIN MCCOY
Soe See #: XXX-XX-2235
GI'OUJl: LEAR RETIREES
GroUI) #: REI
Claim #: 58049209-01
Patient #: 4698644
Date: 08/24/2005
MCCOY
5435 0.5824 AT 0.292
111,11 1.11111111111111111,1,11111.1.111 1111111111111111111111 I
MARLIN MCCOY 22
141 HORSESHOE RD
CARLISLE, PA 17013-9562
~rl>ates ofServlc-e- Sel"Vlce
Code
05-i2S.0SI2S/200S 30
TOTALS
Totlll
C.1Ulrge
96.19
96.19
Explanation of Benefits for SeM'iccs Pl"Ovidcd By:
LANC HMA PHYS MGMT/CENT PEN
c'on Incllgible R;ll~~n I)iscounl Covel'cd By.- Deductible Co-P-;;y
Pold Code Amow,t l'lan Amount Amount
70.43 0.0004 0.00 96.19 0.00 0.00
70.43 0.0 -l_______.o.OO 96.19 0.00 0.00
P.~I POY1"ent
t Amount
96.19 0% 76.95
96.19 ~_~
Total Net l'aY' fnt 6.S2
Plttlent Rcsponslb I't)' _. 19.24
nalance
Accumulators
Your 200S deductible has b.:en satisfied
Pllyment To:
LANC HMA PHYS MGMT/CENT P
Reason Code Description
I I 04 Benefits coordinated with Medicare.
Check No.
00226884
"'-mount
6.52
Service Code
f3<l-- office visit
_~J
Messages
--
... IF YOUR CLAIM WAS DENIED. IN WHOLE OR IN PART, YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE THE IlIGHTTO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF nlls NOTICE. YOU MAY SUBMIT WRITl"EN COM~ aNTS.
DOCUMENTS, RECORDS OR INFORMATION ABOUT TilE CLAIM. YOU l-.>IAY RECEIVE, UpON REQUEST AND FREE OF Cllf-uWE,
ACCESS TO INFORMATION WE REVIEWED IN MAKING THlS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTL Y OF THE INITIAL DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF YO JR DENIAL
WAS BASED IN WHOLE OR IN PART ON A MEDICAL JUDGEMENT. WE WILL CONSULT WITH A HEALTH CARE PROFESS <DNAL ON
YOUR APPEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIOI-lT TO BRING CIVIL ACTIO ,UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WIL! SE MADE
WITIIIN 30 CALENDAR DAYS FROM RECEIPT OF T!-IE APPEAL
...
For eligibility and claim status inlormation, pl~ase visit our website at \\ww.assurecare.com.
t\suuC.uE' 4050 HUlIs4Ickcr Dd\'c
Suite 110
East Lansing. MI 4X823
P8^1QOO<I/"~'
-
~
2uo:'>tIXIV\ 1(11
Qucstions? Contact us at
~
Addrcss Scrvicc RCllucstcd
r-------- ..... ......
(517) 351-6616 or (800) 968-6611
3-DIGIT 170
En I"()lIce: MARLJN
Paticnt:MARLIN MCCOY
Soe See #: XXX-XX-2235
Group: LEAR RETIREES
G"OUI' #: RET
Claim #: 58048831-0]
Paticnt #: 0461172] 537
Datc: 08117/2005
MCCOY
--l
4476 0.3840 AT 0.292
11111111111 " 111111 " 111111.11111.11.11'1 111.11/111111" 111111
MARLIN MCCOY 30
141 HORSESHOE RD
CARLISLE, PA 17013-9562
Exphm:'tion of BCllcfits for Sen'iccs PJ"O\'idcd By:
BLUE MOUNTAIN ANESTHESIA ASSOC
II). ales O(SC~lCeI- se'i-Vke ---'tOt'il--'C61~l Ineilgibl;- Ih.li;onl>is.;;;uirt-- Covel'ed By
Code Ch,u'ge l'uid Code Amounl Plnn
i~~~3-06/03-1i(~I ~. - 487.50 51:7& ---=-o~oo 04-- _ ~0-6.59 80.91
TOTALS ___ 487.50_~_ 0.0 40619 __ 80.91
D..d~~iibi(.' Co-pny- -n;lnnc~---"'--1' 111-
AmOlUlt Amount . I
0.00 0.00 80.91 0%
0.00 0.00 80.91
--"--- -----
TotnJ Net Paynl/nl
PlIfi.,nt R"sponsib Illy i
PO)'lIIent-'
AmowlI
64.73
6473
12.95
16.18
Accumulators
Payment To:
------
BLUE MOUNTAIN ANESTHESIA
Reason Code Description
[04=__~;n~fits coordinated' with Medic:lre.
Check No.
00226152
mount
Your 2005 dllduclible has been satisfied
12.95
Sen'ice Code
[22---;;;lesth';i~logist _. ----. ----------]
-----_.~--------~._---_...__. -...-.-. _..
-----1
-------~
Messages
;;;-----IFymrR-ciAIM WAsi)ENIED.IN WHOi~E OR IN PART.-;;:-oli II.'\\'E CERTAlNRIGHTS uNDER THE LAW. YOU HAVE THE RImIT'ro-
APPEAL THIS BENEfIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRrrrEN COMM . NTS.
LX>CUMENTS. RECORDS OR INFORMATION ABOUT TI IE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF CH RGE,
ACCESS TO INFORMATION WE REVIEWED IN MAKING TillS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF THE INITIAL DENIAL, PERFORMED 13Y SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF YO m. DENIAL
WAS BASED IN WHOLE OR IN PARTON A MEDICALnIDGEt\'IENT, WE WILL CONSULT WITH A HEALTH CARE PROFESS ~~NAl,ON
YOUR APPEAL. AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CLVIL ACTIO UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND UENEFITS ARE DENIED AFTER REVIEW AN APPEAL DETERMINATION WIL BE MADE
WITHIN 30 CALENDAR DAYS FRO/vI RECEII'T OF TilE .\I'I'EAl..
... For eligibility and claim status infonmltion, please visit our websitc at www.assurecare.com.
PH62YOO~(ltlO
~. 4050 Hunsacker Drh'c
Suite 110
East Lansing, MI 48823
-
~
20050110.53300
Address Scn'icc RC<lucstcd
I~ ______--1-->___
Questions? Contact us at i
(517) 351-6616 or (800) 968-66~6
raJ
3-DIGIT 170
EnroIlee:MARLIN
Patient: MARLIN MCCOY
Soc Sec #: XXX-XX-2235
Grou)): LEAR RETIREES
Group #: RET
Claim #: 58046372-01
Patient #: 172 0007224 0 I R
Date: 08/03/2005
MCCO.1
I
I
23610 0.3840 AT 0.292
11111111111111111111111111111111111111111111111111111111111111
MARLIN MCCOY 104
141 HORSESHOE RD
CARLISLE, PA 17013-9562
Explanation of Benefits for Sen'ices Provided By:
CENTRAL PENN MEDICAL GROUP
-nates orServlce Service Total con Inelleible Reason Discount Covered By Deduc:tibl4\ Co-Pay
Code O1arge Paid Code Amount Plan Amount Amount
06/14-06/14/2005 22 136.32 51. 78 0.0004 55.41 80.91 0.00 0.00
TOTALS 136.32 51. 78 O.O( 55.41 80.91 0.00 0.00
llId Pa)'I1letlt
At Amount
80.91 80% 64.73
80.91 64.73
Total Net Pa ~ent 12.95
Patient Respons ~ty 16.18
DlIlHllce
Accumulators
Your 2005 deductible has been satisfied
Pa)'ment To:
CENTRAL PENN MEDICAL GROU
Reason Code Description
I 04 Benefits coordinated with Medicare.
Check No.
