HomeMy WebLinkAbout94-05457
"
f
J
~
~
.
'"
7
f
~
c
!
J
e-
I.{)
-::r
\.0
I
::r
a-~
RICHARD W. MCCURD'i
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNT'i, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 'lIt-,rls 7 (t (,./. (), (
H"-
I
I
vs.
STATE FARM MUTUAL AUTOMOBILE
INSURAIlCE COMPANY,
Defendant
:
JURY TRIAL DEMANDED
NOTICE TO DEFEND
You have been sued in court. If you wish to defend against
the claims set forth in the fol19wing 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. 'Iou 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.
COURT ADMINISTRATOR
4th Floor
Cumberland County Courthouse
Carlisle, PA 17013
(717) 240-6200
50915 I JKD
,
:i
I
~,
i
;
,
.
RICHARD W. MCCURDY
plaintiff
III THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNS'lLVANIA
CIVIL ACTION - LAW
VS.
NO.
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPAN'l,
Defendant
JUR'l TRIAL DEMANDED
NOTICIA
Le han demand ado a usted en la corte. si usted qui ere
defenderse de estas demandas expuestas en las paginas sugnuientes,
usted tiene viente (20) dias de plazo al partir de la fecha de la
demanda y la notificacion. Usted de be presentar una apariencia
escrita 0 en persona 0 por abogado y archivar en la corte en forma
escrita sus defensas 0 sus objeciones alas demandas en contra de
su persona. Sea avisado que si usted no se defiende, la corts
tomara medidas y puede entrar una orden contra usted sin previa
aviso 0 notificacion y por cualquier queja 0 alivio que es pedido
en la peticion de demanda. Usted puede perder dinero 0 sus
propiedades 0 otros derechos importantes para usted.
LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATEMENTE. 51 NO TIENE
ABOGADO 0 SI NO TIENE EL DINERO 5UFICIENTE DE PAGAR TAL SERVICIO,
VA'lA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CU'lA DIRECCION 5E
ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR
ASISTENCIA LEGAL.
COURT ADMINISTRATOR
4th Floor
Cumberland county courthouse
Carlisle, PA 17013
(717) 240-6200
"
.
RICHARD W. MCCURDY
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
vs.
NO. 1)"1/ ~-(/ \ '/ {\,-\I I It h....
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY,
Defendant
JURY TRIAL DEMANDED
COMPLAINT
1. Plaintiff Richard Mccurdy is an adult individual and
citizen of the commonwealth of Pennsylvania who resides at 603-B
Reno street, New cumberland, cumberland county, Pennsylvania.
2. Defendant State Farm Mutual Automobile Insurance company
(hereinafter "State Farm"), is an automobile liability insurance
company with an office located at 115 Limekiln Road, New
cumberland, York county, Pennsylvania and regularly conducts
business in Cumberland county, Pennsylvania.
3. On May 29, 1993, Mr. McCurdy was injured in a motor
vehicle accident that occurred on Interstate Route 83, near New
cumberland, York county, Pennsylvania.
4. Prior thereto, Defendant State Farm provided automobile
medical insurance coverage to Mr. Mccurdy pursuant to the
Pennsylvania Motor Vehicle Financial Responsibility Law (MVFRL), 75
Pa.C.S. 51701 et sea.
5. At the time of the motor vehicle accident, Mr. McCurdy
was insured by state Farm, policy number 667 7760-F03-38F.
6. Said automobile insurance policy provided Mr. McCurdy
with coverage for reasonable and necessary medical treatment and
rehabilitative services as defined by the MVFRL.
7. As a result of the aforementioned automobile accident,
Mr. Mccurdy suffered injuries including, but not limited to acute
I
.
I
left C-6/7 radiculopathy, spondylosis, thoracic outlet syndrome,
muscle spasms, and pain in his arms, some or all of which may be
permanent.
8. As a result of the accident, Mr. McCurdy has been obliged
to receive and undergo medical treatment and to expend various surns
of money or to incur expenses for which medical benefits are
payable. He will be obliged to continue to expend various sums of
money for an indefinite period of time in the future in order to
receive treatment for his injuries.
9. Following the accident, Mr. McCurdy incurred reasonable
and necessary treatment from Dr. Jay J. Cho and Rehabilitation
Medicine Associates, Mechanicsburg, Pennsylvania,
for above
referenced injuries.
10. Dr. cho has found it necessary to hospitalize Mr. McCurdy
at Seidle Memorial Hospital, Mechanicsburg in the course of said
accident related treatment.
11, Of this treatment rendered, fair and reasonable charges
in the amount of $2,126 to Mechanicsburg Rehabilitation Hospital
and $10,753 to Seidle Memorial Hospital, among others, remain
unpaid as set forth in attached Exhibits A and B, respectively.
12. On numerous times, Mr. McCurdy has requested that
Defendant State Farm pay the aforementioned bills, in accordance
with his State Farm Insurance policy, as they have been
accumulating during the period from February 28, 1994, through the
present time.
"
,
COUNT I
RICHARD W. MCCURDY. plaintiff
':U..
STATE FARM MUTUAL AUTOMOBILE INSURANCE cOMPANY. Defendant
13. Paragraphs 1 through 12 are herein incorporated by
reference.
14. Dafendant State Farm, pursuant to MVFRL S1797(b) (1) has
contracted with a peer review nrganization, allegedly for purposes
of confirming reasonableness and necessity of treatment, products,
services, etc. The name and address of the aforementioned peer
review is:
Perspective consulting, Inc., 672C Main Street,
Harleysville, Pennsylvania 19438.
15. Attached Exhibit C shows that in the year. 1992, Defendant
State Farm Insurance contracted for over one-half of all peer
reviews statewide.
Exhibit 0 shows that Defendant state Farm
either fully or partially denied over 76% of those reviews.
16. Exhibit E illustrates that Perspective consultants was
responsible for performing 510 peer reviews in 1992, of which 76%
were fully or in part denied.
17. Exhibit F illustrates that in 1992,
Perspective
Consultants performed 91 peer review reconsiderations, and 68% were
upheld.
18. It is believed and therefore averred and the statistics
reveal, that Defendant State Farm has violated MVFRL S1797{b) in
that State Farm has an express or implied plan to intentionally
cut-off benefits in violation of its responsibility under the terms
and conditions of its contract with the insureds.
19. In May 1994, state Farm sent Mr. Mccurdy's medical bills
to the aforesaid peer review organization and on or about May 20,
1994 state Farm stopped the payment of benefits incurred
retroactively to February 28, 1994.
20. It is averred that all medical bills incurred both before
and subsequent to the review are fair and reasonable and that all
treatment was medically necessitated by the automobile accident.
21. It is further aVbrred that said peer review report
contains no substantive analysis of why said reviewer has
determined that the aforementioned treatment was not reasonable or
necessary beyond mere bald assertions couched in statutory
language.
22. within the statutory period, Mr. McCurdy did request
reconsideration of the initial peer review report. This
reconsideration was performed by Dr. curtis W. slipman, University
of Pennsylvania Medical Center, philadelphia, Pennsylvania, an
agent of State Farm, selected unilaterally by Defendant. See,
Terminato v. pennsvlvania National Insurance Comoanv, ___ Pa. ___,
A.2d ___, No. 47 W.O. (August 4, 1994), attached as Exhibit G.
23. On or about August 20, 1994, Defendant State Farm,
through its "reconsideration" reviewer, refused payment of the
aforementioned medical bills, addressing both casual relation and
medical necessity, in violation of 75 Pa.C.S. S1797(b) and Pro
Regulation 69.52. In view of the substantial number of PRO's which
Defendant State Farm performs yearly, this frequently repeated
violation is willful and wanton, for which under 75 Pa.C.S.
S1797(b) (5), treble damages are requested.
i\
24, Defendant state Farm continues to refuse to pay balances
due under the terms and conditions of its insurance contract and
the MVFRL. Moreover, it is believed that Defendant state Farm is
abusing the peer review process. As a result, plaintiff has had to
incur the services of counsel to collect the payments for
reasonable medical services.
25. Pursuant to MVFRL 51716, Mr. Mccurdy is entitled to
attorney fees in the event that the insurer is found to have acted
unreasonably in refusing to pay benefits when due, as well as 12%
statutory interest.
26. It is further averred that Defendant state Farm has
violated MVFRL 51798 in that the insurer, by relying on such
facially deficient reports, is acting unreasonably, and is liable
as such.
27. Defendant state Farm's unilateral action has forced Mr.
Mccurdy to either become personally responsible for said
obligations or risk delaying needed future treatment in
contradiction to his insurance contract, the stated purposes of the
MVFRL, public policy and established case law.
WHEREFORE, Plaintiff Richard Mccurdy demands judgment against
Defendant state Farm Mutual Automobile Insurance company in an
amount in excess of Twenty Thousand ($20,000.00) Dollars exclusive
of interest, costs, and trebled damages.
Respectfully submitted,
ANGINO & ROVNER, P.C.
Da d L. ~, Esqu re
I.D. No. 35~ 6
4503 North Font street
Harrisburg, Pennsylvania 17110
(717) 238-6791
Counsel for Plaintiff(s)
Dated:
q\';1-\C\~
"I
VERIFICATION
I, RICHARD W. MCCURD'i plaintiff, have read the foregoing
COMPLAINT and do hereby swear or affirm that the facts set forth in
the foregoing are true and correct to the best of my knowledge,
information and belief.
I understand that this Verification is
made subject to the penalties of 18 Pa.C.S.A. section 4904,
relating to unsworn falsification to authorities.
W~
9/J~!tlf
'loJ.)lJd~
RI HARD W. MCCURDY
Dated:
s
g
)
'; I,.. r. _' ":.~ .( ,~.. j j .., II' . I
.1 ',.'J l.i rTII'k.l 1n tJ rl
jJ.O. (It)l'C ;. tJl
rj':1J Cumb,'",'L.Hl\i P!\ 1....:: 0
,1L.:....;.~
DONor
STAPlC
ItlTHI3'
'AFlI!A
_'-<<.7.,-,: '1.
~)iI
rrT'; ~lCA
HEAL TH INSURANCI!! CLAllII FORM
I. VI!'OC4l'a ..WCAlO Ct,""UJlU, Cll"~'" ~"nu~ 'U,;A g,..." ,..1HtUMiA).1to NuflllhA
--,~~ ~ ~""'-'."-'H ""....._ J" r ~.'"
~l- 1/~l;r''''''~''lU\Ill 1""".......,1 i ~SNrJH)J ~ r~ I ": (lDJ t,,-h J4U- .).
I ,.Aflrlr' """fllMllWol"'....,..,.., l,IoICl,II\OI"'I II. ,..-g.,r. WIn. :Mri to ~,~iUAlD'1 'Wi.r..."...... ,...............~ MaO
,~cl:u"IV Plr.tllll'U t..I "tlzl "l'!~ >;y:: urJr1 .,--, IIcelll-,II' niel'b",1
.."ntNrl ADO~.I""", "'."1 ~ ,,,,r.INr lIl...Allf......II 0 'W'I.o~lg t. \.Nt..Mla. ADpar.:sS "11. ""NO
,.. ',J.I 11'~f1~ :i I ..,r3......rl~r-i~'*;---i t)t1:1 i: Jtl(,l :'i t
CIN IIT."'. Ij:-li,i,tiUH iTA'!"..' CITY III'A':1I
l ,,~U 1:lJl1th",'ltlf1d :(~ .....CJ \I....c:J QI",,[3 "t'."" 1;II,ftt."I,l'lnJ f';l
I'I.-;ori I JlI.""O..' 11n5"..u",uON.. ;za.a~o~., n.ll~"'OHI ~I...~. AA'A C!:gU
I I" H.' U I (.' 111).....!~\n: .....LJ :.e:...":i~'::~-rJ ~.I P 'U C . I~ }.;!.n,
li~iir..&..""o'. '....., IlMl ",...... '" .......... '-"W'.~ ,., I;' II 'A i'Nr, COHO"O"" "~....'I" TOI II. ,lo4u~lD'II'O~.C;T ~ QA ,.teA ..u""tA
I tic> I 1I',:j':'
~; O;U(. ~jLiiiIJ'I.OI.CYOo'tOMO\. ........11'" .. ''''''-''YI,IIW1''' ~.I"'rOl' ~fVlOuq & ......,.g .c"'rI'~--'
"ll.j o~ 'i '~.:
. ",'..ov",.Mo\ ~.
L-.J Ui\J U~,; Llf,lIt,~
...--,;il.."A..UIll.>>I......eOA'JW)~~
~~r.ltl:(t ~',\rm t'l~\UI..JIIl.~,'
" . f}<EM A'iQ","U ,.U. TN liNtI'" ",..",..
C'lYl. ~oo ",...'ILIIIIlI.."......',........
IS. IkItJlltIO" 011 AlirHORJllID ~5CH'1 IIO""TUfIlI I aolV'l:lnD
HympI" "'~DlN'I"" fill UN~'" ""J'II'II- ~ 1uODI.. a
,.n1... ClNOrO.OIIl:M.
ttyrl.~ur~ Uti f11u
~
'I. an"" '~u\.Rftf. ~r-...... ....In In
... I 00 I .,., 1t.4~,11
(.ll.I.'Ulnll,"~ IIUlAHA'"
0'"
b. AlI'f~ACca~
OJ,..
..OTt4'''.f.C:O:lium
Cl,n CIJ.a
~o.a. "U''''flO ~ U)C,\I...a&
Goo
,,--'C.(.....
D'"'
t'VJ4 h'UfQii ..~..... """""
KAD IACIC 0' IIOMM IIUOfU; COylt\m..o III","NO THI. 'aRM.
,.. 'ATlIIIT'I eN Al.lrwoNZlD P1n8ON'1 510l't\T\Jft1 I "Wlern me r.t... ~ IfIJI '"*"" Of' Dl~ '''li'IJImalD/t
~ III JfGHtf lhill ".... I tIN foIq.j" Pt)fMm Of ~"'"'" tfndllllllw to""'"" QI till :h.." ""'. 1Ol:'fMI
.....M'~'rtriJ.ttLH tt 0" ~l14' O~J::b/94
StONtO OATS
"c.."/'IOJlClJ''''''''' ~ I~U':.r.""""'~D.Il 1..',."A'IfHT'HA...~u.l.I.;"..lIlL""Il..LNIi..
~ ' 00 . Y'! Ial,JU"" Mild",,, Ol' lMV' nl'l4T E>>of1l ..... DO' yy
\111 !JL ~).J ",1'OHAHC'tt\.WO) ... ~.. '."
11.N""",i 11'N1UlIr<<:I.I'HTIICIAH Oft :1frlL1 SCUilC. 17& "D. "'1.1"'" OJ' nEFIMlhG PH"'~C,^'"
Cho,JHY J,
IL JIlU~'Dr'CW' IoCCAL.I.I'.
CZ"l1l96
'1'10 caA4MJIi. ~~TUAI OJ' .w.UIG1t l"tr.Alt!Y.\I'I!l.Ali l~ij. 1,L:lO~ ..10"""''''.....1114:1
I,~~ .~~.:-4
l~W
.., ,
~lllt)o-UV'C..
.. ~'.:' yy .... ;:
.,~.
"
.
C,='"
..- "~to .oor~~.Ti~);!. C. '''''Pl''' I
~ .A"::" ',- ~,,=-
ij~I:Lh'91l "~~:l~igiJ
I
I
I
I
I
I
i ,
" 1
c
, I'
I .' l
i
i l'
('
; .'
i ij
<
..
62
, Y/111J
",2: l~ I~'I 0';:1 t& i ~'.
"iZ
./, q 11I1I1
. i i j ;
i , j ;
,
I , j ;
j i i i
..~'..Iu. ~.... II. no
c,"-nelllJ~ DrTl
II, lNOw~~~J:..v.~
. ...,...... __... III ....-..
.,.. WltlIIMi_.-...lI'A" IIWMf J
~ ',1
,
:i It"
"
1.'ATlftn~TNO. ~~~:.~~~
mc:Curl al r-;]vul J'IQ
.. "AWI}-_~A.DCAE_...c!'~"'" lIohlq ~~_
~"W\.l_II'lI""" 11I__1
R.h~b M~dl~lnu A~.u~.
"8cfl~nlc~hurQ,P~.
J~y J Cha
1_-
~~ 1l;;;/~!./\l4
~'bfft """CQI..,I\oCI.QIIl "'1QEAl"~IMI)
WHC......',......,
PLI!AS6 PRINT OR TYPE
.~~
"'OA~,,,,.~I'
II
" r-;n
...
.r!
I
.
'I. ~TII 'AnlNT tl"".' TO -'O-JC Ifrf i:1JlIUIII."TOCC',j~AT'-oN
fRC..... i 00 ; YV TO YW I DO ! "'
It HO..-rr...."lZAJ.()"I ::II''''l4llAnOTQC , IS
... . lX'I n ... CO' 'fY
R'OlI laM ... ... TO "" "'I _~ fl.
ao.~~ltl . Cl"IY'Ula
r-l~. ~~! ~.Y~ I
ilL WOICA.O M.u......ION
CQ~'
0I't0IPW."'f1,100.
.. ~AUT~ilA1lOH"l.ow,U1
, . " I J
'~II "<l~'~ .... cot ....-. """
UHIf. ~ LoOCAL _
.
41\ 1111 1 C2"0!16
, .:J 001 I I
~ l 1~~!HHlf1
:,1 ,
,
,
J' I
I
'; !
,
'! ,
,
i
,
I
I
I
D
@
.
i
if
i'
,
,
,
:
't.T01'ALO<AMMI Jlt-A"IO "T~"a ... Al.o\ftO&WII.
I 6 b ..~() . 9 la,,' (; ~ ~ n
.u_~~.. ""fIU"'lIMuHQ """"'I.NIIP'._.&II coot.
1l"t1"b IIldlclnw Acsccl
~12~ ~. TrlndlQ Road
~ooh~nlc.bur9PA 1'&5~
1_. C;o9096 I~
..
~>CI'I'.'"
J1QJUO\oI(P-u.
,,-
~,.,.,..,
,)l)M:"
8r....I"''.-'-
I/jTIlJ:I
~\H~A
-~,~_, ,,,,,,",..-i_Ji
J ~
I J "J ./.l~~-l. In JflHJ
P. l) 0 .-:11"1 '. ~ '
~t:1,., 1;IJlljli~.'lu""J p" 1/",'1'
, .. ~ j' j,!'
fl""I "'rA,
HEALTH INSURANCE CLAIM FORM
'"'CA c:I:
r,.UIr:'WO"AC lllHlt;A,L) cw...".. l;~'rA U"'Cl.ill IlI<:.A (;'lir.n la.lN~lU'1:J ""'...~
I '.(..l.,1'",...... _.tI\'I...'lfJ,l>o. ..ill..U~,li1,..~'btl
~~c::J~I;[--l~~~,C!IW "'~c...,~ _,J_~H" l!__r-ll~ -l_~
~'.".lliT..JWr.!iIUlMI"_."'''......... ....,.., 1.1"'...... ~,w"r,;;m a."""" ... .i....;;."'....."..........,""~.,"......1
~.cCL'r'Jy ~ICh~~.d IJ ~;':,:.~ 'Cf.~ ","""'" .n "'n~lJl'<l'l 1'lon.l'Il
1. '4t'W'TT..r.tlH...." I". 0VNl .. ;'AI,liNI ..~l.on~....,.lUl"'!ll....&' 'iiMi.fiIW".AUMC"t,..,It,-.ru
I tl~).t "'tt(l~) 'it ~L.::"I':-'_~"101twr_ ,J ,_L)~~'.I HflnU ~r.
,~N !I....!I: 1& jI...nl...,. )fA"\ji CIty I jtA~
I "n".... r;IJITl...'rl,,"J _L~ ''''''=:J -'~:::J -CJ rl','~ f;mt'ft' 1"',2-.... I I';,
I, to? Cl;OI I.il.~~-"'i (o"'Q....", "'.. C~ ""<<:;0& "I' nllli'~"'l 'CLL:)1iI .n~ COJII
i 1,U,'tl :(i""_")~':fJt:il j 'OI\f""::-:!~";:'i'L_[~~-:'.'-:J..~~iU.rU . C."I)~r,f,1
,~m '1't4..-tU.H.u..t ~.I NM\I, ~... H.... Wd:t. Irll'~ I ,. III f',r'hl j I;o..OIra. ~tL",f1if;C:-== 11. '~""'1~~ JMC....-O.. 'fCI, '.." "III
fI'J! 41~~119_i
1.:f~"~"'~.'''1l<T,,"'''''''''".," ~-. . .u."',,'.',-, ,0.""" O. ""'0... "_I".~.I1--' 'iiA
i 1 "" I 'e.o .:1.1 .Y Ii T't)" .,-'] . ~
D n~l,"illMC'IM"13'O""H ICrl 1~"l/f'O-'<<IO'N" "~'(II14tI .'~IUNAAt.OJi.eQ,oo~"'lI.lf
UU i OD, "" l.r-";1 'r--' ' CT'. C... L--l (I,\.j t1~~ flo.JCt ..~.
' ~o"t",. NA.... ""'U:oHOO!.""",1 I. QTJ.U'IoC:I;llHI? Co INa.'IA,.1.;1I .#lA'" .~"""I 011II .~y... ,.,"ut
I CJy!. r ti~ 3l.:.,t..., l.lr"m r'1'OIH,!'h:",
iiiQ '-UC!II'v1.g J.()i1l0..~ u.. ._ '. ~Il-"'QnoiA ~nfill~!!:'l'".ii..t""
J rJ YU r-::i1 'loO ".... ..."." l.-IINI .,.... ... . H
IlIlAO &lac Of!,-oRM "I'OR' COIiI'U;:I..o,~i1"'IIIQ THII 1'01111II. 11. ''''URGO', QIlI A\lTHO'UZED ...lIlotONa 1la.......Tl.,tnll I ...1'01_
lZ.'''T1ItVT'''I Oo't AIJT)fOMIUtl III"MSON8 SIO"'iATUAI! I IWIID'\M:Iw,..... ~ WI' 1f'-.l1cll ~ o.'t;er trTromlllbn ~tDtIl'l"'~tll"'Il~_~"",,,,IIfIPl~""
.....NI)"~lhIiIGlam 1"'~II"'''''''loJP..It"'''~.lIlU\eIt!lI'''I'.''Ct.tI'.p:t'tJ'-..t'oKOlOII ,-",'OUdlarl_ Q...
1NIgt'Ir!I"!!f'!rrl"~lJ'.1I1 On flll~ ",.;o/."h.~lll ~!~r.'ltl.';l'd Un f\..1"
8Cl'lfC D,.i,.; IIQ".O ~
C.:;""-OC"'AloflW ft.I.I')
w
..IIdUA4NClIIU""..,....O"HiI~,.A....
1. 0..'" c;;P C'.;~l ~ UH'N\l::.%_Itoo.'! ~
NY ' ~o :'.'t:1 tfJtAlll' OR
U 0 '. L ".J 'N"...,., ~.~
11. iAiil!;AlHO "'TLlC:'AH ~ em4l,11J lOunar
ChO..JbY J.
" AUfJI'J!llJ fOlt U:le...... VIII
1'1' " I"AI1...-r..U >oA:! ..."'. ~ ~1lU.""
Qlvln.q.rDAT' l,\otW ;..Qp i..'fI
I ,fa. ,:) N'.,llntlt ~At:~.o 'H'I'5lC.lAN-~
, C;:~4i~,"
,
",0.'" "'AI...' ~LI TO Vo'O~ I~ C\.IAM1fr 0CC\.j.".,..,Q.~
",o.1l.I" , 00 ; .,., TtI "''' i IX) , Y'i
II. ~.lTAl.lotAT1CW(:AIW "ILoOTtg 10 C10IIIlCHT is&.~~H:n
rnw"''''...j ~.i ,lY. TO ~"I no; Y'l.
>>:-uur-,l'I.I....' . CH.MQ1
.,~. n"".! jJ,UU i
.. ~O<'..., .............
0( . 1 ';.\IItUiNIoL ngo, HO
~.AiOriI4U'HO"lArOol N~...t.....
.II. OIAONUIl8OR "'.ilT;""C", hiNI!alJR 'l.o'l$lY,IJl'U.T'C~j;;"'.'''.JlJf.I'':''Q ~TW lilli' u"~J
101\,' h I j' ;.'3. i\
I, '_ &_'--'
+
.IJ!iJ~
.. ,
oAI"CiiOflu"",CI
ANF,:"VY"'U;;....,
02'l;'9402'1/i!l4
"
1---. ...
,
'. H , . ~
~ul"~r NllnvlCl ,eM
,:.It I'llr"IItW.I 001 LOCAoL U!OI: .
1/'IlfT! "'u .
11 Chlil..fi I
1 ,~.; 9:., '15 I
! i C;':~q'.~l) i
I il
1 r. ,:9\1')'; !
, I '"
,I
I
,
. c
f"I:f' t~
--
.
/"'lIIO';':U*'U. UIMCaIt, ~"-lU ~
'.....,wf't~~MC...
, ..
llIIO_.
tOOOI
1 CifoIAnoU
, 911111 i ; "
',' 1
: ,911.:4 I i '.
" 1
,fl I ~
9/01;, , 1
- .
q101~ I :: 1
; 'r
"
I , l
,
i
,
4,1 ~~
,
,
JI1 ~~
~U Ollf
, I
1'1 OQ'
,
,
,
,
,
,
6 "
"
i;
"':' 1 1 ~ 11 'l 14.l1 l/' 9~ 6~
..
e..1 1 ~' ''ill u;:' 11! ~~, 621
, ",
. "..'!t7~'f4 112' l7'~~ 6)
.
! , I : :
,',
"
I~.__L I 'I '. L. i _..__~
a~ lAolCIQ NOWMA M,. I'" ~. ~..n''''-''AC~l.I'fl NO. ~~~......~~
;:J-~l"i~:J~ I1L~'] mcCI~I'l-"l I~"'., ~1oO
II_:!~ . o._>!,~....-o:u..OirtL"","l" "'_ NAo\oIi~"OAO~'CI'AU..I" ...."1 I~.e":"'.ltl
r=~=~~;:~E:=: '~fY~"')'!?'t""" A-4~ouo
__JQlNIo....._~".,~_) M9Chan Ie r-,bu"g. ;1'..
J"y J Ch.J
:i
"
ATOT.4t.~ j,!I,.IIIlIIO\.,lIIrI"AiD ....~~CI"II
. l;.HJ '-'0 I. k) :ue . lJ'J4utJ
3J. ~...ltlClo:!~" ~"'tI.u.Q ~r._~~ lJI'COOIl;
~~ ~~ulcln~ A~~~Cl
&1;'4 f. 'fdnd16 IIuHI
"ech~nlc.burqPA 1,~&S
.... C:.'!H\<JG I
..
~2/"~/~4
..,>
~.... AloiA Ct'\oJIa.,.'1. ()lIf ,,~0'CAl.~....
WH.:JlI.&..'W..J-I4
I'u.au PFf/N r OR TYPf
P'CfIitlIICl'..,1oOO
lIO'NOIlIC."....
,-
~""I-I-
r' .. ,;.
00 Nor
~'IAPt.C
,OTlUS
AHf;;A
~,
~iif
-~
,"'.;<o!lA.;.,t
, ,
~ .'J.
I ! ~ lIil] j..; .L 1 I
;t: .\
f~' I.' I: '..lIlt'"" t' 1.tl1d
rr-l ";< HEAL TH INSURANCe CLAIM FORM
) I. ).jt~C~It. 1oI1tln.;..,.O :',"""~'J' ;I""..~A "M;~." I.'C. '-'ThE" '. J....l,i..tll " Co "IJW1tIA
;----- ~',,",I)l"'''''N ~,,",,'IIJ ~ltJ...tl!J'le ....Jnll
~.~~l'~~_"L J~~..~~~:-~ ~..~.~t)_C (""'~~~_[ -! ;~L"~ '1,"
1 ""Ill"'" KAU' ,,,,,",,, \...." '11. OW..-, Ud'" 'U'>II) T., " ~Al\,,,,rO ",,"," OA', A"
"fetur-efy . rdJtl..Jl'/! loJl "l',::: 'fl~ '.T~ ...~ ,~
1 ;',t.T''lh'rilWHlI'\'''... ...;;I--------w'7i PI.. wirr A'M)"I~ TO ,N$....l..U
f \.~,I ">In.) '.:or ___.___.__l....'-:IJ..--~...~..r=-::I'l.~ ~0,1 UO'\nu ',if
ION fsf..'! .. ,."r 'NT :n~I\I.
I.".,_~~_!"-l'ttlll(' l'l"';.~1 _. -__-.0~' .....l--t .....'.1---- CII'I":::;
: tl,. ;;OC' P..,~..C',f 1'11-;.1.4' 4... C.~'l -,
I Il"/lJ U' 'I) :'''l!
r'~"'.;:...u..Ct """" r,... "'~ "'" ,...., u.... m...
iiIoWi' - - ---1
i' ..., . v.'""'OU'" "" """_"v_'" ,. , ._ "=: 1;....;.:;:''''O<u~
I "fI::'~""
rn;jH''''''oiDt''''lfO'..'.-- ..... """",';.;;;1,., ......'.....
WIt : go I .,.., . -L" r-::rj ';1 CE]'t1t L>+-''-lO l---l
I;' llotf'lCNVlIl i.III:J1ll SOCXlL \MIC j. Qnl(}11 ACClCi"'"
I ' =:J... CSJ""
! a. ~A.(ci~.. ..M'i OM ~IIl()O"".. "'j'" ,'0iIl ttc\lriV~~~C;.4L ..sc
, ..:..-.."" 0' Fe,,,, ........ co-.n...I. ."."".. '.11 .0........
13. 'AT1!,.,.S OR .w~ "'"IO~. SC>>IATU" I IIU~ 'M ,..... ", ..,,. IUl;J1QN Of "'.,,, ~..~
,..~,. MONt ""lcll-..m laiN rlq\l.~ JIIJ'lItVI:JI p.IlI,.,.,. '*"1lMI""''' IQ '",,,.,., J;J1.\' ~ 4ftO _.....
-'!l'r"il'I,.. tll "IJ (In I'U ~ ~:: I;'!, j'lol
90NED O'''"i!:
.......,.",r- ~"'"".---......r.....---,
'IJ~,_~" .~1IlI'
I'~ a <I~~~~ri.cii'm-'I;;:O
11.000TI~CI.AWlI;HT, ~1C-"oI'''1f\t.,1''I-'''''.'0fIl
..... QU. "'Y "'.A'''!Io~'Ol'l
U ~ ~ 1 ~I J '1II1'0faN7l' ItWpt
111. ",..c~-inN(I ~Tk;Nt OR OTl1\iA lQuMa-
I
, crlc..~ill J,
11"1Il"~~"'U j.Q1t...x1L us.
j 'I OlAru<<:....~T..'l' CJl'Ll.),I:"O~ 1V.i1,ltl "'i1,ATI ,111o.1.1Ji'o;.. m.re-Iofl_ i64 i"LLHtJ
I " II 4 7 ~_ . L!..:!.iJ.,,-1
III ""All""" ""' ~ ''''''1 CIll 5~Nf ,U."IU
~1l~1'I"'lM.l' WoI ;)0......
... ."., .....
'--f'ii' 11'f1......ll':i#Ali"t"'AI;tQ'I...,.IC~
1.
c ;:'1 O~I,
-~
,I :l!; J~__
.
lMT~r:I'~lC'
- To
.... 'fY . 'fY
"..1 ~1 4 O~I ,: l' .:;,-t
\12 : .' l Ill.' ~~I - ..
.1 ~,' I :: 1 i ~~ It ',>::' '1 ' '14 ,
. II .,' " 'q" K ,.1 ;
"
.L-
· t C . ... D
~ j-;';'-,lIIt)cIUU. illA'oIeU. 0.. IUM'\4I
0/ ... llaNo... iJ,1MI ~UIotIol
...... MC . '" H"
.
............
;;001
6l :971lU .. J
.~.j.- -
:; "
''11 L.; ~
i
'91 II J {I J
lp
1
I
I , , , ,
'I' I I I L
.1't000000t~L,,"""''' ;SH -a,.. .\oIT"ii1ACeO.l1oft10 .".6CCcn~"
I _ I ' __.__
'2]-~10;n;l;: CJ~" m,'':ul I-Ill ',.,.. ""
1)1 ~^'l.P10"~NCAfU""11l''' 3&'"".....0 _uII..tO\,.T"l'......IIf1tnR-.cu~
'Cl.Jt-.Q ottaI'Ua Oft l:"toIN~ IVJofO(II!D ", -.......~..... '" d-"
~==:::::::.':."':';:"I I ""'h.Jb "'ffJLclno tL;t-o-.:.
I ""!r:hllnil;,.UUJ'':j,Plt.
a_ J" 'q.,'
.....Tf" fl. I..:J, ..
.
'.
'.1
"
,
J.y
J
Cho
....
~'''''-'''~ OHVUlGLft,ttYICr....
....CI'A.f:;D.'j.f."
PLI!A:l1i PRWT OR T'f'Pe
."
tI,li\
..'
