HomeMy WebLinkAbout06-6542COMMONWEALTH OF PENNSYLVANIA
COURT OF COMMON PLEAS
Cumberland County, PA
JUDICIAL DISTRICT
NOTICE OF APPEAL
FROM
DISTRICT JUSTICE JUDGMENT
COMMON PLEAS No.
NOTICE OF APPEAL
Notice is given that the appellant has filed in the above Court of Common Pleas an appeal from the judgment rendered by the Dis-
trict Justice on the date and in the case mentioned below.
NAME OF APPELLANT MAG. DIST. NO. OR NAME OF D.J.
Joseph and Lucinda Engle 109-1-03 Doucfh!?rty
ADDRESS OF APPELLANT CITY STATE ZIP CODE
Moffitt H
CLAIM NO. CV YEAR CV-0000266-06
LT YEAR 9/ 1 1/ 0 6
sq:
This block will be signed ONLY when this notation is required under PA. If appellant was Claimant (see PIA R.C.P.J.P.
R.C.P.J.P. No. 1008B.
This notice of Appeal, when received by the District Justice, will operate as No. 1001(6)) in action before district Justice, he
A SUPERSEDEAS to the Judgment for possession in this case. MUST FILE A COMPLAINT within twenty (20)
days after filing his NOTICE of APPEAL.
Signature o ro ono ry or ep
PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE
(This section of form to be used ONLY when appellant was DEFENDANT (see PA R.C.P.J.P. No. 1001(7) in action before District Justice.
IF NOT USED, detach from copy of notice of appeal to be served upon appellee.
PRAECIPE: To Prothonotary
Enter rule upon Moffitt Heart & Vascular Group , appellee(s), to file a complaint in this appeal
,. /Name of appellee(s)
(Common Pleas No. ?OJ yoZ 60. within twenty (20) days after service o I or suffer entry ) gm t Of non pros.
Signature f a llant or attorney or agen
RULE: To Moffitt Heart & Vascular Groellee(s)
Name of appellee(s)
(1) You are notified that a rule is hereby entered upon you to file a complaint in this appeal within twenty(210) days
after the date of service of this rule upon you by personal service or by certified or registered mail.
(2) If you do not file a complaint within this time, a JUDGMENT OF NON PROS WILL BE ENTERED AGAINST YOU
UPON PRAECIPE
(3) The date of service of this rule if service was by mail is the date of the mailing
Date: W&2. 9. , Yeai
White - Prothonotary Copy
Green - Court File Copy
Yellow - Appelant's Copy
Pink - Appellee Copy
Gold - D. J. Copy
Proth. - 76
e
PROOF OF SERVICE OF NOTICE OF APPEAL AND RULE TO FILE COMPLAINT
(This proof of service MUST BE FILED WITHIN TEN (10) DAYS AFTER filing the notice of appeal. Check applicable boxes)
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF : ss
AFFIDAVIT: I hereby swear or affirm that I served
a copy of the Notice of Appeal, Common Pleas No. , upon the District Justice designated therein on
(date of service) , year by personal service []by (certified) (registered) mail, sender's
receipt attached hereto, and upon the appellee, (name , on
, year _, ? by personal service ? by (certified) (registered) mail, sender's receipt attached hereto.
? and further that I served the Rule to File a Complaint accompanying the above Notice of Appeal upon the appellee(s) to
whom the Rule was addressed on year by personal service E] by (certified) (registered)
mail, sender's receipt attached hereto.
SWORN (AFFIRMED) AND SUBSCRIBED BEFORE ME
THIS DAY OF , YEAR
Signature of AfBant
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Signature of official before whom affidavit was made
Title of official
My commission expires on , year
f COMMONWEALTH OF PENNSYLVANIA
;
COUNTY OF: CUMBERLAND
Mag. Dist. No.:
09-1-03
MDJ Name: Hon.
RICHARD S. DOUGHERTY
Address: 9 8 S ENOLA DR STE 1
ENOLA, PA
Telephone: (717 ) 728-2805 17025
JOSEPH ENGLE
108 4TH STREET
NEW CUMBERLAND,
NOTICE OF JUDGMENT/TRANSCRIPT
CIVIL CASE
PLAINTIFF: NAME and ADDRESS
riOFFITT HEART & VASCULAR GROUP
1000 NORTH FRONT ST
WORMLEYSBURG, PA 17043
L J
VS.
DEFENDANT: NAME and ADDRESS
rENGLE, JOSEPH, ET AL.
108 4TH STREET
NEW CUMBERLAND, PA 17070
L J
Docket No.: CV-0000266-06
PA 17070 Date Filed: 9/11/06
THIS IS TO NOTIFY YOU THAT:
DEFAULT JUDGMENT PLTF 10/12/06
Judgment: _ _ _ ,.. (Date Qf. J?udgme.ot? -_
® Judgment was entered for: (Name)
Fx1 Judgment was entered against: (Name)
in the amount of $ 686.11
Defendants are jointly and severally liable.
1-1 Damages will be assessed on Date & Tim(
F] This case dismissed without prejudice.
Amount of Judgment Subject to Attachment/42 Pa.C.S. § 8127
Portion of Judgment for physical damages arising out of
residential lease $
Amount of Judgment
Judgment Costs
Interest on Judgment
Attorney Fees
Total
$ 561.27
$ 108.00
$ 16•
$ .00
$ 686.1
Certified Judgment Total $
ANY PARTY HAS THE RIGHT TO APPEAL WITHIN 30 DAYS AFTER THE ENTRY OF JUDGMENT BY FILING A NOTICE
OF APPEAL WITH THE PROTHONOTARY/CLERK OF THE COURT OF COMMON PLEAS, CIVIL DIVISION. YOU
MUST INCLUDE A COPY OF THIS NOTICE OF JUDGMENT/TRANSCRIPT FORM WITH YOUR NOTICE OF APPEAL.
EXCEPT AS OTHERWISE PROVIDED IN THE RULES OF CIVIL PROCEDURE FOR MAGISTERIAL DISTRICT JUDGES, IF THE
JUDGEMENT HOLDER ELECTS TO ENTER THE JUDGMENT IN THE COURT OF COMMON PLEAS, ALL FURTHER PROCESS MUST
COME FROM THE COURT OF COMMON PLEAS AND NO FURTHER PROCESS MAY BE ISSUED BY THE MAGISTERIAL DISTRICT JUDGE.
UNLESS THE JUDGMENT IS ENTERED IN THE COURT OF COMMON PLEAS, ANYONE INTERESTED IN THE JUDGMENT MAY FILE
A REQUEST FOR ENTRY OF SATISFACTION WITH THE MAGISTERIAL DISTRICT JUDGE IF THE JUDGMENT DEBTOR PAYS IN FULL,
SETTLES, OR OTHERWISE COMPLIES WITH THE JUDGMENT.
f
Date Magisteti l District Judge
I certify that this is a true and co ect copy th oft e p edings conta Nrig th"?I'gif ment.
Date M glsterol pistrict Jue ge
My commission expires first Monday of January, 2012 SEAL
AOPC 315-06
MOFFITT HEART & VASCULAR GROUP
ENGLE, JOSEPH
DATE PRINTED: 10/13/06 8:36:00 AM
F I
CERT1FIED MAIL RECEIPT
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(Domestic Mail Only ;
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p R 'cted Delivery Fee C3 (Endorsement Required)
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p (Endorsement Required) O Total Postage & Fees J4 , to O Total Postage & Fees nJ
ru o Recipient's I Gail Guida Souders, Esquire mailer)
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C3 Moffitt. Heart & `V ascula c:3 siree? aPF. No: Guida Law Offices, P.C.
C3 street 111 Locust Street
p 1000 Noah Front Strect
P City, State, ZIPi
ciiy, s Wormleysburg, Pj 170 r- , r r Harrisburg, PA 171 1
smamz? 13M
Postmark,
Here )
V Mal
Richard S. Dougherty ------
l Drive, Suite 1 -------
17025
PROOF OF SERVICE OF NOTICE OF APPEAL AND RULE TO FILE COMPLAINT
(This proof of service MUST BE FILED WITHIN TEN (10) DAYS AFTER filing the notice of appeal. Check applicable boxes)
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF ; ss
AFFIDAVIT: I hereby swear or affirm that I served
a copy of the Notice of Appeal, Common Pleas No. 4> (a- &.5??, upon the District Justice designated therein on
(date of service) IoS, year,2?y0?6rclD by personal service 91by (certified) (registered) mail, sender's
receipt attached hereto, and upon the appellee, (name on
I ( 1 year 6 LO by personal service Mby (certified) (registered) mail, sender's receipt attached hereto.
and further that I served the Rule to File a Complaint accompanying the//above "_ Notice of Appeal upon the appellees) to
whom the Rule was addressed en ) ( -year V 0 by personal service Oby (certified) (registered)
mail, sender's receipt attached hereto.
SWORN (AFFIRMED) ANDS SC?R_I/B?E?D BEFORE MEN/
THIS -Cs" ll_? DAY OFA"'?'iEi 7. YEAR ?clG
Sg mqa of oWbW be0ore wean !mew wn made
N .
TAIe of ofRc
My commission expires on year j .
ONWEALTH, OF PENNSYLVANIA
Notarial seal
Anne IMeria Seshme. Notary Pudic
City Of Dauphin County
W ComntiniNh?i?i EVifss Apr. 5, 2008
Mernbsr, Panns*anis Aeaociabon of Notaries
Alv AA /I
Signature of Afrient
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MOFFITT HEART & VASCULAR GROUP
JOSEPH ENGLE
LUCINDA ENGLE
VS.
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 06 - to54A
NOTICE TO DEFEND
You have been sued in court. If you wish to defend against the claims set forth in
the following pages, you must take action within twenty (20) days after this complaint and notice
are served, by entering a written appearance personally or by attorney and filing in writing with
the court your defenses or objections to the claims set forth against you. You are warned that if
you fail to do so the case may proceed without you and a judgment may be entered against you
by the court without further notice for any money claimed in the complaint or for any other
claim or relief requested by the plaintiff. You may lose money or property or other rights
important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU
DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
CENTRAL PENNSYLVANIA LEGAL SERVICES
213-A NORTH FRONT STREET
HARRISBURG, PA 17101
1-800-932-0356
MOFFITT HEART & VASCULAR GROUP
VS.
JOSEPH ENGLE
LUCINDA ENGLE
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO.
COMPLAINT
AND NOW, this day of November, 2006 comes Moffitt Heart & Vascular
Group, above-named plaintiff, by and through its attorney, Gail Guida Souders, Esquire, and
respectfully avers the following:
1. Plaintiff is a corporation having offices at 1000 North Front Street, Wormleysburg,
Pennsylvania 17043.
2. Defendant, Joseph and Lucinda Engle are adult individuals residing at 108 4t' Street, New
Cumberland, Pennsylvania, 17070.
3. At the specific instance and request of Defendant, Plaintiff provided medical services to
Defendant at the times, amounts, and the prices for these services are indicated in
Plaintiff's Statement of Account, a true and correct copy of which is attached hereto,
marked Exhibit A, and made part thereof.
4. The prices charged by Plaintiff were fair, reasonable, and market prices that prevailed at
the times of the transactions.
ti
5. Defendant Joseph Engle was married to Lucinda Engle at the time services were rendered.
6. Although Defendant Joseph Engle was the Plaintiff's patient, Defendant Lucinda Engle is
also responsible for payment of said services pursuant to 23 Pa.C.S.A Section 4102.
7. Plaintiff avers that the balance due amounts to $561.27, which is below the limit for
mandatory arbitration.
8. As of November 22, 2006, the interest at the legal rate of six percent a year is $33.67.
9. Although repeatedly requested to do so by Plaintiff, Defendant has willfully failed and
refused to pay the aforesaid balance or any part thereof to Plaintiff.
WHEREFORE, Plaintiff respectfully requests that judgment be entered in favor of
Plaintiff and against Defendant in the amount of $594.94 with interest and costs.
Respectfully submitted,
Gail Guida Souders, Esquire
Guida Law Offices, P.C.
111 Locust Street
Harrisburg, PA 17101
717-236-6440
Attorney for Plaintiff
Supreme Court ID #68740
I, Kim Kern have read the foregoing document and hereby aver that it is based
upon information that I have given to counsel and it is true and correct to the best of my knowledge,
information and belief.
I understand that any false statements made herein are subject to the penalties of 18 Pa. C.S.A. §
4904, relating to unsworn falsification to authorities.
Date
900/900 QJ MI?J0 MVI VOIfl9 669696Z XV9 99'.61 900ZINA L
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Marvin Beshore, Esquire
Attorney ID No. PA 31979
130 State Street, P.O. Box 946
Harrisburg, PA 17108-0946
(717) 236-0781 FAX (717) 236-0791
Email: MBeshore@mblawfmn.com
MOFFITT HEART & VASCULAR
GROUP,
Plaintiff
VS.
JOSEPH ENGLE and LUCINDA
ENGLE,
Defendants
Attorney for Defendants
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2006-6542
: CIVIL ACTION - LAW
NOTICE TO PLEAD
TO: Moffitt Heart and Vascular Group, Plaintiff
c/o Gail Guida Souders, Esquire
Guida Law Offices, PC
111 Locust Street
Harrisburg, PA 17101
You are hereby notified to file a written response to the enclosed Preliminary Objections
within twenty (20) days from service hereof or a judgment may be entered against you.
Dated:
Respectfully submitted,
ya4j`
By:
Beshore, Esquire
Attorney ID # 31979
130 State Street
P.O. Box 946
Harrisburg, PA 17108-0946
(717) 236-0781
Attorney for Defendant
Marvin Beshore, Esquire
Attorney ID No. PA 31979
130 State Street, P.O. Box 946
Harrisburg, PA 17108-0946
(717) 236-0781 FAX (717) 236-0791
Email: MBeshore@mblawfirm.com
MOFFITT HEART & VASCULAR
GROUP,
Plaintiff
vs.