00224844
Amount
12.95
Sen'ice Code
~ anesthesiologist
=:J
___I
Messages
... IF YOUR CLAIM WAS DENIED. IN WHOLE OR IN PART, YOU HAVECERTAlN RIGHTS UNDER THE LAW. YOU HAVE TH~ RIGHT TO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. yOU MAY SUHMIT WRITTEN COM 1ENTS.
DOCUMENTS. RECORDS OR INFORMATION ABOlJI' THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF CHARGE.
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF THE INITIAL DENIAL. PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL IF Y UR DENIAL
W AS BASED IN WHOLE OR IN PART ON A MEDICAL JUDGEMENT. WE WILL CONSULT WITH A HEALTH CARE PROFES 10NAL ON
YOUR APPEAL. AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACT!< N UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION wn Il. BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
... For eligibility and claim status information, please visit our website at www.assurecare.com.
PH62900,~(H)(,
~. 4050 Hunsaclicr Drivc
Suite 110
East Lansing, MI 48823
"
'"
200~O~293300
Questions? Contact us at
I!
Address Service Requested
(517) 351-6616 or (800) 968-6616
3-DIGIT 170
Enrollee: MARLIN MCCO\1
Patient:MARLfN MCCOY
Soe See #: XXX-XX-2235
Group: LEAR RETIREES
Group #: RET
Claim #: 58044824-01
Patient #: 5498
Date: 07/27/2005
27957 0.5824 AT 0.292
11111/ 111111/11111/111111111111.11111.111111111111111111111111
MARLIN MCCOY 121
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
EXI)lanation of Benefits for Services Provided By:
BRONSTEIN & JEFFRIES DO PC
rUBtes or~ Service
Code
105/26-05/26/2005 30
TOTALS
Totlll
Cbaree
35.00
35.00
COB Ineligible Reason
Paid Code
16.23 0.0004
16.23 O.OC
Discount
Amount
Covered Uy
Plan
Deductible Co-I'oy
Amount Amount
Bulance
Paid -I'aYment
At Amount
9.64
_ __'. 9.6~
25.36
25.36
0.00 0.00
0.00 0.00
25.36 80% 20.29
25.36 20.29
Total Net 1'1 1Jnent --4.06
Putlent Respon ihllit)' ~-._~
Accumulators
I' our 2005 deductible has been satisfied
Payment To:
BRONSTEIN & JEFFRIES DO P
Reason Code Description
___ ____.__.___ -.J ~ Benefits coordinated with Medicare.
Check No.
00223674
Amount
4.06
Service Code
130 office visit
~--------~
Messages
... IF YOUR CLAIM WAS DENIED, IN WHOLE OR IN PART, YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE T E RIGHT TO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITTEN cm MENTS,
DOCUMENTS. RECORDS OR INFORMATION ABOUT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF }IARGE,
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTEI
INDEPENDENTLY OF THE INITIAL DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF li)UR DENIAL
WAS BASED IN WHOLE OR IN PART ON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFE SIONAL ON
YOUR APPEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACT ON UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION \V L.L BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
...
For eligibility and claim status infomlation, please visit our websit" at WW\V.assurecarc.com.
P862900~0Q()
~. 4050 Hunsackcr Drivc
Suite 110
East Lansing, Ml 48823
;;N
"'..
~o
~-
200'07293300
Addrcss Scrvicc Rcqucsted
I
L
_1...._______
Questions? Contact us at i
I
I
(517) 351-6616 or (800) 968-66161
~
3-DIGIT 170
Enrollee:MARLIN
Patient: MARLIN MCCOY
Soc See #: XXX-XX-2235
Group: LEAR RETIREES
Group #: REI
Claim #: 58044819-01
Patient #: 5498
Date: 07/27/2005
MCCOY---'--
27957 0.5824 AT 0.292
111.11111.11I,11.111111.1,11.11.11111111,11.111111111111111111
MARLIN MCCOY 121
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
Datu of Service Sen.'lce
Code
EXI)lanation of Benefits for Senrices Provided By:
BRONSTEIN & JEFFRIES DO PC
Totol con IneligIble Reason DlscoWlt Covered By Deductible Co-Pay
Charge PaId Code AmoWlt Plan Amount Amount
65.00 40.21 0.0004 2.17 62.83 0.00 0.00
65.00 40.21 O.O( -- 2.17 62.83 0.00 0.00
Pi d' Payment
A Amount
62.83 0% 50.26
62.83 50.26
Total Net Payn ~nt 10.05
Patient Responsib ijty 12.57
L-__~
Balance
05/19-05/1912005 30
TOTALS
Accumulators
Your 2005 deductible has been satisfied
Payment To:
BRONSTEIN & JEFFRIES DO P
Reason Code Description
~ r 04 Benefits coordinated with Medicare.
Check No.
00223673
f\mount
10.05
Service Code
~ office visit
I
Messages
... IF YOUR CLAIM WAS DENIED. IN WHOLE OR IN PART. YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE THE aIGHT TO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRIlTEN COMN ENTS.
DOCUMENTS. RECORDS OR INFORMATION ABOUT THE CLAIM. YOU MAY RECEIVE. UPON REQUEST AND FREE OF CHARGE,
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF THE INITIAL DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF YOUR DENIAL
W AS BASED IN WHOLE OR IN PART ON A MEDICAL JUDGEMENT. WE WILL CONSULT WITH A HEALTH CARE PROFESS ONAL ON
YOUR APPEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACTIOf.li UNDER
ERISA 502(A) IF YOU FILE AN AI'PEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WIL 'BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
... For eligibility aud claim status information, please visit our website at www.assurecare.com.
PH/')2900.'\(i<Il,
=-"uuCAIr 4050 Hunsacl{cr Drive
Suite II ()
East Lansing. MI 48823
~-
~~
-.:'
~
::'(lU\""!<'J; 100
I
I
Qucstions? Contact us at
i1
Address SC/Ticc RCtlUested
(517) 351-6616 0/. (800) 968-6616
3-DIGIT 170
I .u. .... ..'
En mllcc:MARl,lN
. Paticnt:MARUN MCCOY
I Soc See #: XXX-XX-2235
I GnlUl>: LEAR RETIREES
I Group #: RET
[I Claim #: 58052894-0 I
Patient #: 99558Xl
Date: 09/14/2005
MCCOY
30826 0.3840 AT 0.292
1".111".111."".111111.1.1" J I J 1111111111.1 J 1..111111111111
MARLIN MCCOY 117
141 HORSESHOE RD
CARLISLE, PA 17013-9562
Explanation of Benefits for Scn'ices Provided By:
DAVID RROYAL MD
, J),ites'oC'SirvlCe-. ~'l;~kl--l'~l"- --LUll i;"Cliiib.leTIk'nsot... ".n '.i~.';,".' I. c .o"..e.n~I-.lj.j,- '.D.~(.f~. ;iiW[C~:P;Y [ ...;,;;;'.,;. -- P;ilI.... ""P' I>.ijment
i Code ('IIlII'ge I'llld Code .-\II\Ollllt Plnn AmollRt Amollll/ t. Arnow.t
i04i08--:04108/2005 45' - - 735-00 -25583 ---0.004- -. '37l<.clO '357.00 0.00----0:00 -'~70U -- 0;;:. --_m:60
1?~/08~4!?81_200~, .?~_ ,~_ ~?~,~_ __~OO I?~.~O 9__.1_.., OO~ __~.OO _~O ._~~~~ _,_ O.O~ O:~ n 0.00
TOTALS I., .9.Q~,OO.~.5~83 _!.710 L 378.00._. _l5!OO __._~O__ 0...0!.___~7.00 . 285.60
Totnl Net PIIY l~nt r-- 29.77
I'lltil'nt Rl'Sponslb Oty t-~l42.~
Service Code
f 45- x-rny/labl;;sli~lg-~'
I 98 Ineligible service
.Paymen! TO.:.._______n____~,~_~k N~. .. ~rnou~_..,
DAVID R ROYAL !\1D 00228959 2977
Reason Code Description
I~; ~:~~e.~~~~\;:d~::d :ith ~~edi~~re ~ .~~~_ ~~~~~~~~=-l
Messages
-*_._-------'- _..__.__.~---- ._--_.-_._-._-_._---,----~ ._-
99 - DENIED.PROCEDURE IS NOT PAll) SEPARATELY PER
MEDICARE.
