HomeMy WebLinkAbout11-28-05
REV.1500 EX + (6.00)
.
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICiAl USE ONLY
FILE NUMBER
21 -0 5 0 6 3 2
COuNTY"'Co5E --vEA~ - - NuMBER- -
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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DORIS
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DATE OF BIRTH (MM-DD-Year)
SOCIAL SECURITY NUMBER
.1 7 9 - 3 0 - 2 5 6 7
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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McDANNELL
DATE OF DEATH (MM-DD-Year)
07/09/2005 04/01/1936
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
D 3. Remainder Retum (date of death priorto 12.13.82)
D 5. Federal Estate Tax Retum Required
_ 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Mach Sch 0)
lliJ 1. Original Return
D 4. Limited Estate
D 6. Decedent Died Testate (Attach copy of Willi
D 9. Litigation Proceeds Received
D 2. Supplemental Retum
o 4a. Future Interest Compromise (date of death after 12.12.82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trust)
o 10. Spousal Poverty Credi1 (date of death between 12.31.91 and 1.1.95)
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THIS'SECtlbN,Must.BE.COMPl.ETEtJ:AL.LCbRRESPONDENC': .ANDCONElDENT1AI..TAX'lNFORMATfONSHOULl:> BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
MARCUS A. McKNIGHT 11/ 60 WEST POMFRET STREET
FIRM NAME (If Applicable)
IRWIN & McKNIGHT
TELEPHONE NUMBER
717 249-2353 CARLISLE PA 17013
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1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or Li
135,000.00
OFFICIAL USE ONLY -:
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15,345.30
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599.54
0.00 X _(15) 0.00
55,991.45 X .045(16) 2,519.62
0.00 X .12 (17) 0.00
0.00 X .15 (18) 0.00
(19) 2,519.62
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to lax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line '12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
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16. Amount of Line 14 taxable at lineal rate
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(8)
150,944.84
17. Amount of Line 14 taxable at sibling rate
24,474.03
70,479.36
(11)
(12)
(13)
94,953.39
55,991.45
18. Amount of Line 14 taxable at collateral rate
(14)
55,991.45
19. Tax Due
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONSON.REVERSE SIDE AND RECHECK MATH < <
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REV-1502 EX + (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
McDANNELL DORIS J. 21 05 0632
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real Drooertv which is iointlv-owned with riQht of survivorshiD must be disclosed on Schedule F.
SCHEDULE A
REAL ESTATE
ITEM
NUMBER
1.
DESCRIPTION
1435 Goodyear Road, Gardners, Pennsylvania
SOLD - Settlement Sheet Attached
VALUE AT DATE
OF DEATH
135,000.00
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
135 000.00
REV-1508 EX + (6-98)
.
...
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McDANNELL
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
DORIS J. 21 05
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
0632
ITEM
NUMBER
1.
2.
Personal Property
DESCRIPTION
Community Banks - Savings Account
VALUE AT DATE
OF DEATH
7,321.00
8,024.30
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
15 345.30
REV-1509 EX + (6-98)
.
SCHEDULE F
JOINTLY-OWNED PROPERTY
. COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McDANNELL
FILE NUMBER
DORIS
J.
21
05
0632
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. Karen J. Sharrah
290A Bull Valley Road
Aspers, PA 17304
Daughter
B Brenda L. Harris
760 J Buchanan Valley Road
Orrtanna, PA 17353
Daughter
c
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEA TH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL EST ATE. VALUE OF ASSET INTEREST DECEDENT'S INTERES
1. A Adams County National Bank - Checking Account 797.83 50. 398.92
1868306
2. A Adams County National Bank - Savings Account 100.22 50. 50.11
9000115841
3. B Community Banks - Savings Account 301.01 50. 150.51
068509173
TOTAL (Also enter on line 6, Recapitulation) $ 599.54
T
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+(12-99)
*'
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
McDANNELL
ITEM
NUMBER
A.
1.
B.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
FILE NUMBER
DORIS
J.
21
05
0632
Debts of decedent must be reported on Schedule I.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
Mohanan Funeral Home
667.30
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
State
Zip
Year(s) Commission Paid:
Attorney Fees Irwin & McKnight
Family Exemption: (If decedent's address is not the same as claimants, attach explanation)
Claimant Karen J. Sharrah
Street Address 290A Bull Valley Road
City Aspers State P A
Relationship of Claimant to Decedent Dauqhter
7,750.00
3,500.00
Zip 17304
Probate Fees Register of Wills
283.00
Accountant's Fees
Tax Return Preparer's Fees
350.00
Register of Wills - Short Certificate
Register of Wills - Filing Fee
The Sentinel - Estate Notice
Cumberland Law Journal - Estate Notice
Register of Wills - Filing Fee (Petition for Renunciation)
Roy D. Gottshall - Appraisal on Personal Property
Notary Fees
Closing Costs from Sale of Real Estate
Denise Bitzel, Reimbursement
4.00
30.00
151.55
75.00
35.00
55.00
60.00
11.506.03
7.15
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
24474.03
REV-1512 EX + (6-98)
,.
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McDANNELL
FILE NUMBER
DORIS
J.
Include unreimbursed medical expenses.
21
05
0632
ITEM
NUMBER
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
DESCRIPTION
Washington Mutual- Mortgage Payoff
Washington Mutual - Mortgage Payment (August)
Adams-Cumberland Medical Center, Inc., Medical
Alexander Spasic, M.D., Medical
Andorra Radiology Assoc., P.C., Medical
Aspers Ambulance, Medical
Associated Cardiologists, Medical
Belvedere Medical Corporation, Medical
Blue Mountain Anesthesia Associates, Medical
Joseph P. Cardinale, DO, Medical
Carlisle Regional Medical Center, Medical
Central Penn Management Group, Medical
Central Penn Medical Group Emergency, Medical
Gettysburg Hospital, Medical
Richard Griffiths, D.O., Medical
VALUE AT DATE
OF DEATH
52,911.70
501.65
201.36
20.62
287.63
115.70
1.77
27.02
39.01
91.55
912.00
39.01
29.60
107.33
108.99
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
70479.36
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
McDANNELL
pecedent's Name
DORIS
J.
Page 1
21 05 0632
File Number
Schedule I - Debts of Decedent, Mortgage Liabilities, & Liens
ITEM
NUMBER DESCRIPTION AMOUNT
16. Holy Spirit Hospital, Medical 2,052.00
17. Internists of Central Pa., Medical 84.27
18. Jackson Gastroenterology, Medical 38.06
19. Kantor and Tkatch Assoc., P.C., Medical 51.74
20. LANC HMA PHYS MGMT CENT PEN, Medical 471.94
21. Moffitt Heart & Vascular Group, Medical 654.99
22. Nephrology Assoc. of Central Pa., Medical 60.88
23. Penn Rehab Assoc., Medical 154.77
24. Pinnacle Health Hospitals, Medical 1,013.82
25. SCCI Hospitals Harrisburg, Medical 9,927.75
26. Smith Radiology, Inc., Medical 7.36
27. South Central EMS, Inc., Medical 54.01
28. Stoken Ophthalmology, Medical 19.19
29. Vascular Associates, Medical 143.33
30. West Shore EMS - Carlisle, Medical 131.51
SUBTOTAL SCHEDULE I
14,865.62
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
Page 2
21 05 0632
File Number
McDANNELL
~ecedent's Name
DORIS
J.
Schedule I - Debts of Decedent, Mortgage Liabilities, & Liens
ITEM
NUMBER DESCRIPTION AMOUNT
31. West Shore Pathology, Medical 12.61
32. Met-Ed, Electric 115.30
33. Heritage Cardiology Assoc., Medical 34.32
34. Cumberland ENT Facial Plastic Surgery 56.57
SUBTOTAL SCHEDULE I 218.80
GRAND TOTAL SCHEDULE I $ 70,479.36
''''''','' "*
SCHEDULE J
BENEFICIARIES
.. COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
21 Of;
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
M"nANNFLL
DORIS
I.
NUMBER
I.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1.
Eddie D. Sharrah
2000 Goldenville Road
Gettysburg, PA 17325
Karen J. Sharrah
290A Bull Valley Road
Aspers, PA 17304
Denise G. Bitzel
985 Plunkert
Littlestown, PA 17340
Brenda L. Harris
760 J Buchanan Valley Road
Orrtanna, PA 17353
Lineal
2.
Lineal
3.
Lineal
4.
Lineal
On~2
AMOUNT OR SHARE
OF ESTATE
1/4 Remainder
1/4 Remainder
1/4 Remainder
1/4 Remainder
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
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
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OMI:l NO. 2502-0265 o'-r
A. B. TYPE OF LOAN:
U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT 1-DFHA 2-DFmHA 3. [glCONV. UNINS. 4.0VA 5.0CONV INS.
. 6. FILE NUMBER: /7. LOAN NUMBER:
SETTLEMENT STATE~ML.'4 r 05573 0055170971
8. MORTGAGE INS CASE NUMBER:
C, NOTE: This form is furnished fo give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown.
Items marked "{POC]" were paid outside the closing; they are shown here for information a/ purposes and are not included in the lolals.
1.0 3198 (05573/05573/27)
D. NAME AND ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER:
Michael J. Lamason and Doris J. McDannell Estate First Horizon Home Loan Corp
Gayle R. Lamason 4000 Horizon Way
Irving, TX 75063
G. PROPERTY LOCATION: H. SETTLEMENT AGENT: 25-1878915 I. SETTLEMENT DATE:
1435 Goodyear Road Keystone Land Transfer, Ltd.
Gardners, PA 17324 September 22,2005
Cumberland County, Pennsylvania PLACE OF SETTLEMENT
3421 Market Street
Camp Hill, PA 17011
J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION
100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER:
101. Contract Sales Price 135,000.00 401. Contract Sales Price 135,000.00
102. Personal Pronertv 402. Personal Prooertv
103. Settlement Charoes to Borrower (Line 1400l 4,573.20 403.
104. 404.
105. . 405.
Adfustments For Items Paid Bv Seller ;n advance Ad'ustments For Items Paid BV Seller ;n advance
106. CiiVlTown Taxes to 406. CitvlTown Taxes to
107. County Taxes 09/22/05 to 01/01/06 56.87 407. County Taxes 09/22/05 to 01/01/06 56.87
108. School Tax 09/22/05 to 07i01/06 860.33 408. School Tax 09/22/05 to 07/01/06 860.33
109. 409.
110. 410.
111. 411.
112. 412.
120, GROSS AMOUNT DUE FROM BORROWER 140,490.40 420. GROSS AMOUNT DUE TO SELLER 135,917.20
200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER:
201. Denosit or earnest money 1,000.00 501. Excess Deposit (See Instructions
202. Principal Amount of New Loan(s) 108,000.00 502. Settlement Charoes to Selier Line 1400\ 11,506.03
203. Existino loan(s\' taken subiect to 503. ExistinQ loan(s) taken sub'ect to
204. 2nd MOr!Oaae Proceeds 13,384.31 504. Payoff of first Mortgage to Washington Mutual/#005 52,911.70
205. 505. Payoff of second Mortoaae
206. 506.
207. 507. (Deposit disb. as proceedS\
208. 508.
209. 509.
Adiustments For Items Unpaid Bv Seller Adjustments For Items Uimaid Bv Seller
210. CitvlTown Taxes to 510. CitvlTown Taxes to
211. County Taxes to 511. County Taxes to
212. School Tax to 512. School Tax to
213. 513.
214. 514.
215. 515.
216. .516.
217. 517.
218. 518.
219. 519.
220. TOTAL PAtD BY/FOR BORROWER 122,384.31 520. TOTAL REDUCTION AMOUNT DUE SELLER 64,417.73
300. CASH AT SETTLEMENT FROMITO BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER:
301. Gross Amount Due From Borrower (Line 120l 140,490.40 601. Gross Amount Due To SelierlLine 420l 135,917.20
302. Less Amount Paid By/For Borrower (Line 220) ( 122,384.31) 602. Less Reductions Due Selier (Line 520) ( 64,417.73
303. CASH ( X FROM) ( TO) BORROWER 18.106.09 603. CASH ( X TO) ( FROM) SELLER 71,499.47
The undersigned hereby acknowledge receipt of a completed copy of pages 1 &2 of this statement & any attachments referred to herein.
/
Borrower '-1, { J M~>L-----'.
M1Cha~? Lalfjaso,/ ~//
,.f,;" (( { f)<i2.1~ e'U! t~
. Gayle R. ,lamason
/
Selier
Doris J. McDanneli Estate
-v.;ti/; ,- .:7. (/ :;;1. . ..'