JOSEPH ENGLE and LUCINDA
ENGLE,
Defendants
Attorney for Defendants
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2006-6542
CIVIL ACTION - LAW
PRELIMINARY OBJECTIONS TO PLAINTIFF'S COMPLAINT
Defendants, Joseph Engle and Lucinda Engle, by their Attorney, Marvin Beshore,
Esquire, preliminarily object to Plaintiff s Complaint, as follows:
Motion for More Specific Pleading
1. Plaintiff asserts that it provided medical services to Defendant Joseph Engle at the
times, amounts, and prices indicated in Plaintiffs Statement of Account. Plaintiff
has attached no documentation for its assertion, all in violation of Pa. R.C. P. Rule
1019(i). There is no Exhibit A attached to the Complaint served upon defendants.
2. Plaintiff fails to allege with specificity all averments of time, place, and items of
special damage, all in violation of Pa. R.C.P. Rule 1019(f).
WHEREFORE, Defendants, Joseph and Lucinda Engle request this Honorable Court to
dismiss the Complaint or in the alternative, order the Plaintiff to further amend its Complaint and
such other relief as this Court shall deem just.
Date:
Respectfully Submitte ,
c
By:
Marvin Beshore, Esquire
Attorney ID # 31979
130 State Street
P.O. Box 946
Harrisburg, PA 17108-0946
(717) 236-0781
CERTIFICATION OF SERVICE
I hereby certify this L? day of December, 2006, that I served a true and correct copy of
the foregoing Preliminary Objections to Plaintiffs Complaint via United States Postal Service,
postage prepaid and properly addressed to the following:
Gail Guida Souders, Esquire
Guida Law Offices, P.C.
111 Locust Street
Harrisburg, PA 17101
Date: December JJL , 2006
Beshore, Esquire
Attorney ID # 31979
130 State Street, P. O. Box 946
Harrisburg, PA 17108-0946
Telephone: (717) 236-0781
Fax: (717) 236-0791
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MOFFITT HEART & VASCULAR GROUP
JOSEPH ENGLE
LUCINDA ENGLE
VS.
IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 2006-6542
NOTICE TO DEFEND
You have been sued in court. If you wish to defend against the claims set forth in the
following pages, you must take action within twenty (20) days after this complaint and notice are
served, by entering a written appearance personally or by attorney and filing in writing with the court
your defenses or objections to the claims set forth against you. You are warned that if you fail to do so
the case may proceed without you and a judgment may be entered against you by the court without
further notice for any money claimed in the complaint or for any other claim or relief requested by the
plaintiff. You may lose money or property or other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE
SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
CENTRAL PENNSYLVANIA LEGAL SERVICES
213-A NORTH FRONT STREET
HARRISBURG, PA 17101
1-800-932-0356
MOFFITT HEART & VASCULAR GROUP
JOSEPH ENGLE
LUCINDA ENGLE
vs.
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 2006-6542
AMENDED COMPLAINT
AND NOW, this ?1 day of December, 2006 comes Moffitt Heart & Vascular
Group, above-named plaintiff, by and through its attorney, Gail Guida Souders, Esquire, and
respectfully avers the following:
1. Plaintiff is a corporation having offices at 1000 North Front Street, Wormleysburg,
Pennsylvania 17043.
2. Defendant, Joseph and Lucinda Engle are adult individuals residing at 108 4t' Street, New
Cumberland, Pennsylvania, 17070.
3. At the specific instance and request of Defendant, Plaintiff provided medical services to
Defendant at the times, amounts, and the prices for these services are indicated in
Plaintiff's Statement of Account, a true and correct copy of which is attached hereto,
marked Exhibit A, and made part thereof.
4. As indicated in the Exhibit A, Defendant received medical services from Plaintiff at the
Holy Spirit Hospital located at 503 North 21" Street, Camp Hill, Pennsylvania from
February 4th through Ie and 23`d and 24th of 2006.
5. He was then treated by Plaintiff on March 10, 2006 at the Plaintiffs office located at 1000
North Front Street, Wormsleysburg, Pennsylvania. See Exhibit A.
6. The prices charged by Plaintiff were fair, reasonable, and market prices that prevailed at
the times of the transactions.
7. Defendant Joseph Engle was married to Lucinda Engle at the time services were rendered.
8. Although Defendant Joseph Engle was the Plaintiffs patient, Defendant Lucinda Engle is
also responsible for payment of said services pursuant to 23 Pa.C.S.A Section 4102.
9. Plaintiff avers that the balance due amounts to $561.27, which is below the limit for
mandatory arbitration.
10. As of November 22, 2006, the interest at the legal rate of six percent a year is $33.67.
11. Although repeatedly requested to do so by Plaintiff, Defendant has willfully failed and
refused to pay the aforesaid balance or any part thereof to Plaintiff.
WHEREFORE, Plaintiff respectfully requests that judgment be entered in favor of
Plaintiff and against Defendant in the amount of $594.94 with interest and costs.
Respectfully submitted,
141q
Gail Guida Souders, Esquire
Guida Law Offices, P.C.
111 Locust Street
Harrisburg, PA 17101
717-236-6440
Attorney for Plaintiff
Supreme Court ID #68740
1, Kim Kern have read the foregoing document and hereby aver that it is based
upon information that I have given to counsel and it is true and correct to the best of my knowledge,
information and belief.
I understand that any false statements made herein are subject to the penalties of 18 Pa. C.S.A. §
4904, relating to unsworn falsification to authorities.
Date
300/300 1n S30I330 MVI VOIn9 6696983 xH3 01:60 9003/03/31
PLEASE . .
NOT
STAPLE Ci U J. SSA. LAW
ST
IN THIS 1.11. .LOCU ;'1I `P
AREA HARRISBURG, PA 171.01. Q
V
PICA 1 U G4 b J 4 b 2 HEALTH IN SURANCE CLAIM FORM PICAFTT
1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER
(Medicare /) (Medicaid N) ? (Sponsors SSN) ? (VA F11. HEALTH PLAN I LUNG A) (SSN -10) (SSN) (ID) ,1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENTS BIRTH DATE
SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial)
EN(1 1, 1TO1C?>E1?1.1 F[]
09. 2h. 1995MEl
FNGI,1 ,,1OESEI?H E
5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSUREDS ADDRESS (No., Street) 2
108 4 `.1' 11 'S'TREET Self SPouee CNId OCar
El r
103 4rH ST RL:ET O
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CITY STATE e. PATIENT STATUS CITY STATE
NEW CUMBERLAND PA Single11 Mam-d? olherF? NEW CUMBERLAND PA LL
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDING AREA CODE) 2
D
1.1070
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7'17 - 774-96(iC) Full-Tlme Part-Time
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17070 1'4) -77 4 _9666
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9. OTHER INSUREDS NAME (Last Name, First Name, Middle Initial)
10.1S PATIENT'S CONDITION RELATED TO:
11. INSURED'S POLICY GROUP OR FECA NUMBER IM
a. OTHER INS (RED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH p
yW CY r3 0021. a: J 1. U YES NO
? 0 MM DO YY M SEX F
09. 2ti 1955 x z
b. OTHER INSURED'S DATE OF BIRTH
MM YY
SEX F
M
.1 b. AUTO ACCIDENT? PLACE (State)
VES b. EMPLOYER'S NAME OR SCHOOL NAME
?
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115
6, 1959 ?
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c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME a
a
Riverside Hearing Scr ?YES 1. W
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
X 0
V
YES NO N yes, return to and complete Rem 9 ed.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
12. PATIENTS OR AUTHORIZED PERSONS SK)NATURE I augadze the release of any medical or ottw Rao maw noceseery to
process this claim
I also request payment of
govemment benefit other to m
s
lf or t
fire
art
who awe
ts aael
rsr
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lt ow 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE I authorize
payment of medical bene6te to the undersigned physidan or supplier for
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SIGNED 21GNATUI;'1'. ON F TI1Z DATE .l (7EI SIGNED Ci.I. INA'T'I RR ()N 111-1'-p
14. DATE OF CURRENT: ,ILLNESS (Firm symptom) OR
MM DD , YY INJURY (Accident) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE MM DD W 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DO YY MM DD W
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
COX, LAWRENCE F94135 FROM 02. 04; 06 To 0MM DD 2; 07. U6
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
OYES [:] NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY..(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION
1.L4210:71 MYOCARDIAL INFARCT 3.E
-.- CODE ORIGINAL REF. NO.
23. PRIOR AUTHORIZATION NUMBER
1414: ()1 CORONARY All H E.ROSC 4
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24. A B . _
D E F G H I J K F
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DATE(S) OF SERVICE
Fran To
MM DD YY MM DO YY Place
Of
Sawlce PROCEDURES, SERVICES, OR SUPPLIES
U CYdnceWron
CPT (MOPCS Mi" ? DIAGNOSIS
?E S CHARGES DAYS
OR
UNITS EPSDT
Famy
Plan EMG COB RESERVED FOR
LOCAL USE
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25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
'-'.i3 1864
7 Far 9-1. dhi ms see back)
461530 YES []NO
1
$ 205.. 00 Is 113., 11 $ 6 ) 128
.
31. SIGNATURE OF PHYSICIAN OR SUPPLIER .
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
pcenKytnatmestatemernaoRalerevarae ENDERED T, other titan home or o(lfce) ,
14LY Eik?IR17' HC).?iPL`]'.AL b PHONE # ,
MOFF.['.i'T HEART & VAS (?t;5..112. GR(L
'
apply to this bill and are made a part dwreof.)
50.3 NORTH 21S`1.' STREET
1000 NORTH FRONT STREET
BO1i.EEIMAN, TODD A, MD, CAMP HILL, PAE
IhhA G, PA :170433
WORMLEYSBUR
SIGNED 07 18 06 DATE ? -
PIN A GRP A _
APPROVED OMS-09W-M FORM CMS-1500 (12-90), FORM RRB-1500,
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE SASS) PLEASE PRINT OR TYPE APPROVED OMB-1215 FORM.OWCP-1500, APPROVED OMB-0720-001 (CHAMPUS)
PLEASE
DO NOT
STAPLE
IN THIS
AREA
GUIDA LAW OFF1C:E
111 LOCUS'T' ST W
HARRISBURG, PA 1.7101. a
1
PICA HEALTH INSURANCE CLAIM FORM PICA FT7 +
1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
(Medicare N) (Medicaid #) ? (Sponsors SSN) E] (VA Flb M) ? ISSN or IDJAN 1:1 ISBLK SN) LUNG ? (ID)
2. PATIENT'S NAME (last Name, First Name, Middle initial)
).NC7r
T;
j,C) 3. PATIENTS BIRTH DATE SF?
F
'1
M
ly 4. INSUREDS NAME (Last Name, First Name, Middle lprda}
''
.I
'
SEPH ?
9; ?
) 55
? ENG [
,,JOSEPH E
5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSUREDS ADDRESS (No., Street) z
108 4111 STREET Self Y, Sj...e?ChW[:] Olher? 108 4TH STREET a
CITY STATE S. PATIENT STATUS CITY STATE
N1."W CUMBERLAND 1)A Single? Marded? Oth.r? NEW C;I.l.M13EsRl:AND -PA
ZIP CODE TELEPHONE (include Area Code) ZIP CODE TELEPHONE (INCLUDING AREA CODE) z-
17070 . 717 - 7 74- 9 6 66 Employed ? s
?
tre ? s aa
'?1e ? 17070 (71 `)- 774 -- 9 5 6 6 w
tDd
em
n
9. OTHER INSUREDS NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER cc
P.,rigLe, Lucinda
z_
a. OTHER INSUREDS POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED
S DATE
OF BIRTH SEX G
YWC?3()()?144 1101 ?YES a)VO J?
p
MU 9; If .L955 M X F[] Q
b. OTHER INSUREDS DATE OF BIRTH SEX
pq.
M
F
() b. AUTO ACCIDENT? PLACE (State)
YES
NO b. EMPLOYER'S NAME OR SCHOOL NAME
W
?
Q
; ?
?J
Z] F
c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME pa,
}.i1.Vert;.--i
d
(` 1'IEJa:Y`ing S(-?TV YES ? NO W
.
.
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? rc
X YES NO N M return to and complete Item 9 a-d. V
READ BACK OF FOAM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I audwrize dis release of any medlcel or other Wormatlan necessary to payment of medical benefits to the undersigned physician or supplier for
process this claim. I also request payment of govemment beneft either to mysell or to the parry who accepts assignment below. services described below.
SIGNED '""NATURE ON 1''.ILE1. DATE' ,7 18 06 SIGNED SIGNATURE ON FILE
14. DATE OF CURRENT: ILLNESS (First symptom) OR
MM DD YY '
NJURY
A 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
DO YY
GIVE FIRST DATE MM 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
YY MM , DD YY
MM DO
I
(
ccident) OR
PREGNANCY (LMP) , ,
FROM TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN N DATES RELATED TO CUARE DSSERVICYES
18. HOSPITAUZATI
O
LN("L
LAWI3
COX F94
1
35 ?
(
U2
(
1:)
U0
i
.
, .
. .
,
,
TO
FROM
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
?
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1.14.1. 01 (-"01%'ONARY ATHE'RUvSC 3.1 _._
23. PRIOR AUTHORIZATION NUMBER
2.41 1.0:11 MYOCARDIAL INFAR.C 4 0
24. A S C D E F G H I J K F
a
DATE(S) OF SERVICE
To Place
Of Type PROCEDURES, SERVICES, OR SUPPLIES
?
? DI
DIAGNOSIS
$CHARGES DAYS
VN EPSOT
F
s
mily
EMO
COB RESERVED FOR
LOCAL USE
MM DD YY MM DD YY S Mce Sella =
CPTh1CPC8 ITS p
k
In
02 ;06 ;06)
21
01
330`7 126:
1, 2 1
3'.151.00
1 LL
z
W
02 ;06 ;06 ; 21 01 3325 2'6 ; 1 , 2 65, 00 1 a
02 ;06 ;O(3
;
21
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1
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1
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25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
c64722
1:3
Elf] .146630 For govt. claims am badt)
YES NO
0; 00 S f) ;. 5,1 Is 1 `7 3?