... IF YOlIR CLAIM WAS DENIED, IN WHOLE OR IN PART, 1'0[1 HA VE CERTAiN RIGHTS tiNDER THE LA W. YOU HAVE TH :RIGHT TO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MA Y SUBMIT WRIITEN COM '~NTS,
DOCUMENTS. RECORDS OR INFORMATION ABOUT TIlE CLAIM. YOU MAY RECEIVE, UPON REQllEST AND FREE OF C A.RGE,
ACCESS TO fNFORMATION WE REVIEWED IN MAKINU TIllS DETEIUoiINATION. YOUR A1'PEAL WILL BE CONDUCTED
fNDEPENDENTLY OF HIE INITIAL DENIAL. PERFOIU\'IED 13Y SOMEONE NOT INVOLVED IN THE INITIAL DENIAL IF Y UR DENIAL
W AS BASED IN WI [OLE OR IN PART ON A MEDICAL JlII)GEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFES IONAL ON
YOUR AI'I'E...'\L, AND PROVIDE YOU WITH THEIR NAME II' REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACTI }oj UNDER
ERISA 502(A) IF YOU FILE AN A.PPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WI L AE MADE
WITIIIN 30 CALENDAR DAYS FROM RECEIPT OF TilE ,\PPEAL.
... For eligibility and claim status information, please visit our \V~hsile al \Vww.assurecare.cum.
PR621,l(I()"iO{/(,
~. 4050 Hunsackel' Ddve
Suite 110
East Lansing, MI 48823
-
is
200~0722J}OO
Address Sen'ice Requested
~n
Questions? Contact us at I
I
~
(517) 351-6616 or (800) 968-6616
3-DIGIT 170
Enrollee:MARLIN
Patient:MARLIN MCCOY
Soe See #: XXX-XX-2235
Group: LEAR RETIREES
Group #: RET
Claim #: 58043422-01
Patient #: 7501319
Date: 07/20/2005
MCCOY
28012 0.3840 AT 0.292
111111111111111111111.111111111.111111111111111111111111111111
MARLIN MCCOY II?
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
Ditesorservlce Service
Code
06/07-06/0712005 13
TOT AI,S
Explanation of Benefits for Services Provided By:
CARLISLE REGIONAL MED CENT
T otaI COB - ineligible 'Re1i5o-o '--jjiS(,ounr-r- Covered By - O;ductlblc Co-Pay
Charge Paid Code Amount PllIn Amount Amount
21,014.42 3,320.98 O.OO~4 15,803.27 5,211.15 0.00 0.00
21,0]4.423,320.98 O.OC 15,803.27 5,211.15 0.00 0.00
- '--- --, -.;,--r
Balance P~ 0
A
PaynJenC'
Amount
5,211.15 0% 4,168.92
5,2] 1.15 4,168.92
Total Net Payn ~nt 847.94
Patient Rcsponslb Uty '-_ ],042.23
Accumulators
Your 2005 deductible has been satisfied
Payment To:
CARLISLE REGIONAL MED CEN
Reason Code Description
~ I 04 Benefits coordinated with Medicare.
Check No.
00223185
lAmount
847.94
Service Code
~~___ hospital outpatient
__1
Messages
... IF YOUR CLAIM \VAS DENIED. IN WHOLE OR IN PART, YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE THE RIGHTTO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS Of RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITTEN COM~ ENTS,
DOCUMENTS. RECORDS OR INFORMATION ABOUT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF C AAGE.
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF THE INITIAL DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF Y( UR DENIAL
WAS BASED IN WHOLE OR IN PARTON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFES 10NALON
YOUR APPEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACTI< N UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AITER REVIEW. AN APPEAL DETERMINA nON WI t BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
... For eligibility and claim status information, please visit ollr website at www.assurecare.com.
,
,
I!
1'86'","OO'lO\l"
~. 4050 HunsacJ{cr Drh'c
Suite 110
East Lansing, MI 48823
"'_
it
~-
200109013301
3-DIGIT 170
Enrollee:MARLIN
Paticnt:MARLIN MCCOY
Soe See #: XXX-XX-2235
Group: LEAR RETIREES
Group #: RET
Claim #: 58051037-01
Patient #: 4726364
Date: 08/31/2005
Address Sen'ice Requested
l-~51 :::::;;: O::~:::'9~~:' 6
~
MCCOY
6632 0.3840 AT 0.292
I. "11111.111,111,, II ,,11.1, 1",1.1., II"" 1.1.1" 1...11111111
MARLIN MCCOY 58
141 HORSESHOE RD
CARLISLE, PA 17013-9562
mates 0 ,eM' ce SCI"\'lcc Tuta! con [ncllglblc Rcason DlscoIDlt Covercd By
~ Code Charlc Paid Code Amonnt Plan
06/03-06/03/2005 20 1,203.79 277.46 0.0004 770.26 433.53
TOT ALS 1,203.79 277.46 0.0 770.26 433.53
Deductible Co-Pay
Amount Amount
Dahmce
PlIyment
Amount
EXllIanation of Bencfits for Services Provided By:
LANC HMA PHYS MGMT/CENT PEN
0.00
0.00
0.00
0.00
433.53
433.53
Total Net Pay ,nt
l'lItlent Responslb dty L-=
346.82
346.82
69.36
86.71
Accumulators
Your 2005 deductible has been salisfied
Payment To:
LANC HMA PHYS MGMT/CENT P
Reason Code Description
04 Benefits coordinated with Medicare.
Check No.
00227845
SCn'ice Code
~ surgery
__J
Messages
U. IF YOURCLAlM WAS DENIED,IN WHOLE OR IN PART, YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE TH
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITrEN COM
DOCUMENTS, RECORDS OR INFORMATION ABOUT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF C
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF THE INITIAL DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF Y l[JR DENIAL
W AS BASED IN WHOLE OR IN PART ON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFES lONAL ON
YOUR APPEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACT! rlI UNDER
ERISA 502(A) IF YOU FILE AN APPEAI, AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WI r; BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEM..
... For eligibility and claim status infonnation, please visit our wehsite at w\vw.assurecare.COlll.
~ 4050 Hunsackcr Drivc
Suite 110
East Lansing, MI 4882]
Address Sen'ice Requested
SINGLE PIECE
2570 3.0096 SP 1.060
1'1111111111111111111.1.111..11.1111..1111111111'11111...11..1
MARLIN MCCOY 18
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 170=5-1431
P8629t)()~(J()
200$01061 00
~
-- ....
Questions? Contact us at
(517) 351-6616 or (800) 968-61 16
En ro Ilee: MARLIN MCCC y
Patient: MARLIN MCCOY
Soc See #: XXX-XX-2235
Group: LEAR RETIREES
Group #: REI
Claim #: 58037803-01
Patient #: 9305045XI
Dntc: 06/22/2005
. for Senrices P.'ovidcd By:
fER LADD MD
Pald --
nt Covered By Deductible Co-Pay Balance Payment
lit Plan Amount Amount At Amount
8.64 13.36 0.00 0.00 13.36 80% 10.69
1.64 13.36 0.00 0.00 13.36 80% 10.69
0.28 26.72 0.00 0.00 26.72 21.38
Total Net P XJllent 21.38
Patient Respon Ilblllty 5.34
Payment To: Check No. Amount
- -
CHRISTOPHER LADD MD 00220467 21.38
Reason Code Description
I 04 Benefits coordinated with Medicare. --~
HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE l' ~E RIGHT TO
:EIPT OF THIS NOTICE. YOU MAY SUBMIT WRITTEN COI MENTS.
AIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF r.HARGE.
; DETERMINATION. YOUR APPEAL WILL BE CONDUCTE
SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF OUR DENIAL
vfENT, WE WILL CONSULT WITH A HEALTH CARE PROFE SSIONAL ON
EQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL AC T ON UNDER
lENIED AFTER REVIEW. AN APPEAL DETERMINATION W LL BE MADE
1.1.
wwv".assurecare.com.
Explanation of Bencfitl
CHRlSTOPl
ates of Service Service
Code
02/28-02/28/2005 45
02/28-02/28/2005 45
TOTALS
Total
Char&e
32.00
35.00
67.00
COB IneligIble Reason
Paid Code
0.00 0.0004
0.00 0.0004
0.00 0.0
Accumulutors
Your 2005 deductible has been satisfied
Service Code
145 x-ray/lab te:,1ing
---=~======-:J
J)[scou
..unou
]
')
<!.
Messages
... IF YOUR CLAIM WAS DENIED, IN WHOLE OR IN PART, YOU
APPEAL THIS BENEFIT DECISION 'VITHIN 1 gO DAYS OF RE<
DOCUMENTS, RECORDS OR INFORMATION ABOUT TIlE Cl
ACCESS TO INFORMATION WE REVIEWED TN MAKING THI:
INDEPENDENTLY OF THE INITIAL DENIAL. PERFORMED BY
W AS BASED IN WHOLE OR IN P AI~ r ON A MEDICAL JUDGE
YOUR APPEAL, AND PROVIDE YOI J WITH THEIR NAME IF R
ERISA 502(A) IF YOU FILE AN i\PPlAL AND BENEFITS ARE I
WITHIN 30 CALENDAR DAYS FRO).1 RECEIPT OF THE APPE.
...
For eligibility and claim status informati,m, please visit our website at
P862"oo~ono
~ 4050 Hunsacker Dri\'c
Suite 110
East Lansing, MI 48823
~~
~~
~"
200~07061400
~
1 , "
Questions'! Contact us at 1
Address Sen'ice Requested (517) 351-6616 or (800) 968-66116
SINGLE PIECE Enrollee:MARLIN Mcc6, '
2570 3.0096 SP ],.060 Patient:MARLIN MCCOY
111.111111111111111'111.111111111111111111111111111.11111111.1 Soc Sec #: XXX-XX-2235
MARLIN MCCOY 18 Group: LEAR RETIREES
5], MOUNTAIN ST LOT 6 Group #: RET
MOUNT HOLLY SPRINGS, PA 17065-1431 Claim #: 58037876-01
Patient #: 044277 20232
Date: 06/22/2005
:
Explanation of Benefits for Ser\'ices Pro\'ided By:
BLUE MOUNTAIN ANESTHESIA ASSOC
l),des of Service Service Total COB IneUgible Reason Discount Covered By Deductible Co-Pay Balance '~d Payment
Code C'hBrl:e Pald Code Amount Pion Amount Amount At Amount
04/28-04/28/2005 30 165.00 63.18 71.50 04 0.00 93.50 O.OC 0.00 93.50 180% 74.80
TOTALS 165.00 63.18 71.5 0.00 93.50 0.00 0.00 93.50 74.80
Total Net Po ~ent 11.62
Patient Respons ~illty 90.20
Accumulators Payment To: Check No. Amount
Your 2005 deductible has been satisfied BLUE MOUNTAIN ANESTHESIA 00220472 11.62
Service Code Reason Code Description
L30 office visit I 104 Iknefits coordinated with Medicare. I
.--l
Messages
... IF YOUR CLAIM WAS DENIED, IN WHOI.EOR IN PART, YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE Tf :i!: RIGHT TO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITTEN COM NiENTS,
DOCUMENTS, RECORDS OR INFm:MATION ABOUT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF ( mARGE,
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED
INDEPENDENTLY OF THE INITIAl DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF" <l>UR DENIAL
W AS BASED IN WHOLE OR IN PAR T ON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFE $IONAL ON
YOUR APPEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACT ON UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION W ijL BE MADE
WITHIN 30 CALENDAR DAYS FRO\1 RECEIPT OF THE APPEAL.
... For eligibility and claim status informati,,", please visit our websile at www.assurecare.com.
~
4050 Hunsacker Drive
Suite 110
East Lansing, Ml 4882:1
Address Service Re(\uested
SINGLE PIECE
2570 3.0096 SP 1.060
1111111.11111111111111111111111111111111.1111111,1\.1111111..1
MARLIN MCCOY 18
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17D~S-1431
Explanation of Bellefit!
CHRISTOPH
Sen'lcc Total COB Ineligible Reason
Code Otarze Pald Code
- -
04/06-04/0612005 40 33.00 8.86
04/06-04/0612005 40 185.00 35.10
04/07-04/0712005 40 25.00 7.06
04/07 -04/07/200 5 40 73.00 2182
04/06-04/0612005 40 169.00 44.26
- -
TOTALS 485.00 117.10
~--- -
Accumulators
Your 2005 deductible has been satisfied
Service Code
140 x-ray and/or laboratory
___":J
II
I'H6~9{IO~I'('
200~07061-',OO
~
Questions? Contact us at I .-
(517) 351-6616 or (800) 968-416
I
EnroUee:MARLIN MCC( Y
Patient: MARLIN MCCOY
Soc Sec #: XXX-XX-2235
Gmup: LEAR RETIREES \
Group #: RET
Claim #: 5803802].0]
Patient #: 5007486Xl
Dl\te: 06/22/2005
. for Services Provided By:
. ER LADD MD
nt Covered By Deductible Co-Pay Balance Paid !'a~
'1\t !'lnn AnIOmlt ArnOWlt At Amount
9.16 13.84 0.00 0.00 13.84 80% 1\.07
0.15 54.85 0.00 0.00 54.85 80% 43.88
4.00 1\.00 0.00 0.00 1l.00 80% 8.80
8.90 34.10 0.00 0.00 34.10 80% 27.28
9.84 69.16 0.00 0.00 69.16 80% 55.33
l~ 182.95 0.00 0.00 182.95 146.36
-
Total Net P :fIllent 29.26
Pot lent Respon riblllty 36.59
Payment To: Check No. Amount
-
CHRISTOPHER LADD MD 00220475 29.26
Reason Code Description
104 Benefits coordinated with Medicare. -~
- ~-~
HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE T iE RlGHT TO
:EIPT OF THIS NOTICE. YOU MAY SUBMIT WRITTEN cm MENTS,
AIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF "HARGE,
, DETERMINATION. YOUR APPEAL WILL BE CONDUCTEI
( SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF OUR DENIAL
viENT, WE WILL CONSULT WITH A HEALTH CARE PROFE SSIONAL ON
EQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACT ON UNDER
>ENIED AFTER REVIEW. AN APPEAL DETERMINATION W LL BE MADE
www.assurecare.com.
