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Home My WebLink About95-03128 . IN '1'111: ('IIIIH I' Ill' l'()rHllHJ 1'!.I';^~i ,'llfllli:IlI.AtW ,'{}"IHY. I'I:NN::YI.VM ^ (' I V 1 I. ^,''[' 1 illl IJ\\j Nil. IIAI(H I :;llll1lfj HI1~:I' I TAl" I'IJ, 1 NTIII' v IJtltJAI.JJ h', :;IIEI'P^1t1l dlld ^ t-l Y I'. tj II J: I' P f\ I~ 11, 1l1:1'I:NIiMH:: '..\ " , - . -. ~ L <'-J I.. C {} fl I' I. ^ N 'I' '. ~. \ 4:' '" , . .(,: , . \. ..\.} ~, t~ ~.1 t11 \ " ARTHlHl A KlJSIC ^II()I.NI Y ^' I ^W ,1/1111 j,;.'" M,11 )1,,.,, I''> Ii, ...illll! HII!'I;! II' :Ii' I I ',If" \ ~'~i, Ii, 1/1 " I! ,111, 1/1/,1.1 'I.l I IIARRIQnURO 1I0SPlorAL, Plaintiff IN THE COURT OF COMMON PLEAS L~~ COUNTY PENNSYLVANIA V. DONA/.D W. SIIEPI'^,ID and AMY C. SIIEPPARD, Defendanfi CIVIL ACTION - LAW NO. IJOTICIA Le hall demand ado a usted ell la corte. 51 usted Qu1ere detenderse de eslas demandas expuestas en 1as paglllas 81gulente8. usted tlene vlente (20) Jlas de plaza al partir presentar una aparlenCla eSCrlt.a 0 en persona 0 par abogado Y archlvar en 1a corte en forma Hscrlta SUS defensas 0 6US obJeclones alas demanda8 en contra de su persona. 5ea aVlsado que Sl usted 110 se def1ende. la corte tomara medldas y puede entra" una orden contra usted s1n previa aV1SO Q notlflcnclon y par CUalQUler Queja 0 SIlVio Que 88 pedido ell 1/\ pe1.1clon (Je demanda. Usted pUHde perder dlnero 0 IU8 propledade~ 0 otros derechos lmportantes para u8ted. LLEVE ESTA DEMAtWA A UN AB,)OADO INMEDIATAMENTE. 51 NO TIEIIE ABOClAOO 0 51 NO TIEIlE EL DINERO 5UFICIENTE DE PAOAR TAL SERVICIO. VAYA EN PERSONA U LLAME POR TELEFONO A LA oncINA CUYA DIRECCION SE ENCUENTRA ESCRIT_ ABAJO PARA AVERIGUAR DONDE 5U PUEDE CONSEGUIR ASI5TENCIA LEGAL' ~esDectfully submitted: LAWYER REFERRAl, Cumberland Co. Court ^dmln. Fourth ~'loor One Courthouse Squaro Carlisle, PA 1701]-J]87 (717) 240-6200 y:-.-:/ ARTHUR .US 4201 (rums HIll 1'05t C.f flee Bo~ 'Htrr ls11lJro. PA 1717) f,40-~610 S,'PREME (OllPT Nil. 07207 ^TTIIR~I~Y FOil PLAINTIFF ESQUIRE Road 67015 17112 [lHerJ ,It! \II, DONALD .. ..n'UD an4 AMY O. ..."UD, Defendant. MO. I/)"_J I,) I' (.'"".1 T-t......... V. I I I I I I I I 1M THE COURT or COKMON .LIAS CUMBIRLlUfD COUNTY, .IIlIfSYLVAMIA CIVIL ACTION - LAW RAalI..URQ HO.'ITAL, 'laintiff COM P L A I N T AND NOW comes Plaintiff by and through its attorney, Arthur A. Kusic, Esquire, and respectfully represents the following I 1. Plaintiff, HARRISBURG HOSPITAL, is a hospital faoility organized and existing under the laws of the commonwealth of pennsylvania located at South Front street, Harrisburg, Dauphin county, Pennsylvania. 2. Defendants, DONALD W. SHEPPARD and AMY C. SHEPPARD are adult married individuals residing at 3824 Mountain View Road, Mechanicsburg, Cumberland county, Pennsylvania 17055. 3. On or about June 21, 1994 through June 29, 1994, plaintiff, at the request of the Defendant Donald W. Sheppard, did provide health care services to said Defendant. 4. plaintiff in good faith provided the necessary health care services to the Defendant, Donald W. Sheppard and thereafter billed Defendants its usual and customary charges for the services rendered. As evidence thereof, a copies of the billing for services rendered to Defendant, Donald W. Sheppard are attached hereto, made 8 part hereof and marked Exhibit "A". , , 5. Plaintiff did credit Defendants' account with all payments made on the account and there now remains a balance due and owing of $21,749.96. 6. Plaintiff avers that the amount due and owing does not exoeed the jurisdictional amount requiring arbitration referral by local rule. COUNT I. (Plaintiff v. Donald W. Sheppard) (Quantum meruit) 7. Plaintiff inoorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 6. 8. plaintiff did render health oare servioe8 to Defendant with the reasonable expeotation that payment for suoh servioes would be made by the party benefitted. 9. Should Defendant not be required to pay for the balanoe due for the servioes rendered, Defendant would be unjustly enriohed at Plaintiff's expense. 10. Plaintiff avers that the amount due and owing doe. not exoeed the jurisdictional amount requiring arbitration referral by looal rule. WHEREFORE, plaintiff pray your Honorable Court to enter JUdgment in its favor and again8t Defendant Donald W. Sheppard 1n the amount of $21,749.96, along with interest at the rate of 6' per annum and the costs of this proceeding. COUNT II. (plaintiff v. Amy C. Sheppard) (Dootrine of neoessaries) 11. Plaintiff inoorporatss herein by referenoe thereto the averments hereinabove set forth in paragraphs 1 through 10. 12. plaintiff believes and therefore avers that the health oare servioes rendered, upon request, to Defendant Donald W. Sheppard, husband of the Defendant Amy C. Sheppard, were neo....ry for his benefit and welfare. 13. plaintiff believes and therefore avers that pursuant to the "dootrine of neoessaries", Defendant Amy c. Sheppard, a. .pou.. of the reoipient of health oare services, is liable to Pl.intiff for the balance due. 14. Should Defendant Amy c. sheppard not be held liable to Pl.intiff for payment of services rendered her husband, she would be unjustly enriched as the services were neoessary to b.nefit the health and welfare of her spouse and their marital union. 15. plaintiff has made demands for payment upon Dsfendant, whioh demands remain unheeded. 16. Plaintiff avers that the amount due and owing do.s not exceed the juriSdictional amount requiring arbitration referral by looal rule. WHEREFORE/ Plaintiff prays your Honorable court to enter Judgment in its favor and against Defendant Amy c. Sheppard in the amount of $21/749.96 along with interest at the rate of 6' per annum and the costs of this proceeding. COUNT II 1. (Plaintiff v. Amy C. Sheppard) (statute) 17. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 16. 18, Pursuant to 23 Pa.C.S.A. 4321/ married persons are liable for the support of each other. 19. Pursuant to 23 Pa.C.S.A. 4102/ where debts are contraoted for necessaries by either spouse/ a oreditor may institute suit against the husband and wife for the price of the necessariee. 20. Plaintiff did render necessary health care services to Defendant Donald W. Sheppard with the reasonable expeotation that such services would be paid for by the persons benefitted, whioh in the instant case include said Defendant and his spouse, Defendant Amy C. Sheppard as partner in the marital union. 21. Plaintiff hae made demands for payment upon Defendant, which demands remain unheeded. 22. Plaintiff avers that the amount due and owing doeB not exceed the jurisdiotional amount requiring arbitration referral by local rule. WHEREFORE, Plaintiff prays your Honorable Court to enter JUdgment in its favor and against Defendant Amy C. Sheppard in the amount of $21,749.96 along with interest at the rate of 6% per annum and the costs of this proceeding. COUNT IV. (Plaintiff v. Donald W. Sheppard & Amy C. Sheppard) (Total) 23. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 42. 24. Plaintiff has made demands for payment upon the Defendants for the balance due of $21,749.96, which demands remain unheeded. 25. Plaintiff avers that the amount due and owing does not exceed the jurisdiotional amount requiring arbitration referral by local ruls. WHEREFORE, Plaintiff prays your Honorable Court to enter Judgment in its favor and against Defendants in the amount of $21,749.96 along with interest at the rate of 6% per annum and the cost. of this proceeding. DATED I RESPECTF~L0~~~~ ArthUr ~ ,<"~u~ i~, E q~~-~e 4201 CrumB Mill Road Post Office Box 11585 Harrisburg, PA 17108 (717) 540-5610 supreme Court No. 07207 Attorney for the Plaintiff V. I I I I I I I I I. tHI COURT or CONNOIl .LIAI CUIIBIRLAlD COUIlTY, ..IIIlIYLVAlIA CIVIL ACTIO. - LA. HAlaI..URG HOS'ITAL, 1'laintiff DOIlALD .. .......0 and AllY C. .......0, Defendant. .0. V I R I r I CAT I 0 I I, HARRY PARK , the SUPERVISOR. OF I ! I , ! i ; ! I I i , I I CREDIT & COLLECTION of HARRISBURG HOSPITAL verify that the statements made in the COMPLAINT are true and oorreot and that I am authorized to make this Verifioation on behalf of HARRISBURG HOSPITAL. I understand that false statements herein are subjeot to the penalties of 18 Pa. C. S. Seotion 4904, relating to unsworn falsification to authority. HARRISBURG HOSPITAL BYI {? Tf~";1uPERVI SOR DATEI 5/18/95 '. ~ . " (lXlII II] 'I' "II" -TY,iO~'B'\..i. i Di.l,...aDA'E l B~i.''''QJll:RCO - DisCII I[ 05 :01 :95 J 00 :,00 'I 05 ',01 INP. " ~__u_.