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
(I ce" that the statements on the reverse lfRE r )• t
HC? y L' ?.11 11 i- rA.r., r r I r r„ r I C 1 i
1 I 1 11 11I?. I & VA > ( 11L.61I\ (i:k?.?) (.
k
apply to this bill and are made a pert thereof.)
503 NORTH 21`?T c3TRL?C.''
1.000 N0R''1?1 FRONT SN''IZ1 K'1'
t3C-i'lMAN, TODD A, MD, CAMD HILL, RA 1'701.1 PA 1.704,3
SIGNED 07 1.8 06 DATE PIN a GRP 0
1
4
5
6
APPROVED OMB-0838.OIAN7 I-ORM GM6-i6W (tc-w), rvnm nnw-Iwv,
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 6088) PLEASE PRINT OR TYPE APPROVED OMB-1216 FORM OWCP-1500, APPROVED OMB-0720.001 (CHAMPUS)
PLEASE
DO NOT
STAPLE GU.IDA LiAW OFFICE
IN THIS 1.11 LOCUST, ST
AREA -? HA.R.RISBUE).G-, PA 17.101.
U
PICA IUM153452 HEALTH INSURANCE CLAIM FORM
PICA
1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
HEALTH PLAN BLK LUNG
(Medkare R) (Medicald #) 1:1 (Sponsors SSN) ? (VA File #) (SSN or ID) (SSN) a (ID)
2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. P TIENTS BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Ir")
ZNG)1:l:F JOIS, E PfI (j9? T,- 1955"" :X F ENGLE,JOSEPH E
5. PATIENTS ADDRESS ( No., Streat) 8. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)
1.0£3 4TH '>I.V}2EET
SOWER] SP0uee?Ch0d Otiar
108 4TH STREET 0
F
CITY STATE 8. PATIENT STATUS CITY STATE
N k W C.". C)MH ER:GAND }? j\ Single Married other
? ?
NEW CUMBERLAND
PA
LL
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDING AREA CODE) Z
17070 (717_)--774--9666 Employed FsaeeMe stIudeni 1.7070 (71' ) -774- 9666 w
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR MCA NUMBER
1:rtc:1.F
Lucinda N
, z
a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH 0
YtJ (~ () U 214 1 C)1 YES NO
? ? MM DO 1.,, M SEX F
0q. 2 .x 955 Q 2
a
b. (OTHER INDSURED'S DATE OF BIRTH SEX
S
M
F b. AUTO ACCIDENT? PLACE (State)
YES
W b. EMPLOYER'S NAME OR SCHOOL NAME
?
?
t3; 1.6
; 1959 ?
F
O I
c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME a
River dde Hearing D(-
,rv ?YES NO W
.
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? IL
X YES NO M yes, return to and complete Item 9 a-d. IM
(aj
READ BACK OF FORM BEFORE COMPLETING A SIGNING THIS FORM.
12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of an me" or other htbnntlon necessary to
process this claim. I also request payment of government berte0ts eflher to m
self or to me
who acce
art
ts assi
nment Now 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
payment of medical beneft to the undersigned physician or supplier for
s
ic
de
c
ib
d b
l
y
p
p
g
.
y erv
es
s
r
e
e
ow.
SIGNED i_Q1NATURE ON FILE DAT0 7 18 06 SIGNED ?-i k 61NATT IR F. ON F'f 1 ,r
14. DATE OF CURRENT: ILLNESS s
MM DD YY I NJURY (First y (Accident) OR ) OR OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE MM DO YY 18. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD YY MM DO YY
PREGNANCY (LMP) FROM . TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
COX, LAWRENC",) 1'941.3 5
MM : DO YY
2. 09; 06 TO MM 1 DD YY
FROM 0
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
? YES ? NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION
1. 71 (?6: i9 Pr' IN CHEST OTHER 3. L4 -1. 4;_01. CORONAR AT CODE ORIGINAL REF. NO.
23. PRIOR AUTHORIZATION NUMBER
2. I4 1_1: C) PC)STMYOCARDIAL :IN 4 401
, 9 1W.PERr. ENa1:0 0
24. A B C ,
D E F G H I J K Q
DATE(S) OF SERVICE
TO
MM From Yv MM DD. YY Plus
Of
SsMa Type
Beryls PROC(EF?DUgRIEE ,SERVICES, OR SUPPLIES
'CPTA?CPCS MODIFIER
NC6
D?OWEE IS
f CHARGES DAYS
UMTOR
S EPSDT
FPW
IM*
EMO
COB
R LOC/?iIEUSFOR I
M
(12 ;t19 iO6
21
01
)9254
1
2
3
00
125;
1 LL
z
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a
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0
; a
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;
25. FEDERAL TAX I.D. NUMBER SSN EIN 28. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
?
23 ...1864`(22 For govt claims a" beck)
146630 YES 14 F 1 C' $
= 225. 00 t 132:15 33; 1
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRES$ OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
(I certify that the Statements on to reverse RENDERED other titan fame or office)
HOLY SmPIRIT HOSPITAL b PHONE #
MOYFI:TT HEART & VASCULAI:'. (ikWL
apply to this bill and are made a pert thereof.)
503 NORTH 21ST STREET
1000 NORTH F) ONT S`1'R.B)=T
BOKF,C,MN, r.POD.D A, MD, CAMP HILL, PA 17011. WORMLLYSBURG, PA 17043
SIGNED U 7 18 06 DATE PIN a GAP a
APPROVED OMB-0938-0008 FORM CMS-1500 (12-90), FORM RRB-1500,
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8188) PLEASE PRINT OR TYPE APPROVED OMB-1215 FORM OWCP-1500, APPROVED OMB-OnD-001 (CHAMPUS)
PLEASE
DO NOT GUTDA LAW OI'F::LC:E is
STAPLE
IN THIS 111 LOCUST ST
AREA 1iARR 1'S)BY.1R.G , PA t7101
a
v
I
PICA )' b L HEALTH IN SURANCE CLAIM FORM PICA
1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER Ia. INSURED'S I.D. NUMBER (FOR ROGRAM IN ITEM 1)
HEALTH PLAN SLK LUNG
(Medicare ><)? (MedYcald #) (Sponsor's SSN) F? (VA F8e N) (SSN or ID) Q (SSN) (ID)
2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENTS BIRTH DATE SEX 4. INSUF,(ED'S NAME (Last Name, First Name, Middle lord, 01
I?NC.)l::lf? JOSEPH: r9, 1'?5t'"a F[ EN(?LE,,:10;:3EI?lI F
5. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INS, RED'S ADDRESS (No., Street) Z
108 4TH 1.'R]-,:E`I' San X
Spouse?aawE] other?
1
10€3 4r.I'II STREET
a
CITY STATE B. PATIENT STATUS CITY STATE g
NEW C IMBE'1 LAND PA Single? Marrled? Other? NEW (N MBE'RLAND f)A . LL
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDING AREA CODE) Z
1 U 7 (.) 717 --774-9666 Empbyaa ? Student Part-Time me ? 17070 (71 ) -- 774 -- 9 b 6 G w
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER
E'ngl.c?, Lucinda z
a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURE
D''S DATE OF BIRTH 0
YW C 8 U ( )214 41-7 1. 01 ? YES NO AA
1J ?): L J; .L 9 55 M x' F Q
DATE OF BIRTH
b. OTHER IINSURED''SS
SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME
,
F E
?1.M l) ? 1.g C) , i `_-I 5 9 ME] ? YES NO
L-J W
c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME a
1_i..:).. V c'r i d. C'. I'1 c? a r 1 n g S e r V
YES NO
11 El
W
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
X YES NO K ywa, return to and complete Item 9 a-d. U
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I autlalfze ft release of any medbal or other Wairnatbn necessary to 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE I autlartze
paymerht of medical benelfa to the undersigned physician or supplier for
process We claim. I also request payment of govemmard bwwft ether to myself or to the party who accepts assignmem balm. servbes descrted below.
I ON I' I
1
") LNAT0R
17 J
0 06 SIGNATURE ON FILE
.
-
OATS
.
SIGNED SIGNED
14. DATE OF CURRENT: ILLNESS (First symptom) OR
MM DD YY I
U
Y
A
i
OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
YY
DO
GIVE FIRST DATE MM 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD YY
MM DD YY
NJ
R
(
cc
dent)
PREGNANCY (LMP) '
; TO
FROM
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN
' 18. HOSPITALIZATION DATES RELATED TO CURRENT DSERVICYES
Q?
?9
u
COX, LAWRENCE, 1{
94-135 ,
;
' TO ;
FROM
19. RESERVED FOR LOCAL USE 2o. OUTSIDE LA137 $ CHARGES
DYES [:]NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2;3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1 14 .1..0. 71 MYOCARDIAL :f.NP'AR.(_' 3
1
_ _
. 23. PRIOR AUTHORIZATION NUMBER
2. 4114:01 C01ZONARY ATHER.OSC 4.L-.- o
24. A B C D E F G H I J K Q
DATE(S) OF SERVICE
From To Place
of Typo
of PROCEDURES, SERVICES. OR SUPPLIES
Umrsai Giam"n'
NA
S
DUDE IS
$ CHARGES DAYS
UNO? EPSOT
Fan
EM0
COB RESERVED FOR
LOCAL USE
MM DO YY MM DO YY Seals 9ervla CPCS MWFI
CPTR 0
0 :06
(
)Z ;1
21
01
92'3:?
1,2
50,. 00
,1. LL
z
-
. .
i w
J
a
a
U)
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a
1
25. FEDERAL TAX I.D. NUMBER SSN EIN 28. PATI NTS ACCOUNT NO. 27. ACCEPT ASSIGNMENT?
dshns see back)
jFor govt 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
'
<;.3 If3() 4'72- _
.
1•'?f7() 3(.) YES NO
/ i 10
$ `7 0:0 0 0 s Z Oil .3 t:3 $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
FkEjNpIrREA 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
11
WR
U
=
AM I
:F
(icentythatthestatementsontMreverse ?IC
JLLYY ?? ' MTAL . c
,
uA
TT HEART & VASC
AIM to this bill and are made a part thereof.) 503 NORTH 71 .?=>T ST.RE.I`T 1000 NORTH FRONT STREET
BOKE-11M.EAN, ':1'ODD At MI), CAM]") HILL, PA 1.7011 WORMLEY`:BUR.G, PA 1104,3
SIGNED O 18 0,0 DATE PIN N GRP l _
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8188) PLEASE PRINT OR TYPE APPROVED OIL-1215 FORM OWCP•1500, APPROVED OMB-0720.001 (CHAMPUS)
PLEASE
DO NOT
STAPLE
IN THIS
AREA
(DUIDA .LAW 01"1'ICE
1.11 LOCUST ST
IIA.RRISBUR(:3, PA 1. t(.i.t..
1
tx
W
OC
Q
PICA 'U5 24b 1) 4 5 2 HEALTH INSURANCE CLAIM FORM PICA FTT
1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER Ia. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
(Medicare N) (Mekscaid X HEALTH PLAN BLK LUNG
(Sponsors SSN) ? (VA File N) ? (SSN or ID) (SSN) a (ID)
2. PATIENTS NAME (Last Name, First Name, Middle Initial)
'' 3. PATIE QSDBIR SATE S 4. INSURED'S NAME (Last Name, First Name, Middle Initial)
E
] E JOSEPH T9i 2 5. 19 b "r F? I NC,.C,E , JOSEPH E
5. PATIENTS ADDRESS ( No., Street) 8. PATIENT RELATIONSHIP TO INSURED 7. INSUREDS ADDRESS (NO., Street) 2
1003 4TH I self sparse cmd other
X ?
10F3 4TH STREET °
CITY STATE P
ATIENT STATUS
S. CITY STATE
N:E,W CUMBERLAND I PA Single? Married? Other[ NEW CUMBERLAND PA o
ZIP CODE TELEPHONE (Include Ares Code) ZIP CODE TELEPHONE (INCLUDING AREA CODE) Z
17 0 7 0 1 (7.17)-774-9666 Employed F "-19nt sn't'a
? s ? 17070
(71 ) -"174--96-66
W
9. OTHER INSUREDS NAME (Last Name, Firm Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER
Engle
LLIC1
nda
,
. z
e. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH p
YWC00011.4471.01. NO
?YES FX] DO YY [] E]
M09. 25. 1955 M a' SEX F
Q
b. OTHER INSUREDS DATE OF BIRTH
SEX
MM
RD
Y
Y
- b. AUTO ACCIDENT? PLACE (State)
- b. EMPLOYER'S NAME OR SCHOOL NAME
,
r, M
..
199
F FL]
1
YES NO L?
1 FX1
c
EMPLOYER'S NAME OR SCHOOL NAME
. c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME a
Riverside
IIeal'ing Sere ?YES E NO W
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? IS
X YES NO K M return to and complete Rem 9 a-d. S
U
READ BACK OF FORM BEFORE COMPLETING a SIGNING THIS FORM.
12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the refease of any medcal or oUler blormation necessary to 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
medical benefits to the undersigned physician or supplier for
=
process this claim. I also request payment of liwom nerd benefffs alther to myself or to the party who accepts aedgnrrwnt below. aerviaa described below.
described
SIGNED al-ONATURE ON I' TTrE DA1f) 7 1a L SIGNED '11(iNAT11R F: ()N F ) Cr F.
14. DATE OF CURRENT: ILLNESS (First symptom) OR
MM DD W 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE MM DD W 18. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD W MM DD W
INJURY
A
/ ) OR
M
PREGN
)C P) ) FROM TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
COX, L.AWRENCI- P94135
MM : DO YY
FROM 02. 04. 06 TO MM i DD W
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
D
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
x.141.(:): 71 MYOCARDIAL INFAR.C;
23. PRIOR AUTHORIZATION NUMBER
z
1414, 01 CORONARY ATHEROSC 4 o
.
24. A B C . _
D E F G H I J K
DATE(S) OF SERVICE
From To
MM DD Yv MM DO W Piece
a
Sella Type
of
servbe PROCEDURES, SERVICES, OR SUPPLIES
Churalarm)
CPTMCPCS MODIFIER DIAONOSIs
CODE
$ CHARGES DAYS
OR
UNrr8 EPSDT
Ferny
Phn
EMG
COB RESERVED FOR
LOCAL USE
i
t
02 :09 100
21
01
35101 26:
1
2
600:1 00
1 L L
3
,
W
(:12 E0 9 106 ? ? 21 01 3545 2
1 1C)D,00 1 a
,
"j2 109 06
21.