J)ISCOlJ
Alllou
I:'
:,l
~
2
Messages
... IF YOUR CLAIM WAS DENIED, IN WHOLE OR IN PART, YOU
APPEAL THIS BENEFIT DECISION \1JITHIN 180 DAYS OF RE(
DOCUMENTS, RECORDS OR INFORMATION ABOUT THE CL
ACCESS TO INFORMATION WE RE VIEWED IN MAKINO THIS
INDEPENDENTLY OF THE INITIAL DENIAL, PERFORMED B'
W AS BASED IN WHOLE OR IN PAI~ r ON A MEDICAL JUDGE;
YOUR APPEAL, AND PROVIDE YOI) WITH THEIR NAME IF R
ERISA 502(A) IF YOU FILE AN APPLAL AND BENEFITS ARE I
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE AI'PEAL
... For eligibility and claim status infimnati,lO, please visit our website at
P8L')29nO~I)OO
~ 4050 Hunsllcker Drive
Suite 110
East Lansing MI 48823
R. r~
-,-
~~
'"
200~0706I.400
Address Sen'ice Reque~;ted
'--'
i Questions?
I
~
(517) 351-6616 or (800) 968-66 ,6
SINGLE PIECE
Enrollee:MARLIN
Patient: MARLIN MCCOY
Soc Sec #: XXX-XX-2235
Groull: LEAR RETIREES
GrouJl #: RET
Claim #: 58038061-01
Plltient #: 748640]X]
Date: 06/22/2005
MCCaW--
2570 3.0096 SP 1.060
111111111111111111111.111111111.1111111111111111111.1111.11111
MARLIN MCCOY ]8
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
Explanation of Benefits for Sen'ices Provided By:
GEORGE BRODER MD
I Dates of Service Service Total COB IneUglble Reason
I Code Charge Paid Code
1~4/14-04/1412005 45 208,00 82.49 0.0004
04/15-04/15/2005 45 117.00 34.52 0.0004
TOTALS 325.00 117.01 0.01
Discount Covered By Deductible Co-Pay Dalallce l1aJd Payment
Amount Plan ArnOWlt Amount I\t ArnOWlt
79.11 128.89 0.00 0.00 128.89 80% 103.11
63.06 53.94 0.00 0.00 53.94 80% 43.15
142.17 182.83 0.00 0.00 182.83 146.26
Total Net Pa nllent 29.25
Patient Respons ~UJty 36.57
'--
Accumulators
Your 2005 deductible has been satisfied
Payment To:
GEORGE BRODER MD
Reason Code Description
I r 04 Benefits coordinated with Medicare.
Check No.
00220476
Amount
29.25
Service Code
145 x-ray/Jab testing
I
Messages
... IF YOURCLAlM WAS DENIED, IN WHOLE OR IN PART, YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE T IE RIGHT TO
APPEAL THIS BENEFIT DECISION ',VITHIN 180 DAYS OF RECEIPT OF THIS NOTICE, YOU MAY SUBMIT WR1TfEN cm. MENTS,
DOCUMENTS, RECORDS OR INFORMATION ABOUT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF C I!lARGE.
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTE[
INDEPENDENTLY OF THE INITIAL DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF \ OUR DENIAL
W AS BASED IN WHOLE OR IN PART ON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFE $IONAL ON
YOUR APPEAL, AND PROVIDE YOII WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACTION UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAI_ DETERMINATION Wlt.:L BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
...
For eligibility and claim status information, please visit our websile at www.assurecare.com.
II
P86'2QO()~OOCI
~ 4050 Hunsacl{er Drivc
Sui Ie 110
East Lansing, MI 48821
N
...
o
200~07061, 00
Questions? Contact us at
~
Address Servicc Requc!:tcd
(517) 351-6616 or (800) 968-661,6
SINGLE PIECE
EnrolIee:MARLlN
Patient:MARLIN MCCOY
Soc Sec #: XXX-XX-2235
Group: LEAR RETIREES
Grou)) #: RET
Claim #: 58039170-01
Patient #: 7495142
D~ltc: 06/22/2005
MCCO~
2570 3.0096 SP 1.060
1111111111111111,111111,11'1111"11'1111'"11111"111111111111
MARLIN MCCOY 18
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
E:q}lanation of Benefits for Services Provided By:
CARLISLE REGIONAL MED CENT
Service Total COB IneUrlble Reason J)lscou nt Covered By Deductible Co-Pay
Code Charre Paid Code Amoltllt Plan Amount Amount
05/13-05/13/2005 13 114.20 39.58 0.0004 52.35 61.85 0.0 0.00
TOTALS 114.20 39.58 0.0 ~2.35 61.85 0.0 0.00
---
Id paYl1len~t
At Amount
61.85 ,80% 49.48
61.85 .. f- 49.48
Total Net Pa~enl C- 9.90
Patient Respons~~llItY L--12.37
Ballance
Accumulators
Your 2005 deductible has been satisfied
Payment To:
CARLISLE REGIONAL MED CEN
Check No. ' 'Amount
00220487 9.90
~ hospital outpatient
~~
Reason Code Description
I 04 Benefits coordinated with Medicare.
J
Service Code
... For eligibility and claim slatus informati.)n. please visit our website at WWW.8ssurecare.com.
PHb29(10~OOI',
~ 4050 Hunsllckcr Drivc
Suite 110
East Lansing, MI 48823
~~
~~
-~-
R
200507061400
Qucstions? Contact us at
Add.,css Scn'icc RCIIUC!itcd
(517) 351-6616 or (800) 968-6616
SINGLE PIECE
En rollce: MARLIN
Paticnt:MARLIN MCCOY
Soe Sce #: XXX-XX-2235
Group: LEAR RETIREES
Group #: RET
Claim #: 58040289-01
Paticnt #: 4590281
Dllte: 06/29/2005
MCCOY!
2570 3.0096 SP 1.060
1'11111111111111.111111.1. 11111.1111 1111.. 111111,11,1111111111
MARLIN MCCOY 18
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
Explanation of Bencfits for SCn'iccs Providcd By:
WALLACE A LONGTON MD
Dates 01' Service Service Total COB lnellglble Reason Discount Covered By Deductible Co-Pay Balance J'llid Payment
Code Charge Paid Code Amount Plan Amount Amount ~ t Amount
04/12-04/12/2005 42 177.45 73.78 0.0004 62.16 115.29 0.00 0.00 115.29 ' 180% 92.23
04/12-04/12/2005 42 176.26 28.31 0.0004 138.26 38.00 0.00 0.00 38.00 !80% 30.40
04/12-04/1212005 42 113.25 28.58 0.0004 75.25 38.00 0.00 0.00 38.00 !80% 30.40
04/12-04/12/2005 42 87.41 25.09 0.0004 53.41 34.00 0.00 0.00 34.00 !80% 27.20
I
04/13-04/13/2005 42 135.22 70.26 0.0004 37.22 98.00 0.00 0.00 98.00 .180% 78.40
TOT ALS 689.59 226.02 o.oe 366.30 323.29 0.00 0.00 323.29! 258.63
...._-~
Total Net pa~ent 32.61
Patient Respons! IlIty f-.-64:66
, -_.._-~
---~
Payment To:
WALLACE A LONGTON MD
Reason Code Description
~ Benefits coordinated with Medicare.
Check No.
00221653
32.61
Accumulators
Your 2005 deductible has been satisfied
Service Code
~radiation services
-
~essages .
-;;;--IFYOUR CLAIM W AS DENIED, IN WHOLE OR IN PART, YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE r'IffRIGHT TO
APPEAL THIS BENEFIT DECISION WITHIN I 80 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITTEN Cm,.j~ENTS,
DOCUMENTS, RECORDS OR INFOkMA TION ABOUT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF d~IARGE.
! I
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTED 1
I
INDEPENDENTLY OF THE INITiAl DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF \'t<l>UR DENIAL
W AS BASED IN WHOLE OR IN PART ON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFE$~IONAL ON
YOUR APPEAL, AND PROVIDE YOII WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACTj~N UNDER
I
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WjIj.L BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
...
For eligibility and claim status information, please visit our website at www.assurecare.com.