'" ,
~
1'-';;"~"'fUW.JIIlII'M 'I
.-:-;HD..,.NUii-,,-....~.i~.t";:;.-w~.-;,......,.'--
"'CC,"df [Hch.II'" \.J
.,.,........"us "Dg"l'Irl~'-
;ry - -----i11i.--
n !"'; Jal!;, I 'Ifill I: "\
","coo. -p-.-:-I~..t.lll ",...(m.-
I
J ; ~;' 'I , (' 41~ u IJ I
'I fl~U" :u ;tQll "-3iiOUi'i:jllj -1'-' ~'ai,.
ll..) i 01"0 ',;.:
.. ..~U'.~....I:),.tt.~- lilt ---.
Yjf . Coy"" r-ifl. ~___I I
u.: ~'l II.. w~ ~~
..il...~O'Yt...lI""'....O..~a."A.... ...-.--. I
t1 i. () O(ofeo 110'; f....
~"'....~A'Ct "'\.A1t ......jCiiliiOO^""" NAMa!
!1t:JL.4 r,.,'m rn':ll~lr.lnCll
4 .il roo''''. ""Qn-.(1I '~l.'" u""",f '.AH'
,-,a ~.~ ,,..,'1C.tfI!'O....QQ'I'I...~Ml..,l
1t.1H8UA1.:>', 011I fM./THGllillIU PIAao~'. 'Il1'4ATUAI I Ill....,.
..,mtrt OI",~""", IG t" 1I......,1fttt ~.IC'... Of tIWllItr _
-.n.... ~~...Q ~
~igrl~lur~ Un l.l.~
Q1C:U..O
... OIo"IIIIoT,..VT~"'~ fOWO"*,,;"'Uf'A~t Qt;~~1Ic."1
..... go' ,y ....... . w' .,..,
~"" 'I T'Q' I
I' HOP ALl "g....W.h:.iliiAf.ni'O;;,~fI
...... QU'''1 W'CQ'.......
Ji~ .. ~ .". .... TO....I _,. ..
u,------
.,.. -:>il""
.a WOICA. ~.......ICH
<:Joe
III 0"
.""""...
1\,Il11
Cft'GHAL Nil UC.
,
I
ti- -m:J'" .w~1Uo nON HUl.t.....
.
. OlAIIUI "'~\itD~1IIl
""""....
.
4'.1 \40 C;:~O'lh
J~ ~q t~ ~9 ij ~llj
nil C~~H'~6
,
,
:crl
I
~--:--I !--i
I I I
'l.~ ... ~uJ(fjl~ ,~ ~.ou,
· .I ~i5 4~__ I. . ":t'" It l.J~J. a,)
>>.~,iCiit~~IIA--:i&i."Wic-~A.:)()M'" ,.
.~I,
R~hljb M.dL~l'lV A~.o~l
&1::4 0. ir1''Illd Ilo,,(j
"~ct'~r,iCU~tlrqPA l1H&b
"4 C ,~~ 1195 I
Iltl
CJ9
-0(,'
':>
JOlt\a"CII4-'_
"UI'WQlIIICJ'.IKlll
00'"
OU'W .~.'tot
"'>rA urr
r.
~
.
.j
i
I~
II
I
a
Ii
If
.
'1..:-' ~.;.
CO NOT
ar,\PL.
", THIS
ARCA
...I...\....-i...."'~~
J(."':r,f
\ J \, L I /'1 tl~. ~ 1 fI
" . lJ. ilL' h ";:.i.
lfo;'..,J CUI'llJ;",.land
t-"\ I! ',I ",
,:;.1:;' ,:,>1 I'
If.. 1."
.J..d
,"rn"", HEALTH INSURANCE CLAIM FORM P'o.rri
!~''''Ir.>(;)Jt1! W:~CA!O 'tWlIl"JI CI"'~" '11llO\)I ,~~ OI""'..I""U""J"OH.,j..-tiLA. l'O..~AOuIUo..'..l.!\,II)!
l.--. . _ "WIH"'AH ItuW.MJ A Jli'~uh~Cl-4hR j
I 1""'-'M~==-',~~.~O_~~.~~r--},V.41lw"l:] jJIHotOI C!~~,C=L!~_ __. _
j'r;r.f'CHrI It...... t\Ml....... ~Il 1'4_. wrv....,..,... r J. fI"'m;~,..It'''1W Mr. 0'" " .....Uqo:',..AM. "--'...... "'11 H.-r.. ""M. ~Ia'
, 11CG_ur-dy i'tJ,C't'I,'1I'I.: W~ft:.; cpr~ ~~ ...~_~:-, MllClJrdy r, ~c.:.tlcJl'd
~.I"""" "",..........,.....'. L fI.. 'j;. '~n~li". 10 ....."'. /, '~'\'''l)' __'''''::' _.,
(,rJ,l ,"itlll') ~It . .....L _.~..--r:::J~r-.-l~~ ~llJ ~I.~r.') ."t
i ;-tY-- -.;~p.\JiiHn"-i~.~.-- I(TV 11'l'~n:
j I~l'''j i.lhllb~\.ll1nu I"I:'''~-! ~r.lr llII_"1'! or..~ II'''J tIH'1~I, , 1"11 I 1\'1
~"ct~, .-- - ItU.f..."'O"'lltll;'..:I.....~ -. ii"COO,'-- ' l'iu~..~'".r\l~~~OOl,4~U~otI
L I 'H I " { ,;' (l).. ,..'!." '1 I ."'...,...~ ~ ~c=J;::~:;'4r-l J. ;',1/ 0 (' . ,,-).. ..1.1
1'-j....-I"Ih~"Il.C.s ""Y'U{...I H~ 'd 'It... ...u.. ..t...~11II r """11Vr ii'i3~ek "tLATlO~- 'I, M\."'O'. -0\.1(;, ~~ l;n r&CA'....J.m
~1 (~, It I, "J l'!' \
rr.... ",""'.. '0..0' '" 000....'.."'... "'1," ~1M'~'1Ii1'~ (ClJoIIAfKT cpt f'IltV'OWlt ...u.'-l,.I'110 5 oit'--6~-iaM1l1
I ... D'" C:::S'" "Il,\ "i~; ".'1. .,~
1.,an.IR'''lluH'~.:t::l''T1Cf"IU"lot ~. '.AUTOACCDfNfy ,,~.~ i:T'~b'r6ifrl4""~~'C..lXt".ulI' ,
MW : ~ j Y'I' ~1 1" ~V" ClNO L...J 11..t,j lIt.l~1 n(IIJI:,.,
..I....~tM." '-AUI Q~ lif:..CN4.ti...~. .01'''''' "'CoUIIK" ~ 1N1U1lA/IIll;. ,~..... ....w. OA'iiftWAilll "fAb'
C]V'fI I ,\jNO ~.J':llt:11 '""nll I !lldll',HH~'t'
d ''''''''''''1 "'-No ~ Q!Wr.llfoiiil /1G4. ooVll"..CO'lJIlI ~CI:<I.. .JoSe 1..1 T Ul",.u~--O&ijUl' itU/Iff
rJ".OlfotO ",-....,.."...,............'*"...0.
RU,Q UCk ptJ 'GAY INiJOII( CO"'''''.f1MO. IIQ'flf4Q T~" IrOJIU. 18, IN'IH'IO" 0" Aun.(JMQIO "f"Ie...... ~~T'...I I aw!llfi"
If.P~''fl''T'' on AUn<<)"'ZlD I'!MOH"S IIQttA,Tunll ,'.4"0.", It~ ,...... crt -'1 ","cat Of' tJ!l'Iar 1"'o"IIUOI\ &af'N'\I 01 1I"\Hk.! b""..tt tct I... un'IIt.9"''' "".ICl.,. cu....,.. lu
e.:.lH/Yla!lJllQln "'.oItl"" r ..........pevI'NI1lr;J.--.-c b.... tC'*..1!'\If'HllI' OtlO\'1IIl1/tf-.t'o01CCIOl1 Nl'f'mI dINOllOtCI NIGW
IU9m~'~n,1t;UI r:l On fiJ.., 0;~1 ::fl/9~1 !;;.4'JnLltur'I' 00 I'il.,
'l~lrrlfO D.4fW 9tnHlD
14 QA'ICJrCUIllW'tT: ~ IiJ.Hftlt"'" ~"''fi~ ~ It, " rJ"nlNfll.... -'AO""'r,O" SNll.N'!ILUtU. 'J,l3Al11'ATIIHT 1JIIUlM' TO WCIt'C 'IrICU....'hrOOOUl'Af1CN
Iou .IQO . "(:I 1HrJ.;IIV:Aoa.'anI)OA ' d,Vlf\lIIlITDI4r1..... ;.l'>> i.9 illlol ' DO ' 'N w... ' 00 i 'IV
'no t L ~J "AiO~'tIl...... '..0'" r: "'D:.
1" JoloW'Of' "t'.H"nlha "H"l'$CIAHO"oa..~ '0I.i~" II'. 10 tlUWII" c; RU~t4''''Q ~hYJIC+AH tl. "'08,.UA&.lUoOOH ~ru HUA':'m TO(;..~"tI,r. U~'l;U
(hO,J~ly...l. r~!)096 ..1tOW~~Q,P..jlY. TO~"',iDp~Yl..
"'ii"'iiii.i,ID ~ lDl;..lL un at, OU11lX",..1r . CHMun
U,.. G..., 1 lI.illl i
n. ""OCAICI AIILIIMa.t!O"
COOl I 0'\(,1,""4. -. "'0.
n. ,."rQfl MlnteAi1.Alll.iN NL"'..
L,I
Ii
,!
I'
I
I'
~'!
Ul !
.n !
Ii
Ii
1=
'.
I
I.
'1
11. Oi~"lu" .....r.J".C"l\,.lH'.. ORIN.UJI'ff, Iflln....7.1"'e'll.',u:>>t4fOltI..... t411"'Lft~
l,I.141,~ .1 .;:~~4
. I 3 a :,1<
.
Oo\TClQ)OfI,u""'CI
~" T.
IolUDnO/"....""'(y
.
9;~'1Ii 1~'1 ;'::~ J4!<14
I,l--.
. c
'... ~ -1'U.;!Dl.lAn, SLlWlCCS" 0" SUfll'LlU
'::ct .~ II...nli;M1uoc:::.......
,
'OUqJ
. .
C"'fl PlOf
IQI.IoI'QU 1.Itt~. '):t
U ~, 1111 1
,
,
~,i 118 1
,
I
4U ae t
,
,
,:,j 1111 1
,
,
."A >Ill 1
,
,
,
" J
. ~
N'f:n'i'B1ItVl
""'.... . i
c ~ III'" G ~
C.:~~~D I
L~9"!JG
r..(~9n9f\ II:
0
.: ';:l)U~tj ~
f
.... 00'
,,.,
I
I
. l
./ .'
. \
ft: l ,
..
1 ,
~ ; ,
"
. U ~~ I 1'1: H'I :.~: 1'1' ')4 fi"
.,
fl.~ I l., i'J4 (l"1 14: 94 6:1
'.,
u.~ i 1'1 ~ 4 '1 i) ~-~ ! 111' '14 h ~~
.
. 0".' I I" ! ~~ AI 0;'1 .I 4' '14 r\::
..
"
it.
, 1)1l1'1~
'91116 I
'P'J'lll/lllll
'~~elll 1
I
Ii! I
I&.fUoI;JIW. UI.o.NlJI,l.1l UN Ut
'::J-~l""\l::;: rim
JI.IOIA~ll.06 ~'1';'~91l:'UI'I1.~
.,.:Llhloll tl!~11 Oil "'IOIJro/T'W.a
fI"'~L"'___,,(,,-_
.... 'D"1llI .,.. .,..... ~.I ......,
lArlCl
It ,.~r,
h*:ACC~~rAI'~
JW-gcM~__"
mc;CIJI'I.-.Ol )( 'u I JHO
3. "fMII AHO AQU,..,~iUria'WfAIl
~"\~lJ''!\!.''ll''2''!!!fI'l!) A...."g,
~Hch~"le~hu,.QfP~.
21. TOT~c.HNlO. I"' ""'O...H' t'IlU a lIAo..llQ tuI
. li'l 010 . " ~.iO . 111.'l)\I
a ~.!.~L~'SBtlL~"........ot.JOfI\I I],h" """"
R'-fMMf M~u...C LflH fl,:'iou~
S1.~" L. f,.inul", 11;0,,,,1
M~ch~nlc.burgPR L/"~~
. C ~91191\ I
,.."" r,JIII"
JdY J Ct,u
I-m ~_ 02/,'5/'J~
f"'~'If/UNtoCfll.lHClLo.tUB>>CAL~_
...CI'....l.O~~
1'OIW1'C1'/a.'.
rtlMftJolrClLlfIIl
""""'......,.
t'''.''
I"l.EASIIPRINrOR rvn
lledger]
GIlARANTOR * 1 mcCur i -0 0
PATIBNT IlmcCUri-OO
ASSIGNMENT Iyea-yea
LAST PAY DTI10/18/~3
LAST PAY $ I 18.00
LST PLN PAYI07/18/94
LST PLAN $ I 150.00
AT coLLeCTNI 0.00
~
Mocurdy, RiChard W
603 Reno at
Naw Cumberland, FA 17070
Hah~b Medicine Aseociates
PATIEN'l' LEDGER
--------------
Mccurdy, Riohard W
McCurdy, Richard W
603 Reno at
New ~~mborlan~, PA 17070
EMPLOYER NAJoIE z Biq B.. Boata
REF DOCTORI065 Cho, Jay J
iNSUREr) i2
PLAN 1
POLICY
GROUP
Istate parm Insurance
'138-6540-958 PRI--/.-/..
,:doi 053193 TOI../../..
PLAN 2 I
POLICY II
GROUP II
,g,w: BILL II J:llL. CPT/PROCEDURll CHECK #: PLAN
03/17/94 136757 cho 99333-Initial Hoapital Visit
03/18/94 cho 99232-subsequent Hoapital Car.
03/20/94 aho 99233-Subsequent HOBpital Care
OFl"ICE: 20 OX:723.4-RadicU1opathy, Cer State Parm In
03/22/94 137148 cho 99233-Subaequent Hoap tal care
03/23/94 cho 99232-subsequant Hospital Car.
03/24/94 cho 99232-Subs.qusnt Hospital Care
03/25/94 cho 99232-Subsequant Hospital Care
03/26/94 par 99231-sub..quent Rospital Care
03/27/94 par 99232-sub..quant Hospital Care
OFFICEI 20 DX:723.4-Radiculopathy, cer state Pal'lll In
03/28/94 137471 cho 99231-Bub.equent Hospital Care
03/29/94 cho 99232-Subaequant Hoapital Care
03/30/94 cbo 99232-Sub.equent Hospital Care
03/31/94 cho 99232-SUb..quent Hoepital Care
OPFICEI 20 DXI723.~-Radiculopathy, Cer state Fal'lll :in
04/01/94 137652 cho 99238-Hoapital Oiac~arqe
OPFICEI 20 Dx:723.~-Radiculopathy, Cer state Fll1'lll In
La8t statement printed on 08/02/~4 tor 0.00
Credit atatuBI Good aet on 08/24/93
Patient
Plan
ctTRREHT
0.00
0.00
.'AG!:::
1
OATI!: 108/12/94
0.0.8102/15/43
CHART I
HOME :717-774-5876
DIRe 1774-2587
ISPLY1957-3838
,8 S ,:206-32-0833
CLASS. 3 DRlcho
PIU
1'01
R!m CHARGE
1 180.00
1 70.00
1 70.00
320.00 <------
1 70.00
3. 70.00
1 70.00
1 70.00
1 50.00
1 70.00
400.00 <------
1 50.00
1 70.00
1 70.00
1 70.00
260.00 <------
3 95.00
95.00 <----..-
Balance for Mccurdy, Richard W 0.00
Balance for Plan 1075.00
O'J1-0eo
0.00
0.00
061-090
0.00
0.00
091-120
0.00
0.00
J,A.g;t
0.00
1075.00
(.ledger)
Rehab Medicine Associates
PATIENT LBDOER
---------..----
OUARANTOR NlmcCuri-OO
PATIENT NlmCCuri-OO
ASSIGlfMENT Iy.a-yell
LAST PAY DTII0/18/93
LAST PAY $ I 18.00
taT PLN PAYI07/18/94
LST PLAN $ ~ 150.00
AT COLLECTNI 0.00
INSUReD t1
McCurdy, Richard W
1S03 Reno St
New CU~.rlanQ, PA 17070
McCurdy, Richard W
Mccuray, Richara W
603 Rena Bt
New Cumberlana, PA 17070
EMPLOYER NAME:Biq Bee Ba~t.
Rl!:P' DOCTORI065 Cha, Jay J
INsmtED .2
PUN 1
POLICY
OROUP
IState iarm Insurance
'13S-6540-9S8 FRI../../..
"doi 053193 TOI../../..
PLAN:I I
POLICY "
GROUP . I
DAn:
.BILL of Q14 CPT/PROCED~J::
CHECK 'I PLAN
0:1/28/94 1351564 cho 99213-0tt1ce Vie1t, Existing Patient
OFPICEr 30 DX:7:13.4-Radicu1opathy, Car State Farm In
03/08/94 136101 cho 99213-0tt1ce Vi.it, Existing patiant
03/08/94 aho 95900-Motor NCV, Each Nerve
lt lIIedial1/ulnar
03/08/94 cho 95904-Sens~ry NCV, Each Nerve
It medianjulnar
OnICII 30 DXI723.4-Radiculapathy, Car State Farm In
0'/17/94 140318 cho 99:113-0ttice visit, Ex1atinq patient
OFFICE: 30 DX:723.4-Radiculopathy, Cer state Farm In
)7/08/9' 143165 aho 99213-ottice Vie it, Existing Patient
OFFICE I 30 DXI7~3.4-Raaiculopathy, Cor Stat. Farm In
lS/0!l/94 1448.57 cho 99213-0fficQ Visit, Existinq Patient
OFFICE: 3D DxS7~3.4-aadicUlopathY, Cer State Farm In
aat atatement printed on 08/02/~4 tor 0.00
red it status I Good set on 08/24/93
PAGE:
2
DATE 108/12/94
0.0.8102/15/42
CHART 1
HONE 1717-774-5876
IDIRG :774-2587
EHPLYI1l57-3838
S S 1/200-32-0833
CLASSl3 DRICho
J'R:
TO:
EQ.i CHAR.O~
3 40.00
40,00 <-..----
3 40.00
3 120.00
3 120.00
280,00 <------
3 40.00
40.00 <------
3 40.00
40.00 <------
3 40.00
40.00 <------
Balance for Mccurdy, Riohard W 0.00
a.lance tor Plan 440.00
?atient
'Ian
CUlUIJl:H'l'
0.00
40.00
J.4.ll:l:
0.00
320.00
031-060
0.00
40.00
061-000
0.00
40.00
091-120
0.00
0.00
.. , .~............u...
,;.~ ,'.01
~T API,C
IN TMI3
~rA
..I.---::"'~L~''';'''
.('.
.' .... ...J '-"" ~~.. roJll';..
11 (. L ~ ,nil k 1111... Jo" oj
P.lI. Uox ~S7'~-
Now Cumhorland PA 17~70
"
I
,
fTr.,"' HEALTH INSURANCe CLAIM FORM ..r...rrr ~
I.IADI:MI . "'<<lICAO ~~. C)1M>l'V", n.-ou, ,ec,r. :.,..,.,_aTt..Jt 1....~..a.lJl..n.' ~D,,,,,,,,,,,, IfOR"'CGAAW IHlTI\ll,
~ ---- -- - "ulT\iIl'U.~~IW.(lu.~ . ~JtJ-bt)tJllI-~hO
I ~'--'r.. Ifl ..I~"aHl rNA~,,1l N..YoNfq I I (SIN) (fOJ
.. ,,~'ftiHl"H:;t.'ii\':;l~)'--tt N~. 1.Cbf:.1n..1 "i:.i'ntrr. '~Imt ~l' ,a . lNiUl~*~",....~ tw... ......... )/Ih~
",,,Curdy IUghu~ W Wi./; lWlr.; ...:: .n ;n Mcr.urdy . Rlc ord
-
· ""ntllfRlLAMMih.,ftj~U) .1M1Io'MD'" e.,I~
... r~'.....rlOo,f-' 0Nr rI 6" J ({ Q n" S t
. ''':.INT .r.m... ,,,"llY
....0 w.....O -D Nrw Cumbol
,'"""'"
._ ~ ""'...,.-,....""'~ 11\1 ~ 0
"I I (Il"''''L-J~.n..''1 I
III 10 '4nllll'l ~lWlTlYN "&.Armin;
-. ..
.
cPl&.....,
tie:] II.IIU ~ I;
em . - 1""10
Hew Cumb~rlMnd jPA
DP OCC. I n~~HO". I,.... Ai. C.lidti
1711l~ Ie 17r' 74-fi676
.. trfJiI.M 1"-0. ,..4"11LMl ,...".. Inl HII'\t. iJlclltl "'1\*4
.
RWt I"OLIC\I Q.lII o~, If..'W.",
.. IU'LO'rMIN" O:UNlIIfT at ~ClI.m
b.u- 'IQI,nt:l1_IltTW
1.1.. ! ~ i no 'ur*1
"r.IIPW'rtItlw.u.ulOllICl<<)Q.JrW,(1
~""
PU<.I_
0.. L-J
"01lILll~"Tl'
L 1m C!J...
lad RUtM\'lO I"Qf\ ;.QaI"l.IJI
'1lI
.n
Dvu
~ NJ1'O ACCIJEHn
CJyn
~
IIU......... c-. '''00"'''' """".
"AD ....c. 0,. P'~ IIPQJlI COWL01NQ, 8IOHING I'ffil RJIW.
II. PAnlilu', OR AVrkJrlIJtD fll~ 1iIN4T1JAI I ~ I'. ,...... d .,..., "*110olI '" 0". 1111I""-'111'1
~~,.,....wt""l ua .....,."'~8ffO~.,.~Mh..(g~"Of.IhI~WIIllI~
."~"'ll'1a tur.. On PUs 94/17/94
I~~ _ OA~
14, IMfWOf'Cl.MlNf: ~ 1.l.NU'(1n~qDl'l '...'NTtENl'HA.a!iAOOo\....C".I...W_LLlfI.
\I!l" ~t" 1l!'Y "III::;~.\'. .l'/llfll\lJT.... .W~;oDD ~'"
11. HolIIIII (UI !\II"IMWJ ....Vl1aNf 0*' C"ti-otcul.c:8 In. 1.':1. "UlllBl' 0' ".flftRiHII PH'fBICJAH
Cho,Jay J C~909G
II. ""lAveD rQlIl; LDCAI. U..
ft. ClN;II..01~ onp--.ru"'Qfl.u.Hu. OH lkJUJl.'t. (I'&U'nrT1iWI.&IO". fa IrIJA lot.. I" l.
';:3.4
I,!.--,_
,3r,~1l
. .
.. .
0iAT1l(1I~' ioVMC. lit.. rue
... '::" .. "" "~ ..."
,
I~ ill] i!J4 04; n; ~4 J.1 1
~I.--,-
.
.
....."'"
000"
1 ,
-I.--,
P~=~~c:...~~II'
,..,;..,;...... I Ul"!~".
99::38 I I
..
"
i i ,
, ,
i i i i
, ,
; i , i
,
: i i i
I I
I ; ,
~ . "
..} I !
, , i " I
j.; ,
I ,. i
, ,;
I
ilL jI"nun-, ArCcom. NO. ~1~ ....1ImWI't." .
V"\II.II""'" .......
mcC,uri-se k y~"n;"
u ~~It: ~l?.~~~ rACL~T!J!..~ ~VIOl'Wi.u
~':'rd'r:"",:r:;,'ir.l'~T:'i"L Ho.pit..l
"1..,h."J C..bUI'Il, pn
I
tItJiIAU lAA I.D. ~ "II IW
~J-~1"ill.l3c: I ",,'
;:.o;..~.r~'t
~=:- ::::-..::.t:""'::tJ
lay J tho
-
.._;84/ ,1/9~
~fIf AIM awJC,'1.OI>IWfDlC.A&.II'M1aI",
...,-
PI.U./le PRlNr OR rYPf
w
1'","
lond PA
ll.U'HONlI1HCCuuw ""loA UCOI.I
(1'1n~-!;O~6
.... 'uw...
...
,Il
....."
t" DATU 'AN,," u....1L1 TO 'tI;tAIt.,., 1O~1IYT a;eu'AT!OM
....'OD'VV ftW'm,'rt
'''OMI! TO II
'" HOImAUZATCN Mfa flllArio TD CUI'tADIT aUlYlca
.-'"63 If7; !1ll ro 'lI'4i 'lPlj '94
=. OUT1o.Ol LU, . Ctu,lQU
n.,.. rxl"" I 0.illl I
a WUJlCNg "~.......o,,
caDI I ORIaINAl.IIUIIJ frIO.
U. ~Klft ,u"lltOl'l\&A noN 1fU\1I1f\
~
. Q " I
I ")lMQi1 ~r= OUt) - ~ftYlDP'O"
LtNlf1I ... LDC.w..UII
9f:; llil 1 C;;:YI1Yc,
,
,
I !
, I
I
I
, II>
I a:
! 0
I i
,
!
,
I
I
..rCT""'HMOi '_AWe ",",1'lUO 1IlI.~~
. ,9& 11'0 . II :ell. YtJ.~1I
.. ~_rw;wr".uo ~ . p, I'iO IiAoVI. ADM&II; Zl~ caw
R~1f~~ ~.dlclne As.ooi
~li4 ~. Trindl. RDod
h~ch~nl~~burgP~ 17866
.,., C29896 f__'
fIOMIMQIl"'11OI
P(lIIIfOlllQIIo,.,.
-
--..
"";-
..'''\. .:,""'.
'..~ '. J j " d ...,: .. I .J ..: ~
l1r) liITllik.il\ )01111
... n. U". .15/""
N.w Cumb.,'l.nd PA 1101U
"- .....',......
....~-~."'
co Nil:
6TAPl5
IN THIS
AR~
"
00, ,)
Z
~
nTI'lCA HI!AL TH INSURANCE CLAIM FOAM .....rrn
I. WrlUCNtt Jollgc;.40 c.\\"'l""... QlJ.~~ G~' ",-c\ OTt'I" lL 1"....'/"'. ~O,ItU...liA IPM MQU""", Ilfffl\l 'I -
"'lAl.'h"'-.AH IM.(W'I1~ JoI-ij!:>~0"9&11
t::L-n_.il'_.,....I-".."''I il ,-."" bJ tfOf<J' ""'_ ,.. :.:...,~~., NAJllr.......... n.. ~.. ""'W"..1tiIl
r..'~'~...;.~N~.t\MtMlro..,..".."''''....'''''.flftl J.M!1'!lrtT'liiii''rlIu.\1 .u W
I'Icl:urdy Richard W wU<'j "'~ 'If;:' ~r~ '0 McCurdy Richdrd
1-' ,-~"",_, .-AOot'''I~. .._~ I ""mrr'"cu,IOh.''# t'OlktIJ..g ,.II'6MND'._ MAJUiil m.. ....0
liU:1 Il~no n ...r~:-,;:' ~I ]...-n 5101J Il,no St
~':, 1''''' r;.,'''' · ctrY I" ^'~ A I
N..... Cumburl..nd PA '-0 N......O -c::J N..... Cumb"l'i"l'lIl
lSP'WCI . 'TIl~II__,*~~1 \IN..
17070 ('Llr714-6\l16 I -~ 1~"1"D 179'11 f 171"4-6C176
. _..1_.. ri.:IJMD'. ""..... fl_ ...........-- "'...... ~ WWI , 1;' I. "'ATlI""" . Mtu. Q r" " ::lI~~l~U.. A
I , deli 111\31\13 I
.. _"-,,INI\I ~u. .. u.."~"", fCUMM'~ 0'" '''''\ll'OUllf L'lil.U"'-lo!".:ATI ~ ."I'M ,..
0- c:J... "'4 "a YlI2 .n .n
.. DO D. AUtO ACt:iI;l'NTf """'- ......~...,~........:"~AoII/lI. !
.u
- fDOfYT I.,...., .0 c:J- 0'" lUg 1"'0 II""C..
L-..J
.. .,..,.,,--.~KAYlI Go 011i1R ACClOlIfO .. ,.....""""'. '"",,N H~ ......,fItOl!II\W "'...... S
Om r~... Statw fllrm In~ur~ncY
~ .-- MN.i.q 1011 IlUDiYlo '''tit l,.CCAl. ..al ',11 nt!MlIIo-,01't""" "_l.TH -.1", /"UN'
1l'l'U ~HD .,.,...,...........-....M. '"
MAD MCK 01'110"'11 -.a,,, COMPUlnta , 'lo.tHQ THlI nJNlL 1J.INi\,IlIilD" g,. "lITliCI"WZ1O 'INCN" IIIJHAT\JfIUl f .......
1& PATIIHT"I CR IoUTHOflI2I.o NaKN'I .....T\lA. I ~ "- II.... at &I'If fHlIla.II Of cow t.lgrWlttIM ...""... _l'hI4kIII ~ 18 NlIl'l(JM'\l*I ~CIf"""""
~ "l;i' N eiotIfn.l... """rf:4 lJIlIO'i'tfM'_ DIndI ....Ia ~l ore hPt1MtQ... _.....~-'
........... IICUI" On F, '. 4/97/ 4 S gnatur. On Pll.
-- 0"',. u ......., .
'''DIIol'lQIIIC\..RIW:~ ~ ........C~''''' 1" lJ ....T1eNT.............u &l.W1 CiA IIMLAfllU......... Il DAria '''TtlHT u*... '"0 WOftC IH<:ut\IllINT OCCI;'AncN ..
Illl" i1l0 /l!JI ~~ GfotI"'..,QAtJ, _W11 t 10 r w "IQIW4,OOj'tV TO....jOUj'N
, , ,.. HCWrf~IJON OA~U UUTUl TOc~r .....~..
' 1 r, -:- ~ ,.....,."...o".f'i'.""'" Of!; OnocA IIroAIKI IT.. d:CitUYUA C>> M,nARr." ~,,~
Cho ,JIIY oJ C<l9~96 -.."'8 ~ '!'li 9lI to ......j IG~ 'lit.
..._-, ,.... n OurUlI""'l
n'N C'fJ"" I 6.1111 I
~WI NoloTu.lI (2Illu..&a,O"'"'*"ifllV. tl\CC.AJ1:rTia.w 1,l~0A" ml'r&.>>a.tafiYI.IH-, .. II w,~~" kIW~'- aUG"""'MI',1fCL
,"I]:?3:~ ~,---,- WOI I
. >>"1UOn AUT~nDN M./tllDI"
~13l>3~ _L-,
. . . . . . ~
"1'6(11 ~... 'Ir ..~U."IW.cU.OA.~LI.I. ........... ~V' 'NOT: ~...."'"
- ~ "" .: .. u....tl JlIlt\IIIIIt ."""""'. "" ...." .... """
... - - ,- ""'" ""'" ~.. c
83; <Ill i9'1 03; ;:U:94 ~1 1 ~Sl!lnl I ; .lj 1 " , r.ID 11 C~!'''9u I
~ 1,I}o
I
e3il~ ,':14 l:J;t; ":91~4 011 1 9~J~~ I ; 1 .. {~ <JO 1 t;!9U::l& ;
la:ii :99~3:: I . , iHtl
83; 30 iSl4 ,::nj<i-' ;;3 1 , 1 1 , \\ 1 C;:!1I19o>
r992~2 , I:' , I I
U3 i:ll i!J-'I ua; J'l ; ~l" 2\ 1 i , t I. 11\ .li1 1 C,!9096 !
..
. ~ , !l!
i I ,; I
uL , I : , " ! Ii
. I ...
, i ; ; ; I i J I if
I I
--.: AJf I 0.. NUlo6HII .... PI ",~rcn'.ACall.JhT-.o F1i:r9:.... _'\,Ir,....~ I~__ ffr-Am ...
?3-~1979n I. -1L A J mCe u,' i-"ll1 . ZGb ~oII . . ie9 . 26il~il
".~.,t'J,q-OII"""~m"'.llll!" "'-""''''''''''~_N'''f'" ~rrt. R~~"~"iidl.'iirn7'TuOC1 "~
55 OfOltIUQlltCAccw.JlALI
:-:r= ~::-..-.:;...~ J '!'WlJlp_ "",,.two Clap tdi
Il.chatlic..burll. PA &1<:4 E, Trlndlo Il.."d
oJ.Y oJ Cho Ihch~nJ.c.burI;PA 178!'>1I
,
'!" 84/ 7/94 " C<l9I915 L.....; '; ,
......
~ft~COOUlIOfI.o.rlollClCH,"""'ca"ll
.....- '
PtEABI! PRINT OR rrN
lI'OIIII~'_
.'flOMr~
r.... . I
----
'.:.1':.' 1.J(m
1 1~) L i ITl tl K i 1 1\ .. 'tJ '" 1
P.O. UUlC 2$1
No~ Cunlborlutld CA
~...;.. <I..; ...:
"."-0' . "'.<'7'." 4
.
-.
Ij r.# rl ,:__
t
I
rnl'''', HEAL TH INSURANCE CLAIM FORM _rrr.