01
.3543
1,2
1001, 0(.)
1 r n
_ 0
Z
C):()5 C) L,
):l
01
35 6 26;
2
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90;, ()C)
1
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02 :09 :00
21
01
::]55b 26
1
2 r
00
S)0'
1 N
a
. . , , .
, ,
r
25. FEDERAL TAX I.D. NUMBER SSN EIN 28. PATIENTS ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
. I-I
,.,:3 18647'1.2 iY> II _ For govt. claims an back)
146630 YES No $ $ $
9800.00 3h2:.93 08:')2
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
(I Ceruythat thestatements onthereverse RENDERED If odw than home or office)
HOLY SPIRIT HOSPITAL S PHONE A
MOFFITT IIEAR.T & VASCULAR GkOi
I
appy to this bill and are made a part thereof.) 503 NORTH '21ST c aTRFI;I , r ,
., ' r
1000 NORTH FRONT S Ti,. RhC;I.
JONES, STEVEN, MD, FA CAMP HILL, PA 17011 WOR.MTiEYS)B1JRG, PA 17043
SIGNED 07 1.8 06 DATE PIN a GRP M
2
3
4
E
E
APPROVED UM5-WJtf-Uk= rUMw %1M0-10W 0,c ), rvnm nnv-, wv,
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 81108) PLEASE PRINT OR TYPE APPROVED OMB-1215 FORM OWCP-1500, APPROVED OMB-0720.001 (CHAMPUS)
PLEASE
DO NOT G; U I D.A MAW Ol.i' F 1. C'. E
STAPLE IM
IN THIS 111 LOCUST.' ST
AREA HARRISBURG, PA 171.01 a
v
PICA L Q 41±Q 0 g D z HEALTH INSURANCE CLAIM FORM
PICA FTT
1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER
HEALTH PLAN BLK LUNG
(Medicare 1) (Medicald N)O (S
'
SSN 1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
ponsor
s
) O (VA FNe (SSN or ID) (SSN) X (10)
2. PATIENTS NAME (Last Name, First Name, Midde initial) 3. PATIENTS BIRTH DATE
ssx
T 4. INSURED'S NAME (Last Name, First Name, Middle IpM&
L:N(SLE JOSEPH FO
)55M -
r9; nI -f ENGLI_,,.:1OSEPIi E
5. PATIENTS ADDRESS (No., Street) B. PATIENT RELATIONSHIP TO INSURED 7. INS, RED'S ADDRESS (No., Street) 2
108 4TH ::3':1:'1:.1:I::T sen R.7
sp--[:]ch8d0 other
108 4TIi STREET 0
P
CITY
STATE
8. PATIENT STATUS
_
CITY
STATE 2
NEW CC.IMNER1jAND IAA Sln&r
1 MardedR other0 NEW CUMBERLAND PA O
ZIP CODE TELEPHONE (Inch Area Code) ZIP CODE TELEPHONE (INCLUDING AREA CODE) Z
17070 (717)-774-9666 Empbyed?FSIeOsmdenme0 1.`70'70 ('71IV. 7'74 9666 o
W
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Inttian 10. IS PATIENTS CONDITION RELATED TO: 11. INSUREDS POLICY GROUP OR FECA NUMBER
Eric lc,, Lucinda
z
a. OTHER INSUREDS POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX p
YWC80021.44 7101 OYES aNO Ty: T5: 1955 M? F? Q
b.
b.IOMTHER INSUREDS DATE OF BIRTH
1. l) I.1 M ? SEX FE] b. AUTO ACCIDENT? PLACE (State)
? YES NO b. EMPLOYER'S NAME OR SCHOOL NAME 16-
F
c
EMPLOYER'S NAME OR SCHOOL NAME a
. c. OTHER ACCIDENT? c. INSURANGE PLAN NAME OR PROGRAM NAME
River a1 (.'Ic 11paring Se.rV YES NO
?
W_
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? IM
a YES ? NO N yes, return to and complete Nam 9 a-d. a
t.1
READ BACK OF FORM BEFORE COMPLETING A SIGNING THIS FORM.
12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I auCadze the release of erry medal or other Information necessary to 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE I authorize
payment of medical beneels to the undersigned physician or supplier for
process this claim. I also request payment of government beneMs elfMr to myself or to the party who accepts assignment below. services described below.
SIGNED SIGNATURE ON FILE DAT.d'/ 18 06 SIGNED SIGNATURE ON FILE _
14. DATE OF CURRENT:' ILLNESS (First symptom) OR
MM DD YY INJURY
A
d 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE MM OD YY 18. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
DO YY
MM DD
YY MM
(
ent) OR
od
PREGNANCY (LMP) ,
,
FROM TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN RELATED TO CURRENT SERVICES
18. HOSPITALIZATI
O
N
DAT
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S
COX
LA.WRENCE F94135 Q
.
y
?
?
D
ut) Gd MM DD YY
, FROM 1 1 TO 1
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
LIVES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
,. 414.01 CORONARY ATHIR.UISC
23. PRIOR AUTHORIZATION NUMBER
2Lf.LL , 410,11 'M.YOCAIZDIAL _CNFAR.C 4 _ o
24. A B C D E F G H I J K Q
DATE(S) OF SERVICE
From TO Place
Of Type
a PROCEDURES, SERVICES, OR SUPPLIES
" Ck'axrohnca
?I W
N
'
DIAGNOSIS
CODE
$ CHARGES DAYS
OR EPSDT
FarMy
EMG
008
RESERVED FOR
LOCAL USE
MM DO W MM DD YY Servla SsMa MO.1.
CPTA C CP S
r UNITS Plsn
i O
?
02 :05 ;06 21. 01. 9232 1,2 80., 0U 1. z
1
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1 1 1 r r r V
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1
1 1
1
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25. FEDERAL TAX I.D. NUMBER SSN EIN CCEPT ASSIGNMENT?
28. PATIENTS ACCOUNT NO.
or govt Balms no back)
. S. TOTAL CHARGE 129. AMOUNT PAID 30. BALANCE DUE
° ''
23 864'722 ?Ej ,
.
1.466: 10 ONO
2YES
5Ey
54:124 S 1 .a
a £ Oy C)0 a
31. SIGNATURE OF PHYSICIAN OR SUPPLIER WHERE SERVICES WERE
OF
32. NAME AND ADDRESS
FACILITY AN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
I
CI
33. PH
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S
th
INCLUDING DEGREES OR
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503 NORTH 21"'31' S'.['REET _
1000 NORTH FRONT STREET
MYER, Id.)t.Ja_E
DO CAMP PA 17011 WORMI:EYSBUR.G, PlA :1.7043
,
SIGNED 07 18 06 DATE PIN N GRP A _
a
4
5
fi
AVt'HVVtU VMO-WSeKMw rumm ?M_ t.-), 1-1 ,,,...-,..w,
(APPROVED BY AMA COUNGL ON MEDICAL SERVICE 8188) PLEASE PRINT OR TYPE APPROVED OM&1215 FORM OWCPASOD. APPROVED OMB-0720.001 (CHAMPUS)
PLEASE 1
SO NOT
LE GUII_)A 1,AW (A."l C:E W
IN THIS 111. LOCUS,'.[' (ST of
AREA BAR.R. I S BURG , PA 1.710.1.
V
I
PICA 18246:3452 HEALTH IN SURANCE CLAIM FORM PICA FTT
1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER Is. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
HEALTH PLAN BLK LUNG
(Medkare x)? (Medicaid 0)? (Sponsor's SSN) [] (VA FlIe N) (SSN or ID) (SSN) X (ID)
2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SIX 4. INSURED'S NAME (Last Name, First Name, Middle InI8a0
F:NG]::E J0. Sf1PI , 2b, 1955M X F? ENG:I'., JOSE2H E
5. PATIENT'S ADDRESS (No., Street) 8. PATIENT RELATIONSHIP TO INSURED
e
t)
A
DDRESS (No., Sft
7. INSUURED'S O
Z
.1-08 4TH STREET SO X Sp0U9a Cmd Other 7
?
l
108 4'1 H STREET
CITY STATE S. PATIENT STATUS CITY STATE
NI?W CU I ER
LAND PA Single? Married? Other[:] NEW CUMBERLAND PA LL
.
ZIP CODE TELEPHONE (Induce Area Cade) ZIP CODE TELEPHONE (INCLUDING AREA CODE) Z
1 '7 0 `7 0 717 - 7 7 4- 9 6 6 6 Employed ? Stu ldeent 1:1 Sbxieent ? 1.7070 (('11')) -- 77 4 9 6 6 6 w
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER
a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSUR ADDS DATE OF BIRTH SEX Z
YIdC8002144'7101 ?YES RNO U9. 2a 1955 M X F Q
k
b. OTHER INSURED'S DATE OF BIRTH
SEX
M D
W
, b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME `
M
.,
F T
1?0; 7..6; 19
59 ? Q YES NO
? X? u
a
c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME a
RIVIERS.II_)E HEARING SERV
1-1 YES E NO
w
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
I RX
X
a
YES NO M yes, return to and complete Item 9 a-d. V
READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM.
12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any medical or other Inkm adon necessary to 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
payment M medical benefits to the undersigned physician or supplier for
process this claim. I also request payment of government bereft either to myself or to the party who accepts assignment below. servlooe described below.
LIONAT RE ON ' fTIF. DaTQ`7 18 (16
SIGNED
SIGNED =;.rruA'T'I1RF ON I" TTY
_
14. DATE OF CURRENT: ILLNESS (First symptom) OR
MM DO YY
id
NJURY
A
OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE MM DO YY 18, DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DO , YY MM DD YY
I
(
cc
ent)
i PREGNANCY (LMP) i i FROM i i TO i
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
COX, LAWRENCE F941.35 FROM 021 23: 06 TO
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
?YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
.4: C).1 CURON.ARY ATHEROSC 3
L4I
1
1
.
-_•-
.
-
23. PRIOR AUTHORIZATION NUMBER
Z
51 PAIN PRECOR:DIA:I1 4
2
x O
.
:
.
24. A B C D E F G H I J K Q
DATE(S) OF SERVICE
From To Place
of Type
of PROCEDURES, SERVICES, OR SUPPLIES
(Ezp CYabrreWaw
A
S' DIAGNOSIS
COPE
S CHARGES DAYS EPSDT
?
?
Oki RESERVED FOR
LOCAL USE
MM DD YY MM DO YY Service Servo S MOD M
CPTA?CPC ta•1R3 Q
k LL
?
02 123 :06 21 01 92 22 1
2 160;, 00 1
,
W
02 ;24 ;06 11 01. 9232 1,2 801, 00 1 a
N
O
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a
I I
I
25. FEDERAL TAX I.D. NUMBER SSN EIN 28. PATIENTS ACCOUNT NO, 27. ACCEPT ASSIGNMENT?
dalms a" back)
For govt 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
23-1864722 ?FLI .
146630 YES NO $ ,1 Oi, 00 $ 1.48:, 26 $ 37 ; 07
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
5 PHONE
INCLUDING DEGREES OR CREDENTIALS
(Ica tythatthestatementsonthereverse ENDERED it other than home or dfios)
HOLY S IR.I`I' HOSPITAL MO F'F'I:TT HEART & VAISCULAV GIRO
apply to this bill and are made a pan thereof.)
503 NORTH 21.57' STREET
1000 NORTH FRONT T ' F3TREE' I
WALSEi, TIMOTHY, MD DAMP HILL, P.A 1'70:11 WORMLEYSRURG, PA 1.'7043
SIGNED 07 18 06 DATE PIN a GRP t
APPHOVtU LaNlYlnik70iAAla rvrna I--- 10W l!c-w/, ..,....-
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8188) PLEASE PRINT OR TYPE APPROVED OMB-1215 FORM OWCP-1500, APPROVED OMBV20.001 (CHAMPUS)
PLEASE
DO NOT GUIDA LAW 01" FICE ?
STAPLE
IN THIS 1.1,1 LOCUST ST
AREA HARRISBURG, PA. 171011 a
I
PICA j- o zq v j qD z HEALTH INSURANCE CLAIM FORM PICA
1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER
- 1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
HEALTH PLAN SLK LUNG
(Madlcare #)1
1 (Madloald d) ? (Sponsor's SSN) ? (VA F Ie N) (SSN or ID) (SSN) [K] (0)
2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENTS BIRTH DATE
SIX 4. INSURED'S NAME (Last Name, First Name, Middle Ipitie)
I?:NC7I,E JOSEPH F[]
r9; n- i 1%5g' X E.NVL:H,JUSI.i?FI )
S. PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INS RED'S ADDRESS (No., Street) Z
1-08 4111 135TR.EE'T
sen Y? sp-[:]cmd? oti,.r?
-1 08 4T11 STREET ' O
14
CITY STATE 8. PATIENT STATUS CITY STATE 2
N.I.,'W C'.I.TMBERGAND PA Single? Married Other? MEN CUMBERLAND PA
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE
TELEPHONE (INCLUDING AREA CODE)
2
17070 (717)-774--9666 Employed FulS [] Sh?Te ??tt
1 lJ 7 V i 71 -7V4-9666
w
9. OTHER INSUREDS NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSUREDS POLICY GROUP OR FECA NUMBER
1 ngic: , Lucinda z
a. OTHER INSUREDS POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURE
D''S DATE OF BIRTH
SEX p
YWC80021.4471..01 ?YES NO AA
FE]
U??; L5; X955 ME] Q
b. OTHER INSURED'S DATE OF BIRTH
kTA(
) p M SEX F b. AUTO ACCIDENT? PLACE (State)
YES NO b. EMPLOYER'S NAME OR SCHOOL NAME
a
,
I. ?
c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANGE PLAN NAME OR PROGRAM NAME G.