___ _ _ __ " BE"-Eli'ITI!I AIO-O 1""iJR.A~CE CO'wER.AaE -:::-1"~~ -COK!iERC fie A~Z YEI P-iQ ~--_... --- - "e GARHANS I' , 'Af~1 QROL.P ~a POLe,,"'o I NGOI8758lJA I --5- r' , L L DONALD W 3824 HTN HECII PA SIIEI'IIERD VIEW RD 17055 IIARRISBURG 1I0SPITAL IIARRISBURG, PA. 17101 717 - 782-3680 T o L_ J 942816080 SIIEPIIERD DONALll W I t~~t;~21~i:~7E;;:::J;6i~~~4L___~R.S. 23'O~~T:~~30N DATt OESCRIPTIO,", TOTAi. CHARGE 1 ST CQ'iEF\AOE ....0 COVERAGE 3RO CovERAGE AUOUNT .___+_._________ - ~._-- --,--- _.. - .....- -'1--'-' ~--,- ------, 06,21 PRE-CERTIFICATION 00 27,00 27,00 06 :21 ROOH CCU I 1610: 00 1610,00 06 '21 EHER HED V I S IT III 02 88, 00 88' 00 06 :21 EHER CARDIAC HONITOR 02 27: 50 27: 50 06 '21 02 SET-UP - E.D. 02 16' 50 16' 50 06 :21 IV CATHETER 02 7: 50 7: 50 06 '21 IlEHATEST 02 6' 50 6' 50 06 : 21 I V ADK-EO 02 13: 00 13: 00 06 :21 ED YlSn IV 02 143: 00 143: 00 06,21 !VAC SET-ED 02 148, 50 148, 50 06 :21 PHOSPHOROUS 10 31: 00 31: 00 06 '21 CALCIUM STAT 10 36' 50 36 50 06 :21 HAGNESIUM STAT 10 36: 50 36: 50 06'21 CDC AUTO OIFF STAT 10 3000 30' 00 06:21 PTT STAT 10 28: 00 28: 00 06 :21 PRO-TIME STAT 10 28' 00 28 00 06,21 LOll SERUH/URINE 10 31: 00 31: 00 06 :21 LOH ISOENZ 10 56: 00 56: 00 06 '21 BUN STAT 10 27 00 27> 00 06 :21 CK-HB STAT 10 61: 50 61: 50 06 '21 CPK STAT 10 36 50 36' 50 06:21 CREATININE STAT 10 34: 50 34: 50 06 '21 ELECTROLYTES STAT 10 47: 50 47' 50 06 :21 GLUCOSE STAT 10 27,00 27: 00 06 :21 SGOT/AST STAT 10 36: 50 36: 50 06,21 EKG 12 114 00 114, 00 06 :21 PORTABLE EXAII SURCIlG 20 134: 00 134: 00 06'21 CIIEST SINGLE PA 23 8880 8880 06:21 ORAL HEOS 40 1872 18';2 06 '21 ORAL HEOS 40 4 00 4 00 06 :21 ORAL HEOS 40 2 00 2 00 06'21 INJECTABLE HED 411 500 5,00 06 :21 INJECTABLE HED 41 i 5 58 5 58 06 '21 INJECTABLE HEO 41 I 5 58 I 5 58[ 06:21 INJECTABLE MEO 41 1 34, 47 'I 34, 47 Iii' ~TE CH.l"OIl 'OR IERV'CES RE~OERED eccu" "Ou WL~ TOTALS'" I I "ICI"I'OO"'O". ."" ... SEE LAST. I'AGE ' , See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms 'QRJ,l"84A MAKE CHECKS PAYABLE TO: "EEl' '.. S QCA' co., J~R ~~,_R AE:::t~A::S :.E' 'c'! ,..: AE' ..R', "1 S PC"' C'l .... '.. ~A'I,'E'.' ".",..,.", r ._,'dO'" ',"'.'SSO"'.," :' :,-,:,n1E ~"{ , c ""'O"f,T D..'E .1 J p,,' E.... ~. ,- A'.JO'~~I" PAD PATIENT S BlRTHDATE BLUE CROSS GROUP NO KEYSTONE HEALTH NO BLUE CROSS CONTRACT NO SuBSCRIBER GROUP NO (ENCLOSE AUTHORIZATION) MEDICARE PATIENTS PLEASE COMPLETE OUESTIONS BELOW AND SIGN ANY OUESTIONS CONTACT HOSPITAL AT 182,3880 MEDICAL ASBT PATIENTS YOU MUST BRING YOUR CARD WHICH RELATES TO THE DATE OF SERVICE TO HARRISBURG HOSPITAL CUSTOMER SERVICE OFFICE COMMERCIAL INS FORWARD A SIGNED INSURANCE CLAIM FORM FOR PROCESSING CHAMPU8 RETURN COMPLETED AND SIGNED FORM ALONG WITH COPY OF CARDS MEDICARE .... MEDICARE IECONDARY PAYOR ... COMPLETE. EFFECTIVE DATE PART A HOSPIT AL PART B MEDICAL 1. IS THE PATIENT OR PATIENT S SPOUSE EMPLOYED? YES NO IF yES COMPLETE A [~ IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE? IF YES, COMPLETE C 18 THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? YES NO IF VIS. NAME OF GROUP PLAN YES NO 2. DOE8 PATIENT HAVE RENAL DISEASE OR HAD A KIDNEY TRANSPLANT? ~ YES NO IF YES COMPLETE C NO IS PATIENT ENTITLED TO MEDICARE SOLELY ON THE BASIS OF RENAL DISEASE? 18 THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? YES IF YES NAME OF GROUP PLAN HAS PATIENT COMPLETED THE TWELVE 1121 MONTH COORDINATION PERIOD? YES STOP MEDICARE PRIMARY NO SEE ABOVE GROUP INS PLAN YES NO 3. ARE 8!RVICES RELATED TO OR DUE TO AN AUTO ACCIDENT OR OTHER LIABILITY INCIDENT? _,,_, YES NO IF YES COMPLETE B 00 WHAT TYPE OF ACCIDENT CAUSED THE ILLNESS/INJURY? AUTOMOIILE INSURANCE COMPANY AND CLAIM NO OTHER 8PECIFY WAS ANOTHER PARTY RE8PONSIBLE FOR THIS ACCIDENT? NAMEiADDRE88 OF RESPONSIBLE PARTY/LIABILITY INSURER YES NO 4. IS THIS ILLNESS OR INJURY WORK RELATED BLACK LUNG? IF YES EMPLOYER NAME AND ADDRESS AND TELEPHONE NO YES NO 5. DOE8 THE PATIENT HAVE VA HEALTH BENEFITS THRU CARD "0,"14? 5. II THE PATIENT A DISABLED MEDICARE BENEFICIARY UNDER AGE 88? YES NO YES NO M~OICAR~ A88IGNM~NT FQRM I REQUEST PAYMENT OF AUTHORIZED MEDICARE BENEFITS TO ME OR ON MY BEHALF FOR ANY SERVICES FURNISHED TO ME BY OR IN HAARISIURG H08PlTAL INCLUDING PHYSICIAN SERVICES I AUTHORIZE ANY HOLDER OF MEDICAL AND OTHER lNWRMATION ABOUT ME TO MeDICARe AND ITI AGeNTS ANY INFORMATION NEEDED TO DET ERMINE THESE BENEFITS OR BENEFITS FOR RELATED SERVICE i SIGNED D.TE "ORM -211.4"" 1!~~~f'! J;',~r~'5 00 ,1~d'T~r:OI '('~i;~'AI"Q.OII~IIUR",,~CE COvERADE i QJ:\OL:; Ioio ~::nf tOHHERC IALA~Z 'j ~~:~c__:I'.~' ". , , l T o POLe"" ~o NGOl87589A DONALD W SIIEPIIERD 3824 HTN VIEW RD HEC/I PA 17055 GAR MANS /. .~f] HARRISBURG /lOSPITAL HARRISBURG. PA. 17101 717 - 782-3680 L_. J SHEPHERD DONALD W [~~~:~lr~6'9i~~~~IQ~!~~~~i~1 I.R,8. 23'O~;;~~30N OATE D&8CRIPT10"i TOTA~-CH,j;jQi - ., 'II;;Co~:EAAaE' -;~D 'COVE-~AOE ~DcovEl:UaE ...M......,..' r- --.------.---.. -.-------r..--..-- "--',---' "~-----"l--' ____..,_.__ 06,21 INJECTABLE HED 41 29, 70 29, 70 , , 06 :21 INJECTABLE HED 41 5: 58 5: 58 : 06 '21 INJECTABLE HED 41 4452, 80 4452' 80 , 06 :21 INJECTABLE HED 41 5; 00 5: 00 06 '21 INJECTABLE HED 41 8' 10 8 10 06 :21 INJECTABLE HED 41 10: 08 10: 08 06'21 IV SOL GENERAL 0931 70 45' 00 45' 00 , , , 06,21 IV ADKINISTRATION 80 43, 00 43, 00 06:21 IV TWIN CATH 80 14; 50 14: 50 06 ,22 ROOH CCU I 1610,00 1610, 00 06: 22 PIT 10 22: 50 22: 50 06 '22 PIT 10 22' 50 22- 50 06 :22 CBC PilaF AUTO DIFF 10 24; 50 24: 50 06 '22 GLUCOSI 10 21' 50 21' 50 06 :22 CALCIUIt SER 10 31: 00 31: 00 06;22 CREATININE SERUH 10 29; 00 29; 00 06,22 CPK 10 31,00 31,00 06:22 PHOSPHOROUS 10 31: 00 31: 00 06 '22 BUN 10 2l> 50 2l> 50 06;22 HAGNESIUH SERUIt 10 31; 00 JI: 00 06'22 CPK ISOENZYME MB 10 56' 00 56' 00 06:22 ELECTROLYTE PROFIL 3 10 42: 00 42; 00 06 '22 CARDIO-LIPID PANEL 10 48' 50 48' 50 , , , 06,22 PIT 10 22. 50 22. 50 06 : 22 PIT 10 22: 50 22: 50 06 '22 PIT 10 22> 50 22, 50 06: 22 PIT 10 22: 50 22; 50 06 '22 CPK 10 31' 00 31' 00 06:22 CPK ISOENZYME MB 10 56: 00 56: 00 06 '22 EKG 12 114' 00 114' 00 , , , 06,22 ORAL HEDS 40 18, 72 18, 72 06: 22 ORAL HEDS 40 2, 00 2: 00 06,22 ORAL MEDS 40 7, 74 7, 74 06' 22 ORAL MEDS 40 4' 00 4' 00 O~2L INJECIABLE.MED." 41. 21:24 .21,24 'I " ..., IF LATE CH4RQEI FOR SERviCES ~E"40lREO OCCuR. ""01.1 W'lL TOTALS.... , 'i 'I .,c',,,'oO"'O'ALI',','" ... l. SEELASl. PAGE...". See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms I llEED r....,s PO'HO~ 'CR VOwJ:\ ~E':ORDS DPAC..., .1.'0 RETL,.R'--i TH'S POR"'C~.. >'iT.... Pu....E"'.. '" E',' ''''' Ii B ,,'a OA:E 'AO"SSO' IE,"' CE I , , D 'c~.."! 9"! I I MAKE CHECKS PAYABLE TO: FlATi~l ~a ,. c - - .. A~Q~~!-PUE-- :~ ~~Q~NT "_4iQ:.: PATIENT S BIRTHDATE BLUE CROSS GROUP NO KEYSTONE HEALTH NO BLUE CROSS CONTRACT NO SUBSCRIBER GROUP NO IENCLOSE AUTHORIZATION I MEDICARE PATIENTS PLEASE COMPLETE OUESTiONS BELOW AND SIGN ANY OUESTIONS CONTACT HOSPITAL AT 782,3880 MEDICAL ASST, PATIENTS VOU MUST BRING YOUR CARD WHICH RELATES TO THE DATE OF SERVICE TO HARRISBURG HOSPITAL CUSTOMER SERVICE OFFICE COMMERCIAL INS FORWARD A SIGNED INSURANCE CLAIM FORM FOR PROCESSING CHAMPUS: RETURN COMPLETED AND SIGNED FORM ALONG WITH COpy OF CARDS MEDICARE ~ MEDICARE SECONDARY PAYOR COMPLEl E ,_____________,___ EFFECTIVE DATE PART A HOSPITAL PART B MEDICAL _______, 1. IS THE PATIENT OR PATIENT'S SPOUSE EMPLOYED? YES _ NO IF YES, COMPLETE A ~ IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE? IF YES, COMPLETE C IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? YES NO IF YES, NAME OF GROUP PLAN: _,______________" ___u_ VES .., _ NO 2. DOES PATIENT HAVE RENAL DISEASE OR HAD A KIDNEY TRANSPLANT? ,___ YES _ NO IF YES COMPLETE C, [Q] IS PATIENT ENTITLED TO MEDICARE SOLELY ON THE BASIS OF RENAL DISEASE? IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? ,..,_ YES IF YES, NAME OF GROUP PLAN: _______~___ ___ ".. u' ,- ,___uu..