Pk6~9(}(I"')OO
~ 4050 Hunsacker Drive
Suite 110
East Lansing, MI 48823
-
..
o
10(1"'01001.00
Questions? Contact us at
w.~
~
Address Sen'ice Reque~ted
(517) 351-6616 or (800) 968-6616
SINGLE PIECE
I Enrollee:MARLIN
. Patient: MARLIN MCCOY
Soe See #: XXX-XX-2235
Grout): LEAR RETIREES
G.-oup #: RET
Claim #: 58040291-01
Patient #: 4590278
Date: 06/29/2005
MCC011
2570 3.0096 SP 1.060
1,11111111111",111",1,1,1"11.11111111,,,,1111. " ,11",11'1 I
MARLIN MCCOY 18
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 170~5-1431
Dates of Servicc' Service
Code
04/12-04/12/2005 30
TOTALS
Total
Charee
101.34
101.34
I:tplanation of Benefit! for Sen'ices Provided By:
WALLACE A LONGTON MD
COB [nenelble Rcason Discount Covered By Deductible Co-Pay
Paid Code Amou:!It Plan Arnow" Amount
56.15 0.0004 13.60 87.74 0.0 0.00
----
56.15 0.0 ] 3.60 87.74 0.0 0.00
Balance
Payment
Amount
87.74
87.74 I
Total Net PII~ent
Patient ReSPO~rlllty
70.19
70.19
14.04
17.55
Accumulators
Your 2005 deductible has been satisfied
Payment To:
WALLACE A LONGTON MD
Reason Code Description
I 04 Benefits coordinated with Medicare.
Check No.
00221654
i
I
! Amount
-1-------
1404
Service Code
130 office visit
-.-J
--I
-.-I
Messages
... IF YOUR CLAIM WAS DENIED, IN WHOLE OR IN PART. YOU HAVE CERTAIN RIGHTS UNDER THE L<\.W. YOU HAVE n RIGHTTO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITfEN CO~ 1ENTS.
DOCUMENTS, RECORDS OR INFORMATION ABOlJr THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF cC ARGE,
ACCESS TO INFORMATION WE REVIEWED IN MAKINO THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTEO I
INDEPENDENTLY OF THE INlTlAL DENIAL, PERFORMED B" SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF ybUR DENIAL
WAS BASED IN WHOLE OR IN PARTON AMEDICALJUDGE!>1ENT, WE WILL CONSULT WITH A HEALTH CARE PROFEs..;bIONALON
YOUR APPEAL. AND PROVIDE YOI J WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACTl~N UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WliL BE MADE
I
WITl-UN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEIU.. .
...
For eligibility and claim status infommlion, please visit our website at www.assurecare.com.
PK629(}O~I)OC
~
4050 Hunsacker Drive
Suite 110
East Lansing, Ml 48823
-
l's
.
100'01061400
ri1
~--- .
Questions? Contact us at
Address Sen'ice Reque:,ted (517) 351-6616 or (800) 968-66116
SINGLE PIECE Enrollee:MARLIN MCCOll:
2570 3.0096 SP ),.060 Patient:MARLIN MCCOY
111.1111111111111111111.1111111.1111111111111111. II .1111.11111 Soc See #: XXX-XX-2235
MARLIN MCCOY 18 Groul): LEAR RETIREES
5), MOUNTAIN ST LOT 6 Group #: RET ,
MOUNT HOLLY SPRINGS, PA 17065-1431 Claim #: 58040311-01
Patient #: 7491115
Date: 06/29/2005
Explanation of Benefits for Scnrices Provided By:
CARLISLE REGIONAL MED CENT
IJates or /Service Service Total COB Ineligible Reason Discount Covel"1~d By Deductible Co-Pny Blllance ",aJd Payment
Code Charge PnJd Code AnlOunt Plan Amount Amount IIAt Amount
05/02-05/16/2005 45 11,125.97 1,297.28 0.00 04 8,966.81 2,159.16 0.00 0,00 2,159.16 80% 1,727.33
TOTALS 11,125.97 1,297.28 -~ _8,966.81 2,159.16 0.00 0.00 2,159.16 I! 1,727.33
Total Net P4~mellt 430.05
, I----,~
Patient Respoll$ibWty 431.83
Accumulaton
Your 2005 deductible has been satisfied
Sen>lce Code
[45 x-ray/lab testing
-~
Payment To:
CARLISLE REGIONAL MED CEN
Reason Code Description
I 04 Benefits coordinated with Medicare.
Check No.
00221663
Amount
430.05
--4-
!
_J
Messages
... IF YOUR CLAIM WAS DENIED, IN WHOLE OR IN PART, YOU HAVECERTAlN RIGHTS UNDER THE LAW. YOU HAVE Tt E RlGHTTO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITTEN CO* ENTS,
DOCUMENTS, RECORDS OR INFORMATION ABOUT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OF HARGE,
II
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTEJPI
INDEPENDENTLY OF THE INITIAL DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF MOUR DENIAL
W AS BASED IN WHOLE OR IN PARr ON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROF~$SIONAL ON
YOUR APPEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL AC1h~)N UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION WI~L BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE AJ'PEAL. I
I
For eligibility and claim status infonnati.lII, please visit our website at WWW.8SSurecare.com.
...
II
P861"j)O~
~
4050 Hunsaeker Drive
Suite lID
East Lansing, MI 4832]
200~07061.00
SINGLE PIECE
[~uestjons? Contact us at
(517) 351-6616 or (800) 968-6'16
Enrollee:MARLIN MCC~ Y
Patient: MARLIN MCCOY
Soe See #: XXX-XX-2235
Group: LEAR RETIREES
Group #: REI
Claim #: 58041154-01
Patient #: 045003 20232
Date: 06/29/2005
~
Address Service Requested
2570 3.0096 SP 1.060
11111111111111111111111111111111111111111111111111111111111111
MARLIN MCCOY 18
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17D~5-1431
E:qllanation of Benefit!: for Services Provided By:
BLUE MOUNTAIN ANESTHESIA ASSOC
[nelit:lble Reason J)lscount
Code AmoUllt
0.0004 19.10
0.0 __~9.10
Covered By
Plait
45.90
45.90
Deductible Co-Pay
AnlOunt Amount
0.00 0.00
0.00 0.00
Balance
tiiaidTPllymellt
I At AnlOunt
Dates orSe"rvlce Service Total COD
Code Charge I'lud
05113-05113/2005 30 65.00 29.38
TOT ALS 65.00 29.38
45.90! 80% 36.72
45.90 i 36.72
Total Net" yment 7.34
Patient Respo~ IbUlty 9.18
Accumulators
Your 2005 deductible has been satisfied
Payment To:
BLUE MOUNTAIN ANESTHESIA
Reason Code Description
I 04 Benefits coordinated with Medicare.
Check No.
00221670
Amount
734
Sen'ice Code
130 office visit
=:J
~t
. --l
Messages
... IF YOUR CLAIM WAS DENIED, IN WHOLE OR IN PART, YOU HAVE CERT AlN RIGHTS UNDER THE LAW. YOU HAVE E RIGHT TO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITTEN C i MENTS,
DOCUMENTS, RECORDS OR INFORI\.fA nON ABOUT TilE CL AIM. YOU MAY RECEIVE, UPON REQUEST AND FREE O~ ~HARGE,
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCT~~
INDEPENDENTLY OF THE INITIAL DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF! tOUR DENIAL
WAS BASED IN WHOLE OR IN P Ala ON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROFf:~SIONAL ON
I
YOUR APPEAL, AND PROVIDE YOl! WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACllON UNDER
ERISA 502(A) IF YOU FILE AN AI'PI:AL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION W LL BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
...
For eligibility and claim status infimnation, please visit our website at www.assurecare.com.