RiVF'I'Lil(: ) I'1(:'2I'1IJ.C Se.r'V ?YES X NO w
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? Ir
X
Lftj YES NO H yea, return to and complete Item 9 a-d.
(aj
READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM.
12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the rolseee. of any medical or other Information neoeesary to
process this daim
I also request payment of gdwemment benefits either to m
self or to the
who acce
ts assl
nmeM below
art 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I aulhorize
=described medical benefits to the undersigned physician or supplier for
servk:ea described below
.
y
p
y
p
p
. .
SIGNED ST( NATURE; ON FILE DATQ7 18 06 SIGNED S-IUNATURE ON FILE
14. DATE OF CURRENT: ILLNESS (First symptom) OR
MM DD YY
Y 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE MM DO YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DO YY MM DD YY
INJUR
(Acddent) OR
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
COX
ENCE
LAWR F94135 MM DD YY
U6, U4; a
.
, TO
FROM
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
O
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2;3 OR 4 TO ITEM 24E BY LINE)
' 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
7? 86:59 PAIN CHEST OTHER 3.141..0_00 MYC?C.ARDI L'
1.
23. PRIOR AUTHORIZATION NUMBER
4
1
01 CORONARY ATHERO SC
4 0
.
1
:
4.? _
2.
E F G H I J K F
24. A B C D a
DATE(S) OF SERVICE
From TO Play
ot Type PROC(EEDURIr?S, SERVICES, OR SUPPLIES
A
U ?'
CE 81S
DU6NO
= CHARGES
DAYS
OR
EPSOT
w?
F
EMO
COB
REST SERVED R
MM D
D YY MM DD YY
Service
so.
jF(E
OPTIHCPC3
UWrS
ft
cc
02 ,04 ,06
11.
01
9223
1
230: 00
1 LL
Z
W
02 ;05 :06 11 01 2.980 LD ; 2,3 2000:,00 1 a
02, ;0b 06
21.
U1.
31,110 126:
2, 3
600„ 00
1 N
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21
01
3545
2,3
1ClU;, 00
1
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02 05 ;06 21 01. 43543 2,3 100; 00 1 a
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i
26. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO, 27. ACCEPT ASSIGNMENT?
?°?`)
?cl? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
'
23 _ 186472;.'. 1466301 lin YES
NO $ 3030;, 00 s 1212,-
..381$ 303M
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAWS, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS
th
t
th
t
t
i
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L'1
AL
Iit?"'h0` ` r
?Ti li?~:ART & VAS CU:1IAR UROt
I
a
e s
a
emeri
a ill and are made part Hereof.)
a
ppy too
b -
.
I' S`.1'REE`I'
503 NORTH 21.7' -
1000 .NOI:.'I'H FRONT a`l'RL;I"`.1'
RICE, KEII.CI.I, MD .
CAMP HILL, PA 17011 WOI2M:1j)r5'SBT-JRG 1 PA 1.7(.)4;3
SIGNED 0-7 18 06 DATE PIN r GRP e
1
3
4
6
6
A rmvvcU vm.--wvu rvnm -- I - I --" , ,,,,I ........ ........
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE SM) PLEASE PRINT OR TYPE APPROVED OMB-1216 FORM OWCP-1SW. APPROVED OMB-0720-001 (CHAMPUS)
PLEASE 1
DO O
GUIDA ] AW OF1 TCE I?u
IN THIS 111 LOCUST >T ?
AREA HARRISBURG, PA 17101
I
PICA 18246:3452 HEALTH IN SURANCE CLAIM FORM PICA
1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
(Medicare /)? (Medtcald I) ? (Sponsors SSN) ? (VA File k HEALTH PLAN BLK LUNG
(SSN or ID) (SSN) ? (ID)
2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S
BIR SATE
S 4. INSURED'S NAME (Last Name, First Name, Middle Initial)
E?.NG]JE J SEPH O
F?
19i 25i 1
955M X ENG1'
E
JOSEPH E
. ,
.,
5. PATIENTS ADDRESS (No.; Street) S. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Sheet) Z
108 4TH :1)'T'RF1-'-,T
sear F x-]
El El Child oalar
108 4TH STREET O
a
CITY STATE 8. PATIENT STATUS CITY STATE
NEW C:i?M13ERIItZ.AdD I)A Single ? Maniad? Other[:] NEI4 CUMBERLAND PA LL
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDING AREA CODE) 2
17070 (717)---774-9666 Employed s sa'",aanni e 1 '7 0 7 0 (71 )- 7'1 - 9 Ei 6 6 W
9. OTHER INSURED'S NAME (Last Name, First Name, Middle InPoaq 10. IS PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER
Engle
Luai
nd
a z
,
.
.
a. OTHER INSUREDS POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX p
YWC:800214471.01 ?YES aN0 M0q 2? 1955 M X F[:] a
b. OTHER INSURED'S DATE OF BIRTH
DO YY
SEX F
T
M b. AUTO ACCIDENT? PLACE (State)
YES
NO b. EMPLOYER'S NAME OR SCHOOL NAME
[j]
o: 1
6: 11) 5 9
E:]
X
c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME a
R.IV1'.RS' lllE'. 111::.AR.I NG S1: RV ?YES El w
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? FE
X
? V
NO M yea, return to and complete Hem 9 a-d.
YES
READ BACK OF FORM BEFORE COMPLETING A SIGNING THIS FORM. 13. INSURED'$ OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other inlonnadon necessary to payment of medical benefits to the undersigned physician or supplier for
process this claim. 1 also request payment of government benefits either to myself or to the party who accepts assignment below. services described below.
SIGNED a1GNA`T'URE ON T' ITIE?. DATED I S 06 SIGNED 3 M NAT(TRE ON F'L T.T'.
14. DATE OF CURRENT: ILLNESS (First symptom) OR
MM DO YY 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE MM DO YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DO YY MM DO YY
INJURY (Accident) OR
PREGNANCY (LMP) : FROM TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM DO YY MM
' DD YY
COX, LAWIRENCE F94135 FROM 0Z: 23: 06 TO
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
?YES ?NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) -7 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1
1.L47?4: 0,1, CORONARY ATHE.R'.OSC 3.L_._
23. PRIOR AUTHORIZATION NUMBER
z.: 51 PAIN PRECORDIAL 4. o
24. A B C D E F G H I J K a
DATE(S) OF SERVICE
From TO Plow
of TM PROCED?URkE?S, SERVICES, OR SUPPLIES
y
?
UsIC"
W DIA(iN0413
CODE
$ CHARGES DAYS EPSOT
F ?
EMO
CAB RESERVED FOR
LOCAL USE
m DD YY MM DD YY
M SeNts Sarvkv CPS MODIFIE
r
CPTA UNITS O
02 ; 24 i06
21
01
351
0 126:
1
2
600;. 00
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SIGNED 07 18 0 6 DATE PIN 11 GRP Ir
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payment of medical benefits to the undersyned physician or supplier for
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SIGNED a1.GNATURE ON FILE DAT! 7 L8 06 SIGNED SIGNATURE ON L''1LE
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
MM 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 18. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
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DO YY NJURY (Accident) OR GIVE FIRST DATE MM DO YY MM DO YY MM DO YY
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RICH, KE1,1 11, MD 1+ORM1_,EYSBURC, PA 17043 W0RM1'IEYS'f3URG, P.A 1'/043
SIGNED 0 7 18 0 6 DATE PIN a GRP N
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(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8189) PLEASE PRINT OR TYPE APPROVED OMB-1215 FORM OWCP-1500, APPROVED OMB-0720-001 (CHAMPUS)
` I.
MOFFITT HEART & VASCULAR GROUP IN THE COURT OF COMMON PLEAS
PLAINTIFF CUMBERLAND COUNTY, PENNSYLVANIA
VS
CIVIL ACTION -DIVORCE
JOSEPH ENGLE
LUCINDA ENGLE
DEFENDANT : NO. 2006-6542
CERTIFICATE OF SERVICE
14
I hereby certify that on December 1 2006, I served a copy of the Complaint upon
Marvin Beshore, Esquire and in the manner indicated below, which service satisfies the requirements
of Pennsylvania Rule of Civil Procedure. 403.
Service by U.S. Mail to:
Marvin Beshore, Esquire
130 State Street
P.O. Box 946
Harrisburg, PA 17108-0946
Gail Guida Souders, Esquire
Guida Law Offices, P.C.
111 Locust Street
Harrisburg, PA 17101
717-236-6440
Dated: ?eG ,It,, Zl ???°
{? ... ,
?} ??
^
T
13
S.. _ s ? ? .
f.?? .r?
L? ?
12/21/2006 13:25 FAX
MP
EDWARD J. HILTON and
KENNETH DIMINICK trading as
DHD, a Pennsylvania Partnership,
Plaintiffs
v.
MILLER & NORFORD, INC.,
Defendant
IM 002/002
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY
PENNSYLVANIA
No. 06-6582 CIVIL TERM
ACCEPTANCE OF SERVICE
I hereby acknowledge receipt of the WRIT OF SUMMONS filed by
Plaintiffs Edward J. Hilton and Kenneth Diminick, trading as DHD, a
Pennsylvania Partnership, in the above-captioned matter; accept service of same
on behalf of Defendant Miller & Norford, Inc.; and certify that I have authority to
do so,
Dated: December 4, 2006
CD
T- -n
r -
Marvin Beshore, Esquire
Attorney ID No. PA 31979
130 State Street, P.O. Box 946
Harrisburg, PA 17108-0946
(717) 236-0781 FAX (717) 236-0791
Email: MBeshore@beshorelaw.com
MOFFITT HEART & VASCULAR
GROUP,
Plaintiff
VS.
JOSEPH ENGLE and LUCINDA
ENGLE,
Defendants
Attorney for Defendants
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2006-6542
CIVIL ACTION - LAW
NOTICE TO PLEAD
TO: Moffitt Heart and Vascular Group, Plaintiff
c/o Gail Guida Souders, Esquire
Guida Law Offices, PC
111 Locust Street
Harrisburg, PA 17101
You are hereby notified to file a written response to the enclosed Preliminary Objections
to Plaintiff's Amended Complaint within twenty (20) days from service hereof or a judgment
may be entered against you.
Respectfully submitted,
Dated: l 1 ? /'9 7 By:
Ma in Beshore, Esquire
Attorney for Defendant
Marvin Beshore, Esquire
Attorney ID No. PA 31979
130 State Street, P.O. Box 946
Harrisburg, PA 17108-0946
(717) 236-0781 FAX (717) 236-0791
Email: MBeshore@beshorelaw.com
MOFFITT HEART & VASCULAR
GROUP,
Plaintiff
VS.
JOSEPH ENGLE and LUCINDA
ENGLE,
Defendants
Attorney for Defendants
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2006-6542
CIVIL ACTION - LAW
PRELIMINARY OBJECTIONS TO PLAINTIFF'S
AMENDED COMPLAINT
Defendants, Joseph Engle and Lucinda Engle, by their Attorney, Marvin Beshore,
Esquire, preliminarily object to Plaintiff's Amended Complaint, as follows:
Demurrer
1. Plaintiff's original Complaint purported to state a cause of action based upon a
"Statement of Account," but failed to attach any account. Accordingly, Defendants filed
preliminary objections in the form of a motion for a more specific complaint. In response,
Plaintiff filed and served its Amended Complaint.
2. Plaintiff's Amended Complaint also purports to state a claim upon a "Statement
of Account." Plaintiff has attached a copy of the purported "Statement of Account" to Plaintiff's
Amended Complaint as Exhibit A.
To adequately plead an action on a statement of account, the account must be in
writing and a copy of the actual book of account forming the basis of a complaint must be
attached to the complaint. Ryon v. Anderschonis, 42 Pa.D.&C.2d 86 (C.P. Schuylkill 1967).
4. Furthermore, to adequately plead an action on a statement of account, the book of
account must properly identify and itemize debits and credits. C-E Glass v. Ryan, 70
Pa.D.&C.2d 251 (C.P. Beaver 1975).
The papers attached to the Amended Complaint as Exhibit 1 are not from a book
of account and they do not properly identify and itemize debits and credits. Instead, they are a
collection of 10 individual Health Insurance Claim Forms.
6. Accordingly, Plaintiff has failed to state a proper cause of action.
Given that this is Plaintiff's second attempt to plead its cause of action, Plaintiff's
failure to attach a proper book of account indicates that Plaintiff is incapable of pleading and
proving this cause of action.
WHEREFORE, Defendants, Joseph and Lucinda Engle request this Honorable Court to
dismiss the Amended Complaint
Date: /10/0)
Respectfully Submitted,
By:
Marv (n Beshore, squire
Attorney ID # 31979
130 State Street
P.O. Box 946
Harrisburg, PA 17108-0946
(717) 236-0781
CERTIFICATION OF SERVICE
I hereby certify this 10th day of January that I served a true and correct copy of the
foregoing Preliminary Objections of Defendants to Plaintiff's Amended Complaint via United
States Postal Service, postage prepaid and properly addressed to the following:
Gail Guida Souders, Esquire
Guida Law Offices, P.C.
111 Locust Street
Harrisburg, PA 17101
Date: January 10, 2007
Telephone: (717) 236-0781
Fax: (717) 236-0791
Attorney ID # 31979
130 State Street, P. O. Box 946
Harrisburg, PA 17108-0946
c'?
,-- C`7 ,
(77
MOFFITT HEART & VASCULAR GROUP
JOSEPH ENGLE
LUCINDA ENGLE
VS.
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 2006-6542
NOTICE TO DEFEND
You have been sued in court. If you wish to defend against the claims set forth in the
following pages, you must take action within twenty (20) days after this complaint and notice are
served, by entering a written appearance personally or by attorney and filing in writing with the court
your defenses or objections to the claims set forth against you. You are warned that if you fail to do so
the case may proceed without you and a judgment may be entered against you by the court without
further notice for any money claimed in the complaint or for any other claim or relief requested by the
plaintiff. You may lose money or property or other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE
SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
CENTRAL PENNSYLVANIA LEGAL SERVICES
213-A NORTH FRONT STREET
HARRISBURG, PA 17101
1-800-932-0356
MOFFITT HEART & VASCULAR GROUP
JOSEPH ENGLE
LUCINDA ENGLE
vs.