I, WiQC.AA' "ao'CAll cw.""lA \;IIIW..... ,,~,. H'c.Ir. "",n I.. ,,..INn',. Q, HI.l&.l'." ~ MCI.lI'NII iN."'lW 'I ' r
--,,, .r-----, HIALn..."","l 'IJl~LaU I "'tl lil\,l~ ..'r_LJ
~d.~r-- -'~"IJ~...r.r,o,IL. ""~I!i tftHtltIDJ -~ ~1"1 L ......1 tY'I .J ,- '.J",,-~u
.I ~i.1'\Ul'" ~.u,I(l.ul tl..,.. ~ Villi. ......~- ~L~1Ar:-UiiTi~ni~ &U '4. ,,.,....NI)I HAoW'l\.M..."., ...... Ii......~ <rl;'"
IIcCurdy Richdrd ~ "Il'2: !'l>i ~ Mrrl ;n 11cCurdy 1I1r.hard l.J
n.r~"aa.,.,.... - &"'it'l-tHr.....TTOtHH~lO~lN'D ,'_I~..wU"Ii.I_,~
ti Q:l H (fnO S t I ..,CWlt....rJ->>-r -.-Joe.CJ 51 J H ~n 0 S C
ICoN . --fdT.'ra '..Jt""Dn'iTATtJ. ilTY "f*'''''
No,", ~umb""l.I1J II'A -L,J -0 _~ Naw Cumbel'l..nd i ?A
~ 'OCI I T I1DH~1 jH'lWalo'.. \;..- I'll 1:0ClC !TllfrHUN. 11NCLI.DI~..". ~
llWIH 1 (1I1)'2"'1l7 ....-II~I J:::r"'1 1111711 , (14-)?6U7
I- fJn''''''IN.U''IrJ.NAU....-,.,..,.,.",."..,M....lltlllll Ill""T~T"alHO .0HIlIlAnJro II-H&U....'.1'U.~.,__~......P......JItUIIl_" -
dol O!)319J
.. 'MlNJolI.,., 00''1 0" 1111m<
'6':1; 'f6: '4;: _, ".1
.. lWl"\.O't'."'. It".. g" 101'ClO\.__
~ Big B.. Oo~t.
~l.iW<1 P'IwUI """'II: cn PNXI"""'IU..M.
Sl:d1Ce f'dl.1n I'I~Ur"cSnc.
., IS TlII'I"I[ .lHOT)dJII ",&.q,~1 .tNlI"fT '-WVl'P
c=Jws GJNll .............._._IlM......
f~ IN1UA10". CIII AUll1O"ItZm "iDUON'. 8ION4ruAI I ~
:J~"IIl"C&I t.......\CI N UI\0tn""* Pf'YtI*rl. ~_
........ .....0.:0..
Sl~n~tuj. On Pi I.
'10"'"
,
! I
. t.O' A9 1
1 ~H32 I i ~ 1 ~ lOJ CIlI 1 C26~JJ
U 'AT;'''''', NXO:df kg. ~' ~tr ...,~...... _ roTALCl-NQI I :n. ~'NT.oI1O to. _._
lfI"I'.........-OIKoII ....
meCuci-llll I'U "NO . 41111 liP . . ~o . ~I>D.~1I
- PU.... ~ ~~. ~~,... ~ 1IItJ-. ....~ A ' IiUJNOHAYC.ADOMB&" w.ur
~r~'~~~~ H06pltal R.W~.lIadlcind AGacel
"euh~nic$burg. PA 51~~ E. Trindl. Ruad
~ach."ic.bur~PA 1/e~&
1_ C2!lf96 L-.
CQ lo.CT
ST~PL.
INTH'5
AREA
. nt1A,N~.D.~CYonono."pJr,lj..~iPt
. L~""lM7lCLMlKT Oft PMVlCLlaJ
k ar>-B',INIUIIIDIOATlO'..fll IU
... i "", .,., J.~'II
..1~D'YIJt''''_~IC"-'-\Mr
0'"
a. AUTO ACCtgl.'IM
CEJ YII
0. QTt;iM .tor.f1IDIHTl
m...
'\11I;11....
0"
.......
0'" m.o
r 1011 I\UCR..w"'OftL()C.ll...llI
I
HfU,Wlt*I~\lNAW(.
MAD Il4N cw P'ClftM .'~"I callflU'T1!fQ . ""MCI THII 'OM.
.t. !l.\nfHr, 0.. ~rzm lIPtoffl .lo........ruAl I WflOI\&I IN ,....... DI .nv ""'*'" u ou.. "Ibm.,..
....,.1O......U.OIIIIr\, I &llDftq\l>t..,..,.,..tntoflil"'lII\mfn&""" ..w..1lI,...,.,..,,,-P*tr-..tl:l..,.
--s'r~.t...re On Pile' 03/31/94
SIOHIO ~"Te _ _
,6. D.t.TlQacUMIIoft: ~ UJ....1S.1"'...~0I'f t&F..~T1iNTHAe;v..gIAW.0A81...ll,UIU)lIL&O.
.....~JlO ':f' ""~"'.........."" . QMI...,...... 11-' 110 ' .,.,
(lh ..,1 S ,..~Tl,\1.." . " ..
11. ~UJlRI'IRMQ~"...SlCWiQllGniEil.~ 1',,1..). J\oULI&IA OF I'lI"lI!r"lf4(,i ""'Y1t:CWll
Cho.Jd)' J. CZ9096
II MtD'MO ~ LOCA.. ...
". DWIHCleII c.."'l'\.l!W UJ'IUhlllc;;'III\lN.LIW. (fIfJ,AT' rTi:iit I,'," 0". fa In.. t4C.T UIre) ,
n3,4
t,L:...:..:..,_
.j.
1.~.__
~ ,:JbJlI
.
,_"'''~__.Q..
.... ';;" " ... cO ....
.
0 1
,... ':')'PI HlC"DU~~.... lKIt'I'ICM. Oft iM'l'llU i IV4H01l1
~.~ (II-~"=:'- I 00<>1
Cl'T"""~
~1 1 ~ J~l9=:::J.;' I ~ i 1
; ~ !t ,
21 1 ' :99;13.' , ; H 1
,
eJ 12~ KJq '3124194
03 :2:J
~" I" J i 2::'
~1 1"3: 24
:\14
;tol I;' 4
i94
1
I i of
~9~3,' - 1
"
!')!1":J ' "
" .. I. i , ~, l
. I '-
> ; ,
99=:31 ,i 1
::1
;.3 ilf, ~'4
J:/ : 26 ''l4 21
1
13 i;:G "14 II.J :26 i94 2111
13Y' '114 '3 i 27 :91 21
. ~_L TAl W.W.." .... lUll
23-2l.1l7l132 I IIX I
,,-"'... !..~.
li'lCW.oH:I.~~Cli"'E.~~
I::=::=.~";:,j
J.y J tho
-
113/
1/94
. .
~ lV.IoMlccuca aN t4OlC.M. ~ MI)
'MCP............
PUA# P1/INT OR TYn
11 Il i ~
...
-0
I" ~n. "."'NT U~ T:) ~ IN C:~""aNI' ~""TIQH
_... IIU DO. 'N ! MM ,"",'''''
,""'w " a ;
\.. hUl",TAdl.Al1Cf4 Q"'~' M:LA~liNT'1JMCII
."","lbi i"7;9'4 TO .....i ,lI'.i 11.
aa.OUI_LJllf ICHAI\OU
11m [3]"" i ,I. ~Q I
I ~. ~~..."g "QU..........H
CODa I 0AI0lI'cA. q" NO
IJ 'fttO"'''''~mA''Ion'N~(''
"
. 0 . ,
CAYI IJPSDT
.- OA 1IIn1I" tMCI
UMT1 ....
,
; 0' A" I
, I I
, 1 i
; ~), Ul I
, 11
,
J 61 Oil
, i
,
711' 611 1:
i C~9"91i
i
i C~ 91l~1i
r C~6Z3J
.,.,.
.
1Il"1'l'4J fOI
WCAl u.
! c ;;~~096
C~'~1l96
"'M:~"
1IOlW~,..
.....
.....--
I
~
I
I
~
I~
~
~
I
,
.~
..
il!
~
i
:5
II
. - '. .~
.-'- ""j
::-
... I'; oJ '. "~ j' I,':' :. 1.., J I ; ..: oJ
115 LI~~hJl( }U"rl
P . 0, U 0 ,I( :: u ,--
Ho", Cumb,.'lorrd PA P~/0
'~---~~r<""'h<(,~--i
co NOT
STAPU'
IN ,T11'S
AI'....
,.,..,--y"':.A
HeALTH INSURANce CLAIM FORM
1, MWO". "',UCAlD CKNol'VI Of"...'VA. UMnl,;II flOC. Ulll.A I.. trtlW",Q', to, NL1I""
~ .~ ,.......""'--."""- :Ie "."ll "'a
r~/i 1"""'~L~]""''''':'M['_~~R..,~rnNtllq I ; "J~ rJf') [mJ -...,.."'1 - U
'''TIt,vr.HI......(\UI ~ '1... ""'"" ""'U'lMeij ~n[h". r+I~rn 0"'11 II!.ll: .. lI'Ill.II"O" kA.WC 0..1C HIIIw. 'hIN.,...., ~4MI mlQ
"cCurdy Richard ~ 'il'2: r't.: .'l'~ "0 ;11 McCurdy Richard
~llIIn"'OQhi"I"',hwO w,.....'..Jif"idriOIlli'ii1OIH.URiO' II4I.I"'O"ADe"Q1'(PrQ,,"~
60:) ,iRno 9t ...CZ':-..r'.]...rIn..n 6ll:1 RlIno $1;
filY . 1""111 I" ;AlllIN1 ar...,... ':IN
, ,
N NY C umb e I'l ., n ,. .l" ~ ..... CJ .....0
~ lTG.utmH.{lI'CI.........OIiiiij
l' B '0 (7'/ "l-2C>Ul c"""r-I ~.:..,~~~.r--1
'uTtCJ ..t4J~iD" N.UQ jl..ul"..,...",. HItItI, U~'lT\Il:trQ 10. II "...n...T. calil5inOli Mll"'T1l~-ro
.
_I ^; Ne....
t.J;()og1
~- -~-,..~ 'I r
I
I
i
I
g
Ii
cC
..
.. on"," mIilJN:Q"
j:li ..."
Cumb~rl"nd I ~"
I TlI.iJlHCk' ~NCI.l.iOf MCA (::QQllI
170/0 I U"l-}15151
II, lHAUI'lCO'. ro..W1't (>>\O..l" u" "leA NUA.t....
dol "C.;SB:J
~"-6AnonA1)., 10
'Ir.?: 'l,\;: 11..: "r>r1 .Q
ii:-I~"IPMi 0fIl tQOQ.l.......
810 0.... (1o~~o;
..1 PU.HN......:)It~".w.
, ..... ql'lOV' NlI1.4it.M
I ClolruI'I'..Ihf7ICUMIf<<l.lI4....lVIOlJl)
lLiiffi'1A ,"1UIl'Q'. 00\1101' .rint
WW.DDjW ~
' .
&. lMM.O'rtiU 1'1...... CIA iOtOOL ~A~
D-
b. "UTO AC:IOIJIln
0...
Co cmtUtAtUDIINT?
0... mHO
1\,'If, "'Kl'tvw foOf\ LOCAI....~
~tdt. F.lrnl In~~rdnc.
i:llllflAl N\IO,,.,.i!,l H~Tlt ..Hlm fI\.NIrt'
rI "''' r->il WI) JI,. ,..,. 10........... bm....
1i1,IH6UAID'8 M NJTHONlID "UtBCN" elONAnJAI I ...v"...
IIIV"l1'nf gf In..... Mndtllll\l'lt ~"tw-4 ~an;tlW. Or
.....d................
Signature On ~ilB
11tI~_
,I. ~'np"mHT lJHA.I~1 roWON( NCOH......rOCCuMnON
,JIk;""..... i DO i VY Tc toll\t i DO i ".
I'. HDaPrT.....~'ION GA.n. NtlATIO 1Q CUU!.llff.~
,,,,,."1t3: \"1/:, 9'4 TO 1I"1.! I/".! ro.
ao,gur"08W, .~
CJm r:;-,.., ; ".0" I
a. IollglCAlO AtaUiiWIlII'Cf'j
COOl I Cftg""AI.. AV'. r.o.
I *.. I"Rl:R AUTtIC'''V,nON MlMKA
"","
Q!J...
'UCl~
D""~
'" 1H1U'U.IwC:I..u.N IUNII
.......
..IAO BAQ 01' NUl,. _FOM c;:Q(II"-iT1NG , IIGHINQ THII 1fO"".
1" 'ATliHn OR I.UTHOfUlm "Ift:ION'S IIQ~TUAIi I IW'IWt h NlII" ol 1/'11 /flIN1c.tI M ~'" lnIcnnatm
,....,.lDpt....WI~lalIo~"J'WIIII101~tlll._.'''..>>"')''IIf1Q'Io...''n..nollClC'''"'
~!\rPI/ltul... On rile 8:J1;;4/!J~
I'QNth nA OJ
l'.g,l'''DlCI,IIMHTI ... fl.LHIU~..pt""'O" 1I.tIlPA.TItHTHUkAOGNItIOfIa..luA"-UtEl&.
e f)1MJ;j lW ~ r ~ =t~~~r 0..... "MT0I01' . ~.... .. ~D ..."
17. JIl.I.Wt ()IPAitVlMQ P"Hl"d&CIM QfIl OTlt... 'O\l~t;II Ira. \'0, NLIlIi!I!A Cl~ HIl,,,I;\/"tQ "~Cf......
Cha.Jllv J,
'''lSaiM.~ ~ LOCAl...
C29A96
~IAQNOI.l'O"t4o\lU"'QII~1I0A1~'(_I"lI.A"It!N'I,UUA4 TO"i"~ ItY UN~
,.17:"~~~ '.L--._
I
y
., IJh.;lI)
,
1ftIhDA.~g'''''''lnIt8T1
~ ";::' 'fV ...... DO
II,' i, 7 ;, 4 ..; 1,7
, ,----,
. . .
"':' 1).,CII' ~~~~e:~~...
.,., ......... ~bI r."w-;;';' ~ 1 ~;;;"'1It
!4d "1 I, '''9~;'3 I i
".9 ~:i;~ I :
9""1" I ;
I
I
I
. . CI H I
DIAQI\IOItJ DAY11"1Ol'
call 1'"""011 OA ....""" - COIl
loN'" "1M
, , ,
, I ~0' 0.1 J
" I
i 1
\ ? II ~ l')1! \
, ,
~, , I
1 "0' lie 1
~, , ,
,
~ ,
f I
,
,
"
f: ,
I
I
,."..""" Pal ~
""""". ~
C "q<I'," 15
i
I
IS
a
III
..
, if
I"~our- '
, 32U.~O
-.
lU '''1 '.l. L.3 itA i,,~
::~ l I.
I"" 1
I
I
.:
C "!lUll"
A] :"3 b4 1:13 !ZU !?~
r:<'''IIH~
!
I;
I! I
I&. IllDfJW: ToU '.Do 1'IVId1" ...... tW
~3-2107832 r-lIX I
if."'iiiiiA"-"I ~ I"N't8IC\AH eM '~'I"
liIlIC\UOIMCI oeaMi. ~ C"I.OlAI'I1~
C'..-, ,... "'........ 1ft ,..__
WYlIiI..._ar...IIIId."PIIIIPIIrIol.
~
,_,Aliai' NO, ~"/loCU""""IlO~"-ry
""gIM,~ ......,
mcCuri-00 " ,,. I he
. MAN' AHD ~~~ 011 'AOLI'TY w...'" .....-\CI. ~
I'tHOI'JI<<Ot"...ltwllllllloroflq, '"
S.idle "'.m..rlai Ho~pJ C,'1.
M.ch"nlc~b"rg. PA "
Jey'J Cho
..... '
"'- &3/ ~i9"1
U.lOtAI.C>oAACM
. 3.Z0 01l
"~~-.r'PlIU"
R.h~u ~.dLcin. A~.acl
61~4 E. Trln~l. Road
".ch..nLcHburg~A 11166
1_, C2!1ft915 J.-.
/:
"..
o fIlD
~ ~ NMClDUNCI., OHMIOICA&.IIfiM;I",
WWCllI....11Ql1.a."
Pl.EASE PRINT OR 'TYPe '
'~M:H..,,,
"'IIMQIWIOI>II._
,....
"""'-
..
I
i
..c, rn- ~
~
i
,~o NCi
"
","',
:..:.1,
..:oJ
., , ,,' In
ll:, L L'I'tf4: 1111\, .'J~~'l
~;, . O. tj C.( LJ ,.
Nu",", CIJiIIIJ"', lanrt P/l
.t " ~ 7 J
...." I"~
~
i
I
~
Tn "c~ HEALTH INSURANCE CLAIM FORM .." +
1 'ol'U~1' w\:.;".-.n C!\,oVIoj"U, (;l't"..,...." IJ"'l,," ""CA C'1~~f11 '&,I'.LA,"I!O'l)U,lIAILfltA IIA "'1'L&-'A....oHill.. 'I ..
..tAl.lh ,"UN JUl lJ.hQ r
i-'-I.~~~.Lj~(j::....:.~..~~~..,..."J[~ \~.!:~J_C':.!~~I ~~.~_ JII-tJr.40-9Gil I
,~""'ahAW' IWi.t_", 1'1,. ,....,4('1.. WU'J --, - ---, J l'"n,,,,,-:"tUIlHf... f;lotori' _ lIu ....~."[ci,~'T~... H-;;;;'~i:';;W:U~-'-;':'iIIIJ
Il1cc~,~ _____.R:,~~~~I_.I~1 'If:>:~.{"~'Q<':"'O McCunly flich",'Q W,
:0'"_,..,,....,.,...., -,. 1."fThfi"'~""'.H'"'~'L.''' ',:;;;;i'ritlii":W1iA,",,,,, -;.;..... II
~!2. R~~~________, . I .'I~"~~~C- ti0J ROrlo St: __ _
I ~~ . 1'iit.i,-flo"jJ-'\All~Nf ItAT;.'1 cnv--- "'All ~
N..... cumbO"".', nu.. . ~--1 .,.....1. 1 -..0 ""'. ~ He.. CUlTlb~rl.nd ",I~A _I~
~~:III]g.;:t;~.;~W7.~.. I ~--c::1~~'~'~7"~ ';~:~e __ [":V';L::'~C~U~'~i
Iki1'kiIrih'i'G;i!D'lNATi...~:n..;.~'loi~;U.r---'-II'3'(;'IAh~tJ(.l)ldUf'().;:::]TtLl fQ-- 11~"iD"" .-aerUHijjj"-OfII.J..loC,tklillll . 1!5!
dol Ilt:l19J "'
' &. Q'T11U!.l".Jt>lol.l . PCV:f ;:;11 ofiiU)l tI....tll.~ ~ &. n.t"-"""'1oIT1 [\;~"ENr UfIl I'1I.(VlOlJll a. IN.UN.I1'. 'Ali (JII'-"'mf
I .."
' 0... 0...0 ~;t\;;:{..r;n 'L~_ l!!l
. 6ii;;:;;;""""JT,...~-, on . .,,,,, AC'~h" """"'" . .ii"lliffi't"".. ~'IC"""'_ --t i
Uu 00, YV . iur"'l<] '0,___ [EJ,u C;..o L...J 9ig 9l'8' Iiuet.. I
L Dlf'\.C....A'1 ~ all-~tliOl ~Wol' .. U:.ooiA N:I.JODm ~1\.tH;1 "'-AN "lAW' ~" I~.U'"'' N,I.M. !i
I. "'VM'IU ~ H.IJd" ,N1G'iUlo1 1'1"....-- L__p ~.!.-__~~.~)...o .. ..,~.~~I:'O~.r~:; ~k~\~ ~~: C · I'!
,'ot,".U<<"'~/"OA~LUClli "U~I '. a..
II
Jl
t
d
I'
I'
.,.;~ I~.
l. U"i
C;,~9IlY6 '0
I~
!5
..
0-
!5
II>
~
,Z
Ig
Ii
I'
il
11
STA~t:
IN 1')-11:1
M.:;:A
, ~ -. I . i
i
MAD &loCI( ell ~.. IlfOU COtlIfll.!'T1Na . '1lWflrtlG "tll FQMV.
". PAllkNTlJ (lll AJ'TlfOWltC :tfl~N'1 liJOf4ATuli\I! I ~"H .,. ....... Of &IT)' "'101_ 01 ~.t IlIfnlftl.llClIl
'....""bJl"OOlN:I't4.I6i1\t,I....,.~1M111W\101~n.,. t:.."IIII1lJ.II'''IFI~OIlQll'tlllll1~_''.OIIl'h
-"~f\'l'I1alUI'. u., "11. 03/'H/':1'\
SIQ"iD QA"!
14, Q,'llwO#CyMNI,,",. ~ IL~U.l"..cMl'J>l."" OA ,a.lr ""r,,,,-rHA' ".olO iAAf,la""l,Ilu,AII.LHIU
U ~ ~ r ~ ]V , ~~"'t:,}~ 01\1'1\,",' o.rt . "I" ... j)O . .ly
IT."'MiUc llI'N~QI'~'rt"~... ~(lfl1I!" iOl.l'lU!! I "Ll.:) 1i\l"~;Rij:i7uii~s:el"'l
tho,Jay J, I C29D96 .."
'.-"IER\'tOl'OA 1t:t:44.1.'1II
CJ~. ~~ II....NnIn1ll;!_~..ltlII'la"
II, INSUIUD'. OR AUnIQAllED .I!#IlICNlI 8C1N4TUR& . tvlMrlIlI
PI."'''''I''".........IO Co', W\DtrtlQnlld pf\1tGan,V 'uO(/llllt b'
....... HtaDed "'-.
Zl9ndtur~ On Pll.
IlQH;O
II. D.ATtI ltANlNT lJNMUlTCWClIl'f ~t:l,'U'l!!IIfOtC;U"T'C>>f
""'''''''''100 'fV ro.....jCHolj'N
1" H~II"'1li Ootru""'iIi'LAfl."1'OC'liMUiftflri\;tu
",D~""'"i liD..;.'tl TC WI4t j 1iO.-; ~T...
, . I. .
tCI1AMU
UOll"IIOI~.t
~~ Ofl t.ATiiircJo-lll.u,lj,G 014 l'U\SlY. i.!.....T1i IT'~ I.U OR "lOI~J.rlUiii IJ..tj_____~
y
aoo"'''L AU, NO.
1l.011 ,I
I.l~~~'.~
~L-.
tJ. "'UOJlUun
lUl~N"lJ"'EI\
130JU
.
OAT"'l 0- &irro'lC'
...... "
"'AI co TV I.... UII
o ~ i:: n 'i t. (J.~ j ~ U
,
~
I
. L-.....-,
o
:;tc:)li!.S. ,W.\'r.t4. OR iijt~u
(.",.. u.....w; Cnl.-.MIlI'1
. "'c~
. C
'lwJI: f)Ol
~ I ~
""'-~~-.
94 11! 1
~
.
.
,
11
I
,
40' \10
ClACHCIiiI,
CON
. ""......
r
~ 9'':''1 J
, ,
I I
, : : hL-1
:' H-H-t-I:
: : I Lil-Lr I
a. J.ftlC""", IU II), """,,,aiR S8H riw : A-I'A'lt~r,NXOUJ.HO. 27, J.CCi"'~000rlMeW""
...: or....CII__1NalJ
_2J-.:10103J 0;1:-, .lIlcCurl-no . '... ""
II, AuNAn,,.. :J/fPoo'rltC;....oM ~ .li. ,......~~ii"'0I' ~--...:.ilTY ~ IIlftlCESfrLlt;
=~~;:~..= j rl"il'1V'J'jf'li"',,''''''',!;'.''cl'''rtrlndla fld
~.lI'.w""'''''''._~''''1
Meeh4nic~but.~.. PA
J~y J Chu J9J031
'83/ 4/94
...."
c
,
,
I
"
.ilt_~
. 411" , e 118 I. 4W.IIW
n l'tt'ac:lAK"~ ~~~gJllU& l\III elm I
flll'/'itE.' Modici.no A..ocl
&1?-4 E. lrindl. nOdd
".ch.nlc.bur~PA 11ijG&
C29095 I
.
,
,
.___----"<_..1.-
za. ft".....0tA
~.YN4AC~afu~~...
WtCF....,.......
~1iQI..llOO
~0'l'Wl:P.._
PlEASE PRINT OR TYI'E
r....
~.,..,It.
-,j ,I~-;-
$T..J,PLF.
IN TLiIS
;:::tF).
..f ...J
: ~ I 1 _ J 11 ",
". ... H.l "1
.. II:
...............
1-11 ! ~"--'
'~~ '" ''''. ';':,;tt'l ,,' ';~';4"-i:t"~...
'.1 'w I. i..J;r.ti",!;," ..'11.J
:)
\,'
C"
HE.lL TH INSUAANC:: CUlM FCAM
,A
hI '4;.;.;,lO.(;L ut...~:...~ ~1II~U.' 1,".lN"~A ',,,r- " 'c..... (;.0''''111'. "'II...'''t;''''J l>tl1oll'lllOl
~f"1o.1W~ .\......'U.. I .
-!.:',,",=,'c:... V~.....'l.::::1-~'''''''r::I''~~.L...J. -~""l. ::....:W<:~ ~'I _ jl::.!;~~~.2.r,..;___ _ _
t. t'A~""I.t~",\_..,... r.. '.... -"oJn. h'lIIJ r.l. l'A.f1lN"I./lIn'Q.&~ 101 ....S"''''.Il.tu.If.,lMl "..'., ......~ ~. ,...."
L ..... '00.,., - r---''''
i'lr.C~dl.. __,_ ~<." Ird _U..=..lJ!., ~""L-2J ..L........L...!:!'o~ur!.!.:t _ -,-"!..!:.I'2.;.:L
L rAll."'" '~~II.N.I~ ..IlnI'J, .. .."nl.H'''WIClNWtoMl.IlW f, 'lII"I'l..U ''';;.AU" .~, ""II
r' ~.~!':!~._~----- -'---'-I"'~l.. ~,...t"1lI..r.2"'1~~_~..r~ r'..lfJ Rwl"Ju Sl;
....'r .. .....U.~I.,A1\.i~ 'n-r -I''"
_r...~mcl-JI1I~~..l<lE1L_~__ -!....E..~ "-Cl .....-..E 1 w.ctj !\.~G.!.Lrr:..fl~ HId 101
1 ""''COol ItLU'~~'i\4Vol'~I.~'1 1,"00..11 TLfiin4b'fI'i'iNCll.lfi""""
__.]."1.:"'=,__ J.Jli::~,.t-1.::.rltJ I ~ 'O-Ll ::;::rJ.::::':-'~c :1 t I~I "'I-511/6
I (In..A.h!&LI''J;J,, "WoIc 1.....r..-"l1.. ~.. ""l!J'I ,..,,~ ig.,TfIo4t~ '-~;l,iiri\ti;At!O fO' ijJW""-----.
r
!
15
i1
~
.: L ---"::.OJ -ji
...:"..-...oo=~,,: Il1o<t~""''''iN..l'_''"'''~=r1 U;!J"-- il
[---1~~'~-~
~- ~5:~~~&~,.~~~-~.:-,- ~PHfCi:C...'\.-J,.~/...I.ift~.. ~ ~ Zllc~;~~LL
ol~~V'.""'I~"'f-"."'" ,,~_
L
~L...D'i"~'c"'i4'OnO~u"
I. ~l.'S.lfn :O\l"M"" ~ f'A1;'WIOJa
i:i.u~Am-oAliC~'IMn4
.....,00,.,.,
. t. rm.~W'l" Ih"".. OR 8CH:O:.'
0"""
a. AUTO ACQUJlJffl'
L..;,jm
Co an1:,. AeCI~"'"
l....d""
"'.lCI"_J
0'" L-.J
In
.~'U.W~"~"""'^"'.---'-~'-iQl."~~-~:;;NO
-___L _...,
"....O....e<< 0"'1"0"- KK11'2 CCWPU11"a. '~illa nfoe I'OAI&.
11. .....Tlmir& 0'1 "l/TJ.fQA:rD P'tllaC'f'd llGHlll\.IAG I "'11m",. 11'1. ..'.... .. ..., mllnlOlN Of 4V\M I"/Qrn'..~
'*-..,.,10 ,Onltt.~/....... 1&l_Itq..... c:~t'" I~~", w~ ~1t:D"'YI'ilOItClUl.""""",IC\lIKU
--mn~tll,.a On Pile flGIi:(;/94
Sk1Nm OoATlf_
'<t. QA~O'~A5W1' ~ I\L1Ilne.....~.bnlaH Ia.l.'"~''''' ~... tlNJ......., tM'lSlN.lNI'loUd'M.
.... ' 00 . YV IIUJRV~.", tM ~"",~tif'Q.\tlfl .....' W) , .,.,
~ ':1 ~q:1 '~~;\IIP'I ,..1...'....
11.........0f& ,~"'J~IQA,..ClI4on,tH&C:i.H'lo1 .f.tn"~el'UJitn.Hiii~~h~--;u;-------
<,
('
1l....J.~&. '
"'1lml'Qll L.u..
Cl
"
..
/.. -~'''''''' """'" "" ",,,,,v::i<fiAr.;;,M' IA,.o:rriQTr"i....... ""'-="-1
' , ,u,~ 1 ,
I"~/""": 1._'_
. L1,!>-JU.
.. .
,^-~~Wl'{m
- To
l'II on rf "'~l?
(\'~":"~
I I ; :
..L...-j
; I I I
-L--I
; i-I ;-
L-r'~--'-
; i Ii:
~-..l...---i.-___.l.-_ .
1,'LLlfl'UoLTM1-O_f'\'UW.I.Jol ~.....".
~ 3-....'..-'.1L' a:...:.:... [,I r~
'~ru"l'G""'-";;-';""1,'ioa.T~~-
1ttC~~.ncu~o.'O"lIM'
(J -..y tr.. I,.. ____...........
Ip;JIllfl....-..N....1ft11ll'Wlf1
.L.~_,
g
l'aOCiCGRJI&. OUl....- c:'CO,r~I"I"UEI
~ .In-.,,;...........
lIIODo"bI
. T't:
'-J r,M
.. ..
'(y ~........
,
.....",-
";lOll
j
" u..L
I, '
...l.--_____J
,
~
'<
I ~.
, '
-L~.
Pehdb Had ~sg/rrlndl,
J1f1Ch&nict.bunJI PA
J9JU3\
2G/94
Rd
.ley
J
Cho
IJ&
~ P'tIiltMIt. a:u.cu. OflllllW)c.t.L. ~l....
.;M.1~
~SI! PillNT OR TY1'1i
or..
,K,A"...-:()!Uu"lrftlll
!<)J......~J"1
..~,.ttn'.tMJtlOTiif"'nJf
Wltf ' 00 ' Y'f _
, _ u ~lL...1.L.. ~ ~
.. ''''''W'.'''t "'~ 0.1'1 c)-on. ~Ii
I
~
i
5
'..c:L_~~
-I~
Ie
'a.
I
I
I
I
+
If
,..
lli'.l...1!AlJ Eluate..
eo ,MlJ~. PL.4H ....l,IQ'1iit,.fiWiU.. .......
~~.ll;~ F....", lr'5ut"'''nl~''
II f..-n:fr"!tM'"arttU M'J.LI)f .0;,,," """.,.,
~Jvq r-.JNO .,.w..rwtWI'I............,.,.,..
1 J :H'hJ"'tt1., 00t AtIfHOmlm r'1:"-"JH'fI ~N^,1JNi I adllltU.
~rlfl'''d1_!W''''lIItn1~*,~a...OI'u~''''
WnoIC:M <k...,,* :JoIIo...
$.1ynbtIJI'"
(In
1'110
RU;IliEO
III. DoITtI""-1ffT lI'fA81. T'O~ICIl'Icwuw.N1tx::Q...e..T1OH
\,I"'oo'f., "''''00'''''
1'AOW1, T'O II
l' 'to.w,....uzAnO'f t'rl;-i~tu~'iiHT~JMC
"-"l . 1'1:1 . .,., . "Ill ' U~ ' .,.,
~_--::.r_ .. ~ ..... TO -'''' ... .. JI
aJ.WTlIIOi;;~, al,;KAAQU
.~...C"~J
u. WbDGl,tO IlUUWi&aCH
000'
~
lflJU
CACltw. "Eli. "0.
J
U PACtl ". fl-1Ct'1I:Al1:w H'~1Lfl
"M"'l
HI'C.I'fll'
,
3 "
=~Y'I EPItOl"
1,/~,,"1:."
00Il
PtilP~JlOfIl
u:lCA&.u.
.
""'-""Uu
MUG
.'
I
I
'H:I
I
~ '..
R.h4b ~udictr1e A~~OI,l
&124 ~. T~lndl~ R08d
"eChdnlcsbllr PA 17~Gi
C=9U96
IOq ,q-",-
--........""
,...
fQMII....,.&II~
1.1
J
..
.' "1""" ,~. .--'
'...