B .t't...{.:-'~"":'/_~ 1/,-":, ),J,
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( -15 Uh D )""",A.
L. SETTLEMENT CHARGES
700. TOTAL COMMISSION Based on Price $ 135,000.00 @ % 8,437.50 PAID FROM PAID FROM
Division of Commission (line 700 as Follows: '- BORROWER'S SELLER'S
701. $ 4,050.00 to Re/Max Realty Associates, Inc. -- FUNDS AT FUNDS AT
702. $ 4.387.50 to Re/Max Quality Service - SETTLEMENT SETTLEMENT
703. Commission Paid at Settlement 8,437.50
704. Transaction Fee to Re/Max Realty Associates. Inc. 195.00
800. ITEMS PAYABLE IN CONNECTION WITH LOAN
801. Loan Ori ination Fee 0.0000 % to
802. loan Discount % to
803. Appraisal Fee to
804. Credit Report to
805. lender's Inspection Fee to
806. Mortaaae Ins. ADD. Fee to
807. Assumption Fee to
808.
809.
810.
811.
812. Courier Fee to First Horizon Home loan Corp 15.00
813. Underwriting Fee to First Horizon Home loan Corp 225.00
814. Tax Service Fee to Total Mtg. Solution 90.00
815. Application Fee to First Horizon Home loan Corp 350.00
816. Flood Determination Fee to First Horizon Home loan Corp 24.00
817. Commitment Fee to First Horizon Home loan Corp 225.00
818.
819.
820.
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901. Interest From 09/22/05 to 10/01/05 @ $ 18.000000/day ( g days %) 162.00
902. Mort aoe Insurance Premium for months to
903. Hazard Insurance Premium for 1.0 vears to POC $327.00b
904.
905.
1000. RESERVES DEPOSITED WITH LENDER
1001. Hazard insurance 3.000 months $ 27.25 oer month 81.75
1002. Mortoaoe Insurance months $ oer month
1003. Citv/Town Taxes months $ ner month
1004. Countv Taxes 8.000 months $ 17.13 oer month 137.04
1005. School Tax 4.000 months @ $ 92.80 per month 371.20
1006. months @ $ oer month
1007. months ail $ oer month
1008. Agareaate Adiustment months @ $ er month -178.54
1100. TITLE CHARGES
1101. Settlement or Closina Fee to
1102. Abstract or Title Search to
1103. Title Examination to
1104. Title Insurance Binder to
1105. Document Preparation to
1106. Notarv Fees to CASH 25.00 15.00
1107. Attorney's Fees to
(includes above item numbers:
1108. Title Insurance to Kevstone land Transfer ltd. 1 003.75
linc/udes above item numbers: )
1109. lender's Coverage $ 108,000.00 PAL#104469721
1110. Owner's Coverage $ 135,000.00 PA0#104237133
1111. Endorsements 100,300,8.1 to Keystone Land Transfer, ltd. 150.00
1112. Closing Protection letter to Keystone land Transfer, ltd. 35.00
1113. Tax Receipts to Keystone land Transfer, ltd. 7.00
1114. Overnight to Keystone land Transfer, ltd. 14.00 14.00
1115. Retrieve E Mail Documents to Keystone land Transfer, ltd. 35.00
111 G. UV Light to Jim McGraw 556.50
1117.
1118.
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recording Fees: Deed $ 38.50; Mortgage $ 64.50; Releases $ 103.00
E02. Citv/Countv Tax/Stamos: Deed 1,350.00' Mortgage 1,350.00
1203. State Tax/Stamos: Revenue Stamos 1,350.00; Mortgage 1,350.00
1204.
1205.
1300. ADDITIONAL SETTLEMENT CHARGES
1301. Survey to
1302. Pest insoection to Blechler & Tillery, Inc. 50.00
1303. Home Warranlv to American Home Shield 455.00
1304. Reimbursement to Tracv WeiQel 240.00
1305. Septic Service to Pecks Septic Service 110.00 431.03
1400. TOTAL SETTLEMENT CHARGES {Enter on Lines 103, Section J and 502, Section Kl 4,573.20 11.506.03
By ,;go;og p'go 1 of th;, .tatomoot, Iho ';go"odo, ,"'oowlodgo ,o,oipl of, ,omptotod ",py of p'go , of Ih;, two P'? j~J;' ~ ( z. .If' Z /' /.J!
KeystoneTariiJ Transfeft'. ltd.
Certified to be a true copy.
Settlement Agent
( 05573/05573/27 )
Communit'lBanks
Decedent's Name Doris McDannell
Social Security Number 179-30-2567
Date of Death July 9, 2005
Account Number 068509173
Account Type Savings Savings
Date Opened 5/24/04 7/6/05
Principal Balance $301.01 $8,023.87
Accrued Interest at Date of Death $.00 $.43
Balance at Date of Death $301.01 $8,024.30
Maturity Date
Account Ownership Joint lndi vidual
Names of Joint Owners, if any Brenda L Harris
Date Joint Ownership was
Established 5/24/04
Interest Rate .20% .50%
Additional Information
~~~t-,cL \c fuI'"J"
Authorized Signature
I ( J-i:' ( ~\ ..:
Date
~ ADAMS COUNlY
NATIONAL BANK
~~~~uw~~
/- eGOS
September 2, 2005
Irwin & McKnight
Law Offices
60 West Pomfret Street
Carlisle, PA 17013
Re: Estate of Doris Jo McDannell
Dear Mr. McKnight:
The following information is being provided as per your request:
Acct. Type Account
No.
Checking
1868306
Account
Principal on
DoDD.
$797.83
Accrued
mterest to
D.O.D.
NIA
Ownership
Date
Account
Joint
4-16-01
Jt. wi Karen J
Sharrah
Jt. wi Karen J
Sharrah
Inquiries concerning ACNB Corporation stock information should be directed to the Registrar and Transfer
Company at 1-800-368-5948. If you need any additional information, please contact me at (717)339-5116.
Savings
9000115841 $100.22
$006
2-7 -05
Sincerely,
17t7W k ~
Lois Kime
Deposit Services
lY10NAH",I\N FUN.EH/\.L HU1'Vll'~, iNC.
125 C\H.USLE S fREET, GETTYSBUH;, PE,'i'iSYLVA;'-iL\ 1732.5
717-334-2414
27 EAST ~L\lN STnEET, FAJRFIELD, PEC\i:\SYLV\,,'H\ 173:20
R,)bertJ. Monahan 717.642-8266
T() The Estate of Doris J. ~cDanrEll
c/o 11.UY. ~:C'.rcus V-cYJ1iS!'ht, III
FOR THE FUNEHAL EXPENSES OF
Cor1s J. ~,cDannell
July 09,
20 05
RECEl'vED PAYMENT
$6450.00
Ai
::D
Bl
589.00
CEMETERY CHARGES
C) 16371.70)
T()'~
we "?,~~,~,~;~ ~,~;:~}c~: ~~::l-~
FLOWERS
$159.00
CLERGYMAN
_____lQ9 .00__
TRANSPORTATJON BY COMMON CARRIER
rp1'1'1()vrll from Hrlrri Shll1)"T
TELEPHONE & TELEGRAMS
------450-r00---
NEWSPAPER NOT1CES
CERTJF1ED COPlES OF DEATH _1110~O-O~-
TOTAL CASH ADVANCED 8) $589.00
. CREDlTS
Burlal A.ccount vrith Mams County National Bank $6371.70
"'f"r........ .. I
;;.:-:---so3'ir:-iO-
ALEXANDER SPASIC M.D. FAMILY MED, LLC
816 BELVEDERE STREET /
. CARLISLE, PA 170~3.~ ,~~.
20. 62'~
*******AUTO**3-DIGIT 173
26297
DORIS J MCDANNELL
290A BULL VALLEY ROAD
ASPERS PA 17304-9445
1,"111. "1,,11111,, 111'111.111111.1.1" 111.1,1,11111,",11.11
17 86
ALEXANDER SPASIC M.D. FAMILY MED, LLC
816 BELVEDERE STREET
CARLISLE, PA 17013
RETURN TOP pofll1ofi .'RaAIf.'-UMER~: ~:~
~ , ~" J ", ~ ~ ~ ~} " ,I! <- ',,:.... ;r,
Date
---M-ESSAG-ES-EXPLA'NED--.-~-BELOW--------------------------------------------------------------------------- - --------------------- ---------------------------
IDIIII:R!J ImIDm!mmDBm!!I~
Service Descri tion C t Dx
~~~**~~~~~~*~~r*~~~~*~~~~I~I**I~*!~~*~~y.~*~r*9c~~~I!~~~*~~~~*~ZlZ~f.~2*~r.Z7******~~~
05/14/05 1 1 HOSPITAL SUBSEQUENT CARE 99232 435.8 101. 00
08/01/05 Medicare Payment 41.22
08/01/05 Accept Assign Adj. -49.47 10.31*
05/15/05 1 1 HOSPITAL SUBSEQUENT CARE 99232 435.8 101.00
08/01/05 Medicare Payment 41.22
08/01/05 Accept Assign Adj. -49.47 10.31*
ALEXANDER SPASIC M.D.
816 BELVEDERE STREET
CARLISLE, PA 17013
DATE LAST PAID AMOUNT
00/00/00 0.00
PAT# I-DORIS J MCDANNELL
PRV# l-SPASIC, ALEXANDER, M.D.
Ph: (717)-258-0099
Acctll: 17
Date: 08/17/05
Page 1 of 1
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Andorra Radiology Assoc., P.c.
PO Box 892
Concordville P A 1933 1
STATEMENT
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Patient: DORIS J MCDANNELL
Statement Date:
08/15/2005
Account Number:
ARA-93093980
Amount Due:
$42.96
or billing questions, please call 800-748-2413
~illing Office Hours: 9am - 4pm Mon - Fri
( AMOUNT PAID)
IIIB I11I1I nil 1111111 III 11111111111111 III II
111111111111111111111
MAKE CHECK PAYABLE & REMIT TO:
111.111'1111111.11"1111111.1'111..1.1..1.1.1.1.11111111111111
Doris J McDannell
290A Bull Valley Road
Aspers P A 17304-9445
111.111.1'11.1111.1111..111111.1
Andorra Radiology Assoc., P.c.
PO Box 892
Concordville P A 19331
.
MBMSINC1-01 01 478-0000000-0545524-~l:iRPa~~~001 6
,SE CHECK BOX IF ABOVE ADDRESS IS INCORRECT AND INDICATE CHANG S (.; .
(DETACH HERE" AND RETURN THIS TOP PORTION WITH YOUR PAYMENT
. .. USING THE RETURN ENVELOPE ENCLOSED
~
D,Ji.TE DOCTOR CODE DESCRIPTION AMOUNT
~6/05 ERNEST CAMPONOVO MD 76536 ECHOSCAN B THYROID $89.00
U27/05 GEORGE BRODER MD 71010 CHEST SINGLE VIEW $27.00
1I26/05 CHRISTOPHER LADD MD 72125 CT CERVICAL SPINE UNENHANCED $181.00
~/26/05 CHRISTOPHER LADD MD 76375 CT CORONAL SAGITTAL MUL TIPLANAR $30.00
1I26/05 GEORGE BRODER MD 71010 CHEST SINGLE VIEW $27.00
~/26/05 GEORGE BRODER MD 71010 CHEST SINGLE VIEW $27.00
1I29/05 GEORGE BRODER MD 71010 CHEST SINGLE VIEW $27.00
;/20/05 CHRISTOPHER LADD MD 71010 CHEST SINGLE VIEW $27.00
;/14/05 ERNEST CAMPONOVO MD 71010 CHEST SINGLE VIEW $27.00
;/24/05 ERNEST CAMPONOVO MD 71010 CHEST SINGLE VIEW $27.00
;;15/05 ERNEST CAMPONOVO MD 71010 CHEST SINGLE VIEW $27.00
;/18/05 GEORGE BRODER MD 71010 CHEST SINGLE VIEW $27.00
;/16/05 CHRISTOPHER LADD MD 71010 CHEST SINGLE VIEW $27.00
;/21/05 CHRISTOPHER LADD MD 71010 CHEST SINGLE VIEW $27.00
l/30/05 CHRISTOPHER LADD MD 71010 CHEST SINGLE VIEW $27.00
;/11/05 CHRISTOPHER LADD MD 71010 CHEST SINGLE VIEW $27.00
7/15/05 0200 MEDICARE PAYMENT $95.81-
CK106605181
7/15/05 9200 MEDICARE WRITE OFF $231.27-
7/15/05 0200 MEDIC..<\FE PAYMENT $76.13-
CK106605181
7/15/05 9200 MEDICARE WRITE OFF $204.83-
THIS BALANCE IS PAST DUE. PLEASE PAY
Location of Service: CARLISLE HSP IP
CONTINUED
Patient: DORIS J MCDANNELL
Account Number: ARA-93093980
Statement Date: 08/15/2005
lAX ill 233016413
Andorra Radiology Assoc., P.C.