___.. HAS PATIENT COMPLETED THE TWELVE 1121 MONTH COORDINATION PERIOD? _ YES, STOP MEDICARE PRIMARY NO, SEE ABOVE GROUP INS PLAN ..'__ YES NO ,___ NO 3. ARE SERVICES RELATED TO OR DUE TO AN AUTO ACCIDENT OR OTHER LIABILITY INCIDENT? _ YES __ NO IF YES, COMPLETE B 00 WHAT TYPE OF ACCIDENT CAUSED THE ILLNESS/INJURY? _ AUTOMOBILE: INSURANCE COMPANY AND CLAIM NO, _ OTHER: SPECIFY ___________ ,,"--"-'--" WAS ANOTHER PARTY RESPONSIBLE FOR THIS ACCIDENT? NAME/ADDRESS OF RESPONSIBLE PARTY/LIABILITY INSURER YES NO 4. IS THIS ILLNESS OR INJURY WORK RELATED/BLACK LUNG? IF YES, EMPLOYER NAME AND ADDRESS AND TELEPHONE NO NO YES 15. DOES THE PATIENT HAVE VA HEALTH BENEFITS THRU CARD 110,t174? 8. YES NO I I 1 i ! , IS THE PATIENT A DISABLED MEDICARE SENEFlCIARY UNDER AGE 88? YES NO M~DICARE A5510NMEtH FQRM I REQUEST PAYMENT OF AUTHORIZED MEDICARE BENEFITS TO ME OR ON MY BEHALF FOR ANY URVICes FURNISHED TO ME BY OR IN HARRISBURG HOSPITAL INCLUDING PHYSICIAN SERVICES I AUTHORIZE ANY HOLDER OF MEDICAL AND OTHER INFORMATION ABOUT ME TO MEDICARE AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR BENEFITS FOR RELATED SERVICE SIGNED DATE 'OI\V.U'" , , tyPE 0' hl I ~ lllSCII 1 I~~-,_J l!totl'lTI.IG'O B ~~...o DA'i 05 '01 '95 L 8~1'~OPEROO 00000 i 05:01 10 10 10 10 10 10 10 10 10 10 10 12 20 23 40 40 40 41 41 41 41 ! 41 I 41, I TOTALS ~. SEE LAS}' I'AGE , See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms '''''~''-'NCE COvERAGE COHHERCIAL A-Z VIEI totO VIEI NO VEl NO -~~~~-j ~' , L T o DONALD W SIIEI'IIERD 3824 HTN VIEW RD HECII I'A 17055 L_ SHEI'HERD DONALD W eATi DESCRiPTIO,", 06,22 INJECTABLE HED 06:22 INJECTABLE HED 06'22 INJECTABLE HED 06:22 INJECTABLE HED 06'22 INJECTABLE HED 06:22 INJECTABLE HED 06'22 INJECTABLE KED , 06,22 INJECTABLE KED 06:22 EXTERNAL KED 06,22 OXYGEN THERAPY 06:22 OXYGEN THERAPY 06'23 ROOH CCU I 06 :23 PTT 06'23 CBC PROP AUTO DIFF 06:23 CREATININE SERUH 06:23 BUN 06,23 ELECTROLYTE PROPIL 3 06:23 PTT 06 '23 PTT 06:23 BLOOD CULTURE 06'23 BLOOD CULTURE 06:23 CPK 06'23 CPK ISOENZYHE HB , 06,23 EKG 06:23 PORTABLE EXAII SURCIIG 06,23 CHEST SINGLE PA 06:23 ORAL HEDS 06'23 ORAL HEDS 06:23 ORAL HEDS 06'23 INJECTABLE HED 06:23 INJECTABLE HED 06:23 INJECTABLE HED 06,23 INJECTABLE HED 06:23 INJECTABLE HED ,06 ,2L EXTERNAl...~HfJ) _~u IF I..ATI CI1ARQEI ~Ol=l B'I=I\I,CU RE,",PERED OCCull, "Ou W;l~ RECE'\'1i "DDlt:C~'.. 9 ~~ ,",0 0"0...." f.;O GARHANS ! I I "'''QE .J .3.1 POl'C'" ~o I NG0187589A I IIARR ISBURG 1I0SP ITAL IIARRISBURG, I'A. 17101 717 - 782-3680 41 41 41 41 41 41 41 41 41 92 92 [:~~-~~~ [0;:~~~o9~1~~~;~~~~1 I.R.S. 23'O~:T::~30N TOT.l..-CH-ARQE- 1 ri"co..i~aE 2~O COVERAGi 3~COVER.&ciE "~OUNt ~-~._~._, -- - ~.~- '--~-,--"- -----,.- , n 24 210 24 5: 00 5: 00 5 58 5, 58 63: 72 63: 72 20' 00 20' 00 29 70 29: 70 34' 47 34' 47 , , 63, 72 63, 72 6: 57 6: 57 213- 00 213- 00 213: 00 213: 00 1610 00 1610 00 22: 50 22: 50 24' 50 24' 50 29: 00 29: 00 21: 50 21: 50 42, 00 42, 00 22 50 22: 50 22> 50 22, 50 73' 00 73' 00 73 00 73' 00 31: 00 31: 00 56' 00 56' 00 114. 00 114: 00 134 00 134: 00 88, 80 88 80 18 72 18: 72 2' 00 2' 00 4 00 4, 00 I 29 70 I 29 70 I 63 72~ 63 72~ 63 72 ! 63 72 II 20 00 I 20 00 59 40 ! 59 40 I 20 43; 20, 43 l i ., ~At'E~. 't ..,.. PA'E'i.""'f "-HI: 't... 5 po". C"< ':JR >(),R "E::;CR::;S SE.A::;... .....J I';p"~,,, t.... $ peR" C~ ,', fH "'AO.'E',. I' "" ',' OA'! "0'.''' 0', SER, CE ' 'V:L~.. O""E MAKE CHECKS PAYABLE TO: ~ :: :; 5:.>:A...ji ~,A'E AI,'O...'" ~A:; PATIENT'S BIRTHDATE BLUE CROSS GROUP NO KEYSTONE HEALTH NO BLUE CROSS CONTRACT NO SUBSCRIBER GROUP NO IENCLOSE AUTHORIZATION) MEDICARE PATIENTS PLEASE COMPLETE OUESTlONS BELOW AND SIGN ANY OUEST IONS CONTACT HOSPITAL AT 782,3680 MEDICALASST, PATIENTS VOU MUST BRING YOUR CARD WHICH RELATES TO THE DATE OF SERVICE TO HARRISBURG HOSPITAL CUSTOMER SERVICE OFFICE COMMERCIAL INS FORWARD A SIGNED INSURANCE CLAIM FORM FOR PROCESSING CHAMPUS: RETURN COMPLETED AND SIGNED FORM ALONG WITH COpy OF CARDS MEDICARE . MEDICARE EFFECTIVE DATE SECONDARY PAYOR COMPLETE 1 _____________ PART A HOSPITAL ,_,___,__,_,__,_ PART B MEDICAL ,___,_____ ----~----_.....__._-_._-_._." --_._--- ._-_._-_._._--_.,-_.--.._._._._-,-_.-.~ --._.-_._._.....~_.. -. . ~._~_._--~-- 1. IS THE PATIENT OR PATIENT'S SPOUSE EMPLOYED? ___ YES ____, NO IF YES, COMPLETE A. ~ IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE? __, YES IF YES. COMPLETE C, IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? __,_, YES __ NO IF YES, NAME OF GROUP PLAN: ___..._ ..,____.._ ..________,___________,_"" _.._NO 2. DOES PATIENT HAVE RENAL DISEASE OR HAD A KIDNEY TRANSPLANT? ~ "'_" YES _NO IF YES, COMPLETE C, _,NO IS PATIENT ENTITLED TO MEDICARE SOLELY ON THE BASIS OF RENAL DISEASE? IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? __ YES IF YES, NAME OF GROUP PLAN: ____ HAS PATIENT COMPLETED THE TWELVE (12) MONTH COORDINATION PERIOD? _ YES. STOP MEDICARE PRIMARY ,__ NO, SEE ABOVE GROUP INS PLAN _YES ___ NO 3. ARE SERVICES RELATED TO OR DUE TO AN AUTO ACCIDENT OR OTHER LIABILITY INCIDENT? _ YES ,_ NO IF YES, COMPLETE B 00 WHAT TYPE OF ACCIDENT CAUSED THE ILLNESS/INJURY? _ AUTOMOBILE: INSURANCE COMPANY AND CLAIM NO, _ OTHER: SPECIFY ____'___,_________,___ WAS ANOTHER PARTY RESPONSIBLE FOR THIS ACCIDENT? _ YES NO NAME/ADDRESS OF RESPONSIBLE PARTY/LIABILITY INSURER: 4. IS THIS ILLNESS OR INJURY WORK RELATED/BLACK LUNG? _ YES ___ NO IF YES, EMPLOYER NAME AND ADDRESS AND TELEPHONE NO, _.._,__ 5. e. DOES THE PATIENT HAVE VA HEALTH BENEFITS THRU CARD I10,1174? _...._, YES ____ NO IS THE PATIENT A DISABLED MEDICARE BENEFICIARY UNDER AGE 86? __ YES __..__ NO M!:.PIC...~_I;A!!!HgNM"NU9RM I REOUEST PAYMENT OF AUTHORIZED MEDICARE BENEFITS TO ME OR ON MY BEHALF FOR ANY SERVICES FURNISHED TO ME BY OR IN HARRISBURG HOSPITAL, INCLUDING PHYSICIAN SERVICES I AUTHORIZE ANY HOLDER OF MEDICAL AND OTHER INFORMATION ABOUT ME TO MEDICARE AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR BENEFITS FOR RELATED SERVICE, SIGNED_" DATE __ I tv....Ollh.. l,l.'-l()O,,'F B...t.,eJ"IERQO " ' I I>ISCIl : 0501 '95 00 '00 ! 05 '01 INP. I """1" '10'0 1 !""ul\A~C! C;Cl'. l"""(]1! COKKERCIAL A-Z GARKANS' ..at '\ 4 "'II ~o ...... 1'10 "'II NO _:,_J~',:j ~ , , T o " I GAOuP ~c I PUle'!' ,.,0 NGOI87S89A IlONALD W SIIEPIlERD 3824 HTN VIEW RD HECII PA 17055 IlARRISPURG 1I0SPITAI. ItARRISPURG. I'A. 17101 717 - 782-3680 I ERD IlONALD W ;~~~~~2!o::~~~~~l:~':r9~~~4j l,R,S, 23.~:;~~30H CATI OE'CAIP'tIO~ :fot,~ CH"Riii-----;'T-CO~E-ijii -~o-covIiAiQi'" -)RD~COVI""'al A".t\ol\lr4t -r--- ~___b. - -.-,., '-1--'-- ---.---".-- -l' '-' ... .....--------------y------ 06,23 IV PUHP-RENTAI. 70 59 00 59, 00 06:23 IV PUHP-RENTAI. 70 59: 00 59: 00 06'23 IV PUHP-RENTAI. 70 59, 00 59' 00 06:23 IV 501. GENERAl. 0931 70 45: 00 45: 00 06'23 IV 501. GENERAl. 0931 70 45' 00 45' 00 06:23 IVAC 20DllP SEC-3705 70 34: 50 34: 50 06 '23 BASl POWDER 70 2' 00 2' 00 06 : 23 HOUTIIWASH 70 1: 00 I: 00 06:23 PARTIAL PILI. IV-4461 70 17, 00 17: 00 06 ,23 07610064S 92 141, 00 141,00 06:23 IHPP' 92 5400 54:00 06 '23 OXYGIIN THERAPY 92 213 00 21300 06: 24 ROOH 1001 J 920: 00 920: 00 06 '24 PTT 10 , 22' 50 22' 50 06 :24 PTT 10 22: SO 22: SO 06 :24 PTT 10 22: SO 22: SO 06,24 CPC PROF AUTO D1FF 10 24 SO 24, SO 06 :24 PTT STAT 10 28' 00 28' 00 06 '24 SHEAR ONL.Y 10 IS: 00 IS: 00 06 :24 ROUTINE CUI.TURE 10 31. 00 31: 00 06'24 SUN 10 H SO H SO 06:24 EI.ECTROL.YTE PROFII. 3 10 42: 00 42: 00 06 '24 SENSITIVITY 10 29' 50 29' SO 06 :24 ORAl. HEDS 40 18 72 18: 72 06 : 24 ORAL. HEOS 40 2 00 2 00 06 ,24 ORAL HEDS 40 18 72 18' 72 06 : 24 ORAL HEOS 40 2: 88 2 88 06 '24 ORAL HEOS 40 2 00 2 00 06 : 24 ORAL HEOS 40 4 00 4 00 06 '24 ORAL HEOS 40 4 00 4' 00 06 :24 INJECTABLE HEll 41 20 00 I 20,00 06 '24 INJECTABI.E HED 41 29, 70 I 29 70 06 :24 IV PUHP-RENTAI. 70 59 00 I 59 00 I 06 '24 IV PUHP-RENTAI. 70 59 00 i 59,00 I 06 ~21L 1 Y PUMP.,.RENTAL. 70 S9, 00 I S9, 00 ; IF \,Atl CHAMU JlO" le"IjIC, II 0 ALS I 'I ~i"'O ~I!O OCCilR \IOu WI~~ T T.... , "ICI,.I ."","0'" 8,"M ... SEE LAS 1; PAGE, ' See Revers. Side If You Have Not Furnished U8 Your Health In8urance Information and/or Forms L_. I I MAKE CIiECKS PAYABLE TO: 01:(1'''' ''1' ~rJ" L'. ~::..;.