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 2006-6542
AMENDED COMPLAINT
AND NOW, this LM day of January, 2007 comes Moffitt Heart & Vascular Group,
above-named plaintiff, by and through its attorney, Gail Guida Souders, Esquire, and respectfully avers
the following:
1. Plaintiff is a corporation having offices at 1000 North Front Street, Wormleysburg,
Pennsylvania 17043.
2. Defendant, Joseph and Lucinda Engle are adult individuals residing at 108 4t" Street, New
Cumberland, Pennsylvania, 17070.
3. At the specific instance and request of Defendant, Plaintiff provided medical services to
Defendant at the times, amounts, and the prices for these services are indicated in
Plaintiff's Statement of Account, a true and correct copy of which is attached hereto,
marked Exhibit A, and made part thereof.
4. As indicated in the Exhibit A, Defendant received medical services from Plaintiff at the
Holy Spirit Hospital located at 503 North 21St Street, Camp Hill, Pennsylvania from
February 4th through 10th and 23rd and 24th of 2006.
5. He was then treated by Plaintiff on March 10, 2006 at the Plaintiff's office located at 1000
North Front Street, Wormsleysburg, Pennsylvania. See Exhibit A.
6. The prices charged by Plaintiff were fair, reasonable, and market prices that prevailed at
the times of the transactions.
7. Defendant was covered by Capital Blue Crosse Health Insurance at the time of the
services.
8. Capital Blue Cross paid for its obligation and the remaining amount is the Defendants'
coinsurance obligation. See Exhibit B.
9. As indicated in the Exhibit B, Defendants' coinsurance obligation is listed for each
service from February 2006 to March 2006.
10. Defendant Joseph Engle was married to Lucinda Engle at the time services were
rendered.
11. Although Defendant Joseph Engle was the Plaintiff's patient, Defendant Lucinda Engle is
also responsible for payment of said services pursuant to 23 Pa.C.S.A Section 4102.
12. Plaintiff avers that the balance due amounts to $561.27, which is below the limit for
mandatory arbitration.
13. As of November 22, 2006, the interest at the legal rate of six percent a year is $33.67.
14. Although repeatedly requested to do so by Plaintiff, Defendant has willfully failed and
refused to pay the aforesaid balance or any part thereof to Plaintiff.
WHEREFORE, Plaintiff respectfully requests that judgment be entered in favor of
Plaintiff and against Defendant in the amount of $594.94 with interest and costs.
Res e tfully submitted,
Gail Guida Souders, Esquire
Guida Law Offices, P.C.
111 Locust Street
Harrisburg, PA 17101
717-236-6440
Attorney for Plaintiff
Supreme Court ID #68740
I, Kirn Kern have read the foregoing document and hereby aver that it is based
upon information that I have given to counsel and it is true and correct to the best of my knowledge,
information and belief.
I understand that any false statements made herein are subject to the penalties of 18 Pa. C.S.A. §
4904, relating to unsworn falsification to authorities.
6-7
Date
Zoo/Zoo0 S30I330 MVI VOInO 669696Z XV3 00"VL LOOZ/ZL/LO
KK 0111JAN. 12. 2007E 9:32AM4 017)WORMLEYSBURG 7174410592) FROM: 00/00/0NO
9384,12/(P
2 PAGE 1
.
.
JOSEPH E ENGLR MOFFM HEART 6 VASCl" GROUP
108 4TH STREET 10 00 NORTH FRONT STREET
NEW CUMBERLAND, PA 17070 WORMLEYSBURG, PA 17043
(7 17)-731-8315
LAST PER PD: $0.00 on 00/00/00
LAST BIL: 05/26/06 CURRENT 30 60 90 120+ YTD NCHG: $0.00 IN$f -129 - eC PPO
_TTL MAL: $561.27 0.00 0.00 0.00 0.00 561.27 YTD PP?4Y: $0.00 124 - SC COMPREHENSIVE _
ASIGN'D : $0.00 0.00 0.00 0.00 0.00 0.00 YTD OPAY: 50100 10 = GUIDA LAW OFFICE
COLL (Z): $561.37 0.00 0.00 0.00 0,00 561.21 Cov: (-None, !Some)
WC/NF(W): $0.00 0.00 0.00 0.00 0.00 0.00 DR #-NAME T.D. f
PERS 50.00 0.00 0.00 0.00 0.00 0.00 84-RICE, A'EITH, 23-1864722
78-WALSH, TIMOTH 23-1864722
11-HOKELMAN, TOD 23-1864722
16-JONES, STEVEN 23`1864722
18-MYERS, LOUIE, 23-1864722
FEE DIAL DIAr DIAG PER CHG
RECORDS FROM/TO DATES PATIENT CPT/HCPCS DESC SCH f1 f2 f3 L D I A CLAIM CHARGES RECEIPTS BALANCE
I°. eel
86793A 02/04/06 JOSEPH HOSPITAL INITIAL C 99223 786-59 1 84 10 Y 07/18/06 $230.00
86794A 03/14/06 JOSEPH BC PPO(CK#400039265) PAYMENT 1 84 N $146.92
86795A 03/14/06 JOSEPH Accept Assign ADJUST 1 84 N $-46.35 $36.13z
86790A 02/05/06 JOSEPH HOSPITAL SUBSEOUEN 99232 414.01 410.11 1 18 10 Y 07/18/06 $80.00
06791A 03/06/06 JOSEPH BC PPO(CK#400038811) PAYMENT 1 18 N $54.24
86792A 03/06/06 JOSEPH Accept Assign ADJUST 1 .18 N S-12.20 $13.562
86707A 02/05/06 JOSEPH CATH LEFT HEART 93510 414.01 410.00 1 $4 10 Y 07/18/06 $600.00
MODIFIERS: 26
86798A 03Y14/06 JOSEPH BC PPO(CKf400039265) PAYMENT 1 84 N 9248.21
66789A 03/14/06 JOSEPH Accept Assign ADJUST 1 84 N $-289.74 S62.05Z
86784A 02105/06 JOSEPH INJECT FOR HEART A 93543 414.01 d10.00 1 84 10 Y 07/18/06 $100.00
81705A 03/14/06 JOSEPH BC PPO(CKf40003926S) PAYMENT 1 84 N 512.94
86786A 03/14/06 JOSEPH Accept Assign ADJUST 1 84 N $-83.83 53-237
86781A 02/05/06 JOSEPH INJECT FOR CORONAR 93545 41d.01 410.00 1 84 10 Y 07/18/06 $100.00
867M 03/14106 JOSEPH BC PPO(CK$400039265) PAYMENT 1 84 N $17.99
66703A 03114106 JOSEPH Accept Assign ADJUST 1 84 N 5-77.51 $4.502
86778A 02/05/06 JOSEPH TRANSCATH INTRACOR 92980 414.01 410.00 1 84 10 Y 07118/06 $2000.00
MODIFIERS: LD
86779A 03/14/06 JOSEPH BC PPO(CKf400039265) PAYMENT 1 84 N 5786.32
86780A 03/14/06 JOSEPH Accept Assign ADJUST 1 84 N -1017.10 $196.582
86775A 02/06/06 JOSEPH ECHOCARDIOGRAPHY C 93307 414.01 410.11 1 11 10 Y 07/18/06 $115.00
MODIFIERS: 26
86776A 03/14/06 JOSEPH 8C PPO(CK#400039265) PAYMENT 1 11 N
06777A
03/14/06
JOSEPH
Accept Assign ADJUST
1
11
N $46.02
$,57.48 511150Z
86772A 02106/06 JOSEPH DOPPLER ECHO READI 93320 414.01 410.11 1 11 10 Y 07/18/06 550.00
MODIFIERS: 26
86773A 03/14/06 JOSEPH EC PPO(CK#400039265) PAYMENT 1 11 N 519111
8677dA 03/14/06 JOSEPH Accept Assign ADJUST 1 11 N 5-26.11 54.782
86769A 02/06/06 JOSEPH DOPPLER COLOR FLOW 93$25 414.01 410.11 1 11 10 Y 07/16/06 $65.00
MODIFIERS: 36
(continued)
Exhibit A
KK 01/1JAN. 12. 2007;6 9:32AN? (31•1)WORMLEYSBURG 7174410592, . FROM: 00/00/0(NO. 9384,121CP• 3 PAGE 2
FEE DIAG DIAM DIAL PER CHO
RECORD# FROM/TO DATE$ PATIENT CPT/)1CPCS DESC SCH (I1 42 63 L D I A CLAIM CRARC$S RRCRIPTS RA7.ANCF
86770A••. 03/14/06 .• JOSEPH' .•" BC PPO(CK#400039265)' PAYMENT 1 11 N $4.44
66711A 03/14106 JOSEPH AGCept Assign ADJUST 1 11 N $-59.45 $1.112
86766A 02/06/06 JOSEPH HOSPITAL SUBSEQUEN 99232 410.71 414.01 1 11 10 Y 07/18/06 $80.00
86167A 03/14/06 JOSEPH BC PPO(CK#400039265) PAYMENT 1 11 N $54.24
86768A 03/14/06 JOSEPH Accept Assign ADJUST 1 11 N 5-12.20 513.562
86713A 02/07/06 JOSEPH HOSPITAL DISCHARGE 99238 410.71 414.01 1 11 10 Y 07/18/06 3125.00
86764A 03/14/06 JOSEPH BC PPO(CK#400039265) PAYMENT 1 11 N $58.87
86765A 03/34/06 JOSEPH Accept Assign ADJUST 1 11 N S-51.41 $14.72Z
86760A 02/09/06 JOSEPH CATH LEFT HEART 93510 410.71 41x.01 1 16 10 Y 07118/06 $600.00
MODIFIERS: 26
86761A 03/14/06 JOSEPH SC PPO(CK#400039265) PAYMENT 1 16 N $248.21
06762A 03/14/06 JOSEPH Accept Assign ADJUST 1 16 N $-289.74 962.05Z
86757A 02/09/06 JOSEPH INJECT FOR HEART A 93543 410.71 A14.01 1 16 10 Y 07110/06 5100.00
86758A 03114/06 JOSEPH RC PPO(CK#400039265) PAYMENT 1 16 N 512.94
86759A 03/14/06 JOSEPH Accept Assign ADJUST 1 16 N 583.83 $3.232
$6754A 02/09/06 JOSEPH INJECT FOR CORONAR 93545 410.71 414.01 1 16 10 Y 07/18/06 4100.00
86755A 03/14/06 JOSEPH BC PPO(CK4400039265) PAYMENT 1 16 N $17.99
86756A 03/14/06 JOSEPH Accept Assign ADJUST 1 16 N 5-17.51 $4.501
86751A 02/09/06 JOSEPH IMAGING SUPEAVISIO 93555 410.71 414,01 1 16 10 Y 07/16/06 $90.00
MODIFIERS: 26
86752A 03/14106 JOSEPH BC PPO(CK$40003926$) PAYMENT 1 16 N 36.57
867S3A 03/14/06 JOSEPH Accept Assign ADJUST 1 16 N 6-44.29 $9.142
96746A 02109/06 JOSEPH IMAGING SUPERVISIO 93556 410.71 414.01 1 16 10 Y 07/18/06 490.00
MODIFIERS: 26
86749A 03/14/06 JOSEPH BC PPO(CK#400039265) PAYMENT 1 16 N S37.22
86150A 03114/06 JOSEPH Accept Assign ADJUST 1 16 N $-43.48 $9.302
$6745A 02/09/06 JOSEPH HOSPITAL CONSULT I 99254 786.59 411.0 414.01 1 11 10 Y 07/18/06 $225.00
DIAG $4: 401.9
06746A 03/17/06 JOSEPH BC PPO(CK#400039695) PAYMENT 1 11 N 4132.52
86747A 03/17/06 JOSEPH Accept Assign ADJUST 1 11 N $-59.35 $83.132
86742A 02/10/06 JOSEPH HOSPITAL SUBSEQUEN 99231 410.71 414.01 1 11 10 Y 07/18/06 $50.00
86143A 03117/06 JOSEPH BC PPO(CK#400039695) PAYMENT 1 11 N 328.38
86744A 03/17/06 JOSEPH Accept Assign ADJUST 1 11 N 6-14.52 67.10E
86739A 02/23106 JOSEPH HOSPITAL INITIAL C 99222 414,01 786.51 1 78 10 Y 01/18/06 $160.00
86740A 03/23/06 JOSEPH BC COMPRENEN(CK#400040133) PAYMENT 1 I$ N 594.02
86741A 03/23/06 JOSEPH Accept Assign ADJUST 1 78 N ,42.47 S23.51Z
86136A 02/24/06 JOSEPH OATH LEFT HEART 93510 414.01 786.51 1 84 10 Y 07/18/06 5600.00
MODIFIERS: 26
86737A 03/23106 JOSEPH BC COMPREREN(CK#400040133) PAYMENT 1 64 N $296.66
86730A 03123106 JOSEPH Accept Assign ADJUST 1 84 N 5-289.74 $13.582
86733A 02/24/06 JOSEPH HOSPITAL SUBSEQUEN 99232 414.01 786.51 1 78 10 Y 07/18/06 $80.00
66734A 03123/06 JOSEPH BC COMPREHEN(CK4400040133) PAYMENT 1 78 N $54.24
(continued)
Exhibit A
KK 011JAN, 12. 2007,6 9; 32AMHff -(717WORMLEYSBURG 7174410592nD FROM: 00/00/[NO. 9384./12,P. 4 PAGE 3
FEE DIAG DIAG DIAL PER CHG
RECORDS FROM/TO DATES PATIENT CPT/NCPCS DESC SCH 61 y2 *3 L D I A C7,ATM CHARGES RECEIPTS BALANCE
86735A 03/23/06 JOSEPH Accept Assign ADJUST 1 7S N $-12.20 $13.56Z
86730A 03/10/06 JOSEPH OFFICE VISIT NEW L 99203 41a.01 1 84 10 Y 07/18/06 $135.00
86731A 03/23/06 JOSEPH RC COMPREHEN(CK$400040133) PAYMBNT 1 84 N $19.40
86732A 03/23/06 JOSEPH Accept Assign ADJUST 1 84 N g-35.75 $19.052
............................................................ "......................................................................