"~
,
.'........1
co ,~o;-
3TAPl.E
I~ THIS
AREA '
.. ':..:Il,Of ,:.\ rlr, \1',\ lj ,- dn,j tl
1 J :'} l.a. RI L: h ,~J., i;1 0 (J tJ
P.O. (10. ;!57'
Nay Cumo~rland PA 1/~:~
rrn.,.,. HEALTH INSURANCli! CL.AIM FORM .'eA,TI
I,MlOc::.w ...~O ~t1.y"V8 CH4M...... . QMClifl ,~ fr-"" I.,"IIJIlIO', .g."UWOtl' Cn:m'"00~AHI"'IT"I'
~ .-, ...---,WIAl,lHru.".. ILMLl,I"':I..__ '"'Il Nr..':'ll UID '
-n-.r-~r-:_I<\,.A.I)L~ ........~ 1I'lUIf' ~ I"'" ", -U~~.~ . .
l "r1Jirlrw..,:\.ul H6ttlI,'~ ,...,.... ""lNI.. ...u.;J 10 ,..TliNr, II,H,.. DAre 1l:C . ~.. How.I~...... ~ NIIII" "1ON11lGl1
IIcCurdy . Richurd, ,W '8'2:~:~' .;-;r'] .n I'IcCu....ly , RlchllTlI
.. '4"," . iI'V&, .'''1) ., ,....ne,,, I\C'-A 110M..... f'O ,,,,,'~ I, IHtI.l"'Il". ~~IN tJ-M. kwlt
tSBJ liellu ~ l.: "'~._..rlc".rlon..c=J G.,:I Hllno ~1:
GTY . Ip ~1.;1'I P"'.!HT sr.i1WI CfTY I nAl_
Il.w Cun'~~rl~nd If.. ....0.......1 I _~ N,,,. Cu,"b'''rl'''tld I fJA
fD'eo~ ''''Chl'''''''~ lJ(t~1 Ii Tru;~~[(1NCl.UC4AAll'lf.;QIJIQ
Vll18 (/llt7l4-SB76, '''-1 T:~'':::Ll:-'::-.:''D li1HIl, P'-F4-5117/i
..OnlPIttIlwMQ'.NAW1ll.MIH..... "IIHMW,M'C"'IMIlj lo.ltM.rllIN' ClfkjNA:LATiOT'OI 1t,lft.SUlIllu'.POI..l Ofll'iC.\hWMtA
dol 11&319:3
.. OTtfMIHU'Q'1 ~....., \.1'I...~UIt """'_I"
..'WIIlOy"""," ICU__HI!"IT DR ~OIJfl
....UMrl'.DAT.C1'M'lfII
...
,,"'DO''/'( ',~ ~
! I 1"'1 "I '1 I
C.'WI'I.~M'.""",~IC>>>OCl.1WM
D~. ~"O
.. AUTO ACClDthT' J'tAC( 1__
, i "1m U"" L-.J
.. on..r""r;ClDlIrITl
On.. m""
laI. Aarnvc;o KlI'I IoOCA.&. uu
~lIW<<:' P'I.AH NAoMI u. ""OOIWl H.......
.
""g trACk a, F1)fIlM BIPOAG COII~Q '.,aNINQ fH'1 "q.tM,
,.. p",,,,"" 0IlI AlJTHOftII:Io I'IHlCN'S IlClN4T\JAI t Wlltlln Il'I4 ...... 01' 11)' ""akal Of ~., Mtem"l
. "-tyta___t~ C*"" lalO relJl_ 5WpnI'" 0114......... b~.Itl4, 10 iIlPtI Q/t IDt1\41 N~ wtIlI.......
~~~.tur. On Pile 0,/14i9~
IKlh'1O
1c.DilTl~elJllMHTl ~ILLMI"{MI"~~
..... ' f'" ~.... IIW""".._"" .
"I) ~c ., .1- PRiOHAH~t\.WJ
1 . 1"IICMNM~_"IU;'JIl;;I
Cho,JAY J
'" NtItftW:) fg~ l~ u-.
0....
II, I' ""TltHr "AI ~AQ SANli OM MlI,tflAA 'l..LIiUL
OIW"'''OI.lI >II ~\t ... ~ .. .:tV
. ,
IU log, MlM'tJIl w Ht.P'!l'IA~'<<) Ph,.SCIA,.
C291196
11, Ol"w.o...Oft""'ruAlSOI'1.l.NlIlOAIN.lJR....IRn.-~IT1....I.I.3Cft.IQnUltqJrl' ~JHE)
7Z3.4
I,t.:..::.:.,_
,
+
01-,_
L,3b3"
.
'"
uu '::::- VOl ...
',L..-,
. "
'~~~~.Cfl, OA"UPJ'lIQ
~PlM~~",...
..
. c
..... Tw.
'/'(~~..
.
DIMMOIe
""""
'To
co
07 iDa '94 57: 0a :!J4 J l 1 : 51ll~13
i , i
, ,
, ; i
, :
: , j ;
i i i ;
:
.."'!O'"^" TU,.a ~IIR
23-21117932
1'~~~o..C"I~J."
....... N....... '" ""......
...1O--..__.......PIl'1r-....
,I
I
I
I '
I !
I " "
; i f ~.
H.1""nlHt"o\CU;UIIIJNU. ~'~T.qa.'aH1oICIfT'f
.....~......
mcCUI'i-1l1il ~ ..... I I""
w. NAW McOAOOIIC,!!!! ~.!..T! ~H'AI IMAVK.OU WUW
~1II-U."'.0Ibt
, Reh,ib "ed n&c/Tri"dl.. Rd
M.ch4"lc~burg. PA
3931131
4/94 .
1
"
U" ilN
non
~ "y J C.ho,
~ t-..
','
',__ 97/
.
.~ IVA6IACQ,fa. QIf WIDCAL tuMe&.....
-'......
nv.S6 PRfHT OR nl'.
(,
I~
I
I
.
J
L~'lJH'O"Po'lrwOl'.~nt NIC U
~~.!i i'\;,i ll'~ u[/fl"11 i
"IW\.Ioi"'l"" M"~ Off lIQi~ ~li i
Big See a04~e .
"1~l.fl~.lt&.NI. 101...... 0l'I ,.lK;uM,M HoWl i
St.~lt Fdrm I'I~ur~no~ !
d, II JIol'''C N<<]THI" HIAi.fl1 ....orr "-"if, :
rI'I1fS rxlNO .,...,..,n..,.,-.oI......... r
1'. ,H'UAED" 0" AUfHOJIU'ZJ::J 'I",ON'! SJQHAMII .......1'
P~otllWCllllll...."..Wlr.W"G...."..~....~_
MMclM _~rtDlid bilow" '
~~gn..ture On ~lle
O't1Heo
IL""'''''ATIIUT UMIUiTOWCIIN NW""-JfTCCCUH.TICW
fl'OI4 uw .; 00 !, 'N . ro ..... i = I 'fV
It. rc)VlJA.LaA1UN .LlATltii-AaU..fIII:) fa C..ttNN
",01.1 WI,,! .SIIl. _I .q TO 1M, i .PQ. i ~'(.,
In OUnl'OUAt . OfAJ\3u
fl... [Xl "'I , Il,QO I,
D. :'~F HIIIlUllrIIl..wr1 0At01"!AL "", No;
Ilttvt, Uu~hlf!l.
.1, "AIOA~l'UlAtlON HUMOIR
"
, . I . ~
0...'1'1 PlOT lli'I"'-'lDfIlQIt
"(,:h4IilQU 011 '--" IAOO coo ~CCAl uti
lMIT. __ ..
, c;.:g\l~.. ~
4U'OIil 1
,
I ill
: ,~
,
.
, !
I
, l'i
,
, z
, j
,
,
,
, ...
_.NI ;HiAWOtJHTI~Q a),~Q\,.
1 411 oil '. 9 i111 . ~II, 1111
.u.~'^'1" '11IIr..L;HGkNM:AWMt:~DI'COOlI
Reh"'b M8Jic~n. A5soci
6124 f. Trlnd'l. Road"
".Ch4~ic.burq~A 17066:,
I_C;:9095 "","', "
--
IIOfMe OM>>.IMI
'"'"
.~Il"....I_
j;:ORl,I,U."-
,E',,;':;'1..,,j:
'.,.._~,l,:."::: ::::,E~:'.j::
'-~';"s 'rXrE '-F~\RH---84f1
'BLUE CROSS 361
1;;,~,..J ',.:::
~.;..:-- ',,-;
3Soj409ja-'
20632083300
---~.-.._.,._"--._~.,.__.~--_.~.~--------_._~------- -----.
L.:c-
I 1-' a
,
,
RICHARD MCCURDY
603B RENO ST
NEW CUMBERL~~D PA
f
o
L
;~~';~~;";; IMCCURDY. >~.;~~~~
CArE I ceSC;:lIFT:O~
03: 17 ROOM 5208 P)
03:17 ADMISSION KIT
03,17 CERV PILLOWS
03:17 MEDICAL/SURG SUPPLIE
03'17 MED, ACUTE OTHER
03:17 MED, ACUTE OTHER
03' 18 ROOM S208 p)
,
03,18 CBC AUTO DIFF
03:18 ESR-WESTERGREN
03,18 CHEM PROFILE I
03:18 PHLEBOTOMY
03'18 IV ANGIOCATH
03:18 IV SOLU 34 2C0418
03'18 066500337
,
03,18 UR SUP CO~~ODE KAT
03'18 MED. ACUTE OTHER
03:18 INTERMED-PHY THERAPY
03:18 HOT PACK STANDARD
03'18 ELEC STIMULATION
03:18 HOT PACK STANDARD
03'18 ELEC STIMULATION
03: 19 ROOM S208 p)
03'19 CHEM PROFILE II
,
03,19 PHLEBOTOMY
03:19 I V MINI BAG
03,19 MED. ACUTE OTHER
03:19 HOT PACK STANDARD
03'19 ELEC STIMULATION
03:20 ROOM S208 P)
03'20 IV SOLU 34 2C0418
03:20 066500337
03:20 I V MINI BAG
03,20 I V START SET
03:20 MED. ACUTE OTHER
"
I~ '..AT'e C!--lAROeS F:'CR SE~MCES
AE"<C::::!S:I OC::..;R, 'fOU 'Nlu.
AeC;:r'ie Ac:::mc!'U.l. BILuNO
=.11";:',".,0
MAKE CHECKS
PAYABLE TO:
-. .-. -- ..-.-.... ,- ..... .....-.. ...--~,-----~
-.-......., --
450,00
70
70
81
82
82
450.00
10
10
10
10
70
70
70
70
82
90
90
90
90
90
450.00
10
10
81
82
90
90
450. 00
70
70
81
81
82
17070
-
,
,
~
SEIDLE MEMORIAL HOSPITAL
120 SOUTH FILBERT STREET
MEC!lANICSBURG, PA. 17055
717 - 795-6600
LR,S, 23-1352215
I rOTAI. C~ArHJ~
450: 00
12: 00
35, 00
18: 00
20' 00
15: 00
450' 00
36: 00
22: 00
50, 00
7: 00
5' 00
10: 00
5' 00
3: 00
15' 00
67: 00
28: 00
51' 00
28: 00
51' 00
450: 00
45' 00
7: 00
40: 00
15,00
28: 00
51' 00
450: 00
10' 00
,
5,00
80: 00
5,00
15: 00 I
P.\1"IENT
AMOuNT
1 Sf COlfE.:l.AGc I aNO CO'~i;UQe:
450, 00
12; 00
35, 00
18: 00
20' 00
15; 00
450' 00
,
36,00
22: 00
50,00
7: 00
5' 00
10: 00
5' 00
3: 00
15' 00
67,00
28: 00
51' 00
28: 00
51' 00
450; 00
45: 00
7,00
40' 00
15, 00
28: 00
51' 00
450: 00
10' 00
,
5, 00
80' 00
5: 00
IS; 00
'-, -_.' '\" -- -', .'
JPO CO\;E~Oi
450, 00
12: 00
35, 00
18: 00
20' 00
15: 00
450' 00
,
36,00
22: 00
50,00
7: 00
5' 00
10: 00
5' 00
3: 00
15: 00
67,00
28: 00
51' 00
28: 00
51' 00
450: 00
45' 00
7: 00
40: 00
15,00
28: 00
51' 00
450: 00
10' 00
,
5,00
80: 00
5,00
15' 00
,
, '
PATIENT PAY
,HIS AMOUNT
::SC!--l.1I'lOE :"7E
.ol\1CL.N't=-A,Q
TOTALS ~
See Reverse Side If You Have Not Furnished Us
Your Health Insuranc~ Information and/or Forms
_ _ _ _ _ _ " _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _t{ES~ tHjS.POBTjQN.Foe YQUflflec.OilCs.. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ ,
DETACH AND RETURN THIS PORTION WITH PAYMENT
>'"".'-W' li"';'O CA:," 'ACMIS~'C","""c., ,'C I "'CUNf cu.
-
'.
_..__________._n'_____ .________.n
~E',::.=.:) ;,3.]: .'.~\...:.~,C:; :::".i:.:l.l.~:
-, STATE FAJlM 843l
'BLUE CROSS 361
J:lC~" ',~ ;l::~ :'1 ',::: I
--------38;;-54 0958-;
20632083300
I
1 '::
LJ~
.
---,
i
RICHARD MCCURDY
603B RENO ST
NEW CUMBERLAND PA
17070
SEIDLE MEMORIAL HOSPITAL
120 SOUTH FILBERT STREET
MECHANICSBURG, PA. 17055
717 - 795-6600
,
a
~
;,.;:.1.""'..,== ;,~ ,::'<, ,<.lV= RCC,,", NO. ACl,lITTEO OISCHAROED I.R.S. 23-1352215
242742822 IMCCURDY, RICHARD 5208-01103: 17 ,94104, 01 ;94l PATIENT
CAT: I cesC~IPTlON I TOUI. CHARGE 1 ST COVERAGE 2NO COVERAGe 3RO covERAG! AMOUNT
03,21 PHLEBOTOMY 10 7,00 7,00 7,00 , , .
03:21 CHEM PROFILE II 10 45: 00 45: 00 45: 00 , I
, ,
03.21 I V MINI BAG 81 20' 00 20' 00 20' 00 , ,
03:21 MED. ACUTE OTHER 82 15: 00 15: 00 15: 00 , ,
, ,
03'21 ULTRASOUND PHY THERP 90 28' 00 28' 00 28' 00 , ,
03:21 90 28: 00 28: 00 28: 00 , ,
HOT PACK STANDARD , ,
03'21 ELEC STIMULATION 90 51' 00 51' 00 51' 00 , ,
03:21 . , , , ,
HOT PACK STANDARD 90 28,00 28,00 28,00 , ,
03:21 ELEC STIMULATION 90 51: 00 51: 00 51: 00 , I
, I
03,22 ROOM 5208 P ) 450.00 450, 00 450, 00 450, 00 , ,
03:22 I V MINI BAG 81 10: 00 10: 00 10: 00 , ,
,
03'22 MED. ACUTE OTHER 82 15' 00 15' 00 15' 00 ,
03:22 TRACTION-PHY THERAPY 90 30: 00 30: 00 30: 00 ,
,
03'22 ULTRASOUND PHY THERP 90 28' 00 28' 00 28' 00 ,
03:22 90 28: 00 28: 00 28: 00 ,
HOT PACK STANDARD ,
03'22 HOT PACK STANDARD 90 28' 00 28' 00 28: 00 ,
, , , ,
03,22 ELEC STIMULATION 90 5\0 00 51, 00 51,00 ,
03:23 ROOM 5208 P ) 450.00 450: 00 450: 00 450: 00 ,
,
03'23 PHLEBOTOMY 10 7' 00 7' 00 7' 00 , ,
03:23 CHEM PROFILE II 10 45: 00 45: 00 45: 00 , I
I
03'23 IV SOLU 34 2C0418 70 10' 00 10' 00 10' 00
03:23 066500337 70 5: 00 5: 00 5: 00
03'23 I V MINI BAG 81 30' 00 30' 00 30' 00
03:23 , , ,
MED. ACUTE OTHER 82 15, 00 15, 00 15,00
03:23 TRACTION-PHY THERAPY 90 30: 00 30: 00 30: 00
03,23 HOT PACK STANDARD 90 28, 00 28,00 28,00
03:23 TRACTION-PHY THERAPY 90 30: 00 30: 00 30: 00
03'23 HOT PACK STANDARD 90 28' 00 28' 00 28' 00
03:24 ROOM 5208 P ) 450.00 450: 00 450: 00 450: 00 ,
,
03'24 I V MINI BAG 81 20' 00 20' 00 20' 00 ,
03:24 5: 00 , , ,
I V START SET 81 5, 00 5,00 ,
03'24 MED. ACUTE OTHER 82 15: 00 15: 00 15: 00 ,
03:24 ,
EXERCISE-THERAPEUTIC 90 28,00 28,00 28, 00 ,
03 '24 EXERCISE-THERAPEUTIC 90 28' 00 28' 00 28' 00 ,
n. :?J. TO .bUY "'U<'b 'bY on .n: nn .n: nn ,n' nn , ,
'F '...ATE ~",...Mes ~CA SE~CES TOTALS ~ , , , , PATIENT PAY
,Q5'<CE=EJ CC::....R. Ycu Wl1..L. ".<'<' " ,,,., b'''<' : , , THIS AMOUNT
RE.:E,IE ~:IT1CNA!. BiL.l..;NG
L
See Reverse Side If You Have Not Furnished Us
Your Health Insurance Information and/or Forms
. _ . . . . _ . . _ _ . . . . _ . _ _ _ _ _ _ . _ _ .I{E51: LH1S.P08TJQI'tFOB YQUflfl5C.OflC!t _ _ - - . . - - - . . - - - . - - . - . - - - - . . .
...,_,_ ',C ~.~~~~~,~~D RETURN THlj PO~~~~ ~~H PAY'~:'~~CNlSE,""'CE "C ,...CUNT au>
CISC"'ARQe C.HE I ",-,aUNT PAlO
MAKE CHECKS
PAYABLE TO:
'.---1- ,
, . - ~-~'---- ,- -~--
.'~--- --.---,
3:;:',:;:=.:; ..:.._.:.: .,......-l..:....C:::::.::.....~~ ;.:.:_"',':; -1:. ,:- '.'::
---~STATEf ARM ,- 843y-----'---:J3M4t)9SS-
!BLUE CROSS 36l 20632083300
i
,
i
,-
iF:
LJ'.
--~----------~~-----
R IClIARD IICCURDY
603B RENO ST
NEW CUMBERL~~D PA
,
,
o
L
,).l,~;:" ";..V!;o:::I
~'o::', ,-/,l,'.'o::
242742822 MCCURDY, RICHARD
D.ATi I CesCRIFT;CN
03,24 HOT PACK STANDARD
03:24 HOT PACK STANDARD
03,24 ELEC STIMULATION
03:25 ROOM 5208 P)
03'25 PHLEBOTOMY
03:25 OCCUPATIONAL THER E
03'Z5 I V MINI BAG
,
03,25 MED. ACUTE OTHER
03:25 EXERCISE-THERAPEUTIC
03,25 EXERCISE-THERAPEUTIC
03:25 TRACTION-PHY THERAPY
03'25 HOT PACK STANDARD
03:25 HOT PACK STANDARD
03'25 ELEC STIMULATION
,
03,26 ROOM 5208 p)
03:26 I V MINI BAG
03,26 MED. ACUTE OTHER
03:26 EXERCISE-THERAPEUTIC
03'26 TRACTION-PHY THERAPY
03:26 HOT PACK STANDARD
03' 27 ROOII 5208 p)
03:27 CHEM PROfILE II
03:27 PHLEBOTOMY
03,27 IV SOLU 34 2C0418
03:27 IV 250 CC
03,27 IV 1000 CC
03:27 066500337
03'27 I V MINI BAG
03:27 MED. ACUTE OTHER
03 '28 ROOM 5208 p)
,
03,28 POTASSIUM SERUM
03:28 PHLEBOTOMY
03,28 NEUOMUSCULAR-15 MIN
03:28 I V MINI BAG
MAKE CHECKS
PAYABLE TO:
--'-,' ,----
,
90
90
90
450.00
10
68
81
82
90
90
90
90
90
90
450.00
81
82
90
90
90
450.00
10
10
70
70
70
70
81
82
450.00
10
10
68
81
17070
I TOTAl. 04AAGE
28: 00
28: 00
51' 00
450: 00
7' 00
69: 00
20' 00
15: 00
28: 00
28,00
30: 00
28' 00
28: 00
51' 00
450: 00
60: 00
15,00
28: 00
3D' 00
28: 00
450' 00
45: 00
7' 00
,
10,00
3: 00
12,00
5: 00
50' 00
15: 00
450' 00
20: 00
7' 00
,
60, 00
10: 00
~
SEIDLE IIEMORIAL HOSPITAL
120 SOUTH fiLBERT STREET
HECHANICSBURG. PA. 17055
717 - 795-6600
I.R,S.23-1352215
1ST COVERAGe: I 2NQ COvERAGe
3~O :OVERAOi
''''''I!~
AMOuNT
28,00
28: 00
51' 00
450: 00
7' 00
69: 00
20' 00
15: 00
28: 00
28,00
30: 00
28' 00
28: 00
51: 00
450, 00
60' 00
15: 00
28: 00
30' 00
28: 00
450' 00
45: 00
7' 00
,
10,00
3: 00
12,00
5: 00
50' 00
15: 00
450' 00
,
20, 00
7' 00
,
60,00
10: 00
28,00
28: 00
51, 00
450: 00
7' 00
69: 00
20' 00
15: 00
28: 00
28' 00
30: 00
28' 00
28: 00
51' 00
450: 00
60: 00
15,00
28: 00
3D' 00
28: 00
450' 00
45: 00
7' 00
,
lQ, 00
3: 00
12,00
5: 00
50' 00
15: 00
450' 00
,
20, 00
7: 00
60, 00
10: 00
PATIENT PAY
THIS AMOUNT
CrSC......RG2: :,l,';'"f I
AMCUNT PAjD
" LAT'E CJ-lAPOE9 ~OA SEFlVlCES
AI'CEREO CCC,R, vcu W'''- TOTALS ...
PI;CEIVE AC:tT1C1iAI. B,I..Li~a ",..-
See Reverse Side If You Have Not Furnished Us
Your Health Insurance Information and/or Forms
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~E=~ l.HjS.POBTJON.FOB YQuflflec.OflOs. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - - - - - - - -
w ".' '.0 ~,::~~~,~~D RETURN THro~::.~~ ~~H PAY~:'~~CN'SE""CE' 'c I >MCuNT CUE
-"
." .
.E',=~' ~ :.. . :
, . ~
il--~
I ;
. -.,' - ., - ~, ' -
. .,....... ,--.; - - ':: -~..:
STArE F,~M 8~JJ
BleE CROSS J6l
,
R I CH,~D MCCURDY
603B RENO ST
NEW CUMBERL~~D PA
o
,
i_
;~;';~';~;~; I MCCURDY , '~:~.~~~~
OATe I CeSCRPT;C~
)af}5'~11\}1d
21J~ J 2ilil J Jill)
17070
.-J
SEIDlE MEMORIAL HOSPITAL
120 SOUTH fILBERT STREET
MECHANICSBURG, PA. 17055
717 - 795-6600
03,28
03:28
03,2B
03:28
03'28
03:28
03 '29
03 :29
03 :29
03,29
03:29
03'29
03 :29
03'29
03:29
03 '29
,
03,29
03 :30
03'30
03:30
03'30
03:30
03'30
,
03,31
03:31
03,31
03:31
03'31
03:31
03'31
,
03,31
03:31
03,31
03'31
,
II S.;~~~~1 i 0;:~;':o94 i 0:4::~'::~4 i I,A,S, 23.1~~":~:5
j TO;.ll. ::"'.l"Ua I 15'1' COI;E"",oe 4"'0 ::O'.E~aii JFlC co'.e::v.oe I ...ueuM
EXERCISE-THERAPEUTIC 90
TRACTION-PHY THERAPY 90
HOT PACK STANDARD 90
EXERCISE-THERAPEUTIC 90
TRACTION-PHY THERAPY 90
HOT PACK STANDARD 90
ROOM S208 p) 450.00
PHLEBOTOMY 10
CHEH PROfILE II 10
NEUOMUSCULAR-15 MIN 68
MED. ACUTE OTHER 82
EXERCISE-THERAPEUTIC 90
TRACTION-PHY THERAPY 90
HOT PACK STANDARD 90
EXERCISE-THERAPEUTIC 90
TRACTlON-PHY THERAPY 90 I
HOT PACK STANDARD 90 I
ROOM S208 p) 450.00
MED. ACUTE OTHER 82
MED, ACUTE OTHER 82
EXERCISE-THERAPEUTIC 90
TRACTION-PHY THERAPY 90
HOT PACK STANDARD 90
ROOM S208 p) 450.00
PHLEBOTOMY 10
CHEM PROfILE II 10
NEUOMUSCULAR-15 MIN 68
MED. ACUTE OTHER 82
EXERCISE-THERAPEUTIC 90
EXERCISE-THERAPEUTIC 90
TRACTION-PHY THERAPY 90
TRACTION-PHY THERAPY 90
HOT PACK STANDARD 90
HOT PACK STANDARD 90
28, 00 I
30: 00 I
28, 00
28, 00 I
30' 00
28, 00 I
450' 00 I
7, 00
45' 00
60, 00
15: 00
28' 00
30: 00
28; 00
28, 00
30' 00
28, 00
450: 00
15, 00
5: 00
28' 00
30: 00
28' 00
450: 00
7' 00
45: 00
90: 00
15' 00
28: 00
28' 00
30: 00
30: 00 I
28, 00 I
28; 00 I
28,00
30: 00
28' 00
28: 00
30' 00
28: 00
450' 00
7, 00
45: 00
60, 00
IS: 00
28' 00
30: 00
28' 00
28: 00
30' 00
28: 00
450: 00
IS' 00
S: 00
28' 00
30: 00
28' 00
450: 00
7: 00
4S, 00
90: 00
IS' 00
28: 00
28' 00
30: 00
30: 00
28,00
28: 00
28, 00
30: 00
28,00
28: 00
30' 00
28: 00
4S0' 00
7, 00
4S: 00
60,00
15: 00
28' 00
30: 00
28' 00
28: 00
30: 00
28, 00
4S0: 00
IS' 00
S; 00
28' 00
30: 00
28' 00
4S0: 00
7: 00
4S, 00
90: 00
15' 00
28: 00
28' 00
30: 00
30: 00
28, 00
28: 00
, ,
:E~ci ~~SAbg!~:.;'t~~~ES
MEC;i'~E Ac:::mc~...1. QIlJ..Mi
PATIENT PAY
THIS AMOUNT
TOTALS ~
See Reverse Side If You Have Not Furnished Us
Your Health Insurance Information and/or Forms
. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ES~ ~lS_P08TjQN_F08 YQU~ ~EC.OFOS. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - - - - - - - - -
DETACH AND RETURN THIS PORTiON WITH PAYMENT
Ii ,,,-NO :". ,.c"",c..""":" 'c
.;I~ ,. ~'," ',::
;;,~. ;:',. ..~...;:-
MAKE CHECKS
PAYABLE TO:
\-
\
,u"C:.;~T:::l.E
I :s:~'.Q' :.-,
, ,
,l,VC\.."-I:",4.,O I
'.
'.:i~';:':".:::: ::.':,;:;;':','j:;
;~':_J '.':
".:- -' '.':
See Reverse Side If You Have Not Furnished Us
Your Health Insurance Information and/or Forms
___________________________~f~~~YOBDQNJOeYQu~~E~OBQa___________________________
DETACH AND RETURN THIS PORTION WITH PAYMENT
,,"F',TN'ME I .,,",,"" 0'''' 1 'CY'S$CN>SE",",CE I ',e
- -, --.~ , ',~ ~
.:;:; .,,_. -, .~.... '"
----~ STATE FAF.M843J.
! 8 LUE CROSS 361
I
38654if95S-
20632083300
~ ...
I-
I
1
.
I
,
,
R lCHARD HCCURDY
6038 RENO ST
NEW CUHBERL~~D PA
17070
SElDLE HEHORIAL HOSPITAL
120 SOUTH FILBERT STREET
HECH/~ICSBURG. PA. 17055
717 - 795-6600
o
L
~
.2,,'_', ',L.vS;=l 1..:....,..1\1; ROC,", NO I .l.CJ.lrr.;:o OlSCrt.l.~G~O I,R,S, 23-1352215
242742822 IHCCURDY, RICHARD II 5208-01103.17 1941 04, 01 : 941 .....fliNT
C.l.TE ,oeSCFlIF'MCN I 1CUL. cwAAGa: I lS1 COIJE.:l.AG= 2NO CO'JEAAoe JRO COIJERAG& AMOl.lNT
04:01 PHARMACY DRUGS 40 655, 68 655, 68 655, 68 1 1 .
04:01 PHARMACY DRUGS 40 336: 56 336: 56 336: 56 1 1
1 ,
04 '22 LATE CHGICR PHARMACY 25 336. 56 336' 56- 336, 56- 1 1
I ______1__- . ~-----'--- 1 ~----_!.._-
I I -----i'-- I ------i-- ,
TOTAL CHARGES 10753' 68 10753: 68 10753' 68 1 6750' 00
I , , I ,
I -.-..-r--- ----....- ......~_. ------,.... ------j"'--
I , , , 1
, 1 , , ,
I 1 , , ,
, 1 , , ,
, , , , ,
, 1 , 1 I
, I , 1 I
, I , 1 ,
, , , , 1
, , , ,
, , , 1
1 , , 1 ,
, 1 , 1 1
, 1 , , ,
I , , , 1
, 1 1 , 1
I 1 1 , 1
, , I , ,
, , , , 1
, , , , 1
1 , , 1 ,
, , 1 1 1
, 1 , I 1 I
I , 1 , 1 ,
, 1 1 I 1 ,
I 1 1 , 1 ,
I 1 I , I 1
, 1 , , I 1
, , , 1 , 1
, , , 1 1 1
, , 1 1 1 I
, 1 1 1 1 1
, 1 I , 1 ,
, 1 I , 1 ,
, 1 , 1 , ,
, 1 , 1 1 1
, 1 , 1 , ,
I I 1 , , 1
I , 1 1 , ,
I , , I , ,
, 1 , I 1 ,
, 1 , 1 , ,
1 , , 1 , ,
, 1 , 1 I ,
jF LArE Cl-lAAGE5 FOR SER\i1CES TOTALS ~ , , I , PATIENT PAY
~E~CE;;eD CCC:JR. YOU 'Nlll. e".. I, .e~ 0',-" : I 1 THIS AMOUNT
RECEllJE ....ccmcNAI. BlWNG
;:Iii:E'4l'-'O
.l.MC\.iNT Ol.;e
MAKE CHECKS
PAYABLE TO:
::ISCH.l.F1Q; JArs
I .lMct,.;..,.rpA,iO I
--:-\ -
~~u~__
~.,:..~
I
---~_.~_.. -------~,--~_._--_.._"-._--_.__.
3;:',::= ~.. ~:.J':::
...s'....~,:.,..:~ ::.;:"1:.:.:
~=<-::..;J '.~
"':..:Y',O
ATTE~TION PATIENT
THIS BILL IS FOR YOUR INFORMATION
ONLY AS REQUIRED BY ACT 89 - COST
CONTAINMENT COUNCIL. IT IS NOT
~INTENDED FOR INSURANCE PURPOSES
AND IS NOT TO BE PAID BY YOU. YOU
WILL RECEIVE A SEPARATE BILLING
FOR ANY BALANCE DUE AFTER THE
INSURANCE COMPANY HAS PROCESSED
~YOUR BILL AS AUTHORIZED BY YOU.
!
I
I ; C
I I ,i
I i 3
-~,
,
T
C
,'STATE FARM 8431
BLUE CROSS 361
386540-958!
20632083300
I
RICHARD MCCURDY
603B RENO ST
NEW CUMBERLAND PA
17070
a,':;", "-;\...1,,1 :; .:Ia.::~ ~,l,\1 Flce... NO. I .lCVITTeO Ol5CHAFlGEO I,A.S.23-1352215
242742822 IMCCURDY. RICHARD I s208-011 03,17 :941 04. 01,941 PATIENT
OArs: I DeSe~IFrnCN TOT.lL. CHA~oe , ST COIJERAOE ilND CO\lERACe 3,"0 CO....EAAas AMOUNT
S UItMAR CF CHARGES -- . .
:Qn DESCRIPTION INS C[ AMO~NT I
I
, 19 LABORA TOR Y lC 461' 00 I
, 2 PHARMACY 40-4, 992: 24 I
, I
, 15 M I. S SUPPLIES 70-7' 145' 00 I
, 57 PHYSICAL THERAPY 9C 1845: 00 I
, I
, 37 ROUTINE SP CARE OTH 81 368' 00 I
, OBSERVATION UNIT 8, , I
, 17 250, 00 I
, 8 OCCUPATIONAL THERAPY 6E 279: 00 I
, I
, 15 R I. C PRIVATE P 6750. 00 I
, 1 LATE CHRG/CREDIT 99925 336: 56 I
, I
, ------""--
TOTAL CHARGES 10753: 68
, ..----....
,
, I
, I
, I
, I I
, I I
, I , I
, I I I
, , I I
, I I I
, I I I
, I I
, I I
, I I
, I I
, I I
, I I
, I
I I
, I
I I
, I
, I
, I
, I
, I
, I
, I
, I
, I I
, I I I
, I I I
,
IF: l.Af! CI-'AROES fIlaA SEf'VIces TOTALS~ , , I I PATIENT PAY
R!:}IICE,:lEO CC::..:1=l, vou WIt.:. I , I I
RECEiVE Acom~ iJUJNQ THIS AMOUNT
L
See Reverse Side If You Have Not Furnished Us
Your Health Insurance Information and/or Forms
- - - - - - - - -71T': 795--=00 - - - - -- _I\.E;~ 1:rUSJ'08TJQN..FOB ~QU.El.Elec.o.ElCs. - - - -- - - - - - - -- - - - - - - - - - - - - - -
uu DETACH AND RETURN THIS PORTION WITH PAYMENT
I >:I.l....::...., -.0 I "TO.,T ""E I .,,,,NO CATE ACMISSiCN'SERVlCE
, .,t.,,?74'~?" ,,"'(rrtn~nv RrrHAR!:!, I t
MAKE CHECKS C'SC"A.OE CATE
PAYABLE TO: SEIDLE MEMORIAL HOSPITAL
Fie
AMOUNT CUE
AMOUNT FlAIO
-.---_. -.... "
-.-....,...,.