~ _CuR RfCC,Rl)5 DP"CH A'-lb 'IE'"I.H, '''i pritil' (J/.j r' h; p"".'E'" I B '.. ';1 n"E : AU,.. U (J~ ~F.~-;';~! ' , \, ' ! AI~Oi,i'~l PAO ;AHI-.fN" PA'II,";Al.,'( J'C "IJOj;~~t Dli& :J8r>~io~JE t:"f 'OPlV flU" 1'" n_.___. PATIENT'S BIRTHDATE BLUE CROSS GROUP NO KEYSTONE HEALTH NO BLUE CROSS CONTRACT NO SUBSCRIBER GROUP NO _ (ENCLOSE AUTHORIZATION) MEDICARE PATIENTS PLEASE COMPLETE OUESTIONS BELOW AND SIGN ANY OUESTlONS CONTACT HOSPITAL AT 782,3880 MEDICAL ASST PATIENTS YOU MUST BRING YOUR CARD WHICH RELATES TO THE DATE OF SERVICE TO HARRISBURG HOSPITAL CUSTOMER SERVICE OFFICE COMMERCIAL INS FORWARD A SIGNED INSURANCE CLAIM FORM FOR PROCESSING CHAMPUS RETURN COMPLETED AND SIGNED FORM ALONG WITH COpy OF CARDS MEDICARE ~ MEDICARE SECONDARY PAYOR COMPLETE ,--,-- ' " EFFECTIVE DATE PART A HOSPITAL ,_ __..,____ PARTS MEDICAL 1. IS THE PATIENT OR PATIENT'S SPOUSE EMPLOYED? _,_, YES ___ NO IF YES, COMPLETE A, ~ IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE? --- YES IF YES, COMPLETE C, IS THE PATIENT COVERED BY AN EMPLOVER GROUP PLAN? ___, YES NO IF YES, NAME OF GROUP PLAN: ____'n'______' ----,,- ---- - __NO 2. DOES PATIENT HAVE RENAL DISEASE OR HAD A KIDNEY TRANSPLANT? ~ __,_,_ YES __,NO IF YES, COMPLETE C, IS PATIENT ENTITLED TO MEDICAAF SOLELY ON THE BASIS OF RENAL DISEASE? IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? _____ YES IF YES, NAME OF GROUP PLAN __ HAS PATIENT COMPLETED THE TWELVE (12) MONTH COORDINATION PERIOD? YES, STOP MEDICARE PRIMARY ____ _ NO, SEE ABOVE GROUP INS, PLAN __ YES __NO _NO 3. ARE SERVICES RELATED TO OR DUE TO AN AUTO ACCIDENT OR OTHER LIABILITY INCIDENT? _ YES __ NO IF YES, COMPLETE B 00 WHAT TYPE OF ACCIDENT CAUSED THE ILLNESS/INJURY? _ AUTOMOBILE: INSURANCE COMPANY AND CLAIM NO, _ OTHER: SPECIFY WAS ANOTHER PARTY RESPONSIBLE FOR THIS ACCIDENT? NAME/ADDRESS OF RESPONSIBLE PARTY/LIABILITY INSURER __ YES __NO 4. IS THIS ILLNESS OR INJURY WORK RELATED/BLACK LUNG? __ YES ,_,_ NO IF YES, EMPLOYER NAME AND ADDRESS AND TELEPHONE NO, ..,---------,---....,-' ___._k__' ___ ~_._____~_._.__.-____~-^_____ ------ ----- ----. --_._--~~-------_.~ 5. DOES THE PATIENT HAVE VA HEALTH BENEFITS THRU CARD ,10,11741 e. ___ YES ___,_ NO IS THE PATIENT A DISABLED MEDICARE BENEFICIARY UNDER AGE 85? _ YES ____ NO Mj;~lgAR~ AtI!llq~MEtH_EQRM I REOUEST PAYMENT OF AUTHORIZED MEDICARE BENEFITS TO ME OR ON MY BEHALF FOR ANY SERVICES FURNISHED TO ME BY OR IN HARRISBURG HOSPITAL, INCLUDINCl PHVSICIAN SERVICES I AUTHORIZE ANY HOLDER OF MEDICAL AND OTHER INFORMATION ABOUT ME TO MEDICARE AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR BENEFITS FOR RELATED SERVICE, SIGNED DATE ! 1~~~~~219;~~7':~41;~!:;;~~41 I,A,S, 23.~e75.330N rNo"u~." DESCRiPTION rOr"'L CH-'-RGE~- 'S1 COV~RAQE .- '-~OC-OVE~...-aE -- 3RD COVEJtlGE "'" '" _._______.'___..__ -- --"1----- ,...-- --- -..----'" --- --..- T '-"-' 'r-.-~'- 06,24 IV PUHP-RENTAL 70 59,00 59,00 06 :24 SET UP IV PUHP 70 H 50 21 50 06 ,24 SET UP IV PUHP 70 n 50 n 50 06 :24 SET UP IV PUHP 70 21: 50 2\, 50 06 '24 SET UP IV PUHP 70 2i' 50 2i' 50 06 :24 II-IPPB 92 54: 00 54' 00 06'25 ROOH 1001 J 920' 00 92000 06:25 PTT 10 22:50 22:50 06 : 25 CBC PROf AUTO Dl FF 10 24: 50 24' 50 06,25 BUN 10 21, 50 2\, 50 06 :25 ELECTROLYTE PROflL 3 10 42: 00 I 42' 00 06 '25 PTT STAT 10 28 00, 28 00 06 :25 ORAL KEDS 40 18 72 18 72 06'25 ORAL KEDS 40 2' 00 2' 00 06:25 ORAL HEDS 40 4,00 4' 00 06'25 INJECTABLE HEO 41 2970 2970 06 :25 EXTERNAL HEO 41 6 57 6 57 06 :25 EXTERNAL HEO 41 6 571 6: 57 06 '25 IV ADIIINISTRATlON 80 43,00 I 43 00 06 : 25 ANG IOSET 80 9, 00 ' 9 00 06'26 ROOII 1001 J 92000 92000 06 :26 PTT 10 22 50 22 50 06 '26 PTT 10 22 50 22 50 06 :26 PTT STAT 10 28 00 28 00 06 : 26 ORAL IIEOS 40 9 36 9 36 06,26 ORAL HEDS 40 2 00 2 00 06 :26 ORAL HEOS 40 18 72 18 72 I 06' 26 ORAL HEnS 40 2 00 2, 00 I 06:26 ORAL HEOS 40 4 00 4 00 06 '26 INJECTABLE HEll 41 29 70 29 70 I , ' 06,26 INJECTABLE HEll 41 29 70 29 70 I 06'27 ROOH IDOl J 92000 92000! 06,27 PTT 10 22 50 22 50 ! 06 '27 PTT 10 22 50 22 50 I 06;2.7 CALCIUH SER 10 H 00 HOD 1 ;F lATE CHARGES nq SE~.CEi TOTALS ~ RE~DEq~D OCC",i:l "0.. .,' I, ..c.""oo'O"..""o SEE LAS/: I'A(;E See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms ..- .." TYPE OF B'~~ i B ~l"'a CI.tE a ~L,"'a FEROD DISCH I 05 '01 '95 . 00 '00 05'01 INP. ~::~~. '::~'Ii:o~~r~~Cil~"~~O;- VEl ~o VEl NO . ~OL'CY 1\0 1 NGOl87589A I QRO"F ~o ,,.0 ,--' -5-- . I -..----- L L , o DONALD W SHEPHERD 3824 HTN VIEW RO HECII I'A 17055 L_ 942816080 SHEPHERD DONALD W DATE ~ l u; '" 't: t'" "<' (.', I .... -' f< 'ff', . ..I:j;. ~ ,_'~" f;..." JI', - fir', .I'l'. . ",s F,' :..' ! ,', . ,. j:.'.II . I,'f ", > f'A' p,' I,~ " 1<' t ',' " ~ J ,~ 4.'d lo'f H)'U,ltU4A MAKE CHECKS PAYABLE TO: liARHANS ! I i PAGE 5 IfARR ISBURG 1f0SPlTAL HARRISBURG, PA. 17101 717 - 782-3680 I.':','!!l ,', H-Il, ~ "YO\i~' bv~ ~ , ....' '1.1, j! ~'~ _AI,lOvl--jl 'AQ [~I IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE? IF YES, COMPLETE C IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? YES NO IF YES NAME OF GROUP PLAN __ _ YES ___ NO PATIENT S BIRTHDATE BLUE CROSS GROUP NO KEYSTONE HEAL TH NO BLUE CROSS CONTRACT NO SUBSCRIBER GROUP NO IENCLOSE AUTHORIZATION) MEDICARE PATIENTS PLEASE COMPLETE QUESTIONS BELOW AND SIGN ANY QUESTIONS CONTACT HOSPITAL AT 782-3880 MEDICAL ASST PATIENTS YOU MUST BRING YOUR CARD WHICH RELATES TO THE DATE OF SERVICE TO HARRISBURG HOSPITAL CUSTOMER SERVICE OFFICE COMMERCIAL INS FORWARD A SIGNED INSURANCE CLAIM FORM FOR PROCESSING CHAMPUS RETURN COMPLETED AND SIGNED FORM ALONG WITH COpy OF CARDS MEDICARE ... MEDICARE SECONDARY PAYOR .... COMPLETE' EFFECTIVE DATE PART A HOSPIT AL _ PART S MEDICAL______ 1. IS THE PATIENT OR PATIENTS SPOUSE EMPLOYED? YES NO IF YES COMPLETE A. 2. DOES PATIENT HAVE RENAL DISEASE OR HAD A KIDNEY TRANSPLANT? YES NO IF YES, COMPLETE C, [Q] IS PATIENT ENTITLED TO MEDICARE SOLELY ON THE BASIS OF RENAL DISEASE? IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? YES IF YES NAME OF GROUP PLAN,--' _u____ un' --,---------- -,- HAS PATIENT COMPLETeD THE TWELVE 1121 MONTH COORDINATION PERIOD? YES STOP MEDICARE PRIMARY NO SEE ABOVE GROUP INS PLAN , YES NO __ NO 3. ARB SERVICES RELATED TO OR DUE TO AN AUTO ACCIDENT OR OTHER LIABILITY INCIDENT? YES NO IF YES COMPLETE B 00 WHAT TYPE OF ACCIDENT CAUSED THE ILLNESS INJURY? AUTOMOBILE INSURANCE COMPANY AND CLAIM NO OTHER SPECIFY WAS ANOTHER PARTY RESPONSIBLE FOR THIS ACCIDENT? NAME/ADDRESS OF RESPONSIBLE PARTYILIABILITY INSURER YES , NO 4. IS THIS ILLNESS OR INJURY WORK RELATED BLACK LUNG? IF YES EMPLOYER NAME AND ADDRESS AND TELEPHONE NO YES _ NO 5. DOES THE PATIENT HAVE VA HEALTH BENEFITS THRU CARD "0,11141 e. IS THe PATieNT A DISABLeD MeDICARE BENEFICIARY UNDER AGE 881 YES NO YES NO MEDICARE ASSIGNMENT FORM I REOUEST PAYMENT OF AUTHORIZED MEDICARE BENEFITS TO ME OR ON MY BEHALF FOR ANY SERVICES FURNISHED TO ME BY OR IN HARRISBURG HOSPITAL INCLUDING PHYSICIAN SERVICES I AUTHORIZE ANY HOlDER OF MEDICAL AND OTHER INFORMATION ABOUT ME TO MEDICARE AND ITS AGeNTS ANY INFORMATION NHDED TO DETERMINE THESE BENEFITS OR SENE FITS FOR RELATED SERVICE I SIGNED DATE I.~~'E or B-~~ ~ Ih~''',OOA'E ' DISCII 1 05 '01 '95 ; -,!!!P-,-__L i BE~EFIT!I .1.10'0 I~'URA"CE CO.ERAOE 9.. "':1 &:E~ CD GARH^NS "Of 6 00'00 i 05 '01 ,I p,-,~,~", t.jo 1 NG0187589A O~O..." ~o VEl .0 COHHERC I Al. A- Z Vel NO VEl NO ~~ ;c]~- L IIARR I SBURG 1I0SP IT AL IIARRISBURG. PA. 17101 717 - 782-3680 [, L. DONAl.O W SIIEPIIERO 3824 HTN VIEW RO HECII PA 17055 , f~~i=~~J~;:~~~~~ I~::;';:~ij I.R.S, 23.0875.330N SIIEPIIERO DONAl.O W PATIENT DATE OElCR:PTION _._~.,._m TOTAL CI1ARoE 1ST COVERAGE 2ND COVERAGE 3RO COVERAoE AMOUNT ---------.-.- ---.----..