PO Box 892
Concordville P A 19331
)IAGNOSIS 241.1
MBMSINC1-0101478-0000000-0545524-001.001553-#O00015 For billing questions, please call 800-748-2413
I
/
IRWIN 11- ~Ad/~".....,~ __
.... . .. ...
Andorra Radiology Assoc., P.c.
PO Box 892
"c'"
Concordville P.~19331
STATEMENT
.-
\
I
---1.
.--- I CARD NUMBER
--CHEcK"U...,:,JJITCARD ,,-sINo FoKliAyMEJ',.-r AND Flu. om BEl.OW.
o. o~1
I PIN AMOUNT
,,/""']'
i
I
I
I
I
I
NAME ON CARD (pLEASE PRIN1)
EXP. DATE
SIGNATURE
./
STATEMElVTDATE I ACCOUNr#
07/06/2005 ARA-9306975
Patient: DORIS J MCDANNELL
PAVnnsAMOUNT
$67.86
( AMOUNT PAID )
.or billing questions, please call 800-748-2413
3illing Office Hours: 9am - 4pm Mon - Fri
1111111111111111111111111111111111
11111111111111111111111
MAKE CHECK PAYABLE & REMIT TO:
*33 **AUTO**MIXED AADC 300 06473
111.11I'1111111.11111111111.1'111111.1111.1.1.1.1..11111111111
Doris J McDannell
290A Bull Valley Road
Aspers PA 17304-9445
111.11I.111111111I11'11.111111.1
Andorra Radiology Assoc., P.C.
PO Box 892
Concordville PA 19331
..\
.
MBMSINC1-0099670.ooo6473-0529739-001-001781-#008084
ASE CHECK BOX IF ABOVE ADDRESS IS INCORRECT AND INDICATE CHANGES ON BACK,
(DETACH HERE" AND RETURN THIS TOP PORTION WITH YOUR PAYMENT
" USING THE RETURN ENVELOPE ENCLOSED
DATE DOCTOR CODE DESCRIPTION AMOUNT I
)3/26/05 MATTHEW PASTO MD 71010 CHEST SINGLE VIEW $27.00
)3/28/05 GEORGE BRODER MD 70551 MR1 BRAIN $350.00
::>3/26/05 GEORGE BRODER MD 70450 CT HEAD UNENHANCED $133_00
03/26/05 GEORGE BRODER MD 93880 ULTRASOUND CAROTID DUPLEX $82.00
03/30/05 GEORGE BRODER MD 70544 MRA ANGLO HEAD WITHOUT CONTRAST $350.00
MRA OF THE BRAIN
03130/05 GEORGE BRODER MD 70553 MRI BRAIN WITH GADOLINIUM $400.00
MR1 OF THE BRAIN WITH CONTRAST
06/07/05 0200 MEDICARE PAYMENT $271.41-
I CK106501515
06/07/05 9200 MEDICARE WRITE OFF $1,002,73-
THIS BALANCE IS PAST DUE. PLEASE PAY
PROMPTLY OR CALL US WITH INSURANCE
INFORMA nON IMMEDIA TEL y.
THANK YOU
Location of Service: CARLISLE HSP IP
BALANCE DUE: $67.86
Patient: DORIS J MCDANNELL
Account Number: ARA-9306975
Statement Date: 07/06/2005
\
I
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-~--_..-_._.-~--_/
DIAGNOSIS 434.91
Andorra Radiology Assoc., P.e.
PO Box 892
Concordville P A 19331
TAX ID 233016413
MBMSINC1-0099670-0006473-0529739-001-001781-#OO8084
For billing questions, please call 800-748-2413
:::) 'A , t::M't.:.N'
/
Andorra Radiology Assoc., P.c.
PO Box 892
Concordville PA 19331 ~
i
I
I
I
I
I
J
Statement Date: 08/1012005
Account Number: ARA-93093982
Amount Due: $5.52
'-
For billing questions, please call 800-748-2413
Billing Office Hours: 9am -4pm Mon - Fri
Patient: DORIS J MCDANNELL
C AMOUNT PAID)
11111/111111111111111110 II~ 11111111111111 DlII
11111111111111111111
MAKE CHECK PAYABLE & REMIT TO:
*29 **AUTO**MIXED AADC 300 06003
1...111.111.,11,11"111"11,1'111,.1.1111,1,1,1,1,.11,,,.1..11
Doris J McDannell
290A Bull Valley Road
Aspers P A 17304-9445
111.111.1'1111111.11111.111111.1
Andorra Radiology Assoc., P.C.
PO Box 892
Concordville PA 19331
M8MSINC1-0101300-0006oo3.0543845-oo1-001153-#OO6353
o PLEASE CHECK BOX IF ABOVE ADDRESS IS INCORRECT AND INDICATE CHANGES ON BlcK.
(DETACH HERE", AND RETUflNTHIS TOP PORTIONWITH YOUR PAYMENT
" USING THE RETURN ENVELOPE ENCLOSED
DESCRIPTION
CHEST SINGLE VIEW
CHEST SINGLE VIEW
CHEST SINGLE VIEW
MEDICARE PAYMENT
CKI06593914
MEDICARE WRITE OFF
AMOUNT
$27.00
$27.00
$27.00
$22.11-
'\
"
i
n ^ TI:' Y''''''-''T''#"",\ n
DATE DOCTOR CODE
05/17/05 CHRISTOPHER LADD MD 71010
OS/25/05 ERNEST CAMPONOVO MD 71010
OS/22/05 CHRISTOPHER LADD MD 71010
07/12/05 0200
07/12/05 9200
$53.37-
MEDICARE HAS PAID THEIR PART OF YOUR
BILL. PLEASE CALL US WITH YOUR SECOND-
ARY INSURANCE OR PAY THE BALANCE DUE.
Location of Service: CARLISLE BSP IP
BALANCE DUE: $5.52
Patient: DORIS J MCDANNELL
Account Number: ARA-93093982
Statement Date: 07/1212005
DIAGNOSIS 518.3
Andorra Radiology Assoc., P.c.
PO Box 892
Concordville P A 19331
TAXID 233016413
MBMSINC1-0099902-0004297 _0531849_001_001919_#004531
For billing questions, please ca11800-748-2413
CONCORDVILLB. PA 19331
PATIENT NAME
DORIS J MCDANNELL
ACCOUNT NUMBER STMT DATE
9309398 111-09-05
.ANDORRA RADIOLOGY ASSOC PC
PO BOX 892
I
AMOUNT DUE
84.59
1
DORIS J MCDANNELL
290A BULL VALLEY RD
ASPERS. PA 17304
ANDORRA RADIOLOGY ASSOC PC
PO BOX 892
CONCORDVILLE, PA 19331
DATE DOCTOR CODE DESCRIPTION AMOUNT
05-16-05 CHKIS~O~HKK LADD XD 71010 ex.S1 SINaL. VISW 27.00
04-29-05 CHRISTOPH.. LADD He 93926 DuPL.X IlCA!1 LOWJ:R llXT tlWI I L'l'D 54.00
04-29-05 CKRISTOPH.R LADD NO 70450 1;:'1' HIlAD l1NKJnLUfC2D 133.00
04-26-05 CHKI8~CPH.R LADD NO 70450 C'1' 1IBAD mmHJlANC.D 133.00
04-29-05 OKORa. BRODllR He 76880 .CHOSC~ B .X~REKITY 93.00
05-08-05 CHRI8TOPKllK LADD KD 74000 UDOJON on VI.. 27.00
05-24-05 llJDIBS'1' CAJlPOJrovo KD 71010 CHllST SIJrg~. VI.. 27.00
05-11-05 JAY 8 aOS.IOLtIM am 71010 CHllIT SINGLE VIBW 27.00
07-15-05 0200 lDIDICAIlI PAYHllll'l' -122.42
CIC1OU05111
07-15-05 9200 BllDIC~. WRITI CPF -313.99
ACCOUNT NUMBER STATEMENT DATE AMOUNT DUE
9309398 111-09-05 I 1 84.59
PATIENT NAME
DORIS J MCDANNELL Phone# 888-434-6170
MAX. ~CKS PAYA.La TO:
ANDORRA RADIOLOGY ASSOC PC
Tax Id 233016413
Place of ..rvice: caRLISL. HS7 Xl'
..eerriug Doceorl ~XLLtAX S ~vvrMAH
Diagnoe1.t 511.81
CONCORDVILLE, PA 19331
PATIENT NAME
DORIS J MCDANNELL
ACCOUNT NUMBER STIlT DATE
93093981 11-09-05
~~ RADIOLOGY ASSOC PC
.PO BOX 892
I
AMOUNT DUE
86.70
]
DORIS J MCDANNELL
290A BULL VALLEY RD
ASPERS. PA 17304
ANDORRA RADIOLOGY ASSOC PC
PO BOX 892
CONCORDVILLE. PA 19331
~,
.
DATE DOCTOR CODE DESCRIPTION AMOUNT
04-28-05 CHRIBTO.HJlR LADD 'IIJl 71010 ~8T It.aLE VIaw 27.00
04-27-05 CKRIITo.~a ~ADD 'IIJl 71260 C'l' THOilAX IlHKUfClW 194.00
05-11-05 CKRISTOPHE. LAPP KD 71260 cor THOUX IDIJIAl((;KP 194.00
05-1.2-05 ii_liST ~Oll'OVO lID 71010 CHJIilT sr3lau VIP 27.00
05-07-05 CKRrSTOPKBR LAPP KD 78588 PVLRONA~Y paRFUSXOW VENTlLATIOR ABROSOL 150.00
05-07-05 CHRrSTOPHER LAPP KD 93971 DUPLBX SCAM EX'l'RlMITY varNS UNI 60.00
05-08-05 CHRIS'l'OPHER LAPP MIl 71010 ~8T St.a~E VIaw 27.00
05-19-05 OliORCD BJlODBR lIP 71010 CHJlI'l' Irll'OLB vxa" 27.00
05-07-05 CHRtS'1'OPKBK LAPP ~ 71020 CHallT TWO VI.WS 33.00
05-23-05 Cffil.tSTOPKIlR LAPP JlI) 71010 CHSB'r SIHGLE VIP 27.00
05-01-05 ~Ig'l'OPHBR LAPD JlI) 71010 CHJlST SIHGLB Vt._ 27.00
05-02-05 CHRISTOPH.. LAPP KD 71010 CHJlIlT UNGLB VIP 27.00
05-05-05 OEORGB BRopa. JlI) 71010 CHEST SINaL. VI." 27.00
05-11-05 CKRIS'l'OPXE. LAPP JlI) 71010 exaS'l' SIHGLE VI.- 27.00
05-13-05 CHRISTOPHE. LAPP MD 71010 CHJlST SINGLE VI" 27.00
07-25-05 0200 .EOICAR' PAYMENT -181.07
CX10U.:U272
07-25-05 9200 X.Dt~. WRITB 0" -426.68
07-25-05 0200 IODr~1l PAYJIIBlII'T -57.82
Cltl06li2U72
07-25-05 9200 IODr~. '-1'1'. 0.' -148.73
ACCOUNT NUMBER STATEMENT DATE AMOUNT DUE
93093981 111-09-05 I I 86.70
PATIENT NAME
DORIS J MCDANNELL Phone# 888-434-6170
~a ~CKS PAYABL. TO.
ANDORRA RADIOLOGY ASSOC PC
Tax Id 233016413
>>l.~a ct ..rv1ca. CAaLISL. HIP IP
Aa~.rr1ng Doc~orl "rLL1AM 6 ~UFFKRX
P1agno.1., 793.1
i~
I ~ MASTERCA.RD
I CARD ,',UMBtR
i S\GNATURE
I
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~ I~
1& DISCC\(ER ~~
jEXP DATE
I
JAMOUNT
I
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I $665.00
I
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\/1SA
Asp--er;- Ambulance
Billin~ce
. p.rrBox 726.
New Cum berland, P A i 7070
RUN NUMBER
05-28975
Local TEL: (717) 214-6018 TIN: 23-3022903
Toll Free TEL: (877) 214-6018
FAX: (717) 214-6020
email: info@ambulancebillingoffice.com
L
DORIS J. MCDANNELL
290 A BULL VALLEY ROAD
ASPERS, PA 17304
Patient Name: MCDANNELL, DORIS J.