:l~'"T'"'!" ~.
. . ~.. .... \
.-,
.-;-~-:'- ~.
See Reverse Side If You Have Not Furnished Us
Your Health Insurance Information and/or Forms 6750,0
- - - - - - - - - 71T':: 79F6EOO - - - - - - _I\.ESI: tI11SJ'OBTJQKFOB YQuflflEC,OflCs.. - - - - - - - - - - - - - - - - -- - - - - - - - - -
DETACH AND RETURN THIS PORTION WITH PAYMENT
E 'Or,,, '0 I 'Or", ""' I
?~?7~?R?? ",rrTmnV" TrlH"~
MAKE CHECKS
PAYABLE TO:
FOAM .aau,
i 3~'.E::~:; ..:10:;
~;j'...~J.,'.:;;: ::'.:';.;;:.1=
~~:~-' ',;':
:.':_.:/ '..:
,STATE FARM~433
'BLUE CROSS 361
386540958--
20632083300
r--T--1
U
-,
,
,
,--
I
.
,
.
.
T
o
PA
17070
SEIDLE MEMORIAL HOSPITAL
120 SOUTH FILBERT STREET
MEC~ANICSBURG. PA. 17055
717 - 795-6600
RICHARD MCCURDY
603B RENO ST
NEW CUMBERLAND
L
~
n:e,,+r ....u""B_~ ~A.::," '-lAME ROO.'" NO, I .lC'AITTE:l OlSCI<AFlOEO I.R,S, 23-1352215
242742822 IMCCURDY, RICHARD II S208-011 03: 17 ,941 04,01 :941 ,IlAT!ENT
CAre OESCAIPTlCN faTAL. CMARGe I 1 ST COVERAGe: 2ND CCNERAOii JPO COVERAGE AMOuNT
TOTAL CHARGES 10753, 68 10753: 68 10753, 68 ,
, , .
CH4RGE INELIGIBLE UNDER COB 6750: 00- , , , 6750: 00
, , ,
, ~-----,..-- , , , ,
CHARGE ALLOWABLE UNDER COB 4003: 68 , , , ,
, , , ,
, .......-. , , , -....--..
INSUR~CE ---- , ~-----~-- ------~-- ,
, ------1--
~OVER GE BEFORE DEDUCTIONS , 10753' 68 10753' 68 ,
, , , , , ,
""'I" "" -- , , , ,
T~TAL DEDUCTIONS , ______L..__ ______i.__ ______L..__
, , , ,
, , , ,
, -----_!-_- -----_!.._- -----_!.._-
, , , ,
BENEF TS-COB PLANS BEFORE COORI 21507' 36 107SJ1 68 10753' 68 ,
DUPLI ATE COVERAGE - COB PLANS 17503: 68 , ._--_.~_. ,
----....-- ,
,
, ------"--- , , , ,
, 4003: 68 , , , ,
BENEF TS - COB PLANS , , , ,
, ______L..__ , , ------..- ,
, , , , , ,
TOTAL BENEFITS 4003, 68 , , , ,
, , , , , ,
-.---..--
, , , , , ,
PATIENT ---- , , , , ,
C~GfS INELIGIBLE UNDER COB 6750: 00 , , , 6750: 00
, , ,
------"--- , , , -----...--
6750: 00 , , , 6750: 00
P:TIEiT RESPONSIBILITY , , ,
......'-.. , , , .....-.-
, , , , ,
PATIE T BALANCE 6750, 00 , , , 6750, 00
, ......1..- I , I -....1...
, , , , , ,
, , , , , ,
, , , , , ,
, , , , , I
, , , I , ,
, , , , , ,
, I , , , ,
, , , I , ,
, , , , , ,
, , , , , ,
, , , , , ,
, , , , , ,
, , , , , ,
, , , , , ,
, I , , , ,
.
IF LAT! C"",lROeS FOR SERVICES TOTALS ~ , , I , , PATIENT PAY
RENC:::;:lED OCCuR, YOU WILL. , , , , THIS AMOUNT
FlECEive AccmCNAL all.UNa
Bll.lJNQ 0.\ TE
ACMISS:ON/SE~ICE
~!c
.MOUNT :l,;E
,
, l
OISC,..ARGe ~:'Te I
AMC\,;NT PAiD
SEIDLE MEMORIAL HOSPITAL
.~"""_~""___'-_.""""_W'~"_-:.":._:~"~'\ _
~ _ .r
~_. \-_..-\-~
, ..
. ,
.!." '.,:,; ~ " ~ j ~ :
'. ~~',. -.' .
S L\l E HR:\ ~'d \
eLl:E ([\Us) 11)1
IMI))~,j")~
21)" 3 21J~ J 31JO
.,
,........----- .
: I
I
~---~
R lCHARD MCCURDY
603B Rf.NO ST
NEW CUMBERLAND
SEIDLE MEMORIAL HOSPITAL
120 SOUTH FILBERT STREET
MECHANICSBURG, PA. 17055
717 - 795-6600
.
PA
17070
o
---1
L
Ii s';~~~~1 i 0;:~~4i ;t~A;:~41
I TOU~ CrtAI=fOI i I sr cO'II!;:u,ai aka COVEAAGE
~ ~'. "I. ',' ,... ,.' .~','!:
I 242742822 I MCCURDY R (CHARD
I c.are I
::ISC":~C~
CLAIM NO
HIC NL
PRly N, E ADDR PHONE
HARRISBURG
MEDICAL RECORD NO.
PATIENI CONTROL NO.
FEDER A TAX NO
; I
P At NAlIIE MCCURDY
I
PAT ADDR 6038 RENO ST
I
,
BIRTH DATE 02151942
: I
ADM HOVR
, I
COY PEaIOD 00000000
I
LIP'E T ME RES DAYS
,
NO. HARRISl!olJRG
PA I
206320833 I
24274282i
MED PRay
RICHARD
, ' ,
NEW ~UMiERLAN~ STATE P~ ZIP
SEX M HARDTAL STATUS S ADM DjTE 031J1994
I : I : L :
TYP ADM SOURCE ADMj ACC: HOj ~ISH rOUR : PAT
04011994 COY FAYS ~ NON COy! DAYS
OCC COD DATES' , ,
bCC SP~ ODE DA~ES :
PARTY NAME (JAST FIRST MI) RICHARD MCCURDY
PARTY ADDRES$ (STR~ET) 60;lB RlENO ST:
PARTY ADDRESS (CllfY) NEW CUHIlERLAND
PARTY ADDRESS (STATE) P~ :
PARTY ADDRESi (Z:IP) 17~70 :
PTS BLOOD iN : [PTS BL~OD '"EPL :
BLOOD CEO PTS: rPEl PROG rND
RESP
RESP
RESP
RESP
RESP
calm CfDES
PT~ BLboD NOT REPL
YAWE ODE AllTS
. LAn- C""AAon .ell SiRl,1CIS
Fle"C&,;E::l C~':;.oR 'leu 'Nil.....
RIiCi,'~i AC:,T:CNA4.Ilu.....a
TOTALS ~
,
,
T
I,R,S.23-1352215
3~C CO'iE;:u.ae
PRaY: ioER
,
,
,
170:70
STATUS (1
DRG
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
462
I
,
,
,
,
I
,
See Reverse Side If You Have Not Furnished Us
Your Health Insurance Information and/or Forms
- - - - - - - - - -n 7 -.: 795':6-00 - - - - - - - t{E;~ lJ'ilS_POBTjQN_FOB YQuflflec.OflOs. - - - - - - - - - - - - - - - - - - - - - - - - - - -
o DETACH AND RETURN THIS PORTION WITH PAYMENT
I "~::~'~::" I ~rrflRnY .~'T';:::: II '~NaO'TE I ACM'''CNoSE~CE 'c
MAKE CHECKS I o,"O",'OOE 7'TE I
.c......... PAYABLE TO: SElOLE MEMORIAL HOSPITAL 04 ' 01 ,Q4 .
,~' ~~..~. ---.--."'-'.,'.,\. ,
'J: : TRNS TO
HO~P I :AL ; ~ QUTH F~ONT STREE;r
, I ZIP '1711'1 '
, , I
, , ,
T:tPE :BILL: B.C. P~O'I NO
I I ,
NO: : EDICA;ID PRaY NO:
I I I ,
I I I I
I I I I
I I I I
.A.T'1e~T
AMOUNT
,
CO INS' DA' S
,
,
I
,
,
,
,
,
,
,
,
,
,
,
,
I
,
I
,
,
,
,
,
I
PATIENT PAY
THIS AMOUNT
'I
I
., +.__.,,__,___.. _~ ______.______ n_~_ ____ _"_ -----....
., . ~ '.3_~':".::.;, :::. :;:'1..J::: ~",:_" ',,':
-'..:". ~., ;';-sT,\,fCFARM--843r--
BLUE CROSS 361
------..----
'.
-r-'
i
L
.
,
.
,
.
o
RICHARD I1CCURDY
6038 RENO ST
NEW CUI1BERLAND PA
SEIDLE I1EI10RIAL HOSPITAL
120 SOUTH fILBERT STREET
I1ECHANICSBURG. PA. 17055
717 - 795-6600
I.R,S, 23-1352215
DUE,
,
,
I
,
,
,
INS GRDtP NO :
,
,
,
,
,
I
,
,
,
,
,
I
,
,
,
,
,
,
;IS~ C'f ';8
386540958 I
20632083300
I
I
17070
-.J
ROOM NO. -'CMI1'Ti:J OISCHARGEO
II S208-011 03,17,94104: 01,941
TOTAL CHARGE 1ST COVERAGE 2ND COVERAGE ~RO CO'JERAGe
DED' CO INS ,ES' RESP , PRIOR PAY;-
I I I I
I I I I
I I I I
I I I I
I I I I
I I I I
GROUE NAI1E :
,
,
,
,
,
,
E~ PLOYEE: I. D.
SSN.HIC. I.D.
3865'40958
20632083300
,
,
,
,
,
,
,
,
EI1PLOYER LOCATION '
: i :
PRINClfAL AND OTHER DIAG DESC '
I PRINCIPAL DIAG CODE V571 OTHER DIAG CODl S 7210
I PRI,NCII'AL AND OTHER PROCEDURES DESCRIP',TIOI :
OTHER
PRlN P OC CODE DATE 9338 03 - 17: : -
PSRO/Ua APPROVAL INDICATOR ' ,
STA Y ffOtl STAY THRU GRAC;; DAYS: TREATHEN'
AT;ENDtNG PHYSICIAN 1.0. OTfER PHY~IC]~ I.~.
IN~ ALID DOCTOR CODE HOC 35027Y: :
, "
, "
, "
, "
, "
, "
, "
, "
, "
, "
, "
, "
, ,I
, "
L
~,:', ..1....' l:
~'" '_~ ,,<.loVe
242742822 IMCCURDY, RICHARD
ce SC:R1FnON
:Art I
PAYER tD.
STATE fARM 8433
BLr crSS 361
INS NAmE LST,fST,l1ID
RI AS
SEX REL
,
,
,
,
,
,
Eln ESC
,
,
,
EI1PLOYER NAliE
'~LAT: C~ARaES FOR SERVICES
.llE"tC:::lE::) ::::C:.;~, YOU WILl.
ReCE,'.E ;'cCrr:C~ Qll.J.J~a
TOTALS ~
,
,
,
,
,
,
,
,
, ,
, ,
, '
, ,
, ,
, ,
, ,
, ,
, ,
: PC :
OC CODES AND DArES
, '-
, ,
, ,
AUTHORIZATION CbDE
P"TlENT
AMOUNT
, ,
, ,
, ,
, ,
, I
, I
, I
, ,
, ,
I ,
I ,
, I
, I
, ,
I ,
I ,
I , ,
I I ,
, I , ,
,
, , PATIENT PAY I
, , THIS AMOUNT
~_--' _~:-_r - '~'.---"'--- ---".
SEIDLE I1EI10RIAL HOSPITAL
F,C
AMCUNT cuE
See Reverse Side If You Have Not Furnished Us
Your Health Insurance Information and/or Forms
_ _ _ _ _ _ _ _ -nT': 795':6600 - - - - - - _I\.E~~ !HIS_P~BTJQN_F08 YQuflflec.OflCs.. - - - - - - - - - - - - - - - - - - - - - - - - --
OETACH ANO RETURN THIS PORTION WITH FAYMENT
I ,~':::::,~ I HrrTIRnV .~~';:~:: I al~NaOATE AOMISS'C",SE~CE
MAKE CHECKS OISC"A.OE OA'E
PAYABl,E TO:
~MCUNr PAID
~
,- -" .---- ,
- -
. t.~
-:~.,; ~ . .i ~ .:. :
" _ .~..',:.i ::.' . -l." ~
.,...; ~ . -'i " ;
.:l:~ :' ....:
3865-409S~
20632083)00
"srArE FAI\~ 343f'-
BUll:: CROSS 101
_.---~'
h~
~=;.
,
o
I
'---
--.J
SEIDLE MEMORIAL HOSPITAL
120 SOUTH FILBERT STREET
MECHANICSBURG, PA. 17055
717 - 795-6600
J,R,S, 23.1352215
R lCIIARD MCCURDY
603B RENO ST
NEW CUMBERLAND PA
17070
l '," ,'.l ~.
~. "'.'I:
~CCM NO .&CUI1"'i:!:O "ISCHAAaEO
II s208-01l03,17,94104, 01,941
242742822 IMCCURDY, R rCHARD
CATi I
CUCIII~O"l
roul.. ClolAFloe 1ST CovERAGE a....a CO\tWGIi
3RC CO'JEiUoe
PAnENT
AMOuNT
RE~RKf :
PR;VIDjR REPRESENTATIVE SIGNATUjE :ATI
, REVENUE DESCRIPTIONS ACC":;RATE R~COl E
: oboo
, , ,
, , ,
, , ,
BILL SUBI !TTED ' '
, , ,
, , ,
UNITS CI~GE-AKT NON-COVEREI
1 I t I
0, 1;075368, I
I,
I
I
,
,
,
,
,
,
,
,
, ,
, ,
, ,
, ,
I I
, ,
, ,
, ,
, ,
, ,
, ,
1 ,
I ,
I ,
, 1
, ,
, 1
,
,
I
1
1
DCN NU'I'BER
Tn ~u...~. annT
_. '..... CH.'O!S '0' "!Mcn
IIE..cE,:IEO OC...:",A. you WIlL
,AICEN; ACOlTlOkAl.. SlL.UhG
I
I
I
I
I ,
, ,
I ,
I I
I I
I I
, I
I ,
ENTER DATA AND I KESS ENTE' OR
....., I _1:1:'V'<_ ' ....
TOTALS ~
PATIENT PAY
THIS AMOUNT
See Reverse Side If You Have Not Furnished Us
Your Health Insurance Information and/or Forms 6750.0
_ _ _ _ _ _ .. -nT: 795':6000 -. _.. - _I{E=~ trllS.POBTjQJ'l.FOB YQUililEG.OilCS, -. . -. -. - - - - - . - - - - - - - - - - - - .
I ''IT ~~,..o I ~A~~~~~A~~D ~ETU~N THIS11 PO~~~~ ~~H P~Y~:I~~C~ISE~'lCE =c OlMCwNT O\;E
n?74?R?' ~rrllRnV RTrfl>R~ [07 , :94 01: 17 :94 T ti7~0 O~
MAKE CHECKS ~ISC""AHa= :::.\1'= I "MeUNT ~AiD I
PAYABLE TO: SEIDLE MEMORIAL HOSPITAL 04 ' 01 -94 I
-V..'_ .....-..,.--. - . -.~~~--, .,_._", """"":"-.
_ u \_~y_-:
, -
~',- ---
".'1
See Reverse Side 11 You Have Not Furnished Us
Your Health Insurance Information and/or Forms
_ _ _ _ _ _ _ _ -nT: 795:=00 - - - - - - _I{l:;~ tHj.S.P08TJOI'_F08 YQu~fl~c;,OflQS. - - - - - - - - - - - - - - - - - - - - - - - - - -
"" DETACH ,AND RETURN THIS PORTION WITH PAYMENT
I ? :'::: ::?? I ~rrtlR nv '~~';: :'~': I; '~NG c.~ "C"'S~CN,SE~'CE' 'c i
MAKE CHECKS ;::ISC,..A~GE ':.10-:': II ol".CL.~T ~A,:::
PAYABLE TO: SEIDLE IiEMORIAL HOSPITAL 04 ' 01 '94
_.~-----_._---- ------~_._-_.
;:- :- '.:~
:::i:'.,;; -~ ~~.:;: ~I:_'::;""::~ ::.~;::.;.~:: j:;: -~ ',:
. STATEFAR:i-:- 8~3ii---
BLUE CROSS 361
3865~0958
20632083300
I
SEIDLE MEMORIAL HOSPITAL
120 SOUTH FILBERT STREET
MECHANICSBURG, PA. 17055
717 - 795-6600
3
RICHARD MCCURDY
603B RENO ST
NEW CUMBERLAND PA
17070
,
o
--1
L
I ,,-.,-. .,,-. I
r OCCY NO
,l,CUIT"l"!:!
OlSCl-lAi1QEO !
IRS 23.1352215
- - .... -= - '-
242742822 i'lCCURDY, RICHARD 115208-01103,17 :94104: 01,941 "'TlI~
=Ars , CE3C;:lIFlT1CN I TOTAL. CHARQi i 1 ST cC"e;u,Oi I 2~C CC'~wa& )RO CO....iRAQIi oWOl,oNT
SO~IAL1SECURITY NO. - 206-32-08l3 , . . , .
. . . . .
BIRTH ~ATE - 02/15/42 . . , . .
SEX - r , . . . .
IiARITA STATUS- S , , . . .
, , . , .
RACE ,- ~ W . . . . .
- 97556 . . 11D03502lY . ,
ADHITT,NG DOCTOR CHO, J"!Y J , . . ,
ATTENDING DOCTOR - 97556 CHO, MY J , , Mo035027Y . .
DRG CODE - 462 . , . , .
. . . , .
DIAGNO~IS - P v57.1 . . . . .
, . . . ,
DIAGNOSIS - 5 721. 0 , . I . .
PROCEDVRE - P 93.38 , . . . .
. . . , I
PRINCIPAL PROCEDURE DATE - 03/1 /94 . I , I I
PRINCIPAL SURGEON - 97556 CHO, JAY J , . I I ,
, . I I I
AD~INI~TRATION CLASS - 2-URGENi : , I I I
, I I I
DISCHARGE STATUS - ROUTINE . , . , I
PO~ICY I HOLDER EMPLOYER - BIG BEE BOATS: /99~ I , .
I I .
PO~ICY HOLDER - RICHARD/Z ' . I . ,
PO~ICY HOLDER - RICHARD/Z , . I . ,
I , . I I
GRACE UlAYS - 0 I , , , I
COVERED DAYS - 000 I I I I I
, I I I ,
TREATMENT AUTHORITY - I . I I ,
APIiROV~D FROM - , , I I I
I I I I I
APPROVED THRU - I I I I I
, . I I I I
, , I I I I
, I I I I I
, I I I I I
I I , , I
, I I I I
, I I I ,
, , I I I
, I I I I
, I , , I
. I I , I
, . I I I
, I , I ,
, . , I .
, I . I ,
, , I I I
, I , I I I
, I , I I I
iF !...Are CHARGeS FeR SE~CES TOT ALS ~ , I I I I PATIENT PAY
,Q!:Nce-=EiJ OCCt,;Ff, 'fOU WlU. , I , , THIS AMOUNT
~ECE;ve "COITIONAl.. SlUJ,.a
~.lo.=". ....l."-
~
r
,
~
I;
;,
~
[I
!j
L
'I
1:
J
"
r'
, ~_----c-:-._.
I
I
. ,
-' -~ -',';
, :
p :c::..'\~~~)
'J i) 3 ::~
~:;. ~: ~;.)
,"-
,',
~! ;::-i _ _\~'_i ~.!:l !~.~ !..:'\ ~ I
". _..2-': 11
. ~ ,: I
.:... .~ " - ... 'f
'. ,
q '", ."...: .
'''';,:','.:'
,\1L.:J,. 0;; LJ L;! _~ I ~. :~_11~ :~!)t)1~(jH,3-~ ..___.__~
JCO,RII11't\:c '.:1 OC::t.;Hlt"ll;!;.! j.t ,;,;.. IlRO.':'.l5 {~_~I'r.L'lLt ' ;.. . 1;(::,;;"111',(;( ~J~.. .\ j,'
L--,--~L~.__,_~ u,.UL,I____~!~..h.........l ~ 1>"0 ...>--__.,. .-'t______~~t:l\...l~'" ...JiAll, _..<.. ...L'!';'! _~__~~~,~. ".n.;~
, __L.______L_____...~
"
,'~.,11 j
J
~~Lt.f. C~HH!t
....,
,b
, ,
'd~
,,----_.~, '
'J~b(;IlIPfQ~
. 441'C1Ir:~AAlf1
()',(i'IV::,uE "U~VIJ~IT$
10 ROOM-BOARD/PVT
5Q., PHARMACY." "., ..
58 IV SOLUTIONS
70 iMED-SUR SUPPLIES
00 _LABORATORY
00 ,LABORATORY
00 -LABORATORY
00 [LABORATORY
00 LABOP.ATORY
OO:LABORATORY
20 'PHYSICAL THERP
20 IPHYSICAL THERP
20 ,PHYSICAL THERP
20 [PHYSICAL THERP
20 'PHYSICAL THERP
20, : PHYSICAL THERP
30 OCCUPATION THER
01.
45000
15
..1
2
67
1
1
1
6
1
9.
1
2l
2
13
12
8
8
,169
I
i
I
'85025
185650
'80019
180006
184132
IG0001
, 97720
197010
, 97128
197012
, 97110
197118
I
i
J
I
..___, d
,
i'IP"OV1CEA!tO,
=-~.::t.~.!tlKlR ~nM[lfTS
Yi I Y'
Iy ii'll
! , I
:11
15/STATE FARM
39/HEALTHASSORANCE
1 SEj90014~ .
U/lREU &OCERT ,5S/rrI,HIC."C "10
, t!Qi;OUP"I.....E
, '386540958
I.J,20632083300
D ;\, _l,LQ..7.D
1.1, 1 ,:!H..~r)-
:.' . :1
B
C
i.,.....LVALl"ti55D,C[~All,.ECOO!S
,~ ~ -~l~.!.l.U_ .tMll,1i1
i J
I I
i i
LJ
HTor"'I.C"AII(jE~
!&I~,.,(Ovt:AEDC""'R(jES 14'
I
._1
I
I
I..
I
I
I
I..
675000
65568
1500
74800,
3600
2200 I,
50.0 0
27000 I
2000
6300 'I
6700, I
58800.,
5600
390'00 I, ,
33600 I
40800 I
27900 I
10753ii8.:I '.m'.,.. ,. i
..I,_.,..._.u>~,j
.1. .", .'''. ...J
I I
-.
i ~SEsT."UOll'lr DUE
..
,I
1'-." , ,:'._~:-:~.'. ::~~~: ~ .~ ~ ~~ ~:~~~~
I
I QINSUR"'/rrICEGROUP/rrIO,
IHI5/STATE FARM I
:,IH39/HEALTH ASS I..~::
I I
Itl~ "!"PlOleR~A..e
foI[l,IPlOlERLCC.t.TICH
-BIG BEE BOATS
/999 1617 STATS RD, DUNCANNON
"., L.. .0.,_. ,.,
PA 17020
I
I
~l.
,I
\
I
"
, j'
t
,.
UtlU 'I(Xl~f
OTlifflCiAG.l;::oh
~1~~1 j ntC14'
'1111.1'
rteLl"
"ttft
'1'i71,~ 7210... ...
IJ ~'U.C.;II.... ;;"(.~E:',"Ie
, _.T--Ct___~__..:"L-
U'1'1P n'11'7Q
OrHt~;;fl;,J<..;.tUUi't
I1lql :1"'0'1 01...0. co, 1 nE<COE
I I
I"
!
C11'l~~..;';(.i.llUtl.t:
00" ~(r,
~..;t::i
I~:':;'~.~~
iitt;i~i-R'oCi.ciJ'RE-
~ ~'"
"".
a OfHFR PK"'~, 0
~RPt(t'!l.ID
MOD 3 5 Qll.'(_CHO,_J AX->T.
6-'12 HCF,.\.14-;.J
IIDP~'10t"'jl;:llt~UI'A,'''1; .!lAlc
.~_L.D_.......sT.J::R[.rNG.,-r:J\'l'...hC.C'l'G.- _0.7.12 9.4,
cc;.;, C~:<-j;~P.L.
------ '-__._~:--___'''.1 --....-
~
~
c
APPHO:<l:1ATED ST,\TlSnCi BASED m: I'}'}c A:::WAL REPORTS
PEER REVIEWS - INITIAL DETERMINATIONS
BY INSURANCE COMPANY
Insurance comoanv
State Farm
Nationwide
prudential
Allstate
Aetna Life
Hartford
Liberty Mutual
CNA
Metropolitan
American Independent
Motorist Mutual
General Accident
Travelers
Harleysville
Ohio casualty
continental Loss Adjusting Co.
USAA
Federal Kemper
Penn National
Royal
Keystone
Colonial Penn
GEICO
statesman
Amica
commercial Union
worldwide
Maryland casualty
Kemper Insurance
progressive Insurance
Crum & Forster
Donegal Mutual
Old Guard Mutual
Hanover/Amgro
Erie
Medimax
Chester county Mutual
Fireman's Fund
U.S. Fidelty & Guaranty
progressive Casualty
Highland Mutual
Port Authority Transit
Transamerica
Chubb
Mutual Benefit
Number of
Initial Determ,
8054
1788
1158
1059
992
661
622
394
369
328
284
265
228
223
164
159
147
136
136
129
119
114
100
89
80
77
67
67
66
62
59
54
53
51
46
44
42
38
37
34
33
28
28
27
26
Pe~centacte
41.6550%
9.2475%
5.9891%
5.4771%
5.1306"
3.4187%
3.2170%
2.0378%
1.9085%
1. 696H
1.4688%
1. 3706%
1.1792'0
1.1533%
0.8482%
0.8223%
0.7603%
0.7034%
0.7034%
0.6672%
0.6155%
0.5896%
0.5172%
0.4603%
0.4138%
0.3982'0
0.3465%
0.3465%
0.3413%
0.3207%
0.3051%
0.2793%
0.2741%
0.2638%
0.2379%
0.2276%
0.2172%
0.1965%
0.191H
0.1759%
0.1707%
0.1448%
0.1448%
0.1396%
0.1345%
196
APPROXI:1ATED STATrSTrCS BASED 0:; l'!')c ,\~:lI''\L REPORTS
PEER REVIEWS - INITIAL DETERMINATIONS
BY INSURANCE COMPANY
Number of
Initial Determ,
8054
1788
1158
1059
992
661
622
394
369
328
284
265
228
223
164
159
147
136
136
129
119
114
100
89
80
77
67
67
66
62
59
54
53
51
46
44
42
38
37
34
33
28
28
27
26
Insurance Comoany
State Farm
Nationwide
Prudential
Allstate
Aetna Li fe
, Hartford
Liberty Mutual
CNA
Metropolitan
American Independent
Motorist Mutual
General Accident
Travelers
Harleysville
Ohio Casualtj'
continental Loss Adjusting Co.
USAA
Federa 1 Kemper
Penn National
Royal
Keystone
Colonial Penn
GEICO
statesman
Amica
Commercial Union
Worldwide
Maryland casualty
Kemper Insurance
Progressive Insurance
Crum .. Forster
Donegal Mutual
Old Guard Mutual
Hanover/Amgro
Erie
Medimax
Chester county Mutual
Fireman's Fund
u.s. Fidelty .. Guaranty
progressive Casualty
Highland Mutual
Port Authority Transit
Transamerica
Chubb
Mutual Benefit
Percentaqe
41.6550%
9.2475%
5.9891%
5.4771%.
5.1306%'
3.4187%
3.2170%
2.0378%
1.9085%
1.6964%
1.4688%
1. 3706%
1.1792%
1.153H
0.8482%
0.822H
0.760H
0.703H
0.7034%
0.6672%
0.6155%
0.5896%
0.5172%
0.460H
0.4138%
0.3982%
0.3465%
0.3465%
0.341H
0.3207%
0.3051%
0.2793%
0.2741%
0.2638%
0.2379%
0.2276%
0.2172%
0.1965%
0.191H
0.1759%
0.1707%
0.1448%
0.1448%
0.1396%
0.1345%
196
L
.
f
~
.
25
22
19
19
19
18
16
15
14
14
13
12
12
12
11
11
10
10
10
9
9
8
8
8
8
8
8
8
8
8
7
7
7
7
6
6
6
6
6
6
6
6
5
5
5
5
5
4
4
4
4
4
0.1293';
0.1138\
0.0983\
0.0983\
0.0983\
0.0931\
0.0828\
0.0776\
0.0724\
0.0724\
0.0672't
0.0621\
0.0621\
0.0621\
0.0569\
0.0569\
0.0517\
0.0517\
0.0517\
0.0465\
0.0465\
0.0413\
0.0413\
0.0413\
0.0413%
0.0413%
0.0413%
0.0413%
0.0413%
0.0413%
0.0362't
0.0262\
0.0262\
0.0262\
0.0310\
0.0310\
0.0310\
0.0310\
0.0310'1;
0.0310\
0.0310'1;
0.0310\
0.0258'1;
0.0258'1;
~ 0.0258'1;
0.0256'1;
0.0258'1;
0.0206'1;
0.0206\
0.0206\
0.0206\
0.0206\
,
~
;
;
Delaware Mutual
CIGNA
Home Insurance
State Auto Insurance
Old Guard
PIMCa
Brotherly Aide Liability
Selective Insurance
Goodville Mutual
Reliance Insurance
CIS Insurance Group
Horace Mann
Shelby Insurance Company
PRUPAC
Gay & Taylor
American States Insurance
Westfield Insurance Company
PAR Group
Crawford & Company
Motorists Insurance Corp.
ANPAC
National Grange
Aq'"ay
Republic Claims
United Services Automobile
Amerisure
vocational Rehabilitation
Philadelphia Housing Authority
Allegheny County Port Authority
Universal Underwriters
constitution State
Lebanon Mutual
National Indemnity
Motorists Insurance Co.
North Carolina Farm Bureau
Charter Adjusting Service
Pennsylvania Millers
Johns Eastern
Electric
Browning Ferris
PMA Group
Equitable
Claims Management Services
Celina Group
Maryland Insurance Group
ITT Hartford
West American
GAB
Sentry Dairyland
Philadelphia Gas Works
Northwestern National
Merchants
197
-
"
...
'"
~
"'
'"
...
:!:
Z
z
<
N
'"
'"
z
C
~
iil
VI
<
..
VI
U
...
VI
-
...
<
...
~
;:
<
'"
-
~
;;:
..
..
<
.
" '...1' 1 . I I I I ' . . " I I. I
i~ ~~5'S~""~~'~5~'1
u 0 1 , ' I I
~ ,~clc~-col11~0~-~eo
ii.. U.. jj~ ~~ .JjJ.J.J~.J J~~~ ~
n~~lO~I~mIO~~.I'O~INM!~~I~~~O ~
Uii igl~l~i~~I~g ~1~~i~I~I~I:~i =1
1: 3~~ o. ~ calNI,... "" f'1 "" Q\GI.IJ""I~ olN G ~ ~I
II ol1oj;Z: '" 0 "'1m'" N'" "'-''"'1'''1 -I-N I
II~ CD~.N~ N MI_IN -
II .-4 f'4
II
if 'll"'~~ .... ~"I" ~1~1:...I.. ~'''I..I.. "1 ~ ~...l
u N~~~~~r~~o~~=nCnN~C ~ 001
II . . .. . . .... .,. . 0 i
II \O<t:'CCO\DC)a)N NII'""l:"'oc-'l I'""toc:a ...... I
II ~MN~MNI~"" N_~1'""t Mn.. ~
II ..
II '"
II .....
II 0
II "'
II C
II
II
1
II
II
II
II
II
II
II
II
II
II
II
II
II
I
II
II
II
II
II
II
II
II
II
II
II
II
II
II
II
II.....
U 0
II
II "" In
II '" 3
n .Q.~
II eo >
II
II .2 CI
II - -
1
II'
U
"
II
II
"
II
I III
" 0
130
I "'....
I .....~
I > "'I
I QJ N
I :::; '~I
I 0,
to
..
'"
~~
"'roo.
:Sw
rol",
......:
>",
rol",
'"
'" I
rolUl
rolZ
1100
.......
IC'"
=0<
;z:Z
;z:....
..:~
NW
"'t
_C
100..:1
0":
M
>0'"
",M
~~
=
to
~I 611
....1...1....:_
cl~lolO
C
co
OI,QOO
Jd JJI,~~I
~I~I ~ ~I:I~
11'I'" N pof ml...