P862C,lO()\(
t\-.:cnE" 4050 Hunsacker Drive
Suite 110
East Lansing, MI 48823
10(J~07061-400
SINGLE PIECE
~stions? Contact us at
l (517) 351-6616 or (8011) 968-6<116
En rollee: MARLIN
Patient: MARLIN MCCOY
SocSec #: XXX-XX-2235
Group: LEAR RETm.EES
Group #: RET
Claim #: 58041156-01
Patient #: 044565 20232
Date: 06/29/2005
~
Address Sen'ice Reque!.ted
2570 3.0096 SP 1.060
1111111111111'111111111.1'11111.11111111'1111111"..11...11..1
MARLIN MCCOY 18
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
Uates or :service I service T ota! COB IneUglble Reason Discount Covered By Deductible Co-Pay Balance Paid Payment
Code Oiarge Paid Code Amount Plan Amount Amount At Amount
05/04-05/0412005 30 65.00 29.38 0.00 04 19.10 45.90 0.00 0.00 45.90 80% 36.72
TOTALS 65.00 29.38 0.01 19.10 45.90 0.00 0.00 45.90 I 36.72
Total Net * yment 7.34
Pallent Respolt Ibllity 9.18
E\:planation of Benefits for Services Provided By:
BLUE MOUNTAIN ANESTHESIA ASSOC
Accumulators
Your 2005 deductible has been satisfied
Payment To:
BLUE MOUNTAIN ANESTHESIA
Reason Code Description
I 04 Benefits coordinated with Medicare.
Check No.
00221672
Amount
7.34
Service Code
~o office visit
_J
Messages
... IF YOUR CLAIM WAS DENIED, IN WHOLE OR IN PART, YOU HAVE CERTAIN RIGHTS UNDER THE LAW. YOU HAVE r E RIGHT TO
APPEAL THIS BENEFIT DECISION ""o/ITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITIEN CqtfMENTS.
DOCUMENTS, RECORDS OR INFOItMATION ADOm THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE O~ FHARGE,
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTa~
INDEPENDENTLY OF THE INITIAL DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IFI YOUR DENIAL
WAS BASED IN WHOLE OR IN PARTON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROF~SSI0NAL ON
YOUR APPEAL, AND PROVIDE YOU WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL AC ON UNDER
ERISA 502(A) IF YOU FILE AN APPJ:AL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION W LL BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL. I
...
For eligibility and claim status infonnati.IO, please visit our website at WWW.8SSurecare.com.
~ 4050 Hunsacker Drive
Suite 110
East Lansing. MI 48823
l00~07061. 00
Questions? Contact us at
~
t'1'!.()';:I,IOn'lll
Address Sen'ice Requested
(517) 351-6616 or (800) 968-6616
SINGLE PIECE
Enrollee:MARLIN
Patient: MARLIN MCCOY
Soc Sec #: XXX-XX-2235
Group: LEAR RETIREES
Group #: RET
Claim #: 58041157-01
Patient #: 19890
Date: 06/29/2005
2570 3.0096 SP 1.060
1'11111111111111111111111111111.1111111111111111"111111111111
MARLIN MCCOY 18
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 170~5-1431
Explanation of Benefib for Services Provided By:
DANIEL P HEL Y MD
Service Total con I neligible Reason I)Iscount Covered By Deductible Co-Pay BnJance Payment
Code Charge Paid Code Amount Plan Amount Amount Amount
OS/27-05/27/2005 45 75.00 21.99 0.0004 44.00 31.00 0.0 0.00 31.00 i 80% 24.80
OS/27-05/27/2005 45 79.00 20.61 0.0004 50.00 29.00 0.00 0.00 29.00 I 80% 23.20
TOTALS 154.00 42.60 0.0 94.00 60.00 0.00 0.00 60.00 : , 48.00
Total Net ~~ent 5.40
Patient Respo~1lbllity 12.00
I
-1-----.----J
I
~essnges i
-;.;'--WVOUR CLAIM W AS DENIED, IN WHO'L.E'OR IN PART, YOU HAVE CERT AlN RIGHTS UNDER THE LAW. YOU HAVE 1'fE RIGHT TO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITfEN COMMENTS,
DOCUMENTS, RECORDS OR INFORMATION ABOUT TIlE CL AIM. YOU MAY RECEIVE, UPON REQUEST AND FREE OFi tHARGE.
ACCESS TO INFORMATION WE REVIEWED IN MAKINO THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTEq
INDEPENDENTLY OF THE INITIAL DENIAL. PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. IF'tOUR DENIAL
WAS BASED IN WHOLE OR IN PARTON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROf~~SIONALON
YOUR APPEAL, AND PROVIDE "1'01 J WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL Aci'loN UNDER
, I
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE I )ENIED AFTER REVIEW. AN APPEAL DETERMINA nON \VILL BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
Accumulators
Your 2005 deductible has been satisfied
Payment To:
APPALACHIAN ORTHOPEDIC CT
Service Code
145 x-ray/lab testing
Reason Code Description
I 04 Benefits coordinated with Medicare.
=:J
...
For eligibility and claim status information, please visit our websile at www.assurecare.com.
Check No. Amount
i
00221673 .! 5.40
II
P86291l(I
~
4050 Hunsacker Orive
Suite 110
East Lansing, MI 48823
200~07061400
~~
~
Address Sen'ice Recluested
I Questions? Contact us at
I (517) 351-6616 or (800) 968-6616
L
SINGLE PIECE
Enrollee: MARLIN
Patient: MARLIN MCCOY
Soc See #: XXX-XX-2235
GroUI): LEAR RETrREES
Group #: RET
Claim #: 58041158-01
Patient #: ] 9890
Date: 06/29/2005
2570 3.0096 SP 1.060
111I1111111111111111111.11.1111.111111111111111111111111111111
MARLIN MCCOY 18
51 MOUNTAIN ST LOT 6
MOUNT HOLLY SPRINGS, PA 17065-1431
Explanation of Benefits for Services Prmtided By:
DANIEL P BEL Y MD
Payment --.
nellglble Reason Discount Covered By Deductible Co-Pay Balance Paid
Code Amount Plan AmowJt Amowlt At A1nowlt
0.00 104 14.00 56.00 0.00 0.00 56.00 i 80% 44.80
-~ 14.00 56.00 0.00 0.00 56.00 I 44.80
Total Net) yment ---:U9
Patient Resp~1 IblUty 11.20
t
Dates of Service Service Total COB r
Code Olarge Paid
OS/27-05/27/2005 30 70.00 40.21
TOTALS 70.00 40.21
Accumulators
Payment To:
APPALACHIAN ORTHOPEDIC CT
Reason Code Description
I 04 Benefits coordinated with Medicare.
Check No.
00221674
Amount
4.59
Your 2005 deductible has been satisfied
Service Code
130 office visit
--:J
Messages
... IF YOUR CLAIM WAS DENIED, IN WHOLE OR IN PART, YOU HAVE CERT AlN RIGHTS UNDER THE LAW. YOU HAVE t E RIGHT TO
APPEAL THIS BENEFIT DECISION WITHIN 180 DAYS OF RECEIPT OF THIS NOTICE. YOU MAY SUBMIT WRITIEN cq MENTS,
DOCUMENTS, RECORDS OR INFORMATION ABOUT THE CLAIM. YOU MAY RECEIVE, UPON REQUEST AND FREE 011 FHARGE,
ACCESS TO INFORMATION WE REVIEWED IN MAKING THIS DETERMINATION. YOUR APPEAL WILL BE CONDUCTRif>
INDEPENDENTLY OF THE INITIAl. DENIAL, PERFORMED BY SOMEONE NOT INVOLVED IN THE INITIAL DENIAL. If! YOUR DENIAL
W AS BASED IN WHOLE OR IN PART ON A MEDICAL JUDGEMENT, WE WILL CONSULT WITH A HEALTH CARE PROF~SSIONAL ON
YOUR APPEAL, AND PROVIDE YOl J WITH THEIR NAME IF REQUESTED. YOU HAVE THE RIGHT TO BRING CIVIL ACnON UNDER
ERISA 502(A) IF YOU FILE AN APPEAL AND BENEFITS ARE DENIED AFTER REVIEW. AN APPEAL DETERMINATION W'LL BE MADE
WITHIN 30 CALENDAR DAYS FROM RECEIPT OF THE APPEAL.