Patient SSN: 179-30-2567
Date of Service: 4/26/2005 05:15
From: RESIDENCE
To: CARLISLE REGIONAL MEDICAL CENT
Primary Payor: Bill Patient
Secondary Payor:
;::'....E/';:;i:: ,,\/),1/:: '.'::{)A;;~cC-;<,(i,S J.CiJRE:3.S A8u\<;::
CETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
4/26/05
4126105
4726/05
4I2S/()5
4/26/65
7/"13/05
ALS Emergency Transport-Lev 2
Mileage ..... ...
Oxygen
Discount, Medicare
Discount, Medicare
Payment
Total
A0433 1 510.00 510.00
A0425 15 7.00 105.00
A0422 1 50.00 56.66
-44.30
-42.18
:'~
-,
665.00
-86.48
-462.82
-462.82
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This balance is your responsibility and is past due. Either pay the bill in full or contact us about
payment options.
Aspers Ambulance, 877 214-6018
MC DANN ELL, DORIS J. 05-28975
--.-.--..--........-----..--..-...-..-.-----.---.--.. -.-----------.,
PAY THIS AMOUNT Illl+-
$115.70
MAKE CHECKS PAYABLE TO:
BELVEDERE MEDICAL CORPORATION
850 WALNUT BOTTOM RD
CAA.USLE, PA 17013-3698
(717) 243-3120
July 21, 2005
~
Statement
Account #
68981
Bi\1C1:?
~ur Key to Better Health
Payment Due 30 Days From Statement Date
DORIS MCDANNELL
290 A BULL VALLEY ROAD
ASPERS, PA 17304
IF PAYING BY CREDIT CARD, FILL OUT BELOW
o MasterCard o VISA
o Discover
CARD NUMBER
EXP. DATE
SIGNATURE
Practice: BELVEDERE MEDICAL CORPORATION 850 WALNUT BOTTOM RD CARLISLE, PA 17013-3698
Responsible Party: 68981 . DORIS MCDANNELL
Patient 68981 - DORIS MCDANNELL
Visit 509476
COINSURANCE
03/26/2005
06/07/2005
Saturday, March 26~, 2005
" 'EMERGENCY ROOM
Line Item 93010 - ELECTROCARDIOGRAM REPORT
Ins: HGS ADMINISTRATORS Pmt
$45.00
-$43.23
Visif 512233
COINSURANCE
OS/24/2005
06/20/2005
Line Item 36556 - INSERTION NON-TUNNELED CENTRAL
Ins: HGS ADMINISTRATORS Pmt
$1,108.00
-$1,082.75
$0.00
30-60Da
60-900a
A in: Current
$25.25
$0.00
$1.77
$27.02
THERE WILL BE A $25.00 CHARGE IF A CHECK IS RETURNED FOR INSUFFICIENT FUNDS
PAYMENT IS DUE 30 DAYS FROM THE STATEMENT DATE
$0.00
$27.02
**PAST DUE** CALL 243-9463
Bi\1C1:?
~ur Key to Better Health
BEL VEDERE MEDICAL CORPORATION
850 Walnut Bottom Road
Carlisle, PA 17013-3698
(717) 243-3120 FED ID NO. 23-1869105
Page: 1
uuU.a.,U.LK ,'\.) , if'
STATEMENT
BLUE MOUNTAIN ANESTHESIA ASSOC
P 0 "BOX 947
CHAMBERSBURG PA 17201
DIAL EXT 406
SHOW AMOUNT $
PAID HERE
(800)827-3458
OFFICE PHONE NUMBER
07/07/05
CLOSING DATE
01
PAGE NO.
39.01
NEW BALANCE
20955
'fOUR ACCOUNT NUMBER
DORIS J MCDANNELL
209A BULL V ALLEY RD
ASPERS PA 17304
BLUE MOUNTAItJ\ ANESTHESIA ASSOC
POBOX947
CHAMBERSBURG PA 17201
~
/J'o
lH
1'11111.,.1"1,111"",.1111",1.1,,.1..11,"1,1..1111.11,.1.1
NOTE: Charges and paymenis not appearing on this
statement will appear on next month's statement. RETURN THiS PORTION WITH Pi; YMENT
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLqpED ON ANY HOSPITAL BILL OR STATEMENT
~ ~ IPATlENT NAMEI! CHARGES: I PAYMENTS
DATE ~ DQ~OR NAME ~ EXPLANATION OF ACTIVITY CLAIM ACTIVITY AND DESlTS AND CREDITS
050805 KAPOOR
051805
051905 ALSTER
060105
060705
060705
060705
062105
062105
1062105
I
!
SERVICES RENDERED
BILLED:HGS AD"INISTRATORS
SERVICES RENDERED
BILLED:HGS AD"INISTRATORS
HEDICARE PAYHENT
"EDICARE AD4UST"ENT
"C CO-INS $22.96
"EDICARE PAYHENT
"EDICARE AD4UST"ENT
"C CO-INS $16.05
DORIS
864.50
DORIS
604.50
.91.82-
749.72-
0.00
64.21-
524.24-
0.00
PLEASE CO"PLETE THE ENCLOSED FOR" WITH YOUR SECONDARY
INSURANCE INFORHATION AND RETURN TO OUR OFFICE.
STATEMENT 07/07/05
CLOSING DATE:
BALANCE P,<l, 'fMENTS
FORWARD & CREDiTS
PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFiCE:
NEW BALANCE OVER BALf\NCE OVER BALANCE OVER BALANCE OVER
CHARGES 30 DAYS 60 DAYS 90 DA'fS 120 DAYS
20955
NEW BALANCE
PAl THIS AMOUNT
0.00 1429.99- 1469.00
SE:ND INQUjRIE~ TO:
I (800)027-3458
. BLUE "OUNTAIN ANESTHESIA ASSOC
I POBOX 947
CHAHBERSBURG PA 17201
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PO Box 4100
Carlisle, P A. 17013-4100
~/
June 16, 2005
STATEMENT
003251189
DORIS J MCDANNELL
290A BULL VALLEY RD
ASPERS PA 17304
PATIENT:
PATIENT #:
BALANCE:
ADM. DATE:
DORIS J MCDANNELL
9306975
$912.00
03/26/05
DEAR DORIS J MCDANNELL
Your insurance company was billed and has paid according to the
benefits of your policy. However, there is a patient balance due
which is indicated above. Please mail the balance in full today.
For your convenience, you may pay your account with Mastercard,
Visa, Discover or American Express by completing and signing the
form below.
Your prompt payment is appreciated. If you have any questions
regarding the balance, please call our office at the number listed
below.
If you have already made this payment in full, please disregard this
request. ..and thank you.
PLEASE RETURN LOWER PORTION WITH YOUR PAYMENT
CARLISLE REGIONAL MEDICAL CENTER
PATIENT REPRESENTATIVE
(717) 243-6550
8:30 A.M. TO 5:00 P.M.
PIA 03
PATIENT:
PATIENT #:
BALANCE:
ADM. DATE:
DORIS J MCDANNELL
9306975
$912.00
03/26/05
** CREDIT AUTHORIZATION **
VISA( )MC( )DISC( )AMX(
EXP DATE ( )
CARD # (
PMT AMT (
SIGN (
03
*CALLS/INQUIRIES MAY BE MONITORED FOR QUALITY CONTROL*
CARLISLE REGIONAL MEDICAL CENTER
246 PARKER STREET
CARLISLE PA 17013
147
CENTRAL PENN MGMT GROUP
PO BOX 619
EAST PETERSBURG, PA 17520-0619
:l~~:'\
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"1\',.4,
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ru
0-
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0-
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: j
10609-UP91
/
ADDRESS SER'/ICE REQUESTED
,
FOR BILLING INQUIRIES, PLEASE CALL 866 441-9717
9/20/05
$39.01
172-0006658
PAGE: 1 of 1
10/10/05
SH.C)I,M/ ,j,..\lC jl\r;,~
F',6iJ) ;-i2,"iE ;S
":""'_.,n~"';':":tiT-~:-:!t"'-~l"~"", _~. D DR 'E 55 E '2: '~~i'.~~,-~,",~",~;j~4%~~,~:~
~;~12;;--~-~;r;,:~K;;::'}r-,I~~ffi'-&XJ!M",:t?~
TT-:~ ~'lg;al~
11111111111111111111111111111111111111111111111111111111111 III
MCDANNELL DORIS J
290A BULL VALLEY RD
ASPERS, PA 17304-9445
'/111111111111111111111111111,11111,1111111,11111.11111111,111I
CENTRAL PENN MGMT GROUP
PO BOX 619
EAST PETERSBURG, PA 17520-0619
10609-UP91*lMCOVQ53A000077
,~)~~,:'HTlC'rj \tv:iP":,OUR DA_"'/IvlE!'{i
'.
~~ ;foo' ~ ':,,,, ~ . ;<. {. ,> '
,,~~~..~I:JU'{CE ' ::
, .
5/19/05
INFERIOR VENA CAVA LIGATION CHECCHIA,
CRNA SUPERVISED
ESOPHAGUS,THROID;LARYNX;LYM;1+YR LYSAGHT, C
CRNA SUPERVISED
238.56
215.60-
22.96
5/08/05
170.40
154.35-
16.05
Please be aware that your account is now delinquent.
The amount shown in the red box is due before the due date to
avoid further collection activity. You may call our office with
questions or concerns regarding your account responsibility.
39.
:H~~~~r;uAJT I
$39.011
!
0.00
0.00
0.00
39.01
0.00
6/24/05
10609-UP91*lMCOVQ53A000077
I ~~" ~IUII mil 1111 Ulllll/llm III~IIIIIU 10 UlllllllllillllllllU 1/11.11
Central Penn Medical Group Emergency
P. o. P.Jx 619 East Petersburg, PA 17520-0619
Phone 866-247-3141 Fax 1-405-607-1326
TAX ID# 23-3013255 /'
patientinquiry({V,mica.net /
visit us online at www.mjca.net
~~
29.60
1'1.11111111.11.11....11.11.11'111.1.11.1.1.1.111.11111111,111
MCDANNELL, DORIS J 00019
290A Bull Valley Rd
Aspers. PA 17304-9445
9306975
MGDANNELL, DORIS J
MGDANNELL, DORIS J
GRIM MD, LAURA E
05/12/05
o VISA
CARD NUMBER
SIGNATURE
EXP DATE
-".
<
PLEASE DETACH AND RETURN THIS PORTION WITH REMITTANCE
--------------------------------------------PLEA~KE&TllisPORTIONFOiy6UR-~CORDS---------------------------------------
DA TE TREA TING PROVIDER
DESCRIPTION OF SERVICE
CHARGES/CREDITS BALANCE
03/26/05 1102,CRIM MD EMERGENCY DEPT VISIT
04/28/05 1102 CRIM MD PENNSYLVANIA MEDICARE
04/28/05 1102 CRIM MD INSURANCE WRITE-OFF
WE HAVE EITHER RECEIVED NO PAYMENT OR PARTIAL PAYMENT
FROM YOUR INSURANCE COMPANY. THE BALANCE REFLECTED IS
YOUR RESPONSIBILITY AND PAYABLE AT THIS TIME. HOWEVER,
IF YOU ARE UNABLE TO PAY THE FULL BALANCE IN ONE
PAYMENT, IT WILL BE NECESSARY FOR YOU TO CALL OUR
OFFICE TO SET UP A STRUCTURED PAYMENT PLAN. THANK YOU.
Referred by CRIM MD, LAURA E
411.00
-118.39
-263.01
29.60
Please Remit Payment to: If you have questions regarding this bill please call
CENTRAL PENN MEDICAL GROUP EMERGENCY
PO BOX619 1-866-247-3141 (toll free) or email
EAST PETERSBURG, PA 17520-0619 patientinquiry@mica.net. THANK YOU.
FOR YOUR CONVENiENCE. YOU MAY PAY ONLINE ATrvww.mjca.net
1111111111111111111111111111111111111111
P.O. BOX 67015
. HARRISBURG, PA 17106-7015
NATIONAL RECOVERY AGENCY, INC.
A PROFESSIONAL COLLECTION AGENCY
'.~
(717) 540-5605
(800) 360-4319
7/21/2005
IN RE: GETTYSBURG HOSPITAL/SELF
PAY *
ACCT#: 0301056923 *
TOTAL AMOUNT DUE: $107.33 *
DATE OF SERVICE: 10/05/04 *
B94628 - 028
DORIS MCDANNELL
290A BULL VALLEY RD
ASPERS, PA 17304
11111 II ,111.. II I II 111.111 11111111111.11111111.11111 II 11111111/
SEND TO:
NATIONAL RECOVERY AGENCY, INC
P.O. BOX 67015
HARRISBURG, PA 17106-7015
11111 II 11111111 111111.111.1111 1111111111111,111111111.11111111
Dear DORIS MCDANNELL,
Your account has been forwarded to this office for collections. The balance shown above includes interest of $0.00 along
with collection charges of $0. This is a formal demand upon you for payment of this debt. This is an important matter, which
needs to be resolved, and requires your attention.