~ -,
~~~~
. . .0
Cl.t'i.;o....
"' -1-
~ c _ ,,1...1..
I
OCOO~9=N~~O~~_.O\D~CCO ..
%M~~IN~ ~ ~_N_ ~-
"='l/'l..... - N
-
..~...~,~:I~I:~~~~~~~I~~~~.~' : t~
.-. r-:I...ocr-.;,\,Qf"'ol/'llt"" ~C\IMONNI~j~Il'I" ....1
.~ .-II l/'lll'\I~r.' l/'l \,Q \f'. ~l ~lq' ('r-'IN l'"'- ~ I
~ > 01'" '"' N 0 "'I.'''' "'loI"'I''''loI~I,",''' ",10" ... el~1 - '" ...Ie
Co ~I"I~;:: ~:: ~ :: "'II~ "'IT" "'1- I I -I
1'011 ~~~~1~" 01 "'j~l~jjj~oIU~ ~ .LJ .Jj~,..
G M.~N~OM~C.N~I'"'IN~N.O ~ 001 0101'"'0
., ..... .. c . . . . . . . ... . .
~a ~~OI'"'~1 ~~~NM~~.=..~ ~ ~~
i~ N~N N N~ N~~I~I~MINN' ~ 1M
i~~~...JN~O",~~jjJ,",~,",,,,~- ~ 00 JJoo
......9tZQ\~~IN... ".... ~1..-41~1'" II~
~ 1C1 "'... - '" -, I I
..,...!""t
clolc 0
.; .;10
"'I""' "'I
.... 1'::1
OJ ::1
C.l ~i
=- ';:1
"',,~N~_r--o\C\Cor--Iq'Nr-CONr-I"l: c
~ QO~ ~~ ~rcl'" _I"''''
~~ ~IM: MI \r.1~IN ~
~j..cil g U~i ~I~.~ ~ ,~ U
.~ ~~~I,~~1 ~u ~ .2 ~~~]'
'" "'I"" '01 "" c:J .o..Q "-I:;; "::l w
.~ = ~~IOI ~_u ~~~~ ~ ~~
"C '13 ,o,w'UI .=:= "'1:1:'" eo :1:"" '"
::: ~ 111.c tJ.c1 ~I 01 ..... ~ aJ u tt:1'~ Cl). X
< ~I ;,//..;;;. ~ t: rei, ~ Q,j, c::: c::: .~ .,; .... /U ~ .I.J 1":1 ",-
o ~_ > .r: ..... .r: 04 ~I >1 .. 0 '0 s:: c...... Q.l C J...I ....
OJU~ll11ll11 cuI 01'- ~l~!~ Q,jCl11aJl11lUU ~~ >111
"::l '0 0::1 0:: ""I 0: (.; "" 11I1 "'I:' '" > :1:1'0 "'I '-I "::l::1 .. '"
'_~'_I X Cl ~ CI~,1 ~o = _>~C~ll11='~
3IOJ"'I~_ml~~!-~t QUI~I~~C;~~~~~ICl11C::>I~'"
'O"'IOEOJIEll11l-ll11l~C~1 '~~'~"'ll11l~=IU~IOI~CI-d~1
:;i~I'~~:;lgl.~:tl~~:~;~ti~~_I:~~r:I;~I~~UI~:;I~
O! El OJ -I ."::1 CJI O! ;0:;; C1 :./; I: ::; .-i ~i ~: L.. ,...., d C CJ I ~ = QJI:"'; ~
~'~'ut~I~!~'~I='~f~,_j_,=,~,~'~'~'-I- ~ ~I_ -'~'~l
~-
N~i~r
'1f'!O
I
"
I
I
I
I
I
I
I
:: ... ..! .. "..l~..
II w 010 01=10
II
II "
II .c:
II .,
II 0
II 0 00 00 0
II Z
II
I J
II
II ...
II .. ~,;; ~
II ......1'" 01;;
II
II .. a . a a
II ..,: ... .........
I "s: ...
110"
...e
.. ~ .
....0 A,., NN'"
O",z
..
.. :;I~ ~I~f~
0 0
~ I"' ~
II I I"'
II -
II '"
II
I '... . 01"' ~o~
C ~
QI
C
I! :;~ .. ~..
,-- 1"'00
.0
II- I"'
I"'
II '"
II....
II ...
II ": . 00 ~NO
~ ~ ~I~
II
II
I
II ;; ~ ~ !~I;;
II
II .,
II ... .. '" a .
II 0: .. ... ,.,
II :r~ ,.,
II
II
II "0
" : ~ .
n "'0 ...00
II .. 0
II too..:z
II
I
II ....
II 0
II
II UI
II .. :0
/I G.I QJ ~ I"' 1"'''
II ,Q..
II E >
II ::J QI
II :z: e:
if c
II QI <Jl
II E ":Ig
II QI
II ~ tl' '" .
II UI ' '" I~I~
II E U C C
II ~ .... C ,; '" 0 u'~
II "j,: c To ,.
II :o,~ .... c ... I'. 0
II cu. t) '" ;.,'" .., ~
"001 ~ :t .... .. '~ U
~ ::' c,~ Q. '... U ~'":
I "', ....0
I c: ,; U > .... UI I g C
I C .... " .c ,QUI
Iw~ we: '" "'< w 0
IQI " J: UI ,.., .,
I ~ ~ .!! ,,'... IE
~ ~
...
.,
...
...
N
...
..
...
.
...
...
..
1ft
...
.
...
..
...
.
...
.
..
..
N
.
,.,
~
,I
i
f
i
1
l
..
...
.
1ft
,.,
a
...
III
.
N
oil'
III
.
...
N
1ft
.
...
.
...
1ft
N
a
.
III
:/
1
III
W
CJ
~
W
>
.c
...
III
-'l
<
'"'
o
'"'
209
w
E
:c
~
4
,
I
j
,
I
!
,
-----
i'
-
'"
...
'" III
0 t<
0-
'" =
'" 0
-' Po
ral
< =
::>
:z:
~ II:
ral
N ...Ill
'" >:z:
'" 1ol0
- ~...
t<
C =.c
1ol:Z:
::> Iol'"
'" Po~
'"
< ..:I"
., .ct<
'" :>Iol
u :Z:Q
... :z:
... .c..:l
'"
... .c
!;; N'"
"'t<
... "'...
'" ..:z:
[;j ...
'"
~ 0
... >-
>< =
0 .c
'" ~
0-
0-
< :>
III
:1
II..
II
II"
II s:.
II +J
II 0
II
II
:!
II
n~
II III I"
II ....~
II .w .,
II ~.~
II ..
II Po"
II...Q
II 11I::-
II ..
II.... '"
II 0 Po
II t<
M
II
II
II
II
II
.. '" ~I..I" ..~ .. ~ ...... ..l,....
~OI~I~~MO=OOIO~NC~MCO~~
~ co. ~ 9~ ~~ ~~
I g ~ 0 '" '" ~ 0 :- 0 0 01, ~ 0 ::;;,:: 0 0 "'1::,
r,~~"'OO~~~N~Q~O.~.g..
. .
. . .
. I .. ....
.~CN~.~~~m~~O~~N."'.O
~~m~~m~~m~~mmm~~~m~m
I
~N~"'~.~~MO~~~".mN~G~
O~om.~.~~~"~~~~~~~~~~
_~.N~.O~M..MMNN"""'"~"
~ N....;..... "
...
'"
....
e
"
Q
,..I::: '" ;0 '" ~I~ :\ :: ~ :: ~~!: ~ ~1~ 0 N l" ~
.; '" '" '?.,; ..; ..; ~ '" .,; ~ l" '" '" ";1:::1"; "'..; '"
~M ~MN~~~MN~~M~I"M~M~
01 ~ ~ CD r-I CD 0'\ ltl r-- Lt'l CD l""" N I/'l ,.., CC ~I "ll r"" I"'" l"'-
_1~M~~r""CCr-ll"'-O'\l/'lr-lCCCC~~~l"""lr-II""'M
-O"Im.... \D'Q"Nr-I r-Ir-I Nf""I I-
...
L ~~]:,::~5~:SS~5Is~3:';':3
Il.~ IN]~ "' ""'1'" '" '" '" '" ~I"'I 1~ln 1",:;;1
II
:1~~~'occ~oO'\~mO"lccN~I""'~CC~I""'CCCCr-l~
II~~ r-I~~CCI~ltl~I""'I""'Lt'lI""'r-1f""1MN"'O'\~CCf""l
II I""'IOCCI""'I~l""'ltlNMNNM r-Ir-I ~
II ]~
II
\1 ~ ~I~I~ ~I~ ': ": ~ ~ ~I~ ~~I~I~'~ '" ~I~~.
a~"""'o"'I""'''O'''''''N~..O~~'''''''''
"~~ NN~ N~NN~NN~I~~~.N~~~
Ii a ~
II .... 0
II".. I
II" i5 .......CD"'C7'\QCD..N....,O......CG'lO\~CDr"'"
II~~S.."'~~..,..~M"'....~~~..NOI~.I~N
II ~-m"N""M""~"" ....~I ~
"
" ""
" 0
II
II ... III
II " :J
II .Q.~
II e >
II Z QJ
-c:
III
e
:J 0
1I QJ'"
lI'oo4~
II > IQ
II Q.I N
II e::.oo4
" t:
II ~ ttll
:: ~ Ef
1I ~ ""';1
:::
...
"'I
~
'"
'"
I"
o
..
..
'"
..' ..I...
o=>o
'"
...
'"
o~o
~
~~-:.
N
I"
l"I"N
CD "'I"
...
'"
.IN '"
"'I"'"
~ : ~55
~I ... ~I-i ...
l"
N
~ ;
o '"
'" ...
~ 2
'" 0
. ...
~
"''''~
C\..~
~~~~
00
"''''
0......
"''''
u
....ID
. . .
NIDI"
"NN
.O~
.....N
"' "',::, 0 "", ':' ""I... In ... 0 ... N N NI. ... "'I '1'1 ~ ... ~
U"lQ\I~I'" ''QU'\M\ON'''lcr--~\O..cl'"'\ 1'" C'\ ~ l"
~ :::' U"l1 ~ M ~ CD ..c U"l ll'l U"I ~ M NI r; N N ~ ~I;" ..... ~
~ ~
_ u .... I":'" '...
[; ,Q 0 _ .- 10 >
,_e "Ill e 0 = I:" u " g
'. ,I!' """'I~ ,""u '... c:'
,..... I. ~~. ~~u ~ ~ +J
_ lIl"'iO U ~"--....,, III '"
~i~~~u~~g~u ~ ~;i~~~~X~~ ~
~~~_~C~~ ~ ~O'oo4~~~~IO~-
o ~ > .c jooo4 J:. .001 ..., ~ ;:. .: 0 ~ 'C c.. IC C C ~ l1l''''
I1lUl'lJIVaJ cuu 0- QJ.JI;:L.t Q,lta CLlI._lUaJCJCJ.c
'C ~~= ~oc~~ ~IQ.I~ ~>l'lJX~U~O ~IQ
._ 'C . )C III 0 U! Ol.t: I tt:I 01 '... I tC 0 C .-4 >.;: r.n
:a 11l. _ VI _ It! L.t 1Il 4-l _ c.:1 Q u~ 1n),j,.I ~ c: 0 '"C U VI QJ "=' IC L. Q.I C
~ XI 0 81 aJ e Q.I .:::: - QJ C.l 0 ~ '-1::::; ~ tal l1lt..-I lJ1 a. C U Q) c:: 0
_ ,- ~'- .....- > ,- > 1Il""j "'-.... "'I ]1- c: ....Ie <( '" '" '... till ,;.
L..l c ~:l 'tJ OJ tJ E I.. ~:........I - L..I"'O.... - C ._1._ ~ "0 U ~
OJ E 0 _ IQ CJ 01 WI t'Cl at :'1 I I C::.- C,.II ~I ""'.... aJ Cl - :: CJ C::1 e
::' .....1 ~ \1 r' ....: .,.. -, t )1 - r )1 :..: ...1 _I :::' :;., _. :"'1 '>' =... -, , J ..... 'r.: -= ,:"1J
202
... "',:,
... 0,_
~I'"
'.
.'
"
'I
"
"
"
'i
;l
1/ ...
1/ Qj
1/ .<:
1/ ..,
1/ 0
1/
1/
1/
1/
1/
1
1/
1/ ...
1/
:I,~.... ""
II "".
If ....rl
II · r:
II ~ II
I/...e
1/ 1.-
'1/, .:l ~.. ci
1/ 0110 Z
1/ i<
It
1/
1/
1/
1/
1/
1/
1/ ....
1/ ..
II....
1/ C
1/ Qj
II Q
1/
1/
1/
1/
1/
1/ ....
1/ ..
II....
1/ ..,
II "', '
II trJ it; 0
1lQ.,a..Z
/I
1/
Ii
1/
1/ CI
1/ ..,"'1"
II c:.~
/I CIa ...
1/
II .u 0
~ :~... ci
1/'" Z
1/ i<.o:
jL
1/
1/ ...
/I 0
1/
II w U'I
II Q,J:J
:1 .c.~
/I a>
/I :s CLl
II Z IX
,
1/
/I
/I
1/
1/
1/
1/
1/ III
1/ C
/I 30
/I Q,J.~
11'001'"
/I > ta
II Q,J N
1/ p:: ,_
/I <
1/ ... pi<
1/ Qj
II Q,J L.o
II c.. C
..
o
z
..
o
2
..
-:
""
...
'"
'"
~
...
,...
.
...
...
..
o
...
-
'"
-
..
~
CD
'"
N
'"
~. :I~
...
...
III
...
'"
CD
'"
r-
""
o
o
:;
o
...
...
..
..
'"
'"
"'
M
...
...r-
NN
.. .,
00
....t..."'......
OONCOOO
o ....,'"
... N
...~....~
0000
0000
:::!:; ~ ~
.0 . .
M.......
.. ....
,...,.,........
...N....lI'1
~;;~;:::
o ' .
_N'"
N'"
OM~N
N ..
;I~I~ ~
M N"
.. "N
r--OMU1
- ....
~I~I~ ~
. ..
... 11I11I
'"
1000........
MMaJCO
NN ....
..
o
.. ...
'" 0
'"
:;:;
. 0
....
...
~~
.....
'"
-CD
~,:;;
r-N
"''''
CD'"
:;':;
'"
,.,
11I0
'"
-
~~
-~
.\'~
00
:I~
'"
....
:
:;;;;
00
NO-,..,OOO
N ....
o
.... 0
00
NO
M Nr-
... "''''
M ",...
M MM
"'...
...
o .....
0",
,...'"
~!~
~ ~ ... 0 ... ~'~
~
:; ~
::::;
. .
..Ill
...r-
...
...
......
. I I . . . .
.....
....
NG\."G\O,...
loI'ICDlt'I"''''IIll'
..
...
o ..
.. ...
:;;
"',...
.......
NN
:;;
MCD
"''''
..,...
~:;
. .
III III
...",
...,.,
M N
.......
Qj 0 Ie
~ ~ ~ ~ .~ en u';.. ~ ~ (J ~ . .
. ..<: u 0 ,- '" > Q c .. _ Qj C .. 1-01....
~ g;: :t; lJ ~ I? ~ C" H ,~I a. -;;; ... g' II- ,~ t: ~
'<:HIO QjIll...3 P:: Qj '" au ....~u .. cC.Q '0 ~
Q,J Q,J ~"'~Q,J ~ p....c~....o....... taOta+J Q,J~
P::III= cu... -... )......::E;.Q,-,o CIIIX'~.eCIOXCU
~~''''>U'lta ta Q,JCLl~ '~ta"'CLl~Q,Jw +JCUCLlQ. ~.~
"'QjQjIllC"'~QjQjU >'-.QU ~"X~QQj~..p::a .ell..,
~U>EQ,J-Q,J~U,~ >~ :JQ,JQ,J~ ~ c....... CLl~~~U
C .001.... Q,J 'tI =' z: .~ -c CJ 0 Q,J -4 C cu .., a:/... ...-j ~ c.... 'o-l U "C ~ 0 l.4 UJ to
o ~ .iJ ,IJ C Ul ...-4 > aJ IV ... c:: a: 0 ta...."' 1_ ~ ~ to E.-1 0 Q,I rtI ::I cui ~
..... ~ lU 111 Q,J c: '1'0 J,., z: > ra CL. 0 "-' u > ... ....... C Itl U to..... VI U c:: c::.c enl ~
.4.J 4.1 >.~ Co 0 co U ~ I..... 3: ..... ..... Q) V) QJ .c 0 C ..... x .Q VI C' ra 0 I/) en 0
ra VJ 0 tn ~ t.J ..-t Vl . 0 ra c:: ~ . 1... c:: I en ra .~ -=: w "-J to < /U X .-t ~ 4: w
U c ~ <~ VlU'lI_<Q~~ '~U~u ~ VI > ~~ .~
o c:: C 'aJ . a.: CJ t-- ~I . e 1.0 ~I Qj!1l3 e .~ ~ tl ...j .c
'" .... .... lULL - ~'-':r.i:.:!-';;: '"'1":121- ;;: 10 !< <:1:>.. It)
".
......
O\O\~f'oo"'N"
N""''''''NN
:::I~
~I~I~;; ~~I~
"'N
M...
MMM
NN
N"'N
M
~
MNO.-4MO
_.... ....
.. ""...... ..I..
... lt1 "" 0 U1 Nle
e:~~~~~~
~\QMO\r--~~
r--\DO'\r--~Q'I'"
NM..-4..,M.-4.-t
~!: '" 0 . ol~
. .
. .
"0"
.....
00",
"'Ill",
.\OaOONf'oo
.. ...",
L(lL(lNOO"'l..,..-t
U1L(lU"ll-n..,<q>M
203
...
..
'" ..
... ..
..
...
:;; ~
...
~.
.... N
.... ...
N
N N
..
o
o
'"
:;; ;::,
'" '"
'" '"
'"
o '"
....
-:
~ :::
...
'"
. .
,., ..
'" ,.,
..
. III
CD
...
r-
...
11
11 ...
11 .,
11 .c.
11 ....
11 0
11
11
11
11
Ii
11
"... '",
II'" I'" I'
II........ .
II.... IS N
II ~,rt f"o
II ~ r::
II ~ '"
II ... e .
illS ~ III ...
II ... .
II 0 Po 0
II" ;I;
II
11
it
II
II
II
II
II...
II",
11'004
II r::
II .,
II c
!!
I
II
II
II
II
11
II
II
II
II
II
II
II
II
I
II
II
11 '"
II '" '"
II .......'" .
II a.~ ~
II "'S'"
II
II "'" 0 .
II : ~... 0
II w :z; t"1
II....:
II
II ....
II 0
II ... III
II OJ ~
II 1l'~
II ::l >
:: Z~
~
II
11
II
II
II
11
11
11 III
II C
II 30
II QJ'~
1I.....a,.l
II > to
II OJ N
II e::.....
11 C
II J,.. f'tI
II IV ?1
:: ~~!
......
o
...
..u:
'"
'"
0'"
Z
..
.. M
...
'"
'M
t ~ . M
"'p.,O
'" Z
~ ~
go
o
~...;............
O~OOOO:
o
01..,0000...
'"
..
~~~g~gOE
CO ".r4
Ill'" III
t;
.
o
...
..
o
o
'"
'"
I'
N
c; ~
o
...
t;
o
..
...
III
'"
m,.,calnloAO,,",
..
..
o
M
M
~ t;
o
..
..
...
...
o
...
..
o
.. ".!.oN'
~~CO""~o
. o. .
....r;....r-l""l ....
........ ....co ,.,
o
.-4.... c:o...."'oN
...
..
...
.. .. .. ",I - .. oN'
,.... N 0 Ol~ 0 rf
.
I'N
I'N
:;;I~
...
..
'"
...
,....NO~I""lO\O
o
'"
M ... Ol~ t; ~ ~
. .
.....
......
.
I'
...
'"
...
o
..
...,.,Of"tQO....
...
...
'"
'"
'"
","''''''''''0'''
.
III
..
'tit: UlIl g~
~ 8... c g ~ I'~
to lJ) ra ~ .... > .
J...c: Q.l > ..... ~ OJ QJ co
51....U"' 3 ",..:ecc:w
~.......... QJ U'ItOo.c C)
....ra>......... C>UO......JIlC
OCll...."'U1> ...to U'l1tI"
U:::.,C.,.,,,,.cZ"''''CW
C U) 0 () " .... to .... 0 >
~ lit ..-4 .... 0 N . "01 i.i .... tIC
111 . en > 1""'4:J: I"'"J.... tit......
CCll~cn~.l'C.-J+J O'OUJCD
o c s ClI OJ U ClI W C ~ .... OJ ~
.... '.-4 :I: ~ tn .004 :: OJI 0 :J ta ~ ..c
+J1I1 0 "0 'O+JtCl:JO....
.\! ~ ... ~ 081::;'" .21 ~ ~
204
~
!l.
..
~
lJl
I-
0:
o
"-
"'
0:
:;;
~
~
N
'"
'"
5
'"
"'
lJl
<
'"
lJl
U
-
I-
lJl
-
l-
i':
lJl
'"
"'
I-
;'!
-
..
o
'"
"-
'-
<
~""N""C""C::_<o:r'C'<o:rC\C'\C"lO
_r-N_NI_ -
l~ ~ ol~ ~ ~I~~, :;:;; ~ ~ I~ ~:~ M~1~1~,:; :;: :;:
~ ~~ ....~~ ~ NC\~ C'\~NO""N ~ N
W N NMN ~ M....N N....NMM.... M....
,~
....
;~I~C'\CCM~O~O~QC\o~=~c~~c
o_I~~ M~M ~ ~....-.... N....
:0:- 111
"'jl~ ": ~ ~ ~I~ ~.i~ ~ ~I~~,~. ~~ ~I~!~ ~ O~ ~ ~ ~j~~.
~Nm~.~~mNNmoM:l.~~~I=Q :1 01 Jlo'N
~ ~~~~~~~Nm~~~=~l~~~~~= .i m ml~l~
91 I I I I
~~~M~M~~~MOMNM~NI~IQQI=N~ . ~ m~~
oz~~~mm~QM~~~.~MN~~NM~ ~ NI M
-iN P"4 f"'4 1"'4 N
~ ~Iell
, 0 I ~I ~ I
g ~ ~'~ C g ~I I ~ CJ ~ '~ g .
..... .r; Ul ""' ta.... U1 .. ~I:.J .~ ~ .- -:! y
.6J 4.1 .c.... 't] 40J Cl '::.!:I U .... 'tf .6J "'_-
.... _ Ul~taO ~I, ~"I'-_~ ~ ~ ta ~~
III ." C' :J:...... lU 0 L.. U :: .-::.: .;.J 01:1 u :tl X - e .-,J aJ
C ,",: ." CJ.o U .0 '" ..., 9 ....1 CJ CJI III U .. CJ IllI'~ ,~ c:
:I 0 ... ~ lU.... to C to Itl !'- aJ c: C:I 0.... \.l ""' .j.J ~ IU lit .- III
Q,I .... 0 4J > J:. .... .c .... ..a '"' > .. 0 I C "01:' I'tl c: C - ~.... ..... OJ
.... .., QJ U to aJ 4J C1I tJ 0 '... (1J ~I j,., Q.l I'tl eI 4.11 .... lU eJl U U ,J::. tG U
>.. ." ."c:c: c:ocu", III~~ "'>I"'I:O:-U'CCj -Ill C-
diN ''''''C'''' )( tfI0 U g::'l roo'''' tOOt: _>&.U10>
~._ )lU_tfl_l'C~lII.6J_! ~U1U1~""'IC'C"CUllllU"Cta wc.~~
Ie, ~~oe~e~C-~~C~~-I~~~1 ~.~~~c,u~~o~~
..... -,~ III'~ ...'~ > ~ >1 1II1::l CJI - .oJ CJI' - C1'" C < CJ IllI'~ '" .~.. 1Il
I CU '"' e e ~ ::l 'C 0 (,J e '"' L.. cJ 6ol1- L.. ~ - - :: ,- .... 'C 1'0 (,J ~ u
!! ~..., ~ ~ ,0 -; ~I ~ ,g ~ ta ,c~i ~ .!.!.:!~,~, ~ ::1 '.::. 9, ~t r; .: r S :3 ~ ~
:i ... ~ 5 ~ ~:6 ~: ~i:i~ ~i~lsi~i1~~i~i~i:i~i
:: ~, 1 I
II ~E~coca~o~acc-co~C~OINIC
II 0 -..., l"'"
II
II
:1 ~ I- ~j~ ~.,~~. ~ ": ~I~~. ~~~ ~~~.~~ ~;~~.,
~ ~~N~~~~~~~~m~~~.~m~
~~ M~MN.MN~~.~M~MN...~
U "
~1~lo.~~NN~~~~~~~~Nm~~r-Q
Z ~=~~~~~~~~NN~~" N
::
!! ............ ..I.... .... ...... 4"1" ..~....I
I ~M~~~~~~~O~~~~~~~~~~C
~ _~M~_O~~~~M_~~CI~M~q
~ M M _~N______ N__
III
...
CJ
:>OMltl~NC"
~Z~Nltl~-
ID
t-
'"
o
1'0
(oJ
I>:
:a
(oJ
...
&lID
I>:~
cz: .... 11
(oJ t- II
(oJ 0< II
1'01>:11
(oJ II
Q II
~I~ ,I
o<1;l :,
Ng:U
en II
en II
.. II
'"
o
>-
I>:
.c
~
::>
III
I
,
II.... ,
II
II 0 'C
II ..,""
II CJ III
:1 .c a
II au
II Z ~
JI-=-~
Ii I
II
II
II
II
~~ltl~~NN~_~_~~_~C~~~~
~O~l~ltln~-~M~~~ltll~-~ltl~-
~M....I.'__N_.... I
205
~I
,I
'"'I
..1..1 ..I
clclcl
..1
cl
I
01 -
I
d d ~~~
.:1 ..;1 ,.;.;..:
\It ..-t ~.,..,
coo
III III "'....., 0
..
.. ~ .J~ ~
ell r-:~~
.., MON
- _1'1<"'
...
"'1'1_
-
I~~
-
-
...
01'11'1
'"
1'1
-
'"'
~I
o
o
~
o
'Ii
Ii
I
"
I
r
I
o
o
~
o
..
en
'"
II
II
II
II
II
I
II
II
".... .
II 0 'tl
II...,.....
II III
II QI C
II .c 0
II Il U
II :> ClI
II Z"
I
II
II
II
II
II
II
II
II III
II C
II :J 0
II CII.....
II ..... +J
II > lU
II CU N
II 0::.....
II C
II " ~
II QJ:-'I
~ ~ ;:1
::
II
II
II
II
II
II
II
II
II
II
II
I
II
II
II'" ~
II <l -
II ....,
II.., II
1I II ::
II .~ t)
II ... >
II'poI.. .
II .., Ill: 0
II 0 :z:
II lC
II
II
II
II
II
II
II
II
II
II
II
II
II
II
II
I
II
II
II
I
1--
.,0 .,lI~
o 00
...
ClI
.c .
'" 0
a"
o 00
c; C;I~
. .
on 0
N ..
.. ..0
~ ~;;
..
'tl
ClI
III
...
ClI ,
> 0
&,.
'"
....
'" 00
-- ......
"' 00
'" 0
.... ..
I'"
'tl
ClI
'...
...
'...
'tl 0
0,.
:E
'" ..0
....j"'.~.'t\........ ~
~oooooo
'"
NOOOOOO
:. ~ 0 .. 0 O!e;
o
..
..
..
rJ~~~
0000
0000
::.!~ e;1~
. .
. ..
.., 00
.., "'0
..
.-
o
.'" ..,~
00
..,oJl",.. ~
000
,.,OOIl'lONN
.. ... N
...-........-..
OOOY"lOCDO
::
"'0
o
....
00
"'0
..
r40,.,,..
"'
.. ..I.. ...
0000
00
"''''
co...."""
............
Mooe
.., 00
.., ..'"
~o'"
.-
o
o
o
00
..
o
000
o
o 0 01 ~ 0 M N
WI'''''''~H'''H
100001.001"10
o
..
'"
..,
..,
..
e;
e;
~~
c;1~ ~
c;
MOOU"lOQ'lO
.... ......
o
o
..
on
N
. .
00
00
....
t
O..CD
..
o
N
o
..0
000
...
o
...
o
~~
o
o
....
!'!.
f
'"
i
I
...
o
",0
"'0
....
o
o
.... ....
00....
o
~
...
o
......
00
~o~
o
o
;;
o
o
....
'"
o
00
01... 0
o
~
~ ~~ ~~o..,ol~~ ..oo~ ~ c; C;~ ~c;c; ~
..,
...
II
.c
g.
o
:z:
on
..
00
",0
..
. I . . . I
I'1OO\GOO
lI'IOOII'IOIl\
.... ..
. .
... 0
"' ..
.
o
o
..
on
..
o
o
..
.
o
o
..
N ~N ~..~ONO NONe 0 ,., ,.,0 ~oo ~
Pi ... f"'fN
\D ON Nq~\DO~N MOY"lY"l N M ~~ ~~~ ~
........ M ........-q
ClI ~
.... III :a Q U 'tl III
.u C QJ ~ '.... tn U U ~ . Q,I 0
~ 0 0 .~ ~ >0 C c~~....~U
.a.J..-4 U > ,..0 Hlg.... ~U.&.JtatO en
~'tJ OJ?:OJUJ tU...-( ....u> lo.1.,t:cu
~ CU~-~ ~ QJ tn SU U ~ ~ 'tJ WO.a.JU
ClI X"'.. ClI .... P '... C to> I'~ '.. ... .. .., ClI ... p........
: CU~"""" :a........~~I~'tl CIll,CCCXCU.....>
~ 10..... > en ~ ta QJ OJ.... ~ ta C CU en ~ w cu cu ~ QJ'~ 0 CU w
~UJC~~Q,lQJU > ~U ~taX'''''CCU~E ~a~u~Q,I
> 12 cu - ! IX U..... > '0 ) QJ Ql ~ UJ C QJ "-' 0'" U1 U C U}
... ClI 'tl :>... ,~ '0 ;:ClI 0 ClI"" C ClI ., c: ~.... ;: C ,;.., 'tl C' 0 ... III ~...... III
.a.J.a.JCUJ ....>QJQJ ~~OlU.....ta .u~~E~~ ~~ ~.
..!('ClIC,.....:r:>,,'" \1U>.,., C"U"UCC.c1ll ~ClI~
>~~o~u~ -~ 0 .~~~~no~.~xcmo~~ooc~
o (f) QJ CJ ..~ U) . 0 to a: H . w cr:. I iT IV'.-4 .Ie .... tLl ." :E '0"1 .lJ II( ........ ..... :E
c ~ <~ ~~-<C~~ '0"1~~.lJ QJ > ~~ ,~~~
55 ,:1$ 1..;~,s;If;;I~":~ t"I~~ I!;! 1:;1 ~'a: tj~.il
206
..
..
..
.
..
:: ~ ...... ...... I~~
II ... 0 00 00
II
II
" ...
II ~
II 0 010
II ... 0 00 00
II 0 :z:
II
II
I
II '"
II II ~ ~ I~ I.. i~ ..I..
II..
II 0 00
U .
II -a 'U '"
II · . '"
II'... "
II .... ~
II .1'4 I>> .
II '" > .
~~:~ 0 00 O~ 00
II
!!
I
II
II ~ ~ I~ I..
II
II '" 0 0 00
"
" '0
" 41
n UI
" ~
"
" > ' 0 00 00 00
" <ll 0
" p;:Z:
"
I!
I
" ... ...
II '" 0 00 0'" 00
II
" '0 I::'
" <ll
n ....
" ..
'...
'0' 0 00 ol~ 00
~.~
or
~ ~ i~ I" I..
.. 0 ;;. 00
. .
0 0 ...
'" 0 0 ...
" ~ .. ..
" CI
II ~.
" . 01"
n .. 0 00
" 0
" :z:
"
I
" ....
n .
,,0'0
" ,;
\I ... VI
" .8 " r< ~ 0 0 ,.,0 0
" 0
B tJ
i~
" Vl
CUI
U ~ I ~ C :0
Q ,~
~ Q
'" I,... ~ " > ..
> I~ :l
'-l :0 l~ '" E
Ul <ll III 0 I:l
C ~ '.. C>U I~a
I :J ,? '" Ul > '''''Ig Ul
<ll' c" "! ~ .c ..
'..... .S ,~ c: ~ '" I.. I'~ >
~ ~ N ";l~l~ ' .c
VI > ~:J; Ul
c: ,~ lJ1~IO+J ... 0 'C Ullll
... ~ Q.I ~ U Q.I ~ gl~1 ~ .~ ~
.... Vl.~:;:.
~ ~ o 'C .c+JlC:a . ~ ~
1 ... <ll O-~O
" "'0 '" X "-I~ u:::: "''''
...
o
'"
..
ID
...
.
.
'"
'"
o
o
.
..
...
o
.
'"
..
o
.
.
...
.
..
..
'"
...
'"
...
...
..
...
..
..
III
.
..
...
207
~
PAGE 1
citation
---A.2d----
(CITE AS: 1994 WL 406793
Rank(R)
R 2 OF 8
(PA. ))
Database
PA-CS-ALL
Mode
Page
NOTICE: THIS OPINION HAS NOT BEEN RELEASED FOR PUBLICA'rION IN THE PERMANENT LAW
REPORTS. UNTIL RELEASED, IT IS SUBJECT TO REVISION OR WITHDRAWAL.
patricia TERMINATO, Appellant,
v.