GRQ$$ CHARGES: $5775.00
TOTAL ADJUSTS: -2726.26
TOTAL BALANCE: 53048.74 2487.47 561.27
ASSIGNED RPJANCE: $0.00
COLLECT BALANCE: $561.272
WCOMP/NF BALANCE: $O.OOW
PERSONAL RALANC$: 50.00•
SIGNATURE:
PLEASE NOTE: FOLD AT "_" MARKS FOR STANDARD #10 WINDOW ENVELOPE.
THE ABOVE INFORMATION REFLECTS ONE ACCOUNT MEMBER ONLY,
Exhibit A
JAN. '6. 2007 2:09PM
01 a
Hours of Availability:
Monday through Saturday, 24 Hours
Sunday - limited availability
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Claims Inquiry
Claim Summa Results Research Claim
Adlust Claim
Claim Number: 060610259700
Claim Status: FINALIZED (sae details beloO
Dates of Service: 02104/2006.02/04/2006
Member Patien t litforniation
Patient Account 146630
Health Plan: COMPREHENSIVE 1000
Group #: 00500689
Group Name: RIVERSIDE HEARING SERVICES
Member Name: ENGLE, JOSEPH E
Member ID: 80021447101
Birth Date: 09/25/1955 Gender. M
•s
Une Item Details
L nw .•...:,., - • i °?'; .5ril5'
WORML-EYSBURG 7174410592 NO.9460 P. 8
Date of Payment: 03/04/2008
Prior Auth #:
Billing Provider. RICE, KEITH S.
Billing Provider ID. 02276700
Total Amt Billed: $230.00
Total Amt Paid: $146.92
Provider Liability Amt: $0.00
Exhibit B
JAN, 16. 2007 2:10PM
?im0.aws Hours of through Availability;
Monday through Saturday, 24 Hours
Sunday - limited availability
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? OPrint Screen XiRetum to Results i ?..9DRetum to Search
Claims Inquiry
Claim Summary Results
Claim Number: 060540326700
Claim Status: FINALIZED (see details below)
Dates of Service: 02105/2006 - o2/o5/2oo6
i IV]emb(!-,r
' Patient Account #: 146630
Health Plan: COMPREHENSIVE 1000
r Group #: 00500689
Group Name: RIVERSIDE HEARING SERVICES
Member Name: ENGLE, JOSEPH E
Member ID: 80021447101
r Birth Date: 09/25/1956 Gender. M•-
Line Item Details
-- I CBC Reawii
Statue
Cods Cotle:
WORML'EYSBURG 7174410592
21
NO. 9460 P. 9
Res arch Claim
Adlust Claim
Date of Payment: 02/2512006
Prior Auth M
Billing Provider. MYERS .1R, LOUIE A.
Billing Provider ID: 022787oo
Total Amt Billed: $80.00
Total Amt Paid: $54.24
Provider Liability Am t: so.oo
1 1$80.00
C13C Reason Coda nescriptlmr,
0-0.1
-
7'.
Exhibit B
JAN. 1.2007 2:09PM , WORMLEYSBURG 7174410592
NO. 9460 P. 6
Hours of Availability:
a sWus Monday through Saturday, 24 Hours
Sunday - limited availablllty
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I,,,, it-..•?
Print Sage ( ULE`Retum to Results I L? Retum to Search
Claims Inquiry
N, -.._...
Claim Summary Results Research -Claim
Adjust Claim
Claim Number: 060600262100
Claim status: FINALIZED (see details below)
Dates of Service: 02/05/2o06 - o2/05ao06
Patient Account #: 146630
Health Plan: COMPREHENSIVE 1000
Group #: 00500689
Group Name: RIVERSIDE HEARING SERVICES
Member Name: ENGLE, JOSEPH E
Member ID: 80021447101
Birth Date:' 09/2511955 Gender. M
Line Item Det ails
it
' Y.
? f !'
!e< r. !p? ? it
0
2/05/2006
0221 41401 92980 LD
7
001
sras
CB
Resnon
Cod
107 105/2006 02105/20013 21 141401
ANSI CBC ReAkon
status Cade:
Code:
107 j K05
/05/2006 02/05/2006 21 1114011
ANSI CBC Reason
Status Code:
Coap: ,
Date of Payment: 03/0412006
Prior Auth #:
Billing Provider: RICE, KEITH S.
Billing Provider 10: 02278700
Total Amt Billed: $2,980.00
Total Amt Paid: $1,065.46
ProVider Liability Amt so.oo '
00
CBC Reason Code Datesipflon.
t
-71
$786.32
26 1 $600.00 1$310_261$0.001 $0.00 $62.05
?Ilgl? IiM II IM 1 1
IINI,
CBC PGason Code Descrip0an;
1
1 $100.00 j $16.47150.001 $0.00 1 $3.23 $0.00 $0.00 $12.94
COO Reason Coda D66;crip>aon:
Exhibit B
JAN. 6.2007 2.09PM • WORML•EYSBURG 7174410592 NO.9460 P. 7
Exhibit B
J
JAN. 6.2007 2.07PM • WORMLEYSBURG 7174410592
NO. 9460 P. 1
Hours of Availability:
Cw,to stows Monday through Saturday, 24 Hours
Sunday - limited availability
Click "Return to Results" to go back to your list of claims. Click "Return to Search" to complete a new search.
: "Print Screen It, Retum to R ults 1 Lkm to Smirch
Claims Inquiry
i.iJiYY ?.r n n ..p
Claim Summary Results
Claim Number. 060421498100
Claim Status: FINALIZED (see details below)
Dates of Service: 02/06/2006 - 02io612008
Patient Account #: 146630
Health Plan: COMPREHENSIVE 1000
Group 00500689
Group Name: RIVERSIDE HEARING SERVICES
Member Name: ENOLE, JOSEPH E
Member ID: 80021447101
Birth Date: OW611955 Gender. N(
Line Item Details
02108/2006 r
02/06/2006
21 41401 933(
001 AN31
Status CBC Reason
,
Code; Code:
107 K05
/08/2008 02/05/2008 21 41401
to CBC Reason
Status Code:
Code:
107 1 K05
roF006 02/OB/200s 21
BSI COC PAason
s.?a Coo.
Date of Payment-
Prior Auth #:
Billing Provider:
Billing Provider ID:
Total Amt Billed:
Total Amt Paid:
Provider L.iabilityA
Research Claim
Adjust Claim
03/04/2006
13OKEi,MAN, TODD A
02278700
$230.00
$69.57
rnt: $0.00
28 L 1 ( $115,00 $57.52 50.00
CEC' Reason Code Dsm iption:
R,
28 1 $6520 $5.55 _I$ 0.00 $0.00 $1.11 $0.00 $0.00 , $4.44
CBC Reason Code Description:
as # 1 ?so.oo? $23.se
o.oo
?$ ( $o.oo- 4.Ts
CBC Reason Coyle Description:
Exhibit B
$0.001 $19.11
JAN.16.2007 2:08PM - WORMLEYSBURG 7174410592
NO, 9460 P, 2
fttn Hours of Availability:
24 Hours
MOM Monday through Saturday,
Sunday - limited availability
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450'Print Screen J 6.....a'Return to Results J Return to Search
Claims Inquiry ;;;••y
Claim Summary Results
Research Claim
Adjust CI im
Claim Number. 060620311100
Claim Status; FINAL¢ED (see details below)
Dates of Service: 02/06/2006 - 021072006
Patient Account #: 146630
Health Plan: COMPREHENSIVE 1000
Group 00500689
Group Name: RIVERSIDE HEAMNG SERVICES
. Member Name: ENGLE, JOSEPH E
Member ID: 80021447101
Birth Date.
uln•• 0912511955 Gender M
luau ..,w y
Line Item Details
/ Y
J
1
,
Date of Payment: 03/042006
Prior Auth #:
Billing Provider: BOKELMAN, TODD A.
Billing Provider ID: 02278700
Total Amt Billed: $205.00
Total Amt Paid: $113.11
Provider Liability Amt: 60.00
A W1
Status CBC Reason
Code; code:
107 KOS
10712006 0210712006 21 41071
AAISI
Status CBC Reason
Coda Code:
L EII a =.11 ?aG 0-t% `Y, :r,", ,"•,:"•., ?'t ".," q
1 $80.00 1 ss7.80 $0.00
.. 1 KI . ¦V •' Mir
CSC Reason Code Description:
1 L $125.00 1 !73:591$0.001 $0.00
• I W•,••"••• VIM .WYi?
CBC Ronson Code Dmoption:
Exhibit B
0771
J
JAN, 1.2007 2:08PM ' WOMEYSBURG 7174410592
NO, 9460 P, 3
Hours of Availability,
claim'stwe Monday through Saturday, 24 Hours
Sunday - limited 2v811ability
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h r+??, ?
Print Screen 14 JRetum to Results Retum to Search
Claims Inquiry 7
IL
Claim Summary Results Research Claim
Adjust Claim
Claim Number: 060620312800
Claim Status: FINALIZED (see details below)
Dates of Service: 0210912006 - 02109/2008
Patient Account #: 146630
' Health Plan; COMPREHENSIVE 1000
Group 00500689
;. Group Name: RIVERSIDE HEARING SERVICES
Member Name: ENGLE, JOSEPH E
MemberlD: 80021447101
Birth Date: 09/2511955 Gender: M
Lane Item Details
02108/2008 02/09/2006 21 41071 9351
001 Status COO Reason
Code: Code:
/09f2006 0210912006 21
ANSI CI3C Reason
Code: Code:
8??$
109120081 02109/2006 1 21 141071
AIVS{ CBC Reason J
Status Code: R77
Code:
Date of Payment:
Prior Auth #:
Billing Provider.
Billing Provider ID:
Total Amt Billed:
Total Amt Paid:
Provider Liability A
03/04/2008
JONES, STEVEN R.
02278700
$980.00
$352.93
mt: $0.00
26 t 1 $800.00 j $310.26] $0.00 1
090 Reason Code Rescription:
1 .1 $100.00 [ $18.17 $0.00 ? $0.00 $3.23 1$0.00.1$0.00 $12.84
CBC Reason Code Description.
DfCI;EDED CHARGE
111111 lip
1 $100.00 $22.491$0.001-$0.001$4.501$0.0()1$0.001$17.99!
CBC Reason Code DamApttone
Exhibit B
JAN•16.2007 2:08PM , WORMLEYSBURG 7174410592 NO.9460 P. 4
Exhibit B
JAN,16.2007 2:08PM , WORMtEYSBURG 7174410592
NO. 9460 P. 5
Hours of Availability:
Claim 5 ft" Monday through Saturday, 24 Hours
Sunday - limited availability
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`Print Screen 'Retum to Results ?)Return to Search
Claims Inquiry
Claim Summary Results Research Claim
Adjust Claim
Claim Number. 060670242000
Claim Status: FINALIZED (see details 6elou)
Dates of Service: 02109/2006 - 02109/2006
•
Patient Account #: 146630
Health Plan: COMPREHENSIVE 1000
Group 00500689
i Group Name: RIVERSIDE HEARING SERVICES
Member Name: ENGLE, JOSEPH E
Member ID: 80021447101
Birth Date: 09/25/1955 Gender: M
4
i Una Item Details
21
Date of Payment: 03/1112006
Prior Auth #:
Billing Provider: BOKELMAN, TODD A.
Billing Provider ID: 02278700
Total Amt Billed: $225.00
Total Amt Paid: $132.52
Provider Liability Amt: $6.0o'
1IW$225.00]$165.651$0AO $0.00 $33.13 $0.00
007 Wawa OBC ? son CBC Reason Cod®boscription
rode:
107 Kf OCCEE"DED CHARGE
L 412",' • ??? 21' -iiii
Exhibit B
W,"17
0
JAN. 16. 2007 2: 11 PM • WOWLEYSBURG 7174410592 NO. 9460 P. 13
Hours
181- a F 'mss Monday of through Availability:
' Saturday, 24 Hours
Sunday - limited availability
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r?-`Y (-'-? fie*-? 1.4,I
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Claims Inquiry
„„;,`
k.v-Mmr"LLN .dk14Lt .. n
Claim Summa Results Research Claim
Summary Adiust Claim
Claim Number. 060670241900
Claim Status: FINALIZED (see details below)
Dates of Service: 02/10/2006 - o2H 0/2006
i
L71 liffr-411M,
Patient Account #: 146630
Health Plan: COMPREHENSIVE 1000
;; Group 00500689
Group Name: RIVERSIDE HEARING SERVICES
Member Name: ENGLE, JOSEPH E
1 Member ID: 80021447101
f ' Birth Date: '0926N955 Gender: M
Line Rom Details
Date of Payment: 03/112006
Prior Auth #:
Billing Provider. SOKELMAN, TODD A.
Billing Provider ID: 02278700
Total Amt Billed: $50.00
Total Amt Paid: $28.38
Provider (.lability Amt:` $0.00
021102006 02/102006 21 41071 199231 1 $60.00 $35.48 $0,00 $0.00 $7,121$0.001$0.00
528.38
ANSI Cl3C Reason
001 Status Codr?• C13C Roason Code Description:
C040'. '
107 K05 1=JCCEEDED CHARGE
?I .
Exhibit B
ij
JAN. 16. 2007 2:11 PM ' WORMtEYSBURG 7174410592 N0. 9460 P. 14
cish" fts
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` ::::•Print Screen I &?:-Return to Res its I k! %Retum fo Search
Claims Inquiry
Claim Summary Results
Hours of Availability:
Monday through Saturday, 24 Hours
Sunday - limited availability
Research Claim
Adjust Claim
Claim Number: 060771096900
Claim Status: FINALIZED (See details below)
Dates of Service: 02/2312006 - 02124/2008
Patient Account#: 146630
' Health Plan: COMPREHENSIVE 1000
Group #: 00500689
i Group Name: RIVERSIDE HEARING SERVICES
Member Name: ENGLE, JOSEPH E
Member ID: 60021447101
i Birth Date: og125N955 Gender: M
Date of Payment: 03/18/x008
Prior Auth #:
Billing Provider. WAL,SH, TIMOTHY P.