By resolving this matter, you will make continued collection efforts unnecessary. These efforts may include calls, letters
and/or reporting to the credit bureaus. Our demand for payment does not affect your right to dispute this debt.
Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion
thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days from receiving this notice,
this office will: obtain verification of the debt or obtain a copy of a judgment and mail you a copy of such judgment or
verification. If you request this office in writing within 30 days after receiving this notice, this office will provide you with the
name and address of the original creditor, if different from the current creditor.
. Below is a listing of all accounts included in the total amount due listed above:
."Additional amount not reflected above: $0.00
Unless you dispute this debt, your payment should be made directly to this office for prompt credit to your account. A
twenty-dollar service charge will be added to all checks returned to us by your bank. Should you desire a receipt, a
self-addressed, stamped envelope is required. For payment options please see reverse side of this notice or visit our
secure Website at www.nationalrecovery.com. The purpose of this communication is to collect a debt and any information
obtained will be used for that purpose.
Sincerely,
NATIONAL RECOVERY AGENCY, INC
This communication is from a debt collector.
....Please contact your account representative MR. GREEN at extension 3012 regarding this account.
NRNALS-28
1? (~_tl!{y\.Q<U~1u (aUk. pLcfL
~~ ~. ~"L-U UVLaj-
~.. i p J 1-' NRA 10#: 894628
W ~--'--r-'~ l/'--.
-+-t'-<- JJ--?~
PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION
COM-028-100000-NRA-2394
NRA-STM-Q101
Batance Statement
sender
Richard<Griffiths>D. O.
Healing Arts Surgical Associates
1 Tyler Court
Carlisle PA 17013-7671 - (717) 249.1895
addressee
Doris J.<Mcdannell>
290a Bull Valley Rd.
Aspers PA 17304
Monday, August 29, 2005
Account Number: 000917
\
\
\..,
..
Service date(s) Standard fee Applied fee Received Open Payable
Insurance Patient
(3)
May 17, 2005 259.00 138.04 110.43 0.00 27.61 27.61
(3)
May 19, 2005 931.00 406.90 325.52 0.00 81.38 81.38
1,190.00 544.94 435.95 0.00 108.99 108.99
Please pay this amount:
$ 108.99
Charge Service name
000930 Inpatient Consultation-level 4
000931 Placement Of Trach Tube
hOSVf\ I
W t tAl ~ \Ill il It VVi .-tn V'I iJ'{ K IiV \tVt 4tlLt fn fr ~{Jf e. au +
p lW'i. -fb-y ii1i ~ bd I. fi.R.ose. UYt/-Jkf fu arnU.
.( ,L rr ' . "it,-'
?' /~~~~rJll~
Cj /f) cf\" ,()ptJ: ~ ,L-;,1
~). Jr f
(A
fCUO~
&,+hIO'
(1) Medicare was billed for this service. but has not yet acted on this claim.
(2) Medicare acted on this claim. Deductlbles are now included in 'payable'.
(3) The primary insurance carrier now acted on their coverage of this charQe.
(4) The secondary insurer now acted on their coverage of this service charge
(5) Your insurance reimburses their coveraQe of this charge directly to you.
(6) Secondary carrier(s) pay(s) their coverage of this charge directly to you
(7) Some insurance carriers(s) did not pay. Balance is now payable by you
(8) This charge is not covered by insurance, so it is fully payable by you
(9) The secondary carrier was asked to pay their coveraQe of this charQe.
(10) The primary carner was asked to pay us their coveraQe of this charge
(11) The primary insurer has not yet been asked to pay this service charge.
(12) The secondary insurer(s) have not yet been asked to pay this charge.
~Heritage Medical Group, UJ>
Cumberland ENT Facial Plastic Surgery
2025 Technology Parkway, Suite G 03
Mechanicsburg, PA 17050
. ... - .... i Check Card Used and Fill in Below to Pay by Credit Card
VIS4L/-\
\.c~,,;\ 0 MasterCard 0 Visa
\ "___J
L-~
"
mount
Exp. Date
ay IS mount
$56.57
SHOW AMOUNT
PAID HERE
$
1'1111111111111.11111111111.111.1..1.1111.1.1.1.1..11....1..11
miio********** MIXED AADC 442
DORIS MCDANNELL
290A BULL VALLEY RD
ASPERS PA 17304-9445
Cumberland ENT Facial Plastic Surgery
'PO Box 1335
Camp Hill, PA 17001-1335
[] Please check if address or insurance Information
is incorrect and complete form on back.
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAY'-1ENT
Account #: 269843
4,
.
Please Pay: $56.57
Due Date: 09/13/05
DORIS MCDANNELL ID# 269843/RUSSELL A MACALUSO MD
05/09/2005 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL
05/09/2005 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTO
OS/25/2005 SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE
OS/25/2005 PAYMENT FROM MEDICARE
OS/25/2005 PATIENT RESPONSIBILITY - THE BALANCE IS YOUR CO-INSURANCE WHICH IS NOT
--> COVERED BY YOUR INSURANCE.
BALANCE TICKET #CH000016
475.00 475.00 0.00
350.00 350.00 0.00
-542.16 0.00
-226.27 0.00
-56.57 56.57
.00 56.57
...-....--.-.--........,.....--.........---....-...........-,........-.....-.........-....................".,..............
.......-.........-...,.....,...-.-.....,.......--......'.-.--....-...-.--..-...-.-.......-.......-.........-..............................
"$' "'$' ':A~'C"'A'.B...nU.'.."i':'vnt:iD'.A,..,..o...'i'i..rr"""'.
::::.:,:;_::.~~~jji:,,;:;.:::~,,~,:)nH~!~:y~;~~~~,,::::~~~:~~;ijj!i:;:
PRO'-1PT PAY'-1ENT WOULD BE GREATLY APPRECIATED.
56.57
.00
56.57
Make Checks
Payable To:
Cumberland ENT Facial Plastic Surgery
For Billing Questions Call
(717) 728-9700
PLEASE DO NOT SEND CASH THROUGH THE MAIL
EG1521-32
PAGE 1 OF 1
. ,-.,_.... .&. ..... ftl
~eritage Medical Group, LLP
HERITAGE CARDIOLOGY ASSOC.
425 North 21st Street
Camp Hill, PA 17011
V1SAL ,
'.....-'...1
\ . d1 --..l.c.'. \
, "' '-U"C-. ' \
\, ~-)
'---
Check Card Used and Fill in Below to Pay by Credit Card
o MasterCard
o Visa
mount
Exp. Date
ay IS mount
$34.32
ate SHOW AMOUNT $
PAID HERE
1'1.111...1..11.11....1'111.1...1..1.1'11.1.1.1.1..11....1..11
mtN********* MIXED AADC 442
DORIS MCDANNELL
290A BULL VALLEY RD
ASPERS PA 17304-9445
HERITAGE CARDIOLOGY ASSOC.
PO Box 976
Camp Hill, PA 17001-0976
[] Please check if address or insurance Information
IS incorrect and complete form on back.
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
Account #: 269843
Please P~Y: $34.32
Due Date: 09/13/05
DORIS MCDANNELL ID# 269843/BARBARA BIRRIEL CRNP
06/01/2005 INITIAL INPATIENT CONSULTATION COMPREHENSIVE 190.00 190.00 0.00
06/22/2005 SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE -72 .67 0.00
06/22/2005 PAYMENT FROM MEDICARE -93.86 0.00
06/22/2005 PATIENT RESPONSIBILITY - $23.47 CO INSURANCE IS DUE. -23.47 23.47
BALANCE TICKET #IH027207 .00 23.47
DORIS MCDANNELL ID# 269843/STANLEY B LEWIN MD
06/02/2005 SUBSEQUENT HOSPITAL CARE, EXPANDED PROBLEM FOCUSED 85.00 85.00 0.00
06/22/2005 SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE -30.76 0.00
06/22/2005 PAYMENT FROM MEDICARE -43.39 0.00
06/22/2005 PATIENT RESPONSIBILITY - $10.85 CO INSURANCE IS DUE. -10.85 10.85
BALANCE TICKET #IH027342 .00 10.85
34.32
.00
34.32
Make Checks
Payable To:
HERITAGE CARDIOLOGY ASSOC.
For Billing Questions Call
(717) 972-2829 x 20
PLEASE DO NOT SEND CASH THROUGH THE MAIL
t.fi~!.~~1~~2
PAGE 1 OF 1
,,1' 'A\~'
PLEASE MAKE CHECK PAYABLE TO:
::'-=--==---.---. --~r:=
INTER1\!I~rs
of Central Pa.
IRS# 23-2146427
Peter M. Brier, M.D.
Michael L Gluck, MD.
James A. Tyndall, MD.
Ira J. Packman, MD.
Richard Schreiber, MD., FA.C. P
Lawrence B. Zimmerman, M.D.
Michael A. DeMichele, M.D.
Carla f. Dente, M.o.
Domink Mirdrchi, D.O.
Wendy Schaenen, M.D.
Patrick Ratnasamy, M.D
V. MJrtha Kapoor, M.D
Shubha R. Acharya, MD.
Joseph T. Acri, 0.0
Pratheesh Vbwi1nathan, M.D.
Alen L Sweeney, :V1.D.
Roxana Vargas, M.D
Dean L. Lehman, PA-C
Michelle L. Lat~ha, PA-C
=-==-~..__ tTD. =:-.=::.===---===
HARRISVIEW PROFESSIONAL CENTER' 108 LOWTHER ST. . P.O. BOX 107 . LEMOYNE, PA 17043-0107' (717) 774-1366 FAX (717) 774-4232
:!:f.-4 ~.l~i~Jf:! ill :1:1.' l;J .?~ ,.,~" I
CHARGES OR PAYMENTS MADE
AFTER CLOSING DATE WILL
APPEAR ON NEXT STATEMENT.
DORIS MCDANNELL
290A BULL VALLEY RD
Aspers PA 17304
L
J
Page No. 1
~~-'~~~
. "'~""~\1:~~~'
o PLEASE CHANGE ADDRESS IF INCORRECT
** Statement Due Upon Receipt * Thank You *.
* Insurance Pending
.00
DAYS
INSURANCE
PENDING
30 DAYS
84.27
.00
84.27
CLOSING
DATE: 07/21/05
ACCOUNT
NUMBER 32769
INTERNISTS OF CENTRAL PA. . 108 LOWTHER ST. . P.O. BOX 107. LEMOYNE, PA 17043-0107. (717) 774-1366 FAX (7l7) 774-4232
~T^TCI\II&:MT
J";:.GK.s~. GASTROENTEROLOGY
<:2V 21ST STREET, SUITE 100
C~lP HILL, PA 17011
?HONE - 717-761-0930
EJV1AI f'nfo@gicare. com
STATEMENT FOR PROFESSIONAL SERVICES
Place Of Service
SCCI HOSPITAL
PT-0020
Page No.
Return Thi;).Portlon
With Your Payment
THIS.S NOTA BilL
Billing Date
10/03/05
Amount Due
38.06
.Amount I::nclosed
$
DORIS MCDANNELL
290 A BULL VALLEY ROAD
ASPERS PA 17304
Bill To . . Chart No.
. MCDANNELL DORIS ... .... . ..... ....... ....> .' ... 27059
o CHECK HERE and See Reverse For Change of Address,lns.urance Information and/or Credit Card Payment
--------------------------------------------------------------------------------------------------.---------------------
~,
.
Any Payments Or Charl:jes After The Above Billing Date Will Appear On Your Next Statement.
DATE 6~~i~ PROCEDURE CODE DESCRIPTION CHARGES CREDITS BALANCE
07/07/05
07/09/05
07/29/05
07/29/05
07/29/05
07/29/05
08/12/05
DX:
INITIAL INPATIENT CONSULT, COMPR
285.9 ANEMIA, UNSPECIFIED
MEDICARE
MUTUAL OF OMAHA
*PAYMENT MEDICARE
* Co-ins 38.06
*WRITE-OFF MEDICARE c#
CAN' ID PT, NO COVERAGE c#
220.00
220.00
# 1026211
# 1026212
1026211
Filed
Filed
152.25-
67.75
1026211
1026212
29.69-
0.00
38.06
38.06
THIS IS NOT A Bill.