...
For eligibility and claim status information, please visit our website at www.assurecare.com.
-----
I6.ccount Number: 1000202591 2 1
MARLIN L MCCOY Invoice Number: 95480969887
Page 3 of 4
M68
Help keep your community attractive and safe by letting us know when streetlights need repair. To report a
streetlight outage, go online to www.firstenergycorp.com. and click on Customer Care, Online Service Requests and
Report Streetlight Outage. We'll check the light and repair it as quickly as possible.
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When contacting an Electric Generation Supplier, please provide the customer numbers below.
Call Met-Ed at 1-800-545-7741 with questions on these charges.
Met-Ed Basic Charges
Customer Number: 08013932280002088317 - Residential- ME_RS_01D
Customer Charge
Generation Charges
Transmission Charges
Distribution Charges
Transition Charges
State Tax Surcharge
Total State Tax. Surcharge
Total Met-Ed Charges
335 KWH
335 KWH
335 KWH
335 KWH
6.67
14.60
0.58
10.15
2.56
x 0.043570
x 0.001720
x 0.030290
x 0.007630
0.24
0.19
0.43
0.43
$ 34.99
Payments:
05131/05
Total Payments
Amount
-33.12
-33.12
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Residential
Meter Number
Present KWH Reading (Actual)
Previous KWH Reading (Actual)
Kilowatt Hours Used
D12937481
30,232
29,897
335
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TAX YEAR
2005-06 REAL ESTATE TAX
CARLISLE .AREA
MAKE CHECKS PAYABLE TO,
HABLE R SAITESON
.3 TRINE A':'IENUE
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PHONe ::486-3486
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NO:rlCE':<*SCHOOt*~ J1Jt. . ..\t, .~tQ05' 1,,6.30. '481
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CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT
OFFICE VISIT/NEW
NED I Cf.:1RE PAY"lENT
,1:3.-i.::':,--IZl5 rlCRADJ
J5-09-05 MEDIGAP PAYMENT
14~01-05 OFFICE VISIT/ESTABLISHED
)4-22-05 MEDICARE PAYMENT
L~-22-05 rlCRAD,J
15-23-051 INSURANCE PAYMENT
4-06-05 INITIAL INPATIENT CONSULT
.4-29-05 MEDICARE PAYMENT
l~-29-05 MCRADJ
16-08-05 I NSURr-1NCE PAYMENT
4-1217-1215 SUBSEQUENT HOSI="rTf:"~L
. 4-29-Q1S MEDICARE prWMENT
l~-2g""'05 J't1CRADJ
&-08-05 INSURANCE PAYMENT
STATEMENT BALANCE OVER
CLOSINGDAiE 30 DAYS
16-27-05 . ':r0
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,'<-1,-/, Prompt payment is appreciated, forbillingq':;iJ.'il$ call (717) 249,-;:8'U3'idd(
-Io'<-I( Your As:count Balance is Seriouslv Overdue! ".' RaVlnen!:: ImmediatelY!" 'I .*1<*
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Insurance Charges pending to Prv: 400.00
Ins Pay/Adj against Ins pending 78.30"-\321.70 O.OC
04/05/05 1
04/26/05
04/26/05
05/20105
05/20105
04/05/05 1
04/26/05
04/26/05
05/20/05
OS/27/05 1
06/14/05
06/14/05'
07/12Io.~?
05/27/051, 1
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06/14/05
07/12/05:
05127/05: 1
06j1A/05r
06/14/05;-
07/12105::,
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1 HOSPITAL INITIAL CARE 2
Medicare Payment
Accep,!:: Assign Adj.
PHcs7ASSUREC Pa~ent
Accept Assign Adj.
1 X-RAY PELVIS AP ONLY
Medicare Payment
Accep,t Assign Adj.
PHcs7ASSUREC Payment
1 L X~RAY HIP UNILATERAL ONE
Medicare Payment
Accep.t Assign1l.dj.
PHcs7ASSURECPa.yment
X-RAYPELVIS1I.:f>> ONLY;
Medicare Payment
Accep.t Assi~nAdj.
PRCS 7ASSUREl..Pa.ymen t
1 L' OFFICE VISIT EST LEVEL 3:
Medicare Payment .
Accep.t Assign.AdJ.
PHcs7ASSVREC Paymen'u
99222 733.14 130.00
4.24
72170
75.00!
2.69
5.15
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,;"~:A:Itt;I'StE/\PA 170I~
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PAT# I-MARLIN L MCCOY
PRv/f. }- HEtY,DANIEtP,M. D.
Ph: (717):,-'249~6'1I2
Ac t/}:' 1989'0'
Da;, e: 087'29105
l Pa.ge 1 of 1
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Family Home Medical
1 Sprint Drive
Carlisle. Pa 17013
717.249.8051
Invoice No.
1
C t
INVOICE ~
" I
us orner ""'\
Name Marlin L McCoy Date 9/9/05 i
Address 51 Mountain Street Order No. 43624 I
City Mt Holly Springs State P A Zip 17065 Rep las : !
Phone FOB I
Tax Qty Description Unit Price TOTA
1 Walker supplied to you 5/19/05 $24.19 $ 4.19
. '
Medicare and Assure Care paid their portion of this claim. ,
Payment of this invoice is your responsibility. . !
Thank you. . "
, i
80/0{' "
~~,Q ~ .
. .
,
Payment Details SubTotal $2 .19
Shipping & Handling $ .00
. Cash Taxes State $ .00
0 Check
0 Credit Card TOTAL $2 19
Name
CC#
Expires
IOffice Use Only
We specialize 117 making nome care easier
Tnal7k you for your business
i
I
II
r DATE DOCTOR CODE
I 04/08/05 DAVID R ROYAL MD 7126C
I 04/08/05 DA VID R ROYAL MD Q9Y49
05/09/05 0200
05/09/05 9200
06/24/05 0299
07/20/05
09/22/05
9221
0300
09/22/05
DESCRIPTION
CTTHORAXE~~ANCED
LOW OSMOLAR CONTRAST 300-349 MGS 10
100 ML OMNIPAQUE 300 MG/ML
MEDICARE PAYMENT
CK106425148
MEDICARE WRITE OFF
DENIAL BY MEDICARE
DENIED-PROCEDURE IS NOT PAID SEP ARA TEL 1'1
INTEGRAL PART OF ANOTHER PROCEDURE
COMMERCIAL PAYMENT
ASSURECARE
DENIAL BYCOMMERCIAL INS
BALANCEISPTRESP
WE RECEIVED APAYMENT FROM YOUR INSUR+!
ANCE PLAN. THEY INFORMED US THAT YOU ARE
RESPONSIBLE FOR THE REMAINING BALANCE. !
i
Location of Service: WALNUT BOTTOM RADIOLOGY
Patient: MARLIN L MCCOY
TAX ID 251675580
DIAGNOSIS 162.9
AMOUNT
$735.00
$171.00
$255.83-
$415.21-
$0.00
$171.00-
$29.77-
$0.00
BALAN<t~ DUE: $34.19
Account Number: WBR-99558
I
StatemeJ!1~ Date: 09/22/2005
Walnut Bottom Radiology LLC
PO Box 382
Huntingdon P A 16652
MBMSINC1-0103272-0001871-0561200-001-00Q679-#OO2459
For billing questions, please call 800-295-21~ 1
, ,