-,-- ----_.,-- --------,'--- ---, 06,27 MAGNESIUH SERUH 10 31,00 3J, 00 , 06:27 POTASSIUH 10 18: 50 18: 50 , 06'27 IIEHOOYNAH HONITR 12 484 00 484' 00 06:27 XYLOCAINE 12 18: 00 18: 00 06'27 IIYPAQUE HO 76% 12 30 00 30 00 06:27 HEART CATH TRAY 12 92: 00 92: 00 06'27 CATH LAB R" CHGE 12 731' 00 731' 00 , , , 06,27 NORHAL SALINE 250 "L 12 18,00 18,00 06 :27 NORHAL SALINE 100D"L 12 22: 00 22: 00 06,27 GUIDENIRE DIAGNOSTIC 12 44, 00 44, 00 06:27 DIAGNOSTIC CATHETER 12 162: 00 162: 00 06 '27 HEHAQUET 12 97' 00 97' 00 06 :27 CARDIAC CATH LEFT 12 517: 00 517: 00 06'27 HEXABRIX SOHL/OPTIRA 12 262' 00 262' 00 06 :27 , , CHEST PA , LATERAL 20 99, 90 99,90 06:27 ORAL HEOS 40 2: 00 2; 00 06,27 ORAL HEOS 40 2,00 2,00 06:27 ORAL HEOS 40 9: 36 9: 36 06'27 ORAL HEOS 40 2' 00 2' 00 06:27 ORAL HEOS 40 18: 72 18: 72 06'27 ORAL HEOS 40 2' 00 2' 00 06:27 ORAL HE OS 40 4: 00 4: 00 06'27 INJECTABLE HEO 41 5' 58 5' 58 , , 29: 70 06,27 INJECTABLE HEO 41 29 70 06:27 IV PUHP-RENTAL 70 59: 00 59: 00 06'27 IV PUHP-RENTAL 70 59, 00 59, 00 06:27 IV PUHP-RENTAL 70 59; 00 59: 00 06'27 IV PUHP-RENTAL 70 59 00 59' 00 06:27 IVAC 200RP PRIH 5373 70 9: 00 9: 00 06 '27 IV AOHINISTRATION 80 ' 43' 00 43' 00 06 :27 ANGIOSET 80 I 9 00 9: 00 06'28 ROOM 1001 J 40 I 920 00 920 00 06:28 ORAL HEDS 792 7,92 06 '28 ORAL HEOS 40 I 2, 00 2 00 , I 06,.28,. ,ORAl..HEOS,... ...--- .40.1 2,70. .2.,70, u_._._.._____. iF L,&tE CI1A.ROEB FOR SERVICES TOTALS. I I RE~CERED OCCuR_ YOu W'LI. RECE'vE "DD;t!O~AI. BLl'~O SEE LAsn PAGE. See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms PAT'E'~T ..::: "EE" T""S pCRt c,,; ~aR VC_" RECQR:6 CE!,lC" A~,C I<iET...j::l" T....5 PCRT C"o ...i.... p,-,I,'P,' '" p,' ",:, I' B .".',0 O','E "0"" ","ER, OE o sc...'i.l~;jE yATf. ,tjOU".'-Tj,,:~_ , c ,lYOu~foui-.. JOR~ .;&",l MAKE CHECKS PAYABLE TO: PATiENT S BIRTHDATE BLUE CROSS GROUP NO KEYSTONE HEAL TH NO BLUE CROSS CONTRACT NO SUBSCRIBER GROUP NO (ENCLOSE AUTHORIZATION) MEDICARE PATIENTS PLEASE COMPLETE QUESTiONS BELOW AND SIGN ANV OUEST IONS CONTACT HOSPITAL AT 182,3B80 MEDICAL ASST PATiENTS YOU MUST BRING YOUR CARD WHICH RELATES TO THE DATE OF SERVICE TO HARRISBURG liOSPITAL CUSTOMER SERVICE OFFICE COMMERCIAL INS FORWARD A SIGNED INSURANCE CLAIM FORM FOR PROCESSING CHAMPUS RETURN COMPLETED AND SIGNED FORM ALONG WITH COpy OF CARDS MEDICARE ... MEDICARE SECONDARY PAYOR ..... COMPLETE. EFFECTiVE DATE PART A HOSPIT AL PART B MEDICAL ____,____,_ 1. IS THE PATiENT OR PATiENT'S SPOUSE EMPLOYED1 YES NO IF YEB, COMPLETE A ~ IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE? IF YES, COMPLETE C, IS THE PATIENT COVERED BY AN EMPLOVER GROUP PLAN? YES NO IF YES, NAME OF GROUP PLAN _, __ ,___m -, _~_ YES _,_ _, NO 2. DOES PATIENT HAVE RENAL DISEASE OR HAD A KIDNEY TRANSPLANT1 [Q] YES NO IF YES, COMPLETE C, IS PATiENT ENTITLED TO MEDICARE SOLELV ON THE BASIS OF RENAL DISEASE? _,__,_ YES IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? YES ....,__ NO IF YES NAME OF GROUP PLAN,,---..,------- -..------ HAS PATiENT COMPLETED THE TWELVE 1121 MONTH COORDINATION PERIOD? , _,___ VES, STOP MEDICARE PRIMARY NO, SEE ABOVE GROUP INS PLAN _NO 3. ARE SERVICES RELATED TO OR DUE TO AN AUTO ACCIDENT OR OTHER LIABILlTV INCIDENT? __ YES __,_,.. NO IF YES, COMPLETE B [!] WHAT TYPE OF ACCIDENT CAUSED THE ILLNESS/INJURY? _ AUTOMOBILE, INSURANCE COMPANY AND CLAIM NO _, OTHER: SPECIFY_____,.... WAS ANOTHER PARTY RESPONSIBLE FOR THIS ACCIDENT1 NAME/ADDRESS OF RESPONSIBLE PARTY/LIABILITY INSURER YES NO 4. IS THIS ILLNESS OR INJURY WORK RELATED/BLACK LUNG? IF YES, EMPLOVER NAME AND ADDRESS AND TELEPHONE NO YES NO ----" -,--~-,-"'-- n'_~~'_~______"__'________"_ . -__._____ II. DOES THE PATIENT HAVE VA HEALTH BENEFITS THRU CARD .10,1114? YES NO e. IS THE PATiENT A DISABLED MEDICARE BENEFICIARY UNDER AGE BS1 YES NO ME\>ICARE AI!8I(1NMENT FORM I REOUEBT PAVMENT OF AUTHORIZED MEDICARE BENEFITS TO ME OR ON MV BEHALF FOR ANY SERVICES FURNISHED TO ME BY OR IN HARRISBURG HOSPITAL INCLUDING PHYSICIAN SERVICES I AUTHORIZE ANV HOLDER OF MEDICAL AND OTHER INFORMATiON ABOUT ME TO MEDICARE AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINe THESe BENEFITS OR BENeFITS FOR RELATeD SERVice SIGNED I DATE nf~~~i~'J 6;l~610~~5j 00 ~~~'T~~O:OI, . 8E",(FITI 1.80'0 1""iJR.~CE COVEAAOI O~OuP ~O .~E~-l-:'~ COHHERClAL j,-Z VEl "'0 vu "'0 ~C j- .u~_=.-=-_ ~NALD W - l l 3824 I1TN b I1ECH PA PO~'Cl' 1>;0 'NG0187589A HI GARI1ANS I..]~==] SIIEPIIERD VIEW RD 17055 IIARRISBURG HOSPITAL HARRISBURG. PA. 17101 717 - 782-3680 942816080 SHEPHERD DONALD W ll~~~=~i!~:~~~:~~T;:~::~ I.A,S. 23'~:T:~~30N DESCRIPTION TOlAC CHARGE 'IrCOvEiUOE -~O COVE~ 3RO COVERAGE A~OUNT ----_.__.._--~._-- ----------,-- ----,.-----. --_.----..-------,- ORAL I1EDS 40 18, 72 18, 72 , ORAL I1EDS 40 2: 00 2: 00 ORAL I1EDS 40 4, 00 4, 00 ORAL I1EDS 40 7; 92 7; 92 ORAL I1EDS 40 5' 40 5' 40 IV PUI1P-RENTAL 70 59: 00 59: 00 ORAL /tEbS 40 6' 00 6' 00 , , ORAL KEDS 40 18, 72 18, 72 ORAL /tEbS 40 2: 00 2: 00 ORAL /tEbS 40 7, 92 7, 92 ORAL /tEbS 40 5: 40 5: 40 EGG CIATE HATTIESS 70 51' 00 51' 00 OXYGEN THEIAPY 92 213: 00 213: 00 L . _J DATE 06,28 06 :28 06'28 06:28 06'28 06:28 06'29 , 06,29 06:29 06,29 06:29 06'29 06;22 , , _____L-__ , , TOTAL -----'--- ______1-__ ______L-__ 22693: 96 , 22666, 96 CHARGES ......l... , , ......~.. ......... , , , ..-.-..- , , ._._~_J_._.__ __._._..____.. iF LATE CHARQn 'OR IERI/ICU REI<tDERED OCCUR, YOU Will RECEIVE "OD:t.O"'A.~ 8\.L;""0 .. _----L.......___ , TOTALS. Sl::l:: LAS1! I'AGE See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms -EE" r~ 5 POIt'O,," ~OR ~O,R I'lECCflJS epAC.. Ao"D Ap"fl'" t..S PORrO'"' ..,.... PA",'EV 1l.l,'P,''';:: I' o SC.:'fl'3E 9"'~ e......G r;./..'E ADI.,' &5 C~~ SER,: CE PPP.f"",.~ 'OR'" '''''A MAKE CHECKS PAYABLE TO: , , , , , , , , , , , , , , , , , , , , -----1--- , 27,00 .......-- , , , , I , , , , I , , , , , , C ::;~ PATIENTS BIRTHDATE BLUE CROSS GROUP NO KEYSTONE HEALTH NO BLUE CROSS CONTRACT NO SUBSCRIBER GROUP NO , (ENCLOSE AUTHORIZATION) MEDICARE PATIENTS PLEASE COMPLETE OUEST IONS BELOW AND SIGN ANY QUESTIONS CONTACT HOSPITAL AT 782-3880 MEDICAL ASST PATIENTS YOU MUST BRING YOUR CARD WHICH RELATES TO THE DATE OF SERVICE TO HARRISSURG HOSPITAL CUSTOMER SERVICE OFFICE COMMERCIAL INS FORWARD A SIGNED INSURANCE CLAIM FORM FOR PROCESSING CHAMPUS RETURN COMPLETED AND SIGNED FORM ALONG WITH COpy OF CARDS -. MEDICARE . MEDICARE SECONDARY PAYOR COMPLETE' _____'____,_",_,_ EFFECTIVE DATE PART A HOSPITAL _,_ __ , PART B MEDICAL ,__ 1. IS THE PATIENT OR PATIENT'S SPOUSE EMPLOYED? "" , yes __.. NO IF YES, COMPLETE A ~ IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE? , ,,_ YES IF YES, COMPLETE C IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? YES NO IF YES, NAME OF GROUP PLAN __" _, _ __, _.._ NO 2. DOES PATIENT HAVE RENAL DISEASE OR HAD A KIDNEY TRANSPLANT? ~ _ _, YES NO IF YES, COMPLETE C, IS PATIENT ENTITLED TO MEDICARE SOLELY ON THE nASIS OF RENAL DISEASE? IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? , _ __ YES IF YES, NAME OF GROUP PLAN: ,__,__,....__,____, ___, ______,_______ HAS PATIENT COMPLETED THE TWELVE 112) MONTH COORDINATION PERIOD? ,__ YES, STOP MEDICARE PRIMARY NO, SEE ABOVE GROUP INB PLAN YES NO ,__ NO 3. ARE SERVICES RELATED TO OR DUE TO AN AUTO ACCIDENT OR OTHER LIABILITY INCIDENT? _ YES ___ NO IF YES, COMPLETE B 00 WHAT TYPE OF ACCIDENT CAUSED THE ILLNESS/INJURY? _ AUTOMOBILE: INSURANCE COMPANY AND~LAIM NO, _ OTHER: SPECIFY WAS ANOTHER PARTY RESPONSIBLE FOR THIS ACCIDENT? NAME/ADDRESS OF RESPONSIBLE PARTY/LIABILITY INSURER YES NO 4. IS THIS ILLNESS OR INJURY WORK RELATED/BLACK LUNG? IF YES, EMPLOYER NAME AND ADDRESS AND TELEPHONE NO VES NO S. DOES THE PATIENT HAVE VA HEALTH BENEFITS THRU CARD I10'1174? 8. IS THE PATIENT A DISABLED MEDICARE BENEFICIARY UNDER AGE 8&? YES NO YES NO MEDICARE ASSIGNMENT FORM I REOUEST PAYMENT OF AUTHORIZED MEDICARE SENEFITS TO ME OR ON MY BEHALF FOR ANY SERVICES FURNISHED TO ME IY Oil IN HARRISBURG HOSPITAL. INCLUDING PHYSICIAN SERVICES I AUTHORIZE ANY HOLDER OF MEDICAL AND OTHER INFORMATION AIOUT MI TO-' MEDICARE AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR 8ENHITS FOR RELATED SERVICI ~'i:, J SIGNED, DATE , 1- TOTALS ~ ! i See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms ::ETAC" A"t~ !'lEt ,;~'" t.. 5 ":;R' ()!Ij ,. t.. PA ",'f;:" t "'L"'~[. I P.',',' '''.'11' 9__.'.00'." ; 94281608lJ SIlEI'IlERII. [lONAl.Il W . 05 01 95 , 06 MAKE CHECKS PAYABLE TO: .., 8\.l;'-I0 PE~-OD 00000 I 05:01 ':'fijrc'tt [' ;;\~IO~;5 '1 INP. , ,,--.