Chart Number
Bill To
Place of Service
27059
MCDANNELL , DORIS
SCCI HOSPITAL
S H~ 1 TO Sf CON DIN SUR AN C f
.0-
~. I'
,
1 PLACE OF SERV. CODES
r;~-'-----
l 12 I Patient's ~-kme
121 I H\JSp'l.:\i
I ?2 I Hl",JI\a!
';3 i R.'n0!-HospILii
! :>: j C~;!110i
I I 1 Skilled
'l'! 1:0...1 'I'C:::').-!
I ~. I" """"';
l S ; 1!) de ,)') n.,j. '~'.:1.r._ L.:il) n r~,t.!) (1
')9 1 OthOf U~!;~~i-qrj Fa:::lwy )
J'~ ._~._"-,--~
Phone
717 761 0930
Referring Physician
U,l" ,Bill F()RM #21 tilenaflltJ #21Las-C (8/20104) Misys Healthc31'e Systems (800) 877-5678 (588056) 38863l.o19
I' TO CRIDlT YOUR ACCOUNT PROPERI... Y, PLEASE RETURN THE UPPER PORTION OF nus ST A T8VlBfl" WITH YOUR PA YM Bfl"
Patient: DORIS MCDANNELL
Chart Number: MCDDOOOO
~~
Dates Procedure Procedure~
OS/27/05 99253 HaSP CONSULT
** $19.19 COINSURANCE
05/31/05 99232 HaSP SUB CARE
.. $10.85 COINSURANCE
06/07/05 99232 HaSP SUB CARE
.. $10.85 COINSURANCE'
06/12/05 99232 HaSP SUB CARE
.. $10.85 COINSURANCE
Amount Paid by
Charge Insurance
228.00 -76.75
96.00 -43.39
96.00 -43.39
96.00 -43.39
Paid By
Guarantor Adjustments Remainde
-132.06 19.1'
-41 .76 10.8
-41 .76 10.8
-41.76 10.8
Past Due 30 Day Past Due 60 Days Past Due 90 Days Sa la nee Due
0.00 0.00 0.00 51.74
IF PAYMENT HAS BEEN MADE RECENTLY, PLEASE DISREGARD THIS STATEMENT, THANK YOU
Date of 1st Staterrent:
374972
IAN:: 1M! PHYS 1-G1I' C1fNr PEN
EO Ir1X 619
~ 1::1!;~, PA 1752fXJ619
SIATEfv1ENT
PAYMENT OPTIONS
Check #
Amt $
Office Phone Number
/'
AIIRESS SERYICE REJ;J.J.EEJl!D I
\i)~
\ \ \ -.,f'. V ,1) ARDHOLDER NAME
q \ ';Y',;-fJ Y II .~"'"..
~ ~ eJ!' J" R~. ~~ ;.,. ~ANC HMA. PHY S M;MT CENT PEN
. ,\-. .( ty A J'!' {)f' . PO BOX 619
,~~V ~ ~ _lbY EAST PETERSBUR, PA 17520-0619
'\ ~ P \ rl" I '~'J' 1 ",11I...1.1.1. ..1.11I...11....11.....11I, I..", 11I.1..1.1..1
\:-f/ PLEASE RETURN THIS PORTION WiTH PAYMEN1
New Balance SHOW AMOUNT
471. 94 PAID HERE $
V1252
B53,.2M
SA30
!'!'P 001
0053 L
Please Include Securlt Code From Back Of Card
CHECK CARD USING FOR PA YMENT
11II ~9TERCARD
CARD NUMBER
I VISA I ~9A
EXP. DATE
041
..
SECURITY COOE
AMOUNT
-
DORIS J MCDANNELL
717 519-0753
07/28/05
Statement Date
-----------------------------------------------------------------------------------------------------------------------.
-
PROVIDER
NAME
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT
~\
EXPLANATION OF ACTIVITY
PATIENT NAME
CHARGES
AND DEBITS
1IiIm' ...
-. .
. I .. ' .
052305 TARNG MD
062305
062305
INPATIENT SUBSEQ LEV 3 INV#:25
AMOUNT TO BE PAID BY CO INS $15.42
MEDICARE PAYMENT
,MEDICARE ADJUSTMENT
Insurance Balance: 0.00
'DORIS
84.24
-61.69
-7.13
Balance:
15.42
062305
062305
INPATIENT SUBSEQ LEV 3
AMOUNT TO BE PAID BY CO
MEDICARE PAYMENT
MEDICARE ADJUSTMENT
Insurance Balance: 0.00
INV#:26
INS $15.4'2
DORIS
84.24
052405 TARNG MD
-61.69
~7 .13
Balance:
15.42
052505 HILDEN MD INPATIENT SUBSEQ LEV 3 INV#:27 DORIS
AMOUNT TO BE PAID BY CO INS $15.42
062305 MEDICARE PAYMENT
062305 MEDICARE ADJUSTMENT
Insurance Balance: 0.00
84.24
-61.69
-7.13
Balance:
15.42
I
\
,,1\1 t
'iv '
V\
tatement
3te:
07/28/05
PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE:
374972
Current
31-60 Days
61-90 Days
>90 Days'
Total
Ins Pending
NEW BALANCE
PAY THIS AMOUNT
r-----
I
i
MOF.;FITTHEART & VASCULAR GROUP
1000 }fORTH FRONT STREET
. WORMlEYSBURG, PA 17043
Continued
MC VISA Disc
Cardll~ -=- _ _
Sign
Security
Code
Exp /
Address Service Requested
************SINGLE-PIECE
46 103
32399
DORIS J MCDANNELL
290A BULL VALLEY RD
ASPERS PA 17304-9445
1111111'111'111.1111111..11.11111..1.1..1.1.1.1.1..11111111111
MOFFITT HEART & VASCULAR GROUP
1000 NORTH FRONT STREET
WORMLEYSBURG, PA 17043
RETURN TOP POEfnON. RETAIN' L~~E~ '
__:... . ;.... _ .....__~~_..._...,.;..;.:,.:..'--____...._________________________________~________~___'-____.____________ ____~______.o-____________________________
~ii'ii.-BEL-OW BmmI~BmD~
*** Please Pav -Amount Due Now From Patient- See Red Box Thank You!!! ***
***********************************************************************************
Ins/Collection Chrgs pending to Prv: 2160.00
Pay/Adj against Ins/Col1 pending
HOSPITAL CONSULT INITIAL 99254 780.2 225.00
Medicare Payment
Medicare Payment
Accept Assign Adj.
HOSPITAL SUBSEQUENT CARE
Medicare Payment
Medicare Payment
Accept Assign Adj.
ECHOCARDIOGRAPHY COMPLETE 93307 780.2
Medicare Payment
Medicare Payment
Accept Assign Adj.
HOSPITAL SUBSEQUENT CARE
Medicare Payment
Medicare Payment
Accept Assign Adj.
DOPPLER COLOR FLOW VELOCI 93325 780.2
Medicare Payment
Medicare Payment
Accept Assign Adj.
DOPPLER ECHO READING INTE 93320 780.2
Medicare Payment
Medicare Payment
Accept Assign Adj.
ELECTROCARDIOGRAM INTERP 93010 780.2
Medicare Payment
Medicare Payment
Accept Assign Adj.
03/26/05 1
04/11/05
04/20/05
04/20/05
03/27/05 1
04/11/05
04/20/05
04/20/05
03/28/05 1
04/13/05
04/20/05
04/20/05
03/28/05 1
04/13/05
04/20/05
04/20/05
03/28/05 1
04/13/05
04/20/05
04/20/05
03/28/05 1
04/13/05
04/20/05
04/20/05
03/28/05 1
04/13/05
04/20/05
04/20/05
03/29/05-to-
03/30/05 1 12
04/20105
17
17
10
10
10
10
10
00/00/00
DATE LAST PAID AMOUNT
0.00
Service Descri tion C t Dx
778.99-1216.01
0.00
110.43
165.00
27. 6P~
-86.96
99231 780.2
50.00
0.00
26.53
6.63*
-16.84
115 . 00
0.00
38.34
9.59*
-67.07
99232 780.2
80.00
0.00
43.39
10. 85'~
-25.76
65.00
0.00
3.20
0.80''<
-61.00
50.00
0.00
15.93
3.98''<
-30.09
30.00
0.00
7.06
1.77''<
-21. 17
HOSPITAL SUBSEQUENT CARE
Medicare Payment
99232 780.2
160.00
86.78
./
"'\
MOFFITT HEART & VASCULAR GROUP
1000 NORTH FRONT STREET
WORMLEYSBURG, PA 17043
lAKE
HECK
AYA8LE TO:
PRV# 8-PAWLUSH, DAVID, MD, FACC
PRV# 9-SMITH, MICHAEL F, MD, FA
PRV# 10-LINE, DENNIS E, MD, FACC
PRV# 12-MANDAK, JEFFERY, MD, FAC
Ph: (717)-731-8315
Acct/l: 48347
Date: 06/10/05
Page 1 of 4
PAT# I-DORIS J MCDANNELL
,.../,/~
./
v
Nephrolo~y Assoc. Of Cen PA
pob 2, 205 Grandview Ave 402
Camp Hill, PA 17011
717-972-2821
ACCOUNT IAMOUNT DUE I CLOSE DATE I PAGE
004136-001
60.88 I 10/05/05 I 01
-------------------------------------
WE ACCEPT MASTERCARD AND VISA
TO: Doris Mcdannell
290 A Bull Valley Rd
Aspers,PA 17304
PREVIOUS BALANCE-->
60.88
DATE ~I PATIENT I PROC CDE I
DESCRIPTION
I DIAG
AMOUNT
-----------------------------------------------------------------------------
...\o""(\C~ e(\\ '0'1
filJ " ~'J~
~\,..\ 1'"'''''". 'Jo\}~ Q
l"" ~ " e\"e
0.0 (\0\ ~eC "'\ c '? ~cco\}(\\
\\ '-Ne \ D \ ~(\ 'Jo\}~
0. \0 \~ tf.,\0(\'
\o,<c0 co\\eC
'\~ '00 ~ \O~
'-Ne '-N\\ o"e
-----------------------------------------------------------------------------
PAY THIS AMOUNT --> I
60.88
ACCOUNT NolcURRENT I 31-60
61-90
91-120 lOVER 120
-----------------------------------------------------------
004136-00 I
0.001
0.00/
60.881
0.001
0.00
-------------------------------------------------------------------------------
~
.PENN REHAB ASSOCS
2151 LINGLESTOWN ROAD
SUITE 240 4/
HARISSBURG~PA 17110
Tel: 7175410700
MCDANNELL, DORIS J
290A BULL VALLEY RD
ASPERS,PA 17304
BILLING QUESTIONS CALL 717-541-9970
Place Codes:
IH=In Patient
OH=Out Patient
ER=Emergency Room
STATEMENT
Patient: MCDANNELL, DORIS J
Tax I.D. 232161606
STATEMENT DATE PAGE
09/14/05 2
ACCOUNT NUMBER
1008830 - 1 / MC
INDICATE
AMOUNT PAID $
DATE IICD9 CDlpL*1 ~,DESCRIPTION I AMOUNT
____________________________4_______________________________________
05/17/05 MCWO MEDICARE WRITE OFF -31.85
04/14/05 IH 99231 SUBSEQUENT HOSPITAL CARE 65.00
05/11/05 MCCK MEDICARE CHECK -26.53
05/11/05 MCDS MEDICARE DISALLOWANCE -31.84
04/15/05 IH 99231 SUBSEQUENT HOSPITAL CARE 65.00
05/17/05 MCCK MEDICARE CHECK -26.53
05/17/05 MCWO MEDICARE WRITE OFF -31.84
04/16/05 IH 99231 SUBSEQUENT HOSPITAL CARE 65.00
05/17/05 MCCK MEDICARE CHECK -26.53
05/17/05 MCWO MEDICARE WRITE OFF -31.84
04/17/05 IH 99231 SUBSEQUENT HOSPITAL CARE 65.00
05/17/05 MCCK MEDICARE CHECK -26.53
05/17/05 MCWO MEDICARE WRITE OFF -31.84
04/18/05 IH 99231 SUBSEQUENT HOSPITAL CARE 65.00
05/16/05 MCCK MEDICARE CHECK -26.53
05/16/05 MCDS MEDICARE DISALLOWANCE -31.84
04/19/05 IH 99233 SUBSEQUENT HOSPITAL CARE 99.00
05/16/05 MCCK MEDICARE CHECK -61.69
05/16/05 MCDS MEDICARE DISALLOWANCE -21.89
04/20/05 IH 99231 SUBSEQUENT HOSPITAL CARE 65.00
05/16/05 MCCK MEDICARE CHECK -26.53
05/16/05 MCDS MEDICARE DISALLOWANCE -31.84
04/21/05 IH 99238 HOSPITAL DISCHARGE DAY 120.00
05/16/05 MCCK MEDICARE CHECK -55.02
05/16/05 MCDS MEDICARE DISALLOWANCE -51.22
Ref. Phy: WAMPLER,DAVID MD
CURR~T~O~T
$ 154.77
IPAST DUE AMOUNT
$ 0.00
PLEASE PAY I
THIS AMOUNT $ 154.77
.,~,~f ,
,\ \()\ v, ( U" rSJ1J
t... \ \. ~~ ~ )< ~V
"\\/,/, ,\
(L/~'~ -\ ~ .:J,
\.. \ '.\t \'
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tl" 'Nt), \]I
1111111'111111111.1.1.11111111.1.11111111111111111111.11111.11 \ 'Iv n ~
10 \'\ ~
'\t\-: \,,~P
'\
PO BOX 67533
.HARRISBURG, PA 17106-7533
111111I1111I1111111111111111111111111111111~11111
""
'\;',
Return Service Requested
."."