PENNSYLVANIA NATIONAL INSURANCE COMPANY, Appellee.
No. 47 W.D.1993.
supreme Court of Pennsylvania.
Al\g. 4, 1994.
OPINION
ZAPPALA.
*1 This appeal presents a question of first impression under the Motor
Vehicle Financial Responsibility Law ("MVFRL"), 75 Pa.C.S.A. s 1701 et seq.
The MVFRL was amended by the Act of February 7, 1990, P.L. 11 (Act 6). The
amendment established a PEER REVIEW plan for evaluating treatment, health care
services, products or accommodations provided to a person injured in an
automobile accident. The issue is whether an insured must seek reconsideration
of an adverse PEER REVIEW decision before initiating an action in cornmon pleas
court to recover medical benefits under an automobile insurance policy. We
hold that an insured is not required to request reconsideration of a PEER
REVIEW decision before proceeding to court.
The 1990 amendment to the MVFRL requires automobile insurers to contract
jointly or separately with a PEER REVIEW organization or "PRO". "PEER REVIEW
organization" or "PRO" is defined as "Any PEER REVIEW Organization with which
the Federal Health Care Financing Administration or the commonwealth contracts
for medical review of Medicare or medical assistance services, or any health
care review company, approved by the commissioner, that engages in PEER REVIEW
for the purpose of determining that medical and rehabilitation services' are
medically necessary and economically provided." 75 Pa.C.S.A. s 1702. The PRO
evaluates the medical treatment or services provided to an individual injured
in an automobile accident when the insurer challenges the reasonableness and
necessity of the treatment or service.
The PEER REVIEW process for a challenge by the insurer is set forth in 75
Pa.C.S.A. s 1797(b), which provides:
(b) PEER REVIEW plan for challenges to reasonableness and necessity of
treatment--
(1) PEER REVIEW plan.--Insurers shall contract jointly or separately with any
PEER REVIEW organization established for the purpose of evaluating treatment,
health care services, products or accommodations provided to any injured
person. Such evaluation shall be for the purpose af confirming that such
treatment, products, services or accommodations conform to the professional
standards of performance and are medically necessary. An insurer's challenge
must be made to a PRO within 90 days of the insurer's receipt of the provider's
bill for treatment or services or may be made at any time for continuing
treatment or services.
(2) PRO reconsideration--An insurer, provider
reconsideration by the PRO of the PRO'S initial
copr. (C) West 1994 No
or insured may
determination.
claim to orig.
request a
such a request
U. s. govt. works
--A.2d---- PAGE 2
CITE AS: 19'H lolL 4067')], *1 (PA,))
for reconsideration must be made within ]0 days of the PRO's initial
determination. If reconsideration is requested for the services of a physician
or other licensed health care professional, then the reviewing individual must
be, or the reviewing panel must include, an individual in the same specialty as
the individual subject to review.
(3) Pending determinations by PRO--If the insurer challenges within 30 days
of receipt of a bill for medical treatment or rehabilitative services, the
insurer need not pay the provider subject to the challenge until a
determination has been made by the PRO. The insured may not be billed for any
treatment, accommodations, products or services during the PEER REVIEW process.
*2 (4) Appeal to court--A provider of medical treatment or rehabilitative
services or merchandise or an insured may challenge before a court an insurer's
refusal to pay for past or future medical treatment or rehabilitative services
or merchandise, the reasonableness or necessity of which the insurer has not
challenged before a PRO. Conduct considered to be wanton shall be subject to a
payment of treble damages to the injured party.
(5) PRO determination in favor of provider or insured--If a PRO determines
that medical treatment or rehabilitative services or merchandise were medically
necessary, the insurer must pay to the provider the outstanding amount plus
interest at 12% per year on any amount withheld by the insurer pending PRO
review.
(6) Court determination in favor of provider or insured--If, pursuant to
paragraph (4), a court determines that medical treatment or rehabilitative
services or merchandise were medically necessary, the insurer must pay to the
provider the outstanding amount plus interest at 12%, as well as the costs of
the challenge and all attorney fees.
(7) Determination in favor of insurer--If it is determined by a PRO or court
that a provider has provided unnecessary medical treatment or rehabilitative
services or merchandise or that future provision of such treatment, services or
merchandise will be unnecessary, or both, the provider may not collect payment
for the medically unnecessary treatment, services or merchandise. If the
provider has collected such payment, it must return the amount paid plus
interest at 12% per year within 30 days. In no case does the faiiure of the
provider to return the payment, obligate the insured to assume responsibility
for payment for the treatment, services or merchandise.
On October 21, 1989, Appellant patricia Terminato was involved in an
automobile accident. At the time of the accident, she was insured under a
policy issued by the Appellee, Pennsylvania National Insurance Company
(Pennsylvania National). She submitted bills for medical treatment provided to
her for injuries sustained in the accident to the insurance company. Pursuant
to s 1797(b), the insurance company sUbmitted the claim to options, a PEER
REVIEW organization.
On January 21, 1991, Options sent a letter to the insurance company
summarizing the opinion of the PEER REVIEW physician who had reviewed
Terminato's claim. The letter indicated that the physician had concluded that
the medical treatment "was not directly and unequivocally related to her motor
vehicle accident." The letter quoted the physician as stating:
It is also my opinion that the work-up she received, that being cervical
spine x-rays, C7 of the cervical spine, her chemistry or laboratory studies and
the neurological evaluation were not medically necessary nor directly related
Copr. (C) West 1994 No claim to orig. U.S. govt. works
, .
.
11
'I
I,
,I
f
--A.2<;1--^-
(CITE AS: 1994 I-IL 40679], *2 (P,'\.))
to her auto accident. At the time oE the evaluation in October,
really had only subjective complaints oE some tenderness. There
positive objective Eindings including no neurological findings.
there was nothing to indicate that any specific treatment or any
diagnostic evaluation was indicated.
*J R. 1J. By letter dated February 4, 1991, the insurance company advised
Terminato's attorney that it would not be responsible for payment of the
medical bills because "they [were) not related to the automobile accident on
10-21-89. II R. 15.
On April 10, 1991, Terminato filed a complaint in the Washington County Court
of Common Pleas alleging that the insurance company was responsible for payment
of the medical bills arising out of the motor vehicle accident. The insurance
company filed an answer denying responsibility for payment of the bills because
the medical services provided to Terminato were unnecessary. The insurance
company subsequently filed a motion to dismiss the complaint, asserting that
Terminato had no standing to file suit in common pleas court because she had
not requested reconsideration of the initial PEER REVIEW determination.
The trial court granted the motion and dismissed the complaint on July 2J,
1991. The trial court concluded that under s 1797(b) (2), a request for
reconsideration of an initial PEER REVIEW decision must be made and disposed of
before the common pleas court may exercise jurisdiction to review the matter.
The trial court construed reconsideration of an adverse PEER REVIEW decision as
a mandatory administrative remedy that must be exhausted prior to obtaining
judicial review. Because Terminato did not seek reconsideration of Options'
determination, the court found that there had not been a final decision by the
PEER REVIEW organization that would enable it to exercise jurisdiction to
review the initial decision. The Superior Court affirmed, holding that once
the PEER REVIEW process is invoked, the parties must exhaust their statutory
remedies and seek reconsideration before an action may be brought in common
pleas cour.t.
The doctrine of exhaustion of administrative remedies
the PEER REVIEW procedure. A PEER REVIEW organization
agency, a court of record, or a tribunal authorized to
out of an automobile insurance policy.
A PRO is similar to an arbitration panel in that it is neither a court of
record nor an administrative agency. However, a PRO is significantly
dissimilar from an arbitration panel in that the latter is selected by both
arties at the time the dispute arises and the former is a body established by
state or local professional society and selected solely by the insurer before
he dispute arises.
Pennsylvania Chiropractic Federation v. Foster, 1J6 Pa.Cmwlth. 465, 478,
83 A.2d 844, 850 (1990).
Pennsylvania National asserts that the PRO process should be afforded a
tatutory construction consistent with the doctrine of exhaustion of remedies.
onceding that a PRO is not an administrative agency, Pennsylvania National
rgues that it performs a fact-finding function akin to the type of duties
ormally allotted to administrative agencies by the General Assembly.
erminato argues that the lower courts erred because reconsideration under s
797(b) (2) is not a statutorily defined remedy that must be exhausted before
ursuing relief in a court of law. She contends that the PEER REVIEW procedure
Copr. (C) West 1994 No claim to orig. U.S. govt. works
PAGE
3
the patient
were no
Certainly
other
has no application to
is not an administrative
resolve disputes arising
I
Ii
I
,
---A.2d---- PAGE 4
(CITE AS: 1994 i'lL 40679J, *J (PA.))
was not designed as a mandatory and exclusive method to resolve a disputed
claim of insurance coverage and, therefore, cannot be a statutory remedy that
requires exhaustion. Terminato emphasizes the language of s 1797(b)(2) that
"an insurer, provider or insured may request a reconsideration by the PRO of
the PRO's decision" to demonstrate that the reconsideration procedure is
permitted, rather than required.
*4 A PRO is authorized to determine whether the medical treatment provided
to an insured was reasonable and necessary. [FN1] The PEER REVIEW process is
designed to assist the insurer in determining whether to deny the claim of an
insured based upon an assessment of a medical professional. The PRO does not
accept and review conflicting medical evidence proffered by an insured or
provider as part of the process. Unlike an administrative agency, a PRO simply
lends its expertise to an insurer and has no statutory authority to resolve
disputes.
only the insurer participates in the PEER REVIEW process. This fact alone
rebuts Pennsylvania National's contention that a PRO should be entitled to the
judicial deference afforded to administrative agencies. The detachment and
neutrality required of a fact-finder is conspicuously absent in the contractual
relationShip between a PRO and an insurer.
A PRO is not a neutral body. While a PRO cannot be owned by or be otherwise
affiliated with the insurance company (31 Pa.Code s 68.3(d)), the law provides
for the insurance company to select the PRO that will review the claim. The
insurance company initially pays the PRO for its services. The insured plays
no role in the selection process. Obviously, PROs have a strong finar.cial
incentive to appear fair in the eyes of the insurance company. Otherwise, the
insurance company will take its business elsewhere. On the other hand, the PRO
is not concerned with how the insured views the PRO because this will not
affect its future business. Consequently, the PRO does not have the
characteristics of an independent body for which the Legislature would 5eek
jUdicial deference.
Harcourt v. General Accident Insurance Company, 419 Pa.Super. 155, 168, 615
A.2d 71, 78 (1992), citing Lehman v. state Farm Insurance companies, 140
P.L.J. 78, 82 (1992), allocatur denied --- Pa. ----, 627 A.2d 179 (1993).
Where the Legislature provides a statutory remedy that is mandatory and
exclusive, the general rule is that a court is without power to act. No
jurisdictional issue is presented, however, where a statutory remedy is
permissive or alternative. Lilian v. Commonwealth of Pennsylvania, 467 Pa.
14, 354 A.2d 250 (1976); DeLuca v. Buckeye Coal Company, 463 Pa. 513, 345
A.2d 637 (1975).
We explained the rationale behind the general rule in Feingold v. Bell of
Pennsylvania, 477 Pa. 1, 5, 383 A.2d 791, 793 (1977) in which we stated, "When
the Legislature has seen fit to enact a pervasive regulatory scheme and to
establish a governmental agency possessing expertise and broad regulatory and
remedial powers to administer that statutory scheme, a court should be
reluctant to interfere in those matters and disputes which were intended by the i
Legislature to be considered, at least initially, by the administrative
agency." The exhaustion of administrative remedies rule is not absolute
because the court may exercise jurisdiction even where an administrative remedy
exists when the remedy is inadequate or incomplete. "The mere existence of a
remedy does not dispose of the question of its adequacy." Id., 477 Pa. at
copr. (C) West 1994 No claim to orig. U.S. govt. works
,
.
.
.
.
.
.
.
.
"
.
---A.2d---- PAGE 5
(CITE AS: 199.1 \'1L 4067')), .,\ (PA,))
7, )8J A.2d at 794.
*5 In Feingold, an equity action was brought in common pleas court
seeking injunctive relief and monetary damages against Bell Telephone Company
arising from its failure to provide an operable telephonic recording service.
The issue was whether the appellant should have first exhausted his
administrative remedies under the Public Utility Law, 66 P.S. s 1101 et seq.,
before seeking a judiclal remedy. We held that the statutory authority granted
to the public Utility commission (PUC) did not include the power to award
damages to a private litigant for breach of contract by a public utility. We
concluded that the Legislature did not intend for the PUC to have such a power,
stating:
It is clear that the remedial and enforcement powers vested in the PUC by the
Public Utility Law were designed to allow the PUC to enforce its orders and
regulations but not to empower the PUC to award damages or to litigate a
private action for damages on behalf of a complainant. The rule requiring
exhaustion of administrative remedies is not intended to set up a procedural
obstacle to recovery; the rule should be applied only where the available
administrative remedies are adequate with respect to the alleged injury
sustained and the relief requested.
477 Pa. at 9-10, J8J A.2d at 795-96 (footnotes and citation deleted)
(emphasis added). Because the PUC lacked the power to resolve the breach of
contract claim of the appellant, the doctrine of exhaustion of administrative
remedies did not foreclose the equity action from proceeding in common ~leas
court.
section 1797(b) (2) of the MVFRL provides that "An insurer, provider or insured
may request a reconsideration by the PRO of the PRO's initial determination."
We must determine whether this provision is a mandatory and exclusive statutory
remedy that must be pursued before an insured may bring a civil action against
an insurer for nonpayment of medical benefits. We are guided by the principles
articulated in Feingold, which are also compelling in the context of a
statutory remedy.
Section 1797(b) does not empower a PRO to serve as a forum to resolve disputes
between an insured and insurer. The Legislature did not vest authority in a
PRO to entertain litigation arising out of the nonpayment of medical benefits.
Nor does the statutory provision provide a remedy for the nonpayment of medical
benef its.
It is only where the Legislature provides "a specific, exclusive,
constitutionally adequate method for the disposition of a particular kind of
dispute" that the statutory remedy must be exhausted before the courts may
adjudicate the dispute. West Homestead Borough school District v. Allegheny
County Board of School Directors, 440 Pa. 11J, 118, 269 A.2d 904, 907 (1970).
"A statutory remedy cannot be extended to cover matters not within its
scope." Lashe v. Northern York County School District, 52 Pa.Cmwlth. 541,
548, 417 A.2d 260, 264 (1980). "If the statute does not apply to a
controversy, it obviOUSly is not intended to be any remedy, much less an
exclusive remedy." Id.
*6 The PEER REVIEW process is a mechanism through which an insurer may seek
a professional assessment of the reasonableness and necessity of medical
treatment in order to independently determine whether a claim should be paid or
denied. It assists insurers in making an informed decision regarding a medical
copr. (C) West 1994 No claim to orig. U.s. govt. works
,
---A.2d-,--,- PAGE 6
(CITE AS: 1994 WL 406793, *6 (PA.))
claim by mandating review by a medical professional when the claim is
challenged by the insurer, Section 1797(b) is a cost containment provision, f
not an alternative dispute resolution procedure. This accounts for the lack 0\
involvement of the insured or provider in the process. The Legislature did noe
intend to impose reconsideration of the PRO determination as a precondition to
the judicial resolution of a private contractual dispute.
In the instant case, the superior Court relied in part upon a regulation
promulgated by the Insurance Commissioner which interpreted section 1797(b) to
allow for judicial review only after a reconsideration by a PRO has been made.
The regulation, formerly codified at 31 Pa.Code 68.2(c), provided that
"(t]he Insurance Department interprets Act 6 to permit upon final determination
by the PRO, an insurer, provider or insured may appeal the decision in, court." I
(FN2] Although an interpretation of a statute by an administrative agency is I
entitled to great weight, the interpretation may be disregarded if the 'i
interpretation is clearly erroneous or inconsistent with the statute under
which the regulation is promulgated. Wiley House v. Scanlon, 502 Pa. 228,
465 A.2d 995 (1983). To the extent that the regulation forecloses a party from
pursuing an action in court without having sought reconsideration of the PRO's
initial determination, the regulation is erroneous and may be disregarded.
(FN3]
The order of the Superior Court is reversed and the matter is remanded to the
common pleas court for further proceedings consistent with this opinion.
NIX, Chief Justice, files a Dissenting Opinion in which MONTEMURO, (FN*]
Senior Justice joins.
NIX, c.J., dissenting.
I dissent and would affirm on the basis of the well-reasoned opinion of the
Superior Court. senior Justice Montemuro joins in this dissenting opinion.
MONTEMURO, senior Justice, joins in this dissenting opinion.
fN1. Terminato has also challenged whether a PRO is authorized to review
treatment for its causal connection to an automobile accident. We need not
address the issue at this time, however, because our resolution of the
issue of exhaustion of statutory remedies necessitates a remand to the
common pleas court.
FN2. The regulation was subsequently revised, but was substantively
unchanged. The pertinent regulation now in effect provides, "Upon
determination of a reconsideration by a PRO, an insurer, provider or
insured may appeal the determination to the courts." 31 Fa.Code s
69.52(m).
FN3. It is unclear from a reading of the regulation itself whether the
Insurance commissioner specifically intended to construe Section 1797(b) as
precluding judicial review unless reconsideration was sought. It is
possible that the regulation was promulgated in response to earlier .
challenges to Section 1797(b) brought before the Commonwealth Court in
raising the issue of whether the statute entirely prohibited the challenge
Copr. (C) West 1994 No claim to orig. u.s. govt. works
,
~,
---A.2d"--- PAGE 7
(CITE AS: 1994 \'IL 406793, *6 (P!\,))
of a PRO's findings in court when the reasonableness or necessity of the
medical services has been challenged before a PRO. In Pennsylvania
Chiropractic Federation v. Foster, 136 Pa.Cmwlth. 465, 583 A.2d 844 (1990),
the PEER REVIEW process was challenged on the basis that the statute
violated the constitutional right to due process because the PRO's
decisions were not subject to review. The Insurance commissioner asserted
in argument on preliminary objections that the PRO decision was not
entitled to review because it is an "arbitration-like" proceeding. In the
alternative, the Insurance commissioner contended that the Commonwealth
Court could construe the statute as allowing judicial review by applying
the principle of construction that statutes are to be construed so as to
avoid unconstitutional results.
The commonwealth Court overruled the Insurance Commissioner's demurrer to
the due process challenge. The Court determined that it would be premature
at that stage of the litigation to impose any constitutionally based
construction on the statute because it had not been established with a
sufficient degree of certainty what the due process rights of the
pennsylvania chiropractic Federation would require in that context.
The commonwealth Court addressed the same constitutional challenge in its
subsequent decision in Pennsylvania Medical Providers Association, 149
Pa.Cmwlth. 203, 613 A.2d 51 (1992). The medical association had filed a
petition for review alleging that section 1797(b) of the MVFRL was
unconstitutional because it allowed a private, non-governmental PRO with
financial interests aligned with the insurer to control the amount paid to
a provider without providing for any judicial review if the charges are
denied. The commonwealth Court dismissed the petition for review,
concluding that the Insurance commissioner's regulation providing for an
appeal of a PRO's final determination to the courts, 31 Pa.Code s 69.52(m),
addressed the due process concern. The ruling regarding whether the
regulations are themselves vague or inconsistent with the MVFRL. 149
Pa.Cmwlth. at 207, 613 A.2d at 53, fn. 5.
FN* Mr. Justice Montemuro is sitting by designation as Senior Justice
pursuant to Judicial Assignment Docket No. 94 R1801, due to the
unavailability of Mr. Justice Larsen, see No. 127 Judicial Administration
Docket No.1, filed October 28, 1993.
END OF DOCUMENT
copr. (C) West 1994 No claim to orig. U.S. govt. works
. ,
'~
UHAB MEDICINE ASSOCIA1'Q
TRIlftlLB REHAB KIlDIC:nrz
5124 2. '1'1UNDLI!l ROAO
NECHANICSBORG, PI.. 17055
._~..
AMOUN'l' 011' PAGES:
, .
/s Ire..- ~
x2.tA-- c.~__-!~~
/ #'
,
'l'O1
FROM:
~ ./
./?trJn-,/
ANY QUESTIONS PLEASB CALL 717-795-7935
<
" .
AU\JUst 12, 1994
,
...
Anqino , Rovner
4503 N'. Pronto S1:reet.
Harrisburq, Pa. 17110
Attn: Joe Doria
R! I Richard HcCUrdy
Dear Sirsl
Per your reqQest, we are taxinq copiee ot all out.stan~inq bills
and a patient ledger tor Doot.or charqes and Therapy. The cost
1s $10.00 to tax and $ .50 a page.
Fee
$10.00
2.50
5.00
5 Pages CORP
10 Pages RMA
TOTAL
~(/ ,
~ I ~'llf(
Thank you.
"
'.
, "
1l\0..,')J'J.>
..
,~
.
RICHARD W. MCCURDY
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
vs.
NO.
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY,
Defendant
JURY TRIAL DEMANDED
DIRECTIONS FOR SHERIFF
please serve by deputized s3rvice Defendant STATE FARM MUTUAL
AUTOMOBILE INSURANCE COMPANY, at its place of business at 115
Limekiln Road, New Cumberland, York County, Pennsylvania, by
leaving a copy of the enclosed Complaint with an adult in charge at
that time.
Respectfully submitted,
ANGUlO
P.C.
v d L. Lutz, Esqu re
I.D. No. 35956
4503 North Front Street
Harrisburg, Pennsylvania 17110
(717) 238-6791
Counsel for Plaintiff
0... \ "It "v \ C\~
Dated:
::;)
''J
-:--.. \ -
I '-.) ''I
~
-.:J\
v:I.
, v-,
~
r\ 2
\x::,.......
-
~
-
..,.,..
en
.
.,
,'1
-t~
"N
-
a
...........
~
.')
"()
\'<}
6~6;
'-
"')
;. .J
'.'
e,.,
~
. "\. .
..
ROLF E, KROll, ESQUIRE
Po, Supr_ Court 1.0. No. 4nU
REYNOLDS & HAVAS
A Pro't..lonal Corpor.clon
101 Pine Streit
POlt O'fic. lox 932
H.rrl.burg, 'tnnaylvlnt. 11101'0932
T.l_phon'l
Fu.:
l71n 236,3200
l71n 236.6863
Attorney for Dtfendant:
STATE FARM INSURAHCE
RICHARD W. MCCURDY,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
v.
NO. 94-5457
:
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY, : CIVIL ACTION - LAW
Defen1ant : JURY TRIAL DEMANDED
PRAECIPE TO ENTER APPEARANCE
TO TilE PROTHONOTARY OF CUMBERLAND COUNTY:
Kindly enter my appearance as counsel for Defendant,
State Farm Mutual Automobile Insurance Company.
REYNOLDS & HAVAS
A Professional Corporation
DATE: /U/6/1((
?J~t//~/
ROLF E. <<ROLL
By:
Attorneys for Defendant,
STATE FARM INSURANCE
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that I have served a true and correct
copy of the foregoing document cpon all counsel and parties of
record this !~ ~ day of f.::...(' ~\ uG.-L\ 1994, by placing the
same in the United states First Class Mail, postage prepaid, at
Harrisburg, Pennsylvania, addressed as follows:
David L. Lutz, Esquire
4503 North Front street
Harrisburg, Pennsylvania 17110
,,~ ,,~-,
, '
I \ "._ '
\--./
- 2 -
SHERIFF'S RETURN
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
In the Court of Common Pleas of
Cumberland County, Pennsylvnaia
No. 94-5457 Civil Term
Complaint in Civil Action Law
and Notice
Richard W. McCurdy
VS
State Farm Mutual Automobile
Insurance Company
R. THOMAS KLINE, Sheriff, who being duly sworn according to law,
says. tha t he made
diligent search and inquiry for the within named
State Farm Mutual Automobile Insurance Company
defendant, to wit.
but was unable to locate
them
in his bailiwick. He therefore
deputized the sheriff
York
of
Complaint
County. Pennsylvania.
in Civil Action Law and Notice
to serve the within
On
October 3, 1994
, this office was in receipt of
the attached return from
York
County, Pennsylvania.
Sheriff's Costs.
Docke t ing
Out of County
Surcharge
York County
So answers.
Sworn and
14.00
5.00
2.00
29.44
$ 50.44 pd. by
subscribed to before me atty 10-3-94
'f . . ~. k "'
R. THOMAS KLINE. Sheriff
this
r>-
13-
day of (J!<lrt:.-..-
19 -l'f ,A.D.
',~"" . - l;' hI, ~'t,-, I..C/J(.f'
I I . I
Prothonotary
.i:1 Tne Court CT C:;mm~:-i
."-i
I'le:::::s
.
::r
.... It.
\..:J:'. . r." ~::.: =:1 == \,...:; W';;.,':',
:l-"'r:<'y I'/~-l''''
~ =.'.oJ _A' """"
Richard W. McCurdy
'is,
State Farm Mutual AutOloohile Insurance Company
~o. ~,1.:2.457.,S;ivil.Illiq1 :?---
:-iow, Septembe r 26, 1994
:9_ !, s:~~~ O? C~[3:=::'!'.A...'fD CO~~:-? ?~ :0
:==:,y d-;:uc ~
.., .- .
:n=-..::t ot
'fork
Cwu.::r,t ::Jr :.-::-:.::.: =.is .,V:::,
:.::.:.s ~u=:....--u :..:..,':7' -"'..:. 1t ~ ......~ ::d ~ "i
,-.. '
?!3.b:.~.
-::r
CT>
-
~,' ",:' -
,?"""'(.;'/ '/, "
- ~,.. .... _ _ J' I' _~.~ //
-~,;.;.~....~. ~ ..-"'~~ A ~1____~
.sD.e..~ :It c~J..:LCd CJW1rr. :1.
CJ'
..'
:>
~'..
c.,)'..
<oJ..
""
,.
..
c
=
'"""
'"
~
,
....
(l.,~ ...
Affida.vit Or
- .
:::e:"71~
1-
'"
....
'-'
V'>
September 28
o":!cc ,A
10:40
',c.
:9 94 -.
1=-,-::0:1
:-1ow,
~~ wi-":" Complaint & Notice
State Farm Autorrobile Insurance Company
',:pcn
.,
115 Limekiln Rd. , New Cumberland, 'fork County, PA
:;y =.:u:~ :.0 John A. Wilkowski, Claim Supervisor,
. true and attested
~
C':pr ct =~ 0::;'-,1 Complaint & Notice
,-
mo -::I";" Cowtl:O him
== .::::t::::S ~~::=t.
So :L:.>W='
"
""~"...~~,,-
'"-';;' oi York
Kenneth L. Markel
"-.'
. '-.c......___,~-~~
~ - -.
C"W1tT. ?'1.
5~== .J.!1C r~;"<t.-};e:i =-=c:-:
CCSTI
S?3,VIC
Sl4.00
13.44
2.00
=j 10;:6:t;;,?'./~mhn) :9::FI~8E~:: "':y~.
/ 1/;'1',/(; ) . . 1-,11 __ WA:*:lISW.AJ.frNf,'~otdryPlJblie
t tJtar y Ccunly. Pon:"llY""Jn:a
f U) COlMis!Jc.n E.xpt(~ "'arch 25 '11,' j
--~---_.
S 29.44
:- '---l
ROL' I, KROLL, ISQUIRI
Po. lupr... r.our' 1.0. NO. 47243
REYNOLDI I "AVAI
A Profe'llonel Corporlrlon
101 PI". St..o'
POI' Dfflco lox 932
"orrllbur;. Ponnlylvonl. 17108.0932
ToI.pIl0n0:
,...:
(717) 236.3200
171 n 236' 6&63
Auor..., for O.flndon"
STAll 'ARN INSURANCI
RICHARD W. MCCURDY,
Plaintift
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
v.
NO. 94-5457
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY, CIVIL ACTION - LAW
Defendant I JURY TRIAL DEMANDED
ORDER
AND NOW, this
day of
, 1994,
upon consideration of the Preliminary Objections ot State Farm
Mutual Automobile Insurance Company, to Plaintitf's Complaint, IT
IS NOW AND HEREBY ORDERED that Plaintiff's claim for attorn~ys
fees be stricken for failure to state a claim upon which relief
can he granted.
J.
ROL' E. KROLL, ESQUIRE
P., Supromo Court 1.0. No. 47243
REYNOLDS & HAVAS
A Prof...lonal Corpor.tlon
101 Pin. StrOlt
Po.t OfficI ao. 932
Hlrrt.burg. Penn.ylvlnll 17108,0932
To I ephona,
Fax I
I71n 236,3200
1717] 236,6863
AllorlllY for Dlfendant,
STATE 'ARM INSURANCE
RICHARD W. MCCURDY,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
v.
NO. 94-5457
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY,
Defendant
CIVIL ACTION - LAW
JURY TRIAL DEMANDED
PRELIMINARY OBJECTIONS OF DEFENDANT, STATE FARM
MUTUAL AUTOMOBILE INSURANCE COMPANY
TO PLAINTIFF'S COMPLAINT
AND NOW, comes Defendant, State Farm Mutual Automobile
Insurance Company ("Defendant"), by and through its counsel
Reynolds & Havas, a professional corporation, to preliminary
object to the Complaint of Plaintiff, Richard W. McCurdy
("Plaintiff"), as follows:
1. Plaintiff commenced this breach of contract action
against State Farm for the non-payment of certain medical
benefits that Plaintiff, a State Farm insured, contends are due
and owing under the terms of his policy with State Farm.
2. In Plaintiff's Complaint, Plaintiff alleges that in
addition to the payment of medical expenses, he is also entitled
to ans award of attorney fees pursuant to 61716 and 61798 of the
Pennsylvania Motor Vehicle Responsibility Law ("PMVFRL"), 75 Pa.
Cons. stat. 11701 ~ ~.
3. Recently, the superior Court of Pennsylvania has
expressly stated that if an insurer uses the Peer Review Process,
its potential liability is limited to the amount of the claim
plus interest. See Barnum v. State Farm, 430 Pa. Super. 488, 635
A.2d 155 (1993)
4. Plaintiff admits in his complaint that State Farm
utilized a Peer Review. Copies of the initial Peer Review and
the Reconsideration Report are attached hereto as Exhibits "A"
and "B" respectively. Accordingly, Plaintiff's claim must be
limited to the amount of the medical bills plus interest.
WHEREFORE, Defendant, state Farm Mutual Automobile Insurance
Company requests the this Honorable Court strike Plaintiff's
claims for attorneys fees for failure to state a claim upon which
relief can be granted.
Respectfully submitted,
REYNOLDS & HAVAS
A Professional corporation
I
() ./ / / / /"
By: ." />J,. " l-<fl-{
ROLF E. KROLL
I
Dated: / r!) / ::2 / c; c/
. '
Attorneys for Defendant,
STATE FARM INSURANCE
- 2 -
RICHARD W. MCCURDY
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - I~W
vs.
NO. 94-5457
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY,
Defendant
JURY TRIAL DEMANDED
,
,I
"
'I
I
;1
,
1
I
:1
:1
:i
I
:1
:i
!:
PLAINTIFF'S RESPONSE TO
DEFENDANT STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY'S
PRELIMINARY OBJECTIONS TO THE PLAINTIFF'S COMPLAINT
AND NOW, comes the Plaintiff, Richard McCurdy, by and through
counsel, Angino & Rovner, and responds to Defendant State Farm
Mutual Automobile Insurance Company (hereinafter referred to as
"State Farm") Preliminary objections to plaintiff's complaint:
1. Admitted.
2. Admitted.
3.
Denied.
In Barnum v. State Farm, 430 Pa. super.
II
"
:1
Ii
"
ii
'I
!;
'I
:1
i!
488, 635 A.2d 155 the superior Court in an opinion filed December
16, 1993 held that an insured could not file an action in Court
until reconsideration of an unreasonable peer review evaluation had
been sought and held that the bad faith statute, 42 Pa.C.S.A. S8371
applies to claims brought under the pennsylvania Motor Vehicle
Financial Responsibility Law, as long as such claims do not involve
first party benefits. However, the Pennsylvania supreme Court in
an opinion authored by Justice Zappala, decided August 4, 1994 in
Terminato v. pennsvlvania National Insurance Comoanv, No. 47 W.O.
Appeal Docket 1993 (August 4, 1994) held that an insured need not
seek reconsideration of an adverse peer review decision before
initiating an action in the Court of Common Pleas to recover
55060/HLS
i
1
medical benefits under an automobi~e insurance policy. Moreover,
it is specifically denied that state Farm's potential liability is
limited to the amount of the claim plus interest.
4. It is admitted that state Farm utilized the peer
review process but it is specifically denied that Plaintiff's claim
be limited to the amount of medical bills plus interest.
d
I
;1
'!
:1 dismiss the Defendant's Preliminary objections and order that the
Ii
II
"
!
WHEREFORE, Plaintiff requests this Honorable Court to
Defendant file an Answer.
Respectfully submitted,
ANGINO & ROVNER, P.C.
v d L. Lu z, Esquire
I.D. No. 35956
4503 North Front street
Harrisburg, Pennsylvania 17110
(717) 238-6791
Counsel for Plaintiff
Dated:
loll~ 1C1~
RICHARD W. MCCURDY
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
vs.