Billing Provider ID: 02278700
Total Amt Billed: $240.00
Total Amt Paid: $140.26
Provider Liability Amt: so.oo
Exhibit B
Pnm
j
JAN. 6.2007 2.10PM ' WORVLEYSBURG 7174410592
Research Claim
Adjust Claim
CWM SWUS Monday of Availability:
Monday through Saturd2y, 24 Hours
Sunday - limited availability
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r Print Screen f I Retum o R Claims Inquiry
Claim Summary Results
Claim Number. 060771087000
Claim Status: FINALIZED (see details below)
Dates of Service: 02124/2006 - 02242006
Patient Account#: 146630
Health Plan: COMPREHENSIVE 1000
Group #: 00500889
Group Name: RIVERSIDE HEARING SERVICES
Member Name: ENGLE, JOSEPH E
Member ID- 80021447101
Birth Date: 09/25/1955 Gender. M
,
Line Item Detai
ls
.t
M ,
L'
02242006
02/242006 21 41401 8351
001 status CM Reagan
Code; Code:
107 K05
!24/20061 02!242006 1 21 141401
AN51 1 CBO Reason
Status Code:
/24/20061 02/242006 21 141401
ANSI 1 CBC Reatsod ;
?
Code: Code,
Date of Payment: 03/18/2006
Prior Auth #:
Billing Provider. RICE, KEITH S.
Billing Provider ID: 02278700
Total Amt Billed: $880.00
Total Amt Paid: $427.57
Provider Liability Amt: $0.00
1 $600.00 1$310-3J6 0.00 1
`i.,;....111.. ,
CBC Reason Code Deseriptiam
R; CEED0 CHARGE
NO. 9460 P. 10
y
5286.68
1 $1
.00.001 $16.17$0:00 j $0.00 1$0.00 , $0.o0 $0.00 $16.17
111 YI.1-v--?yllll M IIWI IIIYM sl FI
CDC FWason Code Descripmom
1 1$1o0.901$22.49 [$o.oo $0.00 $0.001$0.00 so.oo 22-48
COC Reasod Code 136ssrription;
Exhibit B
JAN. '6, 2007 2;10PM • WORNtLEYSBURG 7174410592 N0. 9460 P. 11
Exhibit B
L 1i ?, y ttt•?h r ? ? ,>; ;, •• i • ntS;b n••, , • ,,,?, ? • ,
JAN• '6. 2007 2.10PM - WORNtLEYS6URG 7174410592
CISI SMS
Flours of Availability:
Monday through Saturday, 24 Hours
Sunday - limited availability
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Claims Inquiry
Claim Summary Results Adju sr i Claim
Adjust Claim
Claim Number: 060730306200
Claim Status: FINALIZED (see details below)
Dates of Service: 03/10!2006 - om 0/2006
Member & Patient Intorniation
Patient Account #: 146630
Health Plan: COMPREHENSIVE 1000
Group 00500689
' Group Name: RIVERSIDE HEARING SERVICES
Member Name: ENGLE, JOSEPH E
Member (D; 80021447101
Birth Date: 09/2611955 Gender: M
Date of Payment: 03/18/2oD6
Prior Auth #:
Willing Provider: RICE, KEITH S.
Billing Provider ID: 02278700
Total Amt Billed: $135.00
Total Amt Paid: $79.40
Provider Liability Amt: $0.00
,1 Line Item Details
Exhibit B
NO. 9460 P. 12
,
J
MOFFITT HEART & VASCULAR GROUP
PLAINTIFF
VS
JOSEPH ENGLE
LUCINDA ENGLE
DEFENDANT
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION -DIVORCE
NO. 2006-6542
CERTIFICATE OF SERVICE
I hereby certify that on January L 2007, I served a copy of the Complaint upon Marvin
Beshore, Esquire and in the manner indicated below, which service satisfies the requirements of
Pennsylvania Rule of Civil Procedure. 403.
Service by U.S. Mail to:
Marvin Beshore, Esquire
130 State Street
P.O. Box 946
Harrisburg, PA 17108-0946
M ?S
Gail Guida Souders, Esquire
Guida Law Offices, P.C.
111 Locust Street
Harrisburg, PA 17101
717-236-6440
Dated: ?j ?, 111 ZO-7
--??,-?
C? <`? .?
r-° .-,-
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r ?:
?, - _ ?,
;? _ a
? ? `_?
..?. -' ? ?
?yY ?-
MOFFITT HEART & VASCULAR GROUP
Vs.
JOSEPH ENGLE
LUCINDA ENGLE
•
:IN THE COURT OF COMMON PLEAS
:CUMBERLAND COUNTY, PENNSYLVANIA
:CIVIL ACTION - LAW
:NO. 2006-6542
TO: Joseph Engle and Lucinda Engle
DATE OF NOTICE: February 13, 2007
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A
WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING
WITH THE COURT AN ANSWER TO Plaintiff's Complaint. UNLESS YOU
ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY
BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR
PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TARE THIS NOTICE
TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT
AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT
WHERE YOU CAN GET LEGAL HELP:
CUMBERLAND COUNTY BAR ASSOCIATION
32 South Bedford Street
Carlisle, PA 17013
717-249-3166
Gail Guida Souders, Esquire
Guida Lave Offices, P.C.
111 Locust Street
Harrisburg, PA 17101
(717) 236-6440
Identification #68740
Attorney for Plaintiff
1 i
MOFFITT HEART & VASCULAR GROUP
VS.
JOSEPH ENGLE
LUCINDA ENGLE
:IN THE COURT OF COMMON PLEAS
:CUMBERLAND COUNTY, PENNSYLVANIA
:CIVIL ACTION - LAW
:NO. 2006-6542
CERTIFICATE OF SERVICE
I hereby certify that I am this February 13" 2007,
serving the Default Notice upon the persons and in the manner
indicated below which service satisfies the requirements of
Pennsylvania Rule of Civil Procedure, 403:
Service by First Class U.S. Mail:
Marvin Beshore, Esquire
130 State Street
P.O. Box 946
Harrisburg, PA 17108-0946
Gail Guida Souders, Esquire
Guida Law Offices, P.C.
111 Locust Street
Harrisburg, PA 17101
(717) 236-6440
Identification #68740
Attorney for Plaintiff
C?
"
's
?
VIM- ?.
MOFFITT HEART & VASCULAR
GROUP, P.C.
Plaintiff
VS.
JOSEPH ENGLE and LUCINDA
ENGLE,
Defendants
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2006-6542
CIVIL ACTION - LAW
ANSWER TO SECOND AMENDED COMPLAINT
NOW COME Defendants, by counsel, Marvin Beshore, Esq., and state their Answer to
Plaintiff's Second Amended Complaint as follows:
1. Denied as stated. Admitted that Moffitt Heart & Vascular Group, a Professional
Corporation, is a professional corporation, organized and existing under the laws of the
Commonwealth of Pennsylvania.
2. Admitted.
3. Denied as stated. It is admitted, however, that Defendant Joseph Engle sought medical
care from the Defendant group of practitioners. After reasonable investigation, Defendants lack
sufficient information on which to base a conclusion as to the remaining factual averments of
paragraph 3 and, therefore, deny them and demand strict proof at trial.
4. Denied as stated. It is admitted that Defendant Joseph Engle was hospitalized at Holy
Spirit Hospital from February 4, 2006, until February 7, 2006, when the documents attached to
the second Amended Complaint indicate that he was discharged. It is specifically denied that
inpatient services were rendered after discharge and it is specifically denied that Plaintiff is
entitled to payment for the services allegedly performed in the hospital after discharge. It is
specifically denied that Defendant Lucinda Engle was hospitalized at Holy Spirit Hospital at any
time during February 2006. After reasonable investigation, Defendants have insufficient
information to make a determination as to the truth and accuracy of the remaining averments of
Paragraph 4 and, accordingly, deny them and demand strict proof at trial.
5. Admitted.
6. It is specifically denied that the prices charged by Plaintiff were fair, reasonable, and
market prices that prevailed at the times of the transactions. To the contrary, the prices charged
by Plaintiff are consistently unfair, unreasonable, and exceed prevailing market prices.
7. It is admitted that Defendants had health care insurance through Capital Blue Cross
and Blue Shield in February and March 2006.
8. After reasonable investigation, Defendants lack sufficient information on which to
base a determination of the truth and accuracy of the factual averments of paragraph 8 and,
therefore, deny same and demand strict proof at trial. By way of further answer, Plaintiffs
specifically deny that they have a financial obligation to Plaintiff.
9. It is specifically denied that Exhibit B identifies, or that Defendants have, any financial
obligation to Plaintiff.
10. Admitted.
11. Denied. Paragraph 11 states a conclusion of law to which no response is necessary.
12. Paragraph 12 states a conclusion of law to which no response is necessary. By way
of further answer, Defendants specifically deny that they owe Plaintiffs any money.
13. Paragraph 13 states a conclusion of law to which no response is necessary. By way
of further answer, Defendants specifically deny that they owe Plaintiff any money.
14. It is specifically denied that Plaintiff has "repeatedly requested" Defendants to pay
"the aforesaid balance," and that "Defendant has willfully failed and refused to pay the aforesaid
balance or any part thereof to Plaintiff." To the contrary, Defendants have paid to Plaintiff any
and all sums properly due it by them. By way of further answer, while Defendants maintain that
they have no financial obligation to Plaintiff, Defendants have repeatedly offered to negotiate a
resolution of this matter and have made offers of payment, but Plaintiff has consistently rejected
them.
WHEREFORE, Defendants request this Honorable Court to enter judgment, with costs,
in their favor and against Plaintiff, plus such other and further relief as the Court deems
appropriate.
Date: 2 2 0
Respectfully Submitted,
lp? ?
By: M f6
Marvi eshore, squire
Attorney ID # 31979
130 State Street
P.O. Box 946
Harrisburg, PA 17108-0946
(717) 236-0781
MOFFITT HEART & VASCULAR
GROUP,
Plaintiff
VS.
JOSEPH ENGLE and LUCINDA
ENGLE,
Defendants
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2006-6542
CIVIL ACTION - LAW
VERIFICATION
I verify that the statements made in the foregoing Answer of the Defendants, and filed
herein are true and correct. I understand that false statements herein are made subject to the
penalties of 18 Pa.C.S. §4904 relating to unworn falsification to authorities.
Date: 2` Z f 1'e-1 2
f J seph ngle
Date: Z Z ? D `7
Lucinda Engle
CERTIFICATION OF SERVICE
I hereby certify this _jj!?rlay of February, 2007, that I served a true and correct copy of
the foregoing Answer of the Defendants via United States Postal Service, postage prepaid and
properly addressed to the following:
Gail Guida Souders, Esquire
Guida Law Offices, P.C.
111 Locust Street
Harrisburg, PA 17101
Date: February Z?! 2007
Marvin Beshore, Esquire
Attorney ID # 31979
130 State Street, P. O. Box 946
Harrisburg, PA 17108-0946
Telephone: (717) 236-0781
Fax: (717) 236-0791
MBeshore@beshorelaw.com
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MOFFITT HEART & VASCULAR GROUP
V.
JOSEPH ENGLE & LUCINDA ENGLE
: IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 6542- 20 06
RULE 1312-1 The Petition for Appointment of Arbitrators shall be substantially in the
Following form:
PETITION FOR APPOINTMENT OF ARBITRATORS
TO THE HONORABLE, THE JUDGES OF SAID COURT:
G a i l G u i d a S o u d e r s, E s q u i r e counsel for th plaintiff/de ndant in the above
action (or actions), respectfully represents that:
1. The above-captioned action (or actions) is (are) at issue.
2. The claim of plaintiff in the action is $ 594.94 with interest and costs
The counterclaim of the defendant in the action is
The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit
as arbitrators:
Marvin Beshore, Esquire
WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to
whom the case shall be submitted.
Respectfully submitted,
* / V "_ ___ ???
ORDER OF COURT
AND NOW,
petition,
Esq., and
captioned action (or actions) as prayed for.
200 , in consideration of the foregoing
Esq., and
_ Esq., are appointed arbitrators in the above
By the Court,
EDGAR B. BAYLEY
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: IN THE COURT OF COMMON PLEAS OF
M O F F I T T HEART & VASCULAR G R O U P CUMBERLAND COUNTY, PENNSYLVANIA
V.
JOSEPH ENGLE & LUCINDA ENGLE
NO. 6542- 20 06
RULE 1312-1 The Petition for Appointment of Arbitrators shall be substantially in the
Following form:
PETITION FOR APPOINTMENT OF ARBITRATORS
TO THE HONORABLE, THE JUDGES OF SAID COURT:
G a i l G u i d a Souders , E s q u i re counsel for th plaintiff/de ndant in the above
action (or actions), respectfully represents that:
1. The above-captioned action (or actions) is (are) at issue.
2. The claim of plaintiff in the action is $ 5 9 4 . 9 4 with interest, and costs
The counterclaim of the defendant in the action is
The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit
as arbitrators:
Marvin Beshore, Esquire
WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to
whom the case shall be submitted.
Respectfully submitted,
ORDER OF COURT
AND NOW3 , 200 , in,,ponsideration of th foregoing
petition, &W) 0 Esq. and ?- ?
Esq., and V ? F f Esq., are appointed arbitrators in the above
captioned action (or actions) as prayed for.
Brthe Court,
DG BA LBY
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MOFFITT HEART & VASCULAR GROUP
VS.
JOSEPH ENGLE
LUCINDA ENGLE
To Prothonotary:
:IN THE COURT OF COMMON PLEAS
:CUMBERLAND COUNTY, PENNSYLVANIA
:CIVIL ACTION - LAW
:NO. 2006-6542
Please mark the above-captioned matter as discontinued.
Date: /''i8 1,7 Respectfully submitted,
ail Guida Souders
Guida Law Offices, P.C.
111 Locust Street
Harrisburg, PA 17101
717-236-6440
Identification #68740
Attorney for Plaintiff
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