r-v
.~,
"
August 4, 2005
,
~
\
\/1
\"
,~ORIS J MCDANNELL 00039944
~ 'r435 GOODYEAR RD
" ",\ GARDNERS, PA 17324-8906
~~
\ '\ ~
~'
~~
"-',,-
CREDIT PLUS COLLECTION SERVICES
2491 PAXTON STREET
HARRISBURG, PA 17111
(717) 236-3520 or (800) 238-5877
Phone Hrs: 8am-9pm EST M-Th 8am-
8pm EST Fr 8am-5pm EST Sat
Office Hrs: 8:30am-5pm EST M-Fr
Re: PINNACLE HEALTH SYSTEMS
For: MCDANNELL ,DORIS
Client ID: 240173085
Acct#: 00039944
PIN number: 12196
AM9UNT DUE: $
876.00
~'C"1\T O'f:<'t-u;.~).o' rriA .f11'...f-r\C' 1"""\t:"':"T......~
THE ACCOUNT LISTED J:lBOVE HAVE E__., "~'tW'f',~D ~~ .......... '-'~"...'-''''
.ir#'
..~
FOR
COLLECTION. IT IS TO YOUR BENE~'.L'l' 'l'U PAY THIS CLAIM.
DO NOT NEGLECT YOUR OBLIGATION.
ACCOUNTS NOT PAID, MAY RESULT IN NEGATIVE OR ADVERSE INFORMATION BEING ADDED TO YOUR
CREDIT FILE.
ALL PAYMENTS MUST BE MADE DIRECTLY TO THIS OFFICE FOR PROMPT CREDIT TO YOUR ACCOUNT
OR CALL 800-238-5877 TO MAKE ARRANGEMENTS.
mILESS YOU NOTIFY THIS OFFICE WITHIN THIRTY-DAYS AFTER RECEIVING THIS NOTICE TH..~T
YOU DISPUTE THE VALIDITY OF THE DEBT OR ANY PORTION THEREOF, THIS OFFICE WILL ASSUME
THE DEBT IS VALID. IF YOU NOTIFY THIS OFFICE IN WRITING WITHIN THIRTY-DAYS FROM
RECEIVING THIS NOTICE, THIS OFFICE WILL: OBTAIN VERIFICATION OF THE DEBT OR OBTAIN A
COPY OF A JUDGMENT AND MAIL YOU A COPY OF SUCH JUDGMENT OR VERIFICATION. IF YOU
REQUEST THIS OFFICE IN WRITING THIRTY-DAYS AFTER RECEIVING THIS NOTICE, THIS OFFICE
WILL PROVIDE YOU WITH THE NAME AND ADDRESS OF THE ORIGINAL CREDITOR IF DIFFERENT
FROM THE CURRENT CREDITOR.
THIS IS AN ATTEMPT TO COLLECT A DEBT AND ANY INFORMATION OBTAINED WILL BE USED F\.~"RR\,\\\~.../)
THAT PURPOSE. THIS COMMUNICATION IS FROM A DEBT COLLECTOR. ,\\\\V
VISIT OUR PAYMENT WEBSITE AT www.cpsg.com/pay OR USE COUPON BELOWt \1\\'
\\~_ ,~' V .
"""""""",,,, 'Plea~e' detach' ,,;;d' 'ret';;;';' 'this' p,;itio';';Xthe '';'oEice' ';':ith' 'your ,~~[~~,~, \"
I f requesting a receipt, please enclose a self addressed stamped "'~mve~e .\~\..;'\ ~t.
All payments must be made directly to the address below. \ \' y, I.)
If your check 1S returned for insufficient funds or closed account, a $25.00 ret~rned ~\
\ I '
check charge wlll be added to your account. ~r~J"\
( ) Enclosed is my payment in full. . \~! 'r'
\ --....... \'\ \ \
\ ._" j\, .'
( ) Enclosed is my VISA or MASTERCARD number: ! i \J'~;
Card Number: Name on Card: \ J'
',..)
1111111111111111111111 ~1111111111111111111~11111
Account # 00039944
240173085
CREDIT PLUS COLLECTION SERVICES
PO BOX 67533
HARRISBURG, PA 17106-7533
Expiration Date:
Signature:
/
Amount to Charge to Card: $
Date:
Phone:
DORIS J MCDANNELL
PINNACLE HEALTH SYSTEMS
August 4, 2005
AMOUNT: $
876.00
JLOO.CBH13OS2.011IC3,IJ5B.00683863
Pinnacle Health Hospitals
P.O. BOX 2353
HARRISBURG, PA 17105
..:-.,..........._..'.....-..,..........',-...-.........._..............-.....'........_..-........,...,....-.... ..'...........'...'.-.._..............._-.-......
M<zP;\.NNtI.,ls,PQRI$HH>\...H/r...
)S~,..vi2~na*~;..>r<..(J5t3ii()5..........
Sla;..,i.~~t6d:..
:kl~Z~:~\'je~~~jii~07/26t~5
(717) 230-3717
For Account Information, Please Call (717) 230-3717
Account # 250293212
Statement of Account
08/15/05
Transaction Date
Description
PREVIOUS BALANCE
1 GAST ROOM 1/2 HR
1 GI CASE
1 SUCTION CANNISTER/LID
4 GLOVES
3 PATCHES EKG
1 TUBING SUCTION
1 UNDERPAD
1 STERIS SCOPE PROCESSIN
1 CATHETER YANKAUER
1 PRE PROCEDURE ASSESSME
1 PHASE II RECOVERY 1/2
1 BITE BLOCKS
1 MOUTHPIECE ENDO GUARD
1 PEG K IT BOWER
1 SPONGE GAUZE
1 SYRINGE 3CC
2 ALCOHOL WIPES
1 SURESITE TRANSPARENT D
1 CANNULA OXYGEN
1 BACITRA UD ONT EA 00000
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
05/31/05
Estimated Insurance Due:
.00
Total Patient Credits:
Account Balance:
137.82
YOUR ACCOUNT IS SERIOUSLY DELINQUENT!
PLEASE CALL OR PAY IMMEDIATELY.
CUSTOMER SERVICE HOURS
MON-WED-FRI 7:00AM TO 4:00PM
TUES-THUR 7:00AM TO 6:00PM
CALL 717-230-3717 LOCAL OR 1-800-603-6064 OUT OF AREA
Pleilse detach and return with your payment
Amount
.00
301.00
.00
5.00
.84
.90
3.00
.24
26.00
1. 00
120.00
126.00
6.00
7.00
623.00
.12
.21
.06
1. 00
1. 00
3.00
I
SL~I Hos2itals
Specialized Complex Care
SCCI HOSPITALS .PO Box 201409. Dallas, Texas 75320-1409 . 800/761-9929
www.sccihospitals.com
September 13, 2005
THE ESTATE OF DORIS MCDANNELL
290 A BULL VALLEY ROAD
ASPERS PA 17304
RE: SCCI HOSPITAL HARRISBURG
Account: 10002362
Date of Service: 5/25/;05-6/13/05 & 6/22/05-7/9/05
Patient: MCDANNELL,DORIS
Balance Due: $9927.7~
Second Notice
To the Estate of Doris McDannell:
Please be advised that this letter is our second notice to
you of non-payment of the above referenced account. If
there is a problem with the account, please contact us
at the number below. If we do not hear from you, we will
expect full payment in this office within five (5) days.
If we do not hear from you within five days, or receive
payment within five days, we may be forced to take legal
action.
Sincerely,
lit1JvlLlir ;jl-atL /-;Gli P-ti
Harriett Goodfriend
Collector
800-761-9929 Extension ~/ ~
Colorado . Michigan . North Dakota . Ohio . Pennsylvania . Texas
PLEASE.RETI;JRN;THISPORT!ON:WITH YOUR PAY~jlE!\iT TO
~
,;
PRbcEDURE
CODE
DESCRIPTION
AMOUNT
DATE
DR.
PATIENT
PRZ Taus BAl.ANCE-"'.)
~). 0121
0S/01./05 nc2 DQ~~i.s
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[: l'~' ,~ <E. t 1 \"i.
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1J; ':5 t; In F~ r'i t
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121.:3/03/1215
'il81 !ZL3.1 Q15
12)9/12/1215
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ft-l: a!i 'n f,~1 Cl. ''l m f:'! f} t' : ;J
Bi 11 Balance--}
!21" QJQ1
:l" flAt
06/03/05 nc~:: Pori s
0.3/11 l\{J5
08/11/0;5
09/12/05
71010
C,h r;; 'i~, t: ~ t)
I:~~ ~~~~, e~ ~J
1==( 1. :il I1 1=1 a, ~t\ men 1:;, ~ _/ .
f:ld:j_tt sot: -iJl:r:T"l_t.
p 1 :::,"""1 Jll !;'!Tit. ;; ,.
frle die a r" 2
1 ;:~.'1 :/ 9 .-.
Bill Balance--}
'), O~:!
1. D,':,
0&/1217/12.'5
QIS/09/05
,08/09/1i:l5
091 12/,QI5,
C:J:~ $3 :',i- 'l; 1.t.)
~::;2", !2Jf;;.!
lllE'nt ~.
111.2'1 t
Pir\ym~nt;; .
'7~ 2:7~'"
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1,-,
L: ..
:ZI. l:i Q)
Bi 11 Bal ance--)
~:o {:;\-"1'
01;;\
7 a 2;7..
\L)9/1;;:;/05
J'1j'.ltl.ta 1 0 f
0. QUZl
I NClU:r f~ I ES t'11U'3T
P:'H 1 ENT PEH HI Pi=tJCl
Medicare has paid its
share of your bill,
This statement is for the
amount payable
directly by you to us.
Please remit.
Bill Balance--)
1. JX- t'3 ij.
:r ,-::- !:-- 1 ; I ~ ::~ (~1 "~'~ >~ E~;' } n~~ :!: ~=, ;\_ ~ (~; ':-
"::r:~ t->,:-~ r -:, ~:::- ";"-.
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PAY THIS AMOUNT ~
r-/' c.:.j\;-;"' ;--"jL_ ~{ f3E F :'''~ ICE: Ct..;rl r~C:;E
';oj ,-: t_ ~_ 13 r;: }~i .;:" r) E:. })
~.~ ;J 'o/ CJ iJ R p, r""1 L_ f:'~J ~i C: [~ jJ
,.
South Central EMS, Inc.
8065 Allentown Blvd.
HARRISBURG, PA 17112
(888) 463-3488
. . --------------Federal Tax 10:-23-7096198
.
.
/
-----~/--
PATIENT NAME: DORIS MCDANNELL
D.~TlENT NUMBER: 6834
CALL NUMBER: 0502942
DATE OF CALL: 06/13/2005
T1ME OF CALL
INSURANCE: PRIVATE (SELF PAY)
Ci'..LLER:
911 or Equivalent
SCCI HOSPITAL-LONG TERM ACUTE
HOLY SPIRIT HOSPITAL
I
I
I
!
I
I
!
i
I
J
7 - 0502942
DORIS MCDANNELL
290A BULL VALLEY ROAD
ASPERS, PA 17304
FR'ONL:
TO:
REASON(S) 518.81
FOR 782.5
TRANSPORT 729.81
Ambulance Member427.3Not a Member
--~ --.------- ---'--'--' ----- ---~--..-.,-~--_..-.._-_.- -,_.-
r------.- -.. -....----.------.---------i.--------.----.--.---.-... ----..-----------
! . ~E~~!P_~'_=~, Of CHARG!______L__~_I~~~j!~~_______UN!T ~~~CE
Advanced Life Support 1 NE A0426 1.0 850.00
Cardiac Monitor Z0224 1.0 120.00
Ground Mileage A0425 4.0 10.00
Oxygen Administration A0422 1.0 70.00
AMOUNT
l
850.00 I
120.00 I
40.00 I
70.00 i
! Total Charges
1080.00
,-
I DESCRiPT10N OF PAYMENT
f---------------.--.--
I CIA MEDICARE HMO
i Medicare Part B Payment
I
RECEIPT PAYMENT
AMOUNT
10/03/2005
106731138 10103/2005
809.97
216.02
I
L_______
Credits
1025.99
TOTAL CHARGE.....