---,.. --.... -- DENIm, ....G.O 1"'8uRA"'CE COVERAGE ::: L{f COKHERCiAC A-Z _~.c. --n:::.:....OONALD W SIlEPIlERD --.." t 3824 HTN VIEW RD 1 HECH PA 17055 o aRO~p ~o l__ 942816080 SHEPHERD OONALD W OATI DESCRIPTION SUHKAR OF CHARGES -- :QTY DESCRIPTION , 10 EHER VISIT" ASSOC : 66 LABORA TOR Y , 18 EKG, PHYS " CARD , 5 RADIOLOGY 'III PHARMACY , 25 H " S SUPPLIES 6 IV SOLUTIONS 5 OXYGEN/RESPIRATORY 3 R " C INTENSIVE CAlE 5 R " C SEKI PRIVATE I HISCELL 00,09,58,98,9 INS C o I I 20,22,2 40-4 70-7 8 9 I TOTAL CHARGES i' LA'I CI1AIllO,IFOfll U.R~-CE' ","'0 ~l~ ace,,", 'vOu 11th R Che ADD "O"'A~ lhi.-~.a 717 782 - 3680 I IIIARR I SBURO 11051' IT AL IlAIlRISBURO. PA. 17101 OAR HANS [_ .A.i . .'1 'oc,c"o ATTENTION I'ATlENT NGOl87589A TillS BILL IS FOR YOUR INFORHATION ONLY AS REQUIRED BY ACT 89 - COST CONTAINHENT COUNCIL. IT IS NOT -IINTENDED FOR INSURANCE PURPOSES AND IS NOT TO BE PAID BY YOU. YOU WILL RECEIVE A SEPARATE BILLING FOR ANY BALANCE DUE AFTER THE INSURANCE COHPANY liAS PROCESSED _IYOUR BILL AS AUTIlORIZED BY YOU. r-I~~~}~~i!~::~~~~]~~:~~~~~ I.R.S. 23'O~:T:~30N TOTA~ CHARGE-- -'.T COvERAGE 2ND CovE~AC)e 3RO COVERAQE AMOUNT --...-.....-1-.--..-.. ---.---.,..-.--- -'---~l'~-- , " f, AI10~NT 450' 50 2105: 00 2819' 00 545: 50 5436' 96 1043: 50 161: 50 675, 00 4830: 00 4600' 00 27: 00 ______1.__ , 22693, 96 ......1... , _1., ,I ..:EEP ""$ po~' (:1." ~C'~ '>'':)_R I:lECCRDS J.;:l'.' as C'~ uq, CE , c ..."'Ou.....'D....E 21 94 5 .., :: S:....An~lE ~A.E A'.~9u'" PA,C FO~1,l .,101' IIARR I SBUI\(; 1I0SI'IIAL PATIENTS BlRTHDATE BLUE CROSS GROUP NO KEYSTONE HEALTH NO, _~_,___..,__ BLUE CROSS CONTRACT NO SUBSCRIBER GROUP NO IENCLOSE AUTHORIZATION) MEDICARE PATIENTS: PLEASE COMPLETE QUESTIONS BEl.OW AND SIGN ANY QUESTIONS CONTACT HOSPITAL AT 782,3880 MEDICAL ASST, PATIENTS YOU MUBT BRING YOUR CARD WHICH RELATES TO THE DATE OF SERVICE TO HARRISBURG HOSPITAL CUSTOMER SERVICE OFFICE COMMERCIAL INS, FORWARD A SIGNED INSURANCE CLAIM FORM FOR PROCESSING CHAMPUS: RETURN COMPLETED AND SIGNED FORM ALONG WITH COpy OF CARDS MEDICARE . MEDICARE SECONDARY PAYOR COMPLETE' ___.._ _ ,..,,_, 1. IS THE PATIENT OR PATIENT'S SPOUSE EMPLOYED? EFFECTIVE DATE PART A HOSPITAL , PART B MEDICAL ,__,..___,_.._,__ YES _..___ NO IF YES. COMPLETE A ~ IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE? IF YES, COMPLETE C, IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? YES_NO IF YES. NAME OF GROUP PLAN: '..,.. _.. .._ '" _,__, _ _" YES ......, NO 2. DOES PATIENT HAVE RENAL DISEASE OR HAD A KIDNEY TRANSPLANT? [g _.. YES NO IF YES, COMPLETE C IS PATIENT ENTITLED TO MEDICARE SOLELY ON THE BASIS OF RENAL DISEASE? IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? ..,.., YES IFYES, NAME OF GROUP PLAN:_.... ,..,_..__.. '" ......______ HAS PATIENT COMPLETED THE TWELVE 112} MONTH COORDINATION PERIOD? __ YES, STOP MEDICARE PRIMARY ........ NO, SEE ABOVE GROUP INS PLAN YES NO __.. NO 3. ARE SERVICES RELATED TO OR DUE TO AN AUTO ACCIDENT OR OTHER LIABILITY INCIDENT? _ YES _.. NO IF YES, COMPLETE B I!l WHAT TYPE OF ACCIDENT CAUSED THE ILLNESS/INJURY? _.. AUTOMOSILE; INSURANCE COMPANY AND CLAIM NO _...... _ OTHER; SPECIFY ____......_..___.......... ..,_" WAS ANOTHER PARTY RESPONSIBLE FOR THIS ACCIDENT? NAME/ADDRESS OF RESPONSIBLE PARTY/LIABILITY INSURER YES NO 4. IS THIS ILLNESS OR INJURY WORK RELATEDiBLACK LUNG? IF YES, EMPLOYER NAME AND ADDRESS AND TELEPHONE NO YES NO 15. DOES THE PATIENT HAVE VA HEALTH BENEFITS THRU CARD ,IO,1174? 6. YES NO IS THE PATIENT A DISABLED MEDICARE BENEFICIARY UNDER AGE 88? YES NO Me[)!CAfle A!lSIGNMENT FORM I REQUEST PAYMENT OF AUTHORIZED MEDICARE BENEFITS TO ME OR ON MY BEHALF FOR ANY SERVICES FURNISHED TO ME BY OR IN HARRISBURG HnSPITAl, INCLUDING PHYSICIAN SERVICES I AUTHORIZE ANY HOLDER OF MEDICAL AND OTHER INFORMATION ABOUT ME TO MEDICARE AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR BENEFITS FOR RELATED SERVICE SIGNED _n DATE i "llll 0' ..~ , GARHANS l ~r-:~~:~ I IlISCII INP. If ~~''''IJ D"( B .l."Q 'ER co 05 '01 '95 00'00 i 05'01 INBuRANCE eO.ER.AGli Il QROuP '-I-O~- "Cl'e'" '-10 NG0187589A 11""111111 "'0'0 ~:::rl ~~ COHHERC IAL A-Z 0.0 I ,- , --rur -\ HARRISBURG 1I0SPlTAL HARRISBURG. PA. 17101 717 - 782-3680 . , , , T o OONALll W 3824 HTN HECI! PA SIIEPIIERD VIEW RD 17055 L,r - I l~i~~~~2r~6~~94 ;6~:~;:~ T01A~-cMARaE ',si"COVEMClE rND COVERAGE "----_._-,~---_. '----, 22693, 96 22666, 96 .....1... , 942 .1RD COVERAOI I.R.S, 23.De75.330N OONALD W PATIENT AYOUNT OAfI -------,---- ----.-- TOTAL CHARGES CEle'HtTION 27,00 ......"'.. , -----1--- , INSURA CE ---- CQVER GE BEFORE DEDUCTIONS 'OED CTIONS -- , , ------1--- -----1--- 22666: 96 , -----1--- , -----r-- , ------r-- , , , -----r-- -----r-- , , TqTAL DEDUCTIONS TqTAL BENItFlTS PAtlEN CHARG , , 22666: 96 22666: 96 ......~.. ......... ......... .....-.. .....-.. , NOT COVERED IY INSURANC 27, 00 , 27' 00 , , ------1-- -----,-- 27' 00 , .....,... PATIE T RItS,ONSIllLlTY , , 27' 00 , ......,... P~TIE T BALANCE 27: 00 27; 00 ......,... ..-.--.. __I J .III,.A'1 CH"AOU 110'11 I&Rv,CU R.E~D "(Ooceu'" "-0", v,~. IIlIClvl ACCI"IO"'A~ B.d.IJ :-1 TOTALS ~ i See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms -. I 717 - 782-]680 "EE''''''S~CR'c..rCIl'Gw~RECC!:l~S CE"'C" 41-.,:) !:IE'LR" h. & ~CR' 01. .,'" "...I)E"'! 'AtL':.ilr I ."""'lil I ',,'00'" ' 942816~8(J SIIEI'IIERlJ. 1l0N:Lll W ' m ' 01 '95 MAKE CHECKS PAVABLE TO: liAR II I SDU/t(; 1I0SI' I l^L 06 29 94 A:J'1'SS 0... SER;'C& . C ::~~, Un 21 94 C 6c....'nJE Q"f 5 'OAM .lId PATIENTS BlRTHDATE BLUE CROSS GROUP NO KEYSTONE HEALTH NO ___ BLUE CROSS CONTRACT NO SUBSCRIBER GROUP NO (ENCLOSE AUTHORIZATION) MEDICARE PATIENTS: PLEASE COMPLETE OUESTIONS BELOW AND SIGN ANY OUESTlONS CONTACT HOSPITAL AT 182,3880 MEDICAL ASST PATIENTS: YOU MUST BRING YOUR CARD WHICH RELATES TO THE DATE OF SERVICE TO HARRISBURG HOSPITAL CUSTOMER SERVICE OFFICE COMMERCIAL INS FORWARD A SIGNED INSURANCE CLAIM FORM FOR PROCESSING CHAMPUS: RETURN COMPLETED AND SIGNED FORM ALONG WITH COpy OF CARDS MEDICARE ~ MEDICARE EFFECTIVE DATE BECONDARY PAYOR COMPLETE ._...._.._,_..,.. PART A HOSPITAL__,_____' _'__,_, PART B MEDICAL ___,___ 1. IS THE PATIENT OR PATIENT'S SPOUSE EMPLOYED? ------.------.----------. ",____ - .. -_'.'0' _____.._ ___ .______._.___ __ YES NO IF YES, COMPLETE A, [!) IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE? ____ YES IF YES, COMPLETE C, IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? ..___ VES _ NO IF YES, NAME OF GROUP PLAN -----'..'-'-___u_...._______u_.. _.. NO ------_.~-.__..__.~~--- 2. ODES PATIENT HAVE RENAL DISEASE OR HAD A KIDNEY TRANSPLANT? ~ ..,___ YES NO IF YES, COMPLETE C, IS PATIENT ENTITLED TO MEDICARE SOLELY ON THE BASIS OF RENAL DISEASE? IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? _ YES IF YES, NAME OF GROUP PLAN: HAS PATIENT COMPLETED THE TWELVE (12) MONTH COORDINATION PERIOD? - YES, STOP MEDICARE PRIMARY NO, SEE ABOVE GROUP INS PLAN __ YES ___ NO _NO "._-_.~-_.._.. ...----------...-..-.,..., _,,_ YES NO ------_.__.,_._-~------_.__._._,,----_. 3. ARE SERVICES RELATED TO OR DUE TO AN AUTO ACCIDENT OR OTHER LIABILITY INCIDENT? - YES _ NO IF YES, COMPLETE B 00 WHAT TYPE OF ACCIDENT CAUSED THE ILLNESS/INJURY? -- AUTOMOBILE: INSURANCE COMPANY AND CLAIM NO, .. _ OTHER: SPECIFY , ._--_._-"._-~--_._----_.~---~~-_.__._..._-_._- WAS ANOTHER PARTY RESPONSIBLE FOR THIS ACCIDENT? NAME/ADDRESS OF RESPONSIBLE PARTYiLIABILITV INSURER __, VES ___ NO 4. IS THIS ILLNESS OR INJURY WORK RELATED/BLACK LUNG? _.-._--~-~._---_.__._-,.- "~'--------~.. ---.-..+------.---- ~---_.._._--_..~._. - ,_..,YES NO IF YES EMPLOYER NAME AND ADDRESS AND TELEPHONE NO, --~----_._._-- ...--...,--- ---., -_._-_...__._~-_..._- - - .. -......--. --,. ---.-----.-__..______ _. ____n_ __.______ .____,~___ __ '__..._ ____...__~..___.._ IS THE PATIENT A DISABLED MEDICARE BENEFICIARY UNDER AGE 85? __,..YES .. NO MI;PICARE A!;SlgNMENT FQI!M I REOUEST PAYMENT OF AUTHORIZED MEDICARE BENEFITS TO ME OR ON MY BEHALF FOR ANY SERVICES FURNISHED TO ME BY OR IN HARRISBURG HOSPITAL, INCLUDING PHYSICIAN SERVICES I AUTHORIZE ANV HOLDER OF MEDICAL AND OTHER INFORMATION ABOUT ME TO MEDICARE AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR BENEFITS FOR RELATED SERVICE, SIGNED ,__, '... _ DATE 'OAftol '''4,1; ! 