NO. 94-5457
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY,
Defendant
JURY TRIAL DEMANDED
CERTIFICATE OF SERVICE
I, MELINDA L. SPICHER, an employee of the law firm of Angino
& Rovner, P.C., do hereby certify that I am this day serving a true
and correct copy of PLAINTIFF'S RESPONSE TO DEFENDANT STATE FARM
MUTUAL AUTOMOBILE INSURANCE COMPANY'S PRELIMINARY OBJECTIONS TO THE
,i PLAINTIFF'S COMPLAINT upon all counsel of record via postage
II
'I
il
!I
il
'I
fi
"
'I
if
'I
II
,I
ii
'I
I,
prepaid first class United States mail addressed as follows:
Foulkrod, Reynolds & Havas
Rolf E. Kroll, Esquire
PO Box 932, 101 pine Street
Harrisburg, PA 17108-0932
Dated:
10 [ I z [qf
~V( ~[Le-)
MELINDA . SPICHER
,
I'
'I
i 546B5/MLS
!
,
"
l'I{AEClPE FOR LISTING C.\SE Fun ,\IH";U\llNT
I\lust be t)'pewritten and submitted in duplicate)
TO THE PROTHONOTARY/OF CU\lBERLAND COUNTY:
Pluse Ii,llhe within mailer fur Ihe next:
o I're.Trlal ArgulIlent CJurt
~ Argument Courl
----------------------------------------------------------------------
CAPTION OF CASE
(enUre caption must be I13led in full)
Richard W. McCurdy
(l'lainIiIT)
VS.
State Farm Mutual Automobile
Insurance Canpany
(Defendant)
VS.
~o.94-5457
Civil
19_
1. Slale mailer to be argued (i. e.. plainliffs illation for new trial.
defendanl"s demurrer to complaint. ete,): Preliminary Objections of Defendant,
State Farm Mutual Automobile Insurance Company to Plaintiff's Complaint
2. Identify counsel who will argue case:
(a) for piainliff: David Lutz, Esquire
(b) for ~efendant: Rolf Kroll, Esquire
3. I will notify 311 parries in wriling within IWo days Ihat this case has been
lisled for argumenl._
C~j fiT,
I AthJI ney lor
Plaintiff
Dated: 2-24-95
cc Rolf Kroll, Esquire
"""
...... ,.
.. < ~
= ;.t .:~
- -,
.... -:.,) "" ,
::r '", ,
N .'
",
-'
,-
'"
..,
....
..... .
.
ROLF B. KROLL, aSQUIRK
.a. supra.e Court I.D. No. 47~43
RKYlIOLDS , HAVAS
101 Pioe Street
Poat Office 80. 93~
Barriaburg, .eooayl.aoia 11108-093~
I
Telepbooe,
,...
[717 ) ~36-3~OO
[717 ) ~36-6863
AttorDe, for Defeadaot,
STAH FIUlIC INSUllAIICa
RICHARD W. MCCURDY,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 94-5457
v.
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY,
Defendant
CIVIL ACTION - LAW
JURY TRIAL DEMANDED
PRAI!lCIPI!I
Kindly withdraw state Farm's Preliminary Objections in
the above-captioned matter.
REYNOLDS & HAVAS
A P~of~ssional Corporation
DATEr:Al
I - /,
I' i f' /
(ROLF E. KROLL
Attorney J.D.
1(/-1/'
/ '//, /
~
BYI
#47243
Attorneys for Defendant,
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY
101 Pine Street
Post Office Box 932
Harrisburg, PA 17108-0932
(717) 236-3200
2912/MISC20
II
ROL' B. KROLL, BSQUIRB
Pa. Supreme Court 1.0. No. 4724~
RBYNOLDS , HAVAS
101 Plne street
Poat Offlce Box 932
Harrlaburg, penneylvanla 1710B-0932
Telephonel
'axl
[711] 236-3200
[711] 236-6B63
Attorney for Defendant.
STATB 'ARM INSURANCB COHPANY
v.
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
NO. 94-5457
RICHARD W. MCCURDY,
Plaintiff
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY,
Defendant
CIVIL ACTION - LAW
JURY TRIAL DEMANDED
ANSWER WITH NEW MATTER O~ DE~ENDANT
STATB ~ARM MUTUAL AUTOMOBILB INSURANCB COMPANY
TO PLAINTIFF'S COMPLAINT
AND NOW, comes Defendant, State Farm Mutual Automobile
Insurance company ("state Farm"), by and through its counsel
Reynolds & Havas, a professional corporation to answer the
complaint of Plaintiff, Richard W. McCurdy ("Plaintiff") as
follows:
1. Admitted.
2. Admitted.
3. Admitted in part and denied in part. It is admitted
that on May 29, 1993 an accident occurred. It is further
admitted that Mr. McCurdy sought and received treatment for
various injuries sustained in the aforementioned motor vehicle
accident. It is specifically denied that any of the care and
treatment at issue is reasonable and necessary and any statement
or implication to that effect contained in this paragraph of
Plaintiff's Complaint is specifically denied.
4. Admitted.
5. Admitted.
6. Denied. This allegation of Plaintiff's Complaint
refers to a writing which speaks for itself and is the best
evidence of all it contains and accordingly, no responsive
pleading to this paragraph of Plaintiff's complaint is required
and it is therefore denied.
7. Denied. It is specifically denied that any of the care
and treatment at issue is reasonable or necessary as defined by
Act 6 and any statement of implication to the contrary contained
in this paragraph of Plaintiff's Complaint is specifically
denied.
8. Denied. It is specifically denied that any of the care
and treatment at issue is reasonable or necessary as defined by
Act 6 and any statement of implication to the contrary contained
in this paragraph of Plaintiff's complaint is specifically
denied.
9. Denied. It is specifically denied that any of the care
and treatment at issue is reasonable or necessary as defined by
Act 6 and any statement of implication to the contrary contained
2
in this paragraph of Plaintiff'. Complaint is specifically
denied.
10. Denied. It is specifically denied that any of the care
and treatment at issue is reasonable or necessary as defined by
Act 6 and any statement of implication to the contrary contained
in this paragraph of Plaintiff's Complaint is specifically
denied.
11. Denied. The allegations of this paragraph of
Plaintiff's Complaint refer to writings which speak for
themselves and are the best evidence of all they contain. By way
of further answer, paragraphs 7 through 10 hereof are
incorporated herein by reference as if set forth in full.
12. Denied. state Farm has paid all reasonable and
necessary medical expenses in accordance with the terms and
conditions of Pennsylvania Law and the terms of state Farm's
policy.
COUNT I
RICHARD .. MCCURDY. Plaintiff
YL
STATE FARM MUTUAL AUTOMOBILB INSURANCB COMPANY. Defendant
13. Paragraphs 1 through 12 hereof are incorporated herein
by reference as if set forth in full.
14. Admitted.
3
15. Denied. The allegations of these paragraphs of
Plaintiff's Complaint refer to a writing which speaks for itself
and is the best evidence of all it contains.
16. Denied. The allegations of these paragraphs of
Pl~intiff's Complaint refer to a writing which speaks for itself
and is the best evidence of all it contains.
17. Denied. The allegations of these paragraphs of
plaintiff's Complaint refer to a writing which speaks for itself
and is the best evidence of all it contains.
18. Denied. It is specifically denied that state Farm had
an express or implied plan to intentionally cut-off benefits for
reasonable and necessary medical expenses and strict proof to the
contrary is demanded at trial.
19.
20. Denied. The allegations contained in this paragraph of
Plaintiff's Complaint constitute conclusions of law to which no
further pleading is required and they are therefore, denied.
21. Denied. The allegations contained in this paragraph of
Plaintiff's Complaint constitute conclusions of law to which no
further pleading is required and they are therefore, denied.
22. Denied. It is specifically denied that the
reconsideration report was performed by a "an agent of state
Farm." Moreover, it is specifically denied that the
4
reconsideration reviewer is selected by state Farm. To the
contrary, in accordance with the terms and conditions of
Pennsylvania Law, the reconsideration reviewer is selected by the
Commonwealth approved Peer Review Organization.
23. Denied. It is specifically denied that state Farm in
any way violated the terms and conditions of the Peer Review
statutes and the regulations. Moreover, it is specifically
denied that state Farm's lawful utilization of the statutorily
authorized Peer Review procese demonstrates any evidence of
"willful or wanton" conduct. To the contrary, state Farm
reasonably relied upon the reports from Commonwealth approved
Peer Review Organizations. Accordingly, Plaintiff's claims for
wanton and willful conduct are meritless and are incorrect as a
matter of fact and a matter of law.
24. Denied. It is specifically denied that state Farm's
lawful use of the Peer Review process constitutes any form of
"abuse". Moreover, State Farm's denial was reasonable under the
circumstances, Plaintiff was not forced to incur the services of
counsel but rather freely chose to do so in an effort to take
issue with state Farm's reasonable and lawful challenge to the
reasonableness and necessity of the care and treatment at issue.
25. Denied. Paragraph 24 hereof is incorporated herein by
reference as if set forth in full.
5
26. Denied. The allegations contained in this paragraph ot
plaintiff's Complaint constitute conclusions of law to which no
further pleading is required and they are therefore, denied as
being legally and factual incorrect.
27. Denied. This allegation is incorrect as a matter of
fact and a matter of law as Plaintiff cannot be personally
reasonable for the care and treatment at issue pursuant to 75 Pa.
Cons. stat. S1797(a).
WHEREFORB, Defendant, state Farm Mutual Automobile
Insurance company demands judgment in its favor and against
Plaintiff, Richard W. Mccurdy with costs of suit assessed to
Plaintiff.
NEW MATTER
1. The claims of Plaintiff are limited by the terms of the
Pennsylvania Motor Vehicle Financial Responsibility Law, 75 Pa.
C.S.A. section 1701 et sea. as amended by Act 6, April 15, 1990
("Act 6").
2. The bills in dispute were incurred after the effective
date of Act 6.
3. State Farm has paid $3,696.27 to various health care
providers on behalf of Richard w. McCurdy.
4. Thereafter, based upon the totality of the
6
circumstances including a lack of objective evidence of injury,
state Farm sought professional assistance in assessing the
reasonableness, necessity and relatedness of said injuries.
5. state Farm submitted plaintiff's bills to a
Commonwealth approved peer review organization established for
the purpose of evaluating treatment and health care services
provided to an injured person. state Farm is required by the
terms of the pennsylvania Motor Vehicle Financial Responsibility
Law to contract with such Commonwealth approved peer review
organizations for the purpose of assessing the reasonableness,
necessity and relatedness of treatment.
6. A Commonwealth approved peer review organization has
opined that the medical expenses at issue were neither reasonable
or necessary under the terms of the policy under Pennsylvania
law. On the basis of the peer reviews, state Farm has denied
treatment. A copy of the peer review is attached hereto as
Exhibit "A".
7. A Commonwealth approved peer review organization
performed reconsiderations of the findings rendered in the
initial peer reviews.
8. The report& of the reconsideration provided that none
of the care at issue was reasonable or necessary as it relates to
the motor vehicle accident in question.
7
9. A copy of the report of reconsideration is attached
hereto and made a part hereof as Exhibit "B".
10. On the basis of the reconsideration, state Farm
affirmed its denial of payment for the services rendered because
the benefits at issue were not recoverable under the terms of
state Farm's policy and the Motor Vehicle Financial
Responsibility Law as amended.
11. Plaintiff has not and cannot sustain damages as a
result of diminished payment or nonpayment of automobile accident
related bills. See, 75 Pa. Cons. Stat. section 1797(a).
12. Since Plaintiff, Richard W. McCurdy cannot sustain such
damages, he lacks standing to sue State Farm.
13. This Honorable Court lacks jurisdiction to entertain
this matter as State Farm performed a peer review and a
subsequent reconsideration of same in accordance with the terms
of the Pennsylvania Motor Vehicle Financial Responsibility Law.
Accordingly, Plaintiff's claims are barred by the terms of
section 1797(b)(4).
14. The amounts in dispute in this case represent charges
for excessive treatment which was neither reasonable nor
necessary within the meaning of the insurance policy in question
and/or the Motor Vehicle Financial Responsibility Law.
15. The charges at issue in this case and for which
8
insurance coverage is claimed trom answering Defendant are
unreasonable and unnecessary and/or are tor injuries and/or
conditions unr$lated to the accident in question.
16. The nature and extent ot injuries, d~mages and other
losses alleged by Plaintiff are denied.
17. Plaintiff's claim for insurance benefits is barred by
lack of consideration.
18. Any application of a legal rule so as to broaden
Defendant's liability under the insurance policy in question is
barred as a matter of equity.
19. Plaintiff is not entitled to recover attorney's fees
incurred in obtaining any insurance benefits which may ultimately
be paid by Defendant, since Defendant's withholding or of said
benefits was made in good faith and for reasonable cause.
20. Plaintiff has not pled any claims in respect to
Plaintiff, Richard W. McCurdy. Therefore, Plaintiff, Richard W.
McCurdy, has failed to state a claim for which relief can be
granted.
21. Plaintiff has failed to state a claim in whole or in
part upon which relief can be granted.
22. Plaintiff's claims are barred by the applicable statute
of Limitations.
WHBREPORE, D~fendant, state Farm Mutual Automobile Insurance
9
VDII'ICATIOM
I, DAVE COOK, hereby acknowledge that I am the
Claims Representative of STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY, the Defendant in this action; that I have
read tho foregoing pleading; and that the facts stated therein
are true and correct to the best of my knowledge, information
and belief.
I understand that any false statements herein are
made subject to penalties of 18 Pa.C.S.A. Section 4904,
relating to unsworn falsification to authorities.
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY
By: y;:j",i' (I.~l"~
DAVE COOK
CLAIMS REPRESENTATIVE
Date: 51;1 \K
Exhibit A
1';')
!
i
II
~
. ----~ - ,"
,
Associated Physiatrisls
of
Southern New Jersey
HMfRI r-, -J
.)/ IJFJ (,
, ,
,''"/,4,,, _
... ,< ,"
Fie -',-
CEIl/co.,,': :
..:~::, :.<....".'-~r.c:;. ',1 ::
May 9, 1994
Perspective Consulting, Inc.
Attn: Cheryl Cressman
672C Main st.
Harleysv~lle, Pa. 19438
Re: Claimant: Richar4 HCCUr4y
Insured: same
Claim I: 38-6540-958
D/I: 5/29/93
File I: 2681
~=':M'J= .~ .. :IOC. :: :
.r:I..',;; '.CL":'.'J. =.::
Dear Ms. Cressman:
I received your request to perform a comprehensive peer review
as to the reasonableness and necessity of treatment rendered by
Rehab Medicine Associates for office visits and physical therapy
for the dates of 8/24/93 through 3/27/94. I reviewed the
following records: a report of the accident; a letter from Dr.
Litton dated 6/10/93; a typed evaluation note and progress notes
dated 8/24/93 through 3/8/94 and initialed JJC; a report of an
electroneuromyograph dated 3/8/94 by Dr. Cho; physical therapy
and medication prescriptions written by Dr. Cho; health
insurance claim forms from Rehab Medicine Associates; a report
of an upper extremity arterial study and upper limb art~rial
imaging with spectrum analysis dated 8/27/93; a report of an MRI
of the cervical spine dated 10/6/93; an initial evaluation _
physical therapy by Terri Everhard, LPT dated 8/30/93; physical
therapy progress notes; a discharge summary - physical therapy
by Terri Everhard, LPT dated 11/2/93; an initial evaluation _
physical therapy by Rick Baer, LPT dated 12/7/93; physical
therapy progress notes dated 12/17/93 and 12/23/93; and health
insurance claim forms from Trindle Rehab Medicine.
In his letter dated 6/10/93, Dr. Litton stated that he saw the
patient in his office on 6/10/93 and that he had some neck pain
and tingling and a numb feeling on the left side of his neck
~adiating toward his left shoulder. Dr. Litton stated that he
felt that the patient strained his neck and that this strain,
from the automobile accident, was superimposed on degenerative
changes causing some nerve irritation. He stated that he did
Lourdes Regional
Rehabilitation Ceoler
Elmer Community Hospital Underwood Memorral Hospllal
MemOrial Hospital of
Burllnglon County
>'1' ..'
HARRISBUIW
t-IAI ::.' i~,-.
Page 2
He: Richard Mccurdy
5/9/94
RECEIVED
not feel that any treatment was needed at that time and felt
that the prognosis was good. He stated that he planned to see
Mr. McCurdy in 1 month.
In a progress dated 7/12/93, Dr. Litton stated that the
patient's' same symptoms were present and they were bothering
him. He stated that they are a nuisance and are not really
painful. He stated that he placed the patient on Relafen 1 gram
per day with food. In his letter dated 8/13/93, Dr. Litton
stated that oral anti-inflammatory medication, Relafen, did not
help the patient after taking it for 3 ~..eek. He stated that he
asked Mr. McCurdy to stop taking the medication and told him
that he felt that no other treatment would really be
beneficial. He stated that he expected that with passage of
time his symptoms would subside.
In a note dated 8/24/93, there was a statement that the patient
suffered a cervical strain as a result of an automobile accident
on 5/31/93. However, due to this muscle ligament strain with
associated muscle spasms, the patient was sUffering from TOS on
the left. He recommended daily PT for 10 treatments, Relafen
and a doppler study at Dr. Travisano's office. The note was
initialed JJC which I assume stands for Dr. Jay J. Cho.
I reviewed a report of an electroneuromyograph dated 3/B/94
which revealed acute radiculopathy in left C6 and
hyperirritability evidence in left C7 root. The report of the
MRI of the cervical spine dated 10/6/93 revealed degenerative
spondylosis with stenosis most marked at C5-6 but also involving
levels C4-5 and C6-7. There were minimal disc degenerative
changes at C3-C4. No disc herniations were noted.
The progress note dated 10/19/93 indicated that the patient was
doing generally better and that Zoloft or Flexoril were not
recommended at that time.
In the note dated 11/23/93 the patient was reported to not be
progressively recovering from the cervical radiculopathy. It
was recommended that the patient take Medrol tabs for a 30 day
program and hold the Relafen.
The 12/23/93 note indicated that the patient was doing a lot
better since he had been taking the Medrol.
HARRI~BI1Rr.
I"IAY 2 '.' ,:;;~
Page J
Re: Richar4 Kccur4y
5/9/94
RECEIVED
In the 2/1/94 progress note the patient was noted to have a
flare-up of left C6-7 radiculitis and increased muscle spasms.
In the 3/8/94 progress note it was reported that the patient had
an epidural steroid injection in the neck 1 week ago but
unfortun~tely was not any better. He was still taking Relafen
and Flexoril. There was a report that an EMG test was done on
that date which still showed acute radiculopathy at the C6 nerve
root and hyperirritability evidence at C7.
In the discharge summary - physical therapy dated 11/2/93, Ms.
Evernard indicated tnat the patiel.t had a Loadu.::tlo;'l 1:: m'Jscle
spasm but still had palpable upper trap spasm present at the
last treatment. There was a report that initially there was
decreased cervical range of motion but that at the time of
discharge cervical range of motion was within functional limits
except for lateral flexion to the left.
In my opinion, within a reasonable degree of medical certainty,
the initial physician evaluations and physical therapy
treatments appear to have been reasonable and necessary for
accident related symptomatology. However, it appears that the
patient received an extended course of physical therapy for what
appears to have been chiefly soft tissue injuries. In fact, Dr.
Litton did not feel that physical therapy treatments were
indicated in 6/93 or 8/93. The patient may have required the
initial evaluation and follow-up treatments by Dr. Cho from
8/24/93 through 12/23/93. He may have required physical therapy
treatments through 12/23/93. By this point in time, the patient
was already approximately 7 months post accident. Treatments
past 12/23/93 do not appear to have been reasonable or necessary
for accident related symptomatology based on the records
reviewed.
Please note that my opinions in this r.eport are based solely on
the records that I ha.."e reviewed. I did net have th~
opportunity to examine the patient.
Sincerely,
Ortw'ea~~0
Ja~ P. DiMarco, M.D.}
/cd
Exhibit B
,~\
"., ..,. vtJ
~. UNIVERSITY OF
PENNS YLV AN IA
MEDICAL CENTER
('urli, W. Silliman. \1.1l.
()Irl:t.:lor. Pl'nn Spinc Center
('hil'f. Clini..:al ~lu"t.:uJU'ikclclal Program
..\,'.Iolant Pnlfcssur of Rchabllilulion
Depanmem III' Rehabililuliun Medicine
University of Pennsylvania School of Medicine
Hospilalof the UmvcrsllY of Pennsylvania
July 25,1994
Cheryl Cressman
Perspective Consulting,lnc.
672 C Main Street
Harleysville, PA 19438
HARHISE?UPG
RE:
Claimant:
Insured:
Claim #:
D/I:
File #:
Richard McCurdy
Same
38~413-958
3/29/93
2681
AUG 1 5 1994
RE"":i:'IVED
Dear Ms. Cressman:
Per your request I am completing a reconsideration of a comprehensive peer review as provided under
ACT 6 of the Motor Vehicle Responsibility law as to the reasonableness and necessity of treatment
rendered by Rehab Medicine Associates for office visits of 8/24/93 through 3/27/94.
The records submitted include a claimed insurance form received on 6/313/93; medical reports from
Pennsylvania Orthopedics dated 6/10/93 and 8/13/93; records of Jay J. Cho, MD of 8/24/93 through
4/13/94; nerve conduction study and EMG of 3/8/94 compleled by Dr. Olo; prescriptions from
Rehabilitation Medical Associales for physical therapy to be provided daily for two weeks dated
~124/93, Relafen 750 mg bid on 8124/93; Doppler study 10 work up thoracic ouUet syndrome dated
~/24/93; a refill of a Relaten prescription; an MRI requesl of the cervical spine dated 9/313/93; another
physical therapy prescription of 9/30/93; Flexeril of 9/313/93; repeat electrodiagnostic study of
9/30/93; Medrol schedule of a 30 day duration beginning on 11/23/93; repeat physical therapy
prescription and reordering of medications; a request for .ln0ther EMG on 2/28/94; a request for an
epidural injection on 212~/94; Soma daled 4/13/94; Darvocet dated 4113/93; Prozac dated 3/31/94;
Daypro dated 3/31/94; corroborative bill sheets; records provided by the law offices of Angino and
Romer; a discharge summary of 4/ 1/94 from Dr. Cho was provided; an MFJ report of 10/6/93;
physical therapy notes from 8/30/93 throuHh 4/26/94; records from Seidle Memorial Hospi~11 of
3/17/94 through 4/1/94; and a letter d.lted 7/5/94 frum Dr. Choto David lutz, Esquire.
According to the records submitted Mr. RichMd McCurdy was 51 years old when he presenled 10 Jason
Lillon. 1'.10 with a chief complaint of "tingling and a numb feeling" in the left cervical region with
r.ldiation tu the shoulder". These symptoms began after.1 motor vehicle accident which transpired on
5/29/93. The patient denied any symptomatology below his shoulder. It was Dr. Litton's Impression
this patient sustained a "strain", He felt there were underlying degenerative changes and possibly
nerve irritation. He felt the patient was best served with a one month follow up as he expected these
symplorns to spontaneo\lsly resolve. Dr. Litton's nole of 7/12/93 indicales the patient has "his same
symploms" and "they are a nuisance". However, these symptoms are "not really painful". Dr. Litton
recommended the patient utilize Relafen and return in one month. The patient ulilized this
medication for three weeks and said il did nol provide him symplom reduction. As of 8/19/93 it was
Dr. Lillon's firm impression this p.llient's symplorThltology would resolve without specific
Intervention, Oy August 1993 the p,lIient came under the care of j.,y J. Cho, MO of Rehabilitation
\ledicine Associales. Dr, Cho inlll..llv considered this p.llient 10 e'perience symptom.llolob'Y of
Ground Flour White Buddlnll . \400 Sprul.:C StI~(1 . PhlIJJclphlJ. (1\ 11)ll)4..a::~J . !15._UI).~lklH' FAX; ! 15..1..lIJ.tmfl!
I \/l. '!i'-n) ;j P- ',','lll \ 1,\11 Iii \; Il/)'\,:'I/
f.' l(aI1'u,1 Md,:ufllv
r,l~" :
lhorJcic oullet syndrome, Acwrdin~ to Dr. Cho's noles this p.llient descnbl'll nl'Ck p.lin ..Ion~ with
numbness which r.ldiJtl'lllnlo the left h.lnd. He does not describe which portion of the Idt hand this
numbness is perceived. A diagnosis of thoracic outlet syndrome apparently was predic.lted upon a
positive Ads<m's maneunr, nl!gative examination for cervical radiculitis, and positive Doppler
studies. Consequently an exhaustive physical therapy regime concentrating on passive modalities,
anti-inflammatory agents including Relafen and Medrol, muscle relaxants including Soma and
Flexeril, and narcotics including Darvocet was prescribed. The patient demonstrated no significant
improvement. By 9/30/93 Dr. 010 decided to pursue electrodlagnostic testing to rule out any nerve
entrapment such as "carpaltl!nnel syndrome". He also recommended MRlto "rule out stenosis". It was
at that time Zoloft was started. The MRl demonstrated a cervical spondylosis extending from C4 to
C7. On 10/18/93 Dr. Cho states this patient has continued decrement of sensation at the left C6
distribution however this Is in connict of the Initial evaluation in which "pin prick exam in the upper
extremity Is intact". Further, the exam of 9/30/93 st.ltes "neurology exams are Intact". There were no
sensory deficits identified on 9/30/93. In Ie res tingly enough, after the patient underwent an MRl
which demonstrated underlying degenerative changes in the cervical spine and had a reportedly
positive EMG, the exam suddenly demonstrates sensory deficits. The first mention of a sensory deficit
in the C6 distribution was on 10/18/93, a full five months after the motor vehicle accident. On
11/23/93 Dr. Cho uncovers weakness of the "left shoulder girdle". It was in October and November of
1993 that Dr. Cho was treallng this patient for a cervical radiculitis. A 30 day dose of Medrol was
provided along with a therapeutic exercise regime. By his return visit of 12123/93 the patient had
demonstrated improvement. Due 10 the patient's continued symptomatology it was deemed by Dr. 010
he required an inpatient admission to Seidle Memorial Hospital. While an inpatient an evaluation
by an orthopedic surgeon was ""lde. He suggested a discectomy and fusion. Another EMG was
completed. It was also noted the patient now had a depressed left triceps reflex but his shoulder
slrength was intact. It should be noled an EMG was completed on 3/8/94 and this demons trolled "acute
radiculopathy in the left C6 and hyper irritability in left (7". An MRI of 10/6/93 demonstrated
degenerative spondylosis extending from C4 through C7.
During most of the time this patient was treated by Dr. 010 physical therapy was provided. There
was concentration on passive modalities although some exercises were prescribed.
HARRlS8UR
The following determination is based upon a reasonable degree of medical certainty, is constructed
from the reports provided, and meets the standard of practice in this community.
AUG 1 5 199
RECEiVE:
Mr. McCurdy was involved In a molar vehicle accident on 5/29/93. His initial care was rendered by
Dr. George Litton on 6/10/93. At that time, approximately 11 days after the event, the patient had no
complaints of symptomalology below the shoulder. In fact, Ihe patient had minimal complaints as he
stated thl! sensations he was experiencing was "really not painful". His one month follow up,
approximately five and a half weeks after the inciting event demonstrated nonnal neuroloboical
tesling and there were no compl.linlS of symptoms below the shoulder. Based on this clearly
documented medical information it is inconceivable 10 ascribe this patient's left arm symptoms to be a
consequence of the molor vehicle accident. The patient's arm complainlS were not articulated until. at
the eJrliest, a full six weeks afll!r the inciting event. This patient would have had to complain of left
.lrm symptomatology within the first seven to ten days of the inciting event. Let me be more
instructive. The patient had a cervical MR1 which demonslrated cervical spondylosis. The
combination of a flexion and exlension motion to the cervical spine, underlying tightness of the
cervical canal, the knoYon anatomic tethering of the cervical roots, could have led to a traction
radiculitits. This is an injury which dot!s occur after motor vehicle accidenlS. However, the symptoms
present early on, not six or more weeks after the inciting event. This patient had to have sustained a
second injury unrelated to the motor vehicle accident to complain of numbness in the left arm.
As Dr. Litton indicated in his inilial report this patient had some neck pain and a sense of numbness
.1lld tingling in the left paracervical area. The patient did not require physical therapy nor the
r,' i<t1,t'I.wl .'-I,\.II(IIV
;'.1~1" \
exh.lUstivt! (Me rendered by Dr, Cho .IS it rt!I,lIed to the symploms evolving from the motor vehicle
accident.
In conclusion, the inHial evaluation by Dr. Cho was medically reasonable and medically necessary.
However, Dr. Cho should have explaim>d to this patient his current symptomatology was not related
to his motor vehicle accident.
With regard to the care rendered (or this patient's left arm symptoms it was, (or the most part,
medically unnecessary and medically unreasonable. Let me be specific. Dr. Cho recommended this
patient undergo an eli!Ctrodiagnostic study to work up carpal tunnel syndrome v. cervical
radiculopathy. This would mean the patient had complaints of parasthesia or numbness in the left
thumb, index or long fingers. Carpal tunnel syndrome does not provide symptoms in the ring or fifth
dib';t. Since Dr. Cho requested the patient have d workup (or carpal tunnel syndrome it is
inconceivable he would request a work up for thoracic outlet syndrome since this disorder effects the
lower trunk of the brachial plexus giving rise to symptoms in the ring and small finger. Under such a
scenario requesting Doppler studies was not medically necessary nor medically appropriate.
Furthermore, the extended physical therapy (or thoracic outlet syndrome was not medically
necessary nor medically justified.
The request for an MRI and EMG, when it was finally made, was medically necessary and medically
justified. This patient apparently had symptoms in the left thumb and index finger which had not
been resolving. An MRI could demonstrate pathology consistent with the patient's symptoms. Once
the diagnosis of a left C6 and possibly C7 radiculiUs is made then the (ollowing care is rendered:
The patient is placed in a soft cotlar, participates in aggressive reactivation physical therapy
program, has some cervical traction applied, and utilizes anti-inflammatory agents. If there is no
improvement over a two to three week interval then oral steroids can be employed. If oral steroids,
over a seven to ten day interval. fails to provided symptom reduction then a cervical s..lective nerve
root block or cervical epidural can be performed. A sequence of three to four of thc'Se injections can be
compleled. If a sleroid effect is achieved and the patient fails to improve than a foraminolomy may
be indicaled. It is conceivable a discectomy and fusion would be recommended depending upon the
patient's symptoms, examination, and imaging studies. You will note in the aforementioned scenario
only one EMG is necessary. More than one EMG is medically unnecessary and medically unjustified.
An inpatient admission is medically unnecessary and medically unjustified. The care for cervical
radiculitis, and even cervical radiculopathy, requires an outpatient venue,
Lei me reiterate, the treatment rendered by Dr. Cho was for a medical disorder which was causally
not relaled to the motor vehicle accident of 5/29/93.
If you have a y question concerning this reconsideration please contact me at your convenience.
HARFl:~8URG
CWS/slf
AUG 1 5 1994
RECEIVED
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that I served a true and correct
copy of the foregoing ANSWER WITH NEW MATTER OF DEFENDANT, STATE
FARM MUTUAL
AUTOMOBILE INSURANCE COMPANY TO ~tAINTIFF'S
Ol~
u~on counsel of record this -~) day of May,
1995,
COMPLAINT,
by placing the same in the united states Mail, first-class mail,
postage prepaid at Harrisburg, Pennsylvania, addressed as
follows:
David L. Lutz, Esquire
Angino & Rovner, P.C.
4503 North Front Street
Harrisburg, Pennsylvania
(Attorney for plaintiff)
17110
corporatr
"-- / /
.
ARKANS I, SECRETARY
By: /
S'rA Y L.
RICHARD W. MCCURDY
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
.
.
VS.
: NO. 94-5457
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY,
Defendant
JURY TRIAL DEMANDED
PLAINTIFF'S REPLY TO DEFENDANT'S NEW MATTER
1. through 22. Denied. Defendant State Farm has failed to set
forth any factual allegations that require plaintiff to admit
and/or deny said allegations inasmuch as all of the allegations in
the Defendant's New Matter are all conclusions of law to which no
response is necessary.
WHEREFORE, Plaintiff demands that State Farm'S New Matter be
dismissed.
---
Date: l/ - Lr fl.)
ANGINO ~\. P.C.
~L' Lu,"
I.D. #35956
4503 N. Front Street
Harrisburg, PA 17110
(717) 238-6791
Counsel for Plaintiff
,I
;f 6971J/HTG
iI
I
,.
CERTIFICATE OF SERVICE
I, Mary T. Geraets, an employee of the law firm of Angino ,
Rovner, P.C., do hereby certify that I am this day serving a true
and correct copy of PLAINTIFF'S REPLY TO DEFENDANT'S NEW MATTER
upon all counsel of record via postage prepaid first class United
States mail addressed as follows:
Rolf E. Kroll, Esquire
Reynolds & Havas
101 pine street, P.O. Box 932
Harrisburg, PA 17108-0932
\"'iJ
Mary T.
Dated: l, -I..' - LJ \
\
1
\
-
..,..
.... -~
- ...
... .
or.:- " "
'- '-' --
a
..... .,
C""), ,
.,
,,-
"r
r- :11....
;t:"
% '- :.-'
::0 .-, '-
-.,