Please make your check pavable to: South Central EMS. Inc.
$54.01
-. ----------,_._--_.._._._--------~-" '-~---,'.--'"----_._-~...._~._~.._,--~...---, -----.-.-,. - ~-'----_.~--~-,._'-,.__._.._'------~-------~~-~----------~-
( DETACH ALONG PERFORATION ABOVE AND RETURN STUB WITH YOUR PAYMENT '\
I TOTAL OUTSTANDING 1080.00 I
i PATIENT NAME; MCDANNELL, DORIS CALL NUMBER: 0502942 CHARGES ___ i
I, PATIENT NUMBEP- 6834 _ m _ ____ _ ____ ___~ _~~lING DATE- _~~0812005 AMOUNT $ ENCLOSED ___ ______ ____ _ j
IF INSURANCE 1~~FORMAT:ON IS AVAILA,BLE, COMPLETE REVERSE SIDE AND RETURN IN THE ENCLOSED ErNELOPE.
PAST DUE! We responded promptly to your needs for service, please pay us the same
courtesy. Please contact our office for payment arrangements.
South Central EMS, Inc. 8065 Allentown Blvd. HARRISBURG, PA 17112
"
STQ~~HTHALMOLOGY
~38 ALEXANDER SPRING RD.
'CARLISLE, PA 17013
19.19"<
Return Service Requested
MC VISA Disc
Cardll~ _ _ _
Sign
Security
Code
Exp /
*******AUTO**3-DIGIT 173
25191
DORIS MCDANNELL
290 BULL VALLEY ROAD
ASPERS PA 17304-9445
1,"111"11..11.1111"1..11.1'1111.1.1"1.1.1.1.1..11'"111111
9 73
STOKEN OPHTHALMOLOGY
338 ALEXANDER SPRING RD.
CARLISLE, PA 17013
Date
"'
----MESSAG-EsExPLAiNE-D---.---eEi.-ow----------~--------,--------------------------------------------------------,----------------'----.----------- -----------------
ID.rIm BmmI~BmD~
. ' .
RETURN TOP POR:TlON. RETAIN'LOWER ..,'
Service Description Cpt Ox
*** PAYMENT DUE ON JULY 06, 2005. FOR BILLING QUESTIONS CALL 249-6337 ***
**,~,~"*~,tx~ix~~~l~:~2~2!~9.~,~~~2w"~trO,,m,,~~~!ix2!:~,,2xe,,*~x9.,,~,9.x,,~~~~~~I2~n,,~~r2~111,,~,,~:::
.. ......... ...................,'...........1..............,..............1\,."..... ......"..,... .............. .. ..........,...............,...,...."", ..,....".... .",....,,, ..1.... ..."....,..,........"...."........ ..,..........,.......,..,,,.... ..". ..,..........,..
03/29/05 1
05/09/05
05/09/05
1
HOSPITAL CONSULT INITIAL
Medicare Payment
Accept Assign Adj.
99253 366.16 105.00
76.75
-9.06
19.19"<
00/00/00
0.00
DATE LAST PAID
AMOUNT
MAKE
CHECK
PAYABLE TO,
STOKEN OPHTHALMOLOGY
338 ALEXANDER SPRING RD.
CARLISLE, PA 17013
PAT# I-DORIS MCDANNELL
PRV# I-STOKEN, DREW J., M.D.
Ph: (717)-249-6337
Acctll: 23352
Date: 06/21/05
Page 1 of 1
'--
,,-----
it
. .
Amount Due
Procedure Code
Description
Please remove and return this portion with your payment
~
~l
.
Chrgs./Credits
Item Balance
Date
Patient Name:
Account Anatysis.
PATIENT IJ'
BALANCE I
AMOUNTDUE
Insurance Balance
Patient Balance
__I
.
WEST SHORE EMS - CARLISLE
~ GRANOVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone tJ: (800) 367-0512 Federal Tax 10: 23-2463002
.///
,
,
'"
\ i'~":;j ~:.',;t'Y\,:I;':
INSURANCE: MEDICARE B
179302567A
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
39330
131265M
OS/25/2005
NMCI
SUP1
PATIENT NAME: DORIS MCDANNELL
131265M
CARLISLE HOSPITAL
CARLISLE REGIONAL MEDICAL CTR
SCCI
DORIS MCDANNELL
290A BULL VALLEY RD
ASPERS, PA 17304
REASON(S)
FOR
TRANSPORT
CEREBROVASCULAR ACCIDEN-
INVOICE
DESCRIPTION OF CHARGE
"QUANTITY
UNIT PRICE
AMOUNT
ALS TRANSPORT
ALS MILEAGE
A0426
A0425
1.0
24.0
750.02
8.85
750.02
212.40
11
6. . y--
\6\0 "Q.,1t-
~+\ ~ivl~
Total Charges
962.42
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Medicare Assignment Adjustment 06/24/2005 586.13
Medicare Part B Payment 106550549 06/24/2005 301.03
Total Credits 887.16
PLEASE PAY THIS AMOUNT _ $75.26
PATIENT NAME:
PATIENT NUMBER:
MCDANNELL, DORIS
39330
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
75.26
CALL NUMBER
BILLING DATE:
131265M
08/17/2005
This account is now PAST DUE!! Payment must be received
WITHIN 10 DAYS. Collection process will begin.
WEST SHORE EMS - CARLISLE 205 GRANDVIEW AVE
r~::~=1 VISA i ..-.i
I. ..."'" J AND~V.!
MASTER CARD
ACCEPTED
CAMP HILL, PA 17011
~,/
P~'#:
WEST SHORE EMS - CARLISLE
205 GRANDVIEW AVE
SUITE 211
CAMP HILL, PA 17011
(800) 367-0512 Federal Tax ID: 23-2463002
..
WEST SHORE
C,....f'('. -,'
INSURANCE: MEDICARE B
179302567A
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
39330 NMCI
132168M NONE
06/22/2005
PATIENT NAME: DORIS MCDANNELL
132168M
HOLY SPIRIT HOSPITAL
HOLY SPIRIT HOSPITAL
SCCI
DORIS MCDANNELL
290A BULL VALLEY RD
ASPERS, PA 17304
REASON(S)
FOR
TRANSPORT
Respiratory Failure
HYPOXIA
INVOICE
~
DESCRIPTION OF CHARGE ,. QUANTITY UNIT PRICE AMOUNT
ALS TRANSPORT A0426 1.0 750.02 750.02
ALS MILEAGE A0425 6.0 8.85 53.10
Oxygen Administration A0422 1.0 50.93 50.93
Total Charges 854.05
DESCRIPTION OF PAYMENT
RECEIPT
PAYMENT DATE
AMOUNT
Medicare Assignment Adjustment
Medicare Part B Payment
106602761
07/13/2005
07/13/2005
572.82
224.98
Total Credits
797.80
PLEASE PAY THIS AMOUNT __
$56.25
r
PATIENT NAME: MCDANNELL, DORIS
PATIENT NUMBER: 39330
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
56.25
CALL NUMBER
BILLING DATE:
132168M
08/17/2005
WEST SHORE EMS - CARLISLE 205 GRANDVIEW AVE
~~ ul VISA
AND
MASTER CARD
ACCEPTED
CAMP HILL, PA 17011
!-~".
',i <lsle'liliili I
,~-----
This account is past due!!! The balance amount is your
Copay/Deductible. Payment must be made now.
WEST SHORE PATHOLOGY
PO e.OX 750
SCRANTON, PA 18501
Date: 09/09/2005
..
Return Service Requested
......---"
Amount Due: 12.61
/
/-
12.61
PHL4*26*25697194
ME>>S71A170B2DD~TAO.D023S4
DORIS MCDANNELL
290 BULL VALLEY RD A
ASPERS PA 17304-9445
Mail Payment to:
111.11111.11111.1\ 'II.I..II .111I1..1.11.1.1.1.1.1111\11111..1\
WEST SHORE PATHOLOGY
PO BOX 750
SCRANTON, PA 18501
-
-
~
-
-
-----
~
-
MED571
-1\
.
Patient Name - DORIS MCDANNELl
Account Number - 26*25697194
Account Balance - 12.61
Place of Service: HOLY SPIRIT HaSP IP
Referring Doctor: TIMOTHY A CLARK
Date of Service: 06/16/2005
Dear Doris Mcdannell:
This is a reminder that payment on your account is now due.
As a courtesy to you. our business office has assisted you by
billing your insurance. Insurance paid their portion.
You are now responsible for this account. Please submit payment
in full today.
Mail your payment to the address shown above. To insure proper
credit. enclose this letter and write your account number on the
check.
If payment in full has been made. please disregard this notice.
Sincerely.
BILLING OFFICE
1-800- 238- 3614
~HQLY
SR~
The Spirit of Caring
Holy Spirit Hospital
503 N 21ST ST~
CAMP HILL PA 17011
#
717-763-2141
...,.........,....'.-.'.....'......,.,...,..........-........................,...,........,...,.........,...............................-..--.........-.........
.....l\'tqPt\NN~tp,I)Q~I$</)>..
...SerNic:;eI).:rte{)<>. o 6!1 3(()5)
>S~)"',,;i;c:;~)EHc:I:........ ......J.../)).. 9~12.??Ol)...<.
L~~~St#3~~~9tP~t#<.(J6.!3~?-~!i
.........1\.d:()uf11N~#.)25697194.>>....<>............. .
For Account Information, Please Call 717-763-2141
Sta~e'nent of Account
07/22/05
Transaction Date
Description
Amount
06/22/05
06/22/05
06/22/05
06/22105
06/22/05
06/22/05
06/26/05
06/28/05
06/29/05
C7/14/05
07/14/05
07/14/05
PREVIOUS BALANCE
CANISTER SUCTION 1200CC
TUBE CONNCT 3/16"
ADP FIBEROPTIC BRaN
BRONCH SUCTION VALVE
BRaNCH BIOPSY VALVE
GIS LEVEl II
MED CIA HOSP-t~ M90 MEDICARE lIP
MEDI LATE CHRG ADJ I M90 MEDICARE lIP
NON-COVERED SERVICES M90 MEDICARE I/P
MEDI PYMT-HOSP IP M90 MEDICARE lIP
MEDI CIA HOSP-IP M90 MEDICARE lIP
MED CIA HOSP-IP M90 MEDICARE lIP
63,012.81
7.00
2.00
46.50
20.50
8.50
807.00
45,648.16-
891.50-
9.60-
15,296.01-
45,655.20-
45,648.16
Estimated Insurance Due:
.00
Total Patient Credits:
Account Balance: 2,052.00
M90 MEDICARE liP
.00 098 MAPA MED ASSI
.00
PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID.
_ _ _. _ ~ ._ _.~___~__ ___ ___ __"_. _.u' _~__ _ __ _ _. .._ ~" _ ~_n.. ~~_..__ ___. __., __ ..__ ___.___~~e_~!_~_e~!~sh_ ~~~ !~!.u!~,'V!i_!~ Y~~~...e~"if!l!~_____ --------------------------------------------------------- - -.
MCDANNELL ,DORIS
D.D~D
For Hospital Use Only
Account Number:
25697194
IIOLY SPIRIT HOSPITAL
503 N 21ST STREET
CAMP HILL PA 17011
#
ADDRESS SERVICE REQUESTED
ADM DT: 061305
DSH DT: 062205
SB: 21020
717-677-4775
Patient Name:
Card Number:
HR:
518.81
HSG
Signature:
Make Check Payable To HOLY SPIRIT HOSPITAL
. The CVV2 Number is the last J digits on the back of your credit card, by your signature
1"1111'1111111.11111.11111.11111..1.1'1111.1.1.11.1111..11111
00044165 1 MB 0.309 01
25697194
DORIS MCDANNElL
290 BULL VALLEY RD
ASPERS PA 17304-9445
111.111.1111111111.11.1.11111.1111.1111.1.1..1111111111.1.1111
HOLY SPIRIT HOSPITAL
503 N 21ST STREET
CAMP HILL, PA 17011
o Please check this box if your address or insurance information has changed and record the changes on the back of this statement
----
NAPD
C(;,~~
-----
.
..
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