'H'I OJ B'l. .. ~~~) [)A'e I,;. 0., a t:i~ 0:;; IlISCII 05 '0195 DO '00 05 'OJ INP. (jAltMANS "0' ~ i i i 10 8E~E"" i'G'O " 1~'uA"'Plie6 CO..'iJ;l"'lli i (lRD,," ~o "o..!e, "0 YII '0 yEt '0 YII '0 F,e I 5 ~ COltMERCIALA-l NGOI87589A DONALD II SIIEI'IIERl> 3824 MTN YIEII RIl MECII PA 17055 IIARRISBlJRG HOSPITAL HARR ISBURG. PA. 17101 717 - 782-3680 r o I, I, .OQ~ ~Q j .qM,;n~i1, 'j' 11, ~rH,,'.,~, '9 I l 1001-02 0621 :~94 06 ,29 ,9~ 'CTAl c~t~Qi is;' CO~El,~aEl'_""~C-COYE1~~~~- - ~3AD CO~'ET~_~.E.. , , , , , , OONALD II I.R,S. 23.08715.330N OAtt . DUCA.ptiOIo4 ..-'---.'T---.- -.... _...~.. SOCIAL SECURITY NO. - 283-44-85 3 BI~TII ATE - 11/16/47 SEX - M~ITA STATUS - M RAqE - II AMITT NG DOCTOR ATTEND NG DOCTOR - DRG CO E - 121 DI~GNO IS P 410.41 DIAGNO IS - 8 427.1 DI~GNO 15 - 8 413.P PROCEO RE - P 37.22 PROCEO RE - 0 88.56 PROCED RE - 0 88.53 PRI>CEO RE - 0 99.29 I PRINCI AL PROCEDURE DATE - 06/2~/94 , PRINCI AL SURGEON - 04005 GUTIE~El FELIX ADIIINI TRATION CLASS - I-EHERGiCY , DISCH GE STATUS - ROUTINE PO' ICY HOLDER EMPLOYER - DIHLER [TRUCKING PO~ICY HOLDER - DONALD II/l I GUCE AYS - 0 I CO~ERE DAYS - 000 i TRIA TH NT AUTIIOR lTY - I AP~ROY 0 fROM - I APPROY 0 TIIRU I p,r"., "''''OU~T ....--~-r--- 1903 GL-BR- 1033 GLUCK I I Y-SC-PA-B~-JO I CIIAEL: L I , OI674,8E IR/99tj I , I I I ., ~"'T' CI1A~OIl 'OR IER.',en "1I,jDfIlID oec",;" VO'~ Vn~ '" chi AOO",O".... Ih '- ~() , I TOTALS .. See Reverse Side If You Have Not Furnished Us Your Health Insurance In'ormatlon and/or Forms . t: 1 I 717 782168lJ 9:'~~':;~1I(l I SIlEI'III"tII.";:';~~':;l II MAKE CHECKS PAYABLE TO: II^H/l1 SlIlf/l(i 11115/' II ^' 06 29 94 ..[ ~p '" ~ 1': ,jj' '. "." '-I R "'~ - '..Il:_,& ::.f'...,- H iIi,',. 0<['.,1.11, '" ~ I'...f\' (;', ,.. '., "P.'.','l",' I o~ ...."j:'-,l.'f ;l::I,~ \i;SP. '!.tn, rf. r C "'0,," Oui J ""0) Z.:pOj 01 l)~ 11/\ 21 1)4 [:!iC '~Mi'H :;:"'t ~ ~ PATIENTS BIRTHDATE BLUE CROSS GROUP NO KEYSTONE HEAL TH NO . -, '------. .__.~..~"._-----_._-_._._._- BLUE CROSS CONTRACT NO, SUBSCRIIlER .~ '~'-"'- _._-.----~--- .. -. '--"~-'--"'--- GROUP NO '~-"'-'- (ENCLOSE AUTHoRIZ,A MEDICARE PATIENTS PLEASE COMPLETE OUEST IONS BELOW AND SIGN ANY OUESTloNS CONTACT HOSPITAL AT 782,3580 MEDICAL ASST, PATIENTS YOU MUST BRING YOUR CARD WHICH RELATES TO THE DATE OF SERVICE TO HARRISBURG HOSPITAL CUSTOMER SERVICE OFFICE COMMERCIAL INS FORWARD A SIClNED INSURANCE CLAIM FORM FOR PROCESSING CHAMPUS RETURN COMPLETED AND SIGNED FORM ALONG WITH COpy OF CARDS MEDICARE .... MEDICARE SECONDARY PAYOR r' COMPLETE., EFFECTIVE DATE PART A HOSPITAL._ . PART B MEDICAL .-----------..-----..--- . 1. IS THE PATIENT OR PATIENT'S SPOUSE EMPLOYED? -----..----._ 0-'.. . -_. YES "~ NO IF YES, COMPLETE A, ~ IS THE PATIENT ENTITLED TO MEDICARE ON THE BASIS OF END STAGE RENAL DISEASE? _, YES IF YES, COMPLETE C. IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? YES NO IF YES, NAME OF GROUP PLAN _. _ '..~ "'_ '__"'_"_'" _NO -------------....--..---------...----- --._-._-... -..-.---. _.-._--_.._~- - ----- ""', -- 2. DOES PATIENT HAVE RENAL DISEASE OR HAD A KIDNEY TRANSPLANT? [gJ ,-_, YES -_NO IF YES. COMPLETE C, IS PATIENT ENTITLED TO MEDICARE SOLELY ON THE BASIS OF RENAL DISEASE? IS THE PATIENT COVERED BY AN EMPLOYER GROUP PLAN? '._ YES IF YES. NAME OF GROUP PLAN. __.. _ '-'--'-~'-n'_.n"'__.n, HAS PATIENT COMPLETED THE TWELVE (121 MONTH COORDINATION PERIOD? --- YES, STOP MEDICARE PRIMARY '__ NO. SEE ABOVE GROUP INS, PLAN -YES ._NO _NO -----------...-------- .-...._.n________..._____. ~._________ 3. ARE SERVICES RELATED TO OR DUE TO AN AUTO ACCIDENT OR OTHER LIABILITY INCIDENT? -, YES -_. NO IF YES, COMPLETE B, f!J WHAT TYPE OF ACCIDENT CAUSED THE ILLNESS/INJURY? -- AUTOMOBILE; INSURANCE COMPANY AND CLAIM NO, __On -- OTHER; SPECIFY ..'--_nh ':.,- :; :-t1i ._-----..,_._._._~_._-..__._---.- --- WAS ANOTHER PARTY RESPONSIBLE FOR THIS ACCIDENT? NAME/ADDRESS OF RESPONSIBLE PARTY/LIABILITY INSURER; '-'.'''' YES -_NO ,'? -----------------...-------------..-------..- ---.-------..- - 4. IB THIS ILLNESS OR INJURY WORK RELATED/BLACK LUNG? (:, --,_, YES NO IF YES. EMPLOYER NAME AND ADDRESS AND TELEPHONE NO, _ '_ ~'___", -------.-----.-----. - ----------- .... -...---------------...------ -._-- ---._----- --- - - ----- -- ---- ..--- '-.- -..------------------. ..----------.--..----...--.. ._-~_.._---._-----_..- "--'-~,,-----, .- --._---.-. 'n, YES _n NO IS THE PATIENT A DISABLED MEDICARE BENEFICIARY UNDER AGE es? .~---.....----__._..._u__._.. _ ---_,yES --~_NO -.------..-.,-------- _.~-~-+-.. MEPIC~~" ~l!!IIGNM"NHQ~M I REOUEST PAYMENT OF AUTHORIZED MEDICARE BENEFITS TO ME, OR ON MY BEHALF FOR ANY SERVICES FURNISHED TO ME BY Oft IN HARRISBURG HOSPITAL. INCLUDING PHYSICIAN SERVICES I AUTHORIZE ANY HOLDER OF MEDICAL AND OTHER INFORMATION ABOUT MI TO' MEDICARE AND ITB AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR BENEFITS FOR RELATED SERVICE, 11 ;; SIGNED DATE. ---,- _I . --_.._---------~_.~ . ;, F I ! ' . , lii.< I;;', \' , -~a,.~? , p-:,'4 l' ...,,~::;....;.,,~...~.(: r-.-e:;'~ J." S, ...~.---:'. \.~ 'I j i , .---/ ~- -' ~/./!//.' 1_ /'7-1-'" / ~y' V vi' . ,'?- '- \,..-V V J 3..... (I( j-- '--+~L'-' (I, h..u,..., IJ!f'7' " iil ,. If.i 1'!'!I' 'i '. I.i' ': IJ i I''': , " i ,.~ i :,;'1 ; 'Ii- ,j, !. .j I' 1'-j " , , !lI'li"ll ":i I:,' :'!li 'Jlfi , j, i!' I; ,,' ", I-II t\ h; ~ '. rll. . ~ ' " , ~; f': t " ! ! , , ! , ! i ~ ^' . . ' ..-af;-rt"'~'''''''/ 1 ,.;;:.;;' ~ . , ~ ,,,..~.€< . . . ,-~ ;(:'/' , , __/ ~~1 r/J-1W '/ , / ' 'f):~ ,I(~'// " '. t t; oJ ~'I'( 9....,,'- ., ) '-/"/L. (. )It...." , .- A("..- , r I IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HARRISBURG HOSPITAL Plaintiff No. 96.3128 CIVIL TERM vs, CIVIL ACTION. LAW DONALD W. SHEPHERD and AMY C. SHEPHERD, Defendants JURY TRIAL DEMANDED PRELIMINARY OBJECTIONS AND NOW, thls'yr' \\~ay of "",fu~.1 , 19~") comes the \ Defendants, Donald W. Shepherd and Amy C. Shepherd, by and through their attorneys, Frankel, Bare & Associates, Douglss R. Bare, Esquire, and flies the following Pralimlnary Objections to the Plalntlff'B Complaint: 1. In Count III of the Complslnt, the Plaintiffs allege that Amy C. Shepherd has a statutory obligstlon to pay the alleged outstanding balences. 2. Paragrcph 18 /Il1eglls that r.~rt of thl'l Btatutory obligation la based on Title 23 Pa. C,S.A, S4321. 'UNKll .ANI . A..OC1AlU AtTONHIU At LAW I. WII' KINO ,"'n' Y(iI"1I PINh"LV"kIA 1'.01 3. AB a matter of law, In paragraph 19, the Plaintiff improperly relies on S4321 10 support lIS cause of action agalnsl Ihe allaged wife, Amy C. Shepherd, I' l4 f 'to." 4. AI a mattar of low, 14321 does not ptovldo eufflclent legal balls for the Plaintiff to form a ceuse of action agelnBt the Defendant, Amy C. Shopherd. Thereforo, any couse of action based on the Btatutory claim Bhould be dlBmlssed. 6. Tltla 23 Po. C.S.A. 14321 Is legally Inapplicable under the clrcumstancas. Undar the guidelines and caselaw Interpreting 14321, the alleged wife, Amy C. Shepherd, has no flnenclal responsibility or obligetlons to provide any payment or support to her alleged husband, Donald W. Shepherd. 8. The Plaintiff has felled to allege and establish 01 a matter of law eny financial dependence of Donald W. Shephard on Amy C. Shepherd. 7. The Plaintiff has failed to provide and attech to the Complaint any signed documents or elleged contracts which form any basis of the claim ageinst the Defendants. 8. In Ccunt II of the Complelnt, the Plaintiff Improperly alleged a I'''AHKIL, .ANI . A..CCIATII ""ONHnl AT LAW .. WI.T "INO iTN11T '0"" 'INN'~L"''''HI''' IUOI "doctor necessities" which does not form a proper legal basis for which Plaintiff can meke a claim egainst the alleged wife, Amy C, Shepherd, and for whioh Plaintiff hOB foiled to Itate a ceule of action for which relief con be granted. 2 WHEREFORE, the DefendentB respectfully requeBt that the Plelntlff'e requested relief be denied. Respectfully Submitted, FRANKEL, BARE. ASSOCIATES --" 14 WeBt King Street P.O. Box 1389 York, PA 17405-1389 (7171 854-3836 3 ,.IAHUL, BAAl. A..OCIATES AnORNIYI At LAW ,. WilT KI~O ITRllt 'fOIl" ~I~N.'LY"'NI" 'HOI IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HARRISBURG HOSPITAL Plalntl If No, 95-3128 CIVIL TERM VB. CIVIL ACTION. LAW DONALD W. SHEPHERD and AMY C. SHEPHERD, Defendants JURY TRIAL DEMANDED CERTlFI QAtILQE SE RVICE I, Dougles R, Bare. Esquire, of the law firm of FRANKEL, BARE III ASSOCIATES. attorneys for Defendants, do herBby certify that I am this day sBrvlng a copy of the foregoing Preliminary Objections upon the counsel of record In the following manner. BY REGULAR MAILi Arthur A, Kusic, Esquire 4201 Crums Mill Road P,O. Box 67015 Harrisburg, PA 17112 Dated: July 28, 1995 o , B 1.0, #43877 Attornev for Defendants 14 West King Street PO Box 1389 York, PA 17405-1389 (7171 854.3836 '''ANMIL, IA"I . AIIOCIAtll Af10'U~I'tI "T L.AW t. WII' tll~Q .,,,.U .0".. ~'''''nL~.t,I'(I. 1'401 VERIFICATION I verify thet the statements made in this o are true and correct. I underBtand that false statements herein are made subject to penaltleB of 18 PA C.S. 14904, relating to unsworn falsification to authorltlee, if) / ,~,) Date C( \5- 'J/~,tt(/! t~~. s:i;1d-~- '(11t;lant (I Jlt)~ IN '1'111,; ('OUH'I' OF ('()fH'lllN I'I.L^l; UNIlI';IlI.^NIJ ('(llJN'I'Y, I'I-:tmS I' I.VMJ ('IV II. ^(""lllrJ l.A\'i tW. 'i', , JI.'1l ('lvII '1'",," 1'^1l1l1 SIIlJIl(; 1I1l:;!' 1 'l'^1. V. IlllrJ^"fl \'1. :;III:J'lIi':1W MJIJ MIl' c'. :;III:I'III:IW NSWLIl 1~ PIlELININ^HY UUJEC'I'l N 'ER'I'IFIC^'I'L OF SERVICE I tl, " r Itil,. Hldl t!iI' ~11:ilil 1"1 r I , d ! I !~ ,it "J ')I ~ 1 '. I I j II)' d /, l' 1."+"'1[;,11 tlll'd Ifl 1I11'-~ r'li'''l. Y \ \.i "r!' 1\, '/ "I, i I :. t I' <t' . ~., I: 11'-.; ; '-J "t I ,'.11 J I I j,l' L' r; 1.' I 11 . ,I ~ I!". ): I ,-, t',.. r I' "\;" I..'dl 1\/ i.'If'f-nl. II ,) i l ," I~",.! ,-j-i';/J,t, ,'I I 'f Ii'.! r" Ii I 1,'J",l Hil-', II. I. J ARTHUR A, KUSIC Al101U1!)'ATIAW .f?UII.III!W" Mill. 111 ,,\p I' t) fl, J( fill J\ I~, HMlill'l/l!ilil, 1'1 'j'h'l VM,IA I J IOll.IO!!} 1/11! ~,1u '-:;b l(l HAlII.BUIO 10'PITAL, 'laintiff . 1M TI. OOUIT or OOKMOM 'L.A' . OUMI.ILAWO OOUITY, P....YLVAWIA . . OIVIL AOTIOI - LAW . MO. '1-311' OIVIL T." . . . v. DOIlLO .. II.'I.RD AWD JUly O. '..'"110, Oefen4anh 11I.1. TO '.ILIMIMAlY OIJ1Q7XQ11 AND NOW comes Plaintiff by and through its attorney Arthur A. ~usio, Esquire and, inoorporating herein by reference thereto the averments set forth in paragraphe 1-25 of Plaintiff's Complaint, respectfully makes its Answer to preliminary Objections ae followsl 1. Admitted. J. Admitted since said statute states that married persons ars liable for the eupport of each other. Ilowever, any implioation that Count III of Plaintiff's Complaint rests solely upon said statute is danied. By way of further answer, the statute upon which Plaintiff reliee ie 23 Pa.C,B.A. 4102, whioh states as followSl "In all oases where debts are contracted for necessaries by either spouse for the support and maintenance of the family, it shall be lawful for the creditor in this caee to institute suit againBt the husband and wife for the price of the necessaries." 3. Defendants set forth a conclusion of law to which no answer is required. Ilowever, should an answer be required then Plaintiff specifically denies Defendants' allegation and avers to the contrary that paragraph 19 of Plaintiff's Complaint relies on 23 Pa.C.S.A. 4201. By way of further answer, Plaintiff incorporates herein by referenced thereto the avermsnts as hereinabove set forth in paragraph 2. 4. Defendants set forth a conclusion of law to which no answer is required. However, should an answer be required then Plaintiff specifioally dsnies Defendants' allegation and avers to the oontrary that Plaintiff's causs of action based upon statuts should not be dismissed. Plaintiff belisves and therefors avers that 23 Pa.C.S.A. 4201 provides suffioient basis to hold both husband and wife liable for the debts of the husband in the instant oase. 5. Defendants set forth a conolusion of law to which no answer is required. However, should an answer be required then Plaintiff speoifioally denies Defendants' allegation and avers to the oontrary that Defendant Amy shepherd is liable to Plaintiff under 23 Pa.C.S.A. 4201 if not also under 23 Pa.C.B.A. 4321. 6. Defendants set forth a conolusion of law to which no answer is required. However, should an answer be required then Plaintiff admits that it has not set forth the financial dependenoe or independence of Defendant Donald Shepherd. However, Plaintiff believes and therefore avers that suoh dependence or independenoe is immaterial to the liability of Defendant Amy Shepherd to Plaintiff for the necsssary medical services rendered her husband. 7. Plaintiff admits that it has not attached a signed contraot to the Complaint. However and by way of further answer, Plaintiff attaohed itemized billinge setting forth the services Plaintiff did provide to Defendant Donald Shepherd with the reasonable expeotation that it would be compensated for euch services. 8. Defendants eet forth a conclusion of law to which no answer is required. However, should an answer be required then Plaintiff speoifioally denies Defendante' allegation and avers to the oontrary that the dootrine of necessaries, a common law doctrine, subsequently codified in 23 Pa.C.B.A. 4102, does indeed form a proper legal basis for Plaintiff's claim against Defendant Amy Bhepherd. Plaintiff believes and therefore avers that it has eet forth a cause of action for which relief may be granted. WHEREFORE, Plaintiff prays your Honorable Court to dismiss Defendants' Preliminary objections and to allow the case to proceed. RESPECTF9LL'C ,,"' , ~;;~;~: K S , ESQUIRE 4201 Crums Mill Road HarriSburg, PA 17112 (717) 540-5610 Supreme Court No. 07207 Attorney for Plaintiff v. . II TH. COURT or COMMOI PLIA. . CU...RLAlD COUITY, P....YLVAlIA . . CIVIL ACTION - LAW . NO. 11-3121 . . . ....I..URG HO.'ITAL, 'laintiff DONALD W. ...'..ID AID AlY O. ...'...D, Defenclant. V.lIfICATION I, HARRY PARK , the TEAM LEADER of Harrisburg Hospital verify that the statements made in the Answer to Preliminary Objections are true and correct and that I am authorized to make this Verification on behalf of Harrisburg Hospital. I understand that false statements herein are subject to the penalties of 18 Pa. C.S. section 4909, relating to unsworn falsification to authority. HARRISB~G HOSPI~ By: ~ .,,~ rtUel EAM LEADER Datel 8/7/95 HARRISBUEG HOSPITAL IJla lilt It'f v. DONALD W. SHEPHERD AND AMY C. SHEPHERD De fendallt : IN /fit: l,'()/llll 0/ COMMON I'U.A,S : CUMUERLANif-'OUNIY. I'fNNS'r'L VANl A CIVIL Ac:TION' LAW NO. 95-3126 Civil '1'erm CEIHIF1CATE OF SfRVICE f. A,rthur A. I\lISIC. EsquIre. do herebY certlf,v that on thIS 9th d.~.v of August . I~j 95, r placed III the UnIted States Mall true alld correct cople< of AnBwer to Preliminary Obj~ctions with firBt class postage affixed and addressed to fo 1101'1 I n9: Douglas R. BAre, Esquire FRANKLE, BARE & ASSOCIATES 14 Weet King Street York, PA 17401-1413 ;;.0.;:"), ) ) \"A~~r~~IC, ESQUIRE 4201 Crume /01, II Road P.O. Box 11585 Harrisburg, PA ,7',2 ( 7/7) 540-56 to A,ttornev for the PlaIntiff Supreme Court I.D. 07207 ""ANK~L, .AIl~. AS.OCIATE. ATTO"NUI AT LAW 14 WilT 'UNO ITRIIT 'f0"" PIHN.VL\I'ANIA 11401 }, , I" (\ I \, , I ( I { i I / (, t,., t. \' (~ I .,....., , ~ugtas:" '-:>'! 1.0. #43877 Attorney for Defendent ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HARRISBURG HOSPITAL Plaintiff No. 96-3128 CIVIL TERM VB. CIVIL ACTION - LAW DONALD W. SHEPHERD and AMY C. SHEPHERD, Defendants JURY TRIAL DEMANDED DATE: August 10, 1996 -- f"l ,...., or_ a:~: ~:;', I t;tl~ ,. W . "r. 1\1 . ._.' 1\ .... h _.L'"'\ N f';~ n -0 l..,.~.l" :s :-.~ .. .< " , .~, !i -.~ TO: Pioneer Life Insurance Company ATTN: Attorney LiBe A. Day, Associate Counsel 304 North Main Street P.O. Box 120 Rockford, IL 61106-6000 t:ft NOTICE You are hereby notified that Donald and Amy Shepherd have Joined you es an additional Defendant in the above referenced action which you are required to defend. Respeotfully Submitted, FRANKEL, BARE II ASSOCIATES c.' ---.~ ,.e ;, '", (t ....Jl I ~ /\;,1", I d ( If 1;1 14 West King Street P.O. Box 1389 York, PA 17406-1389 (717) 864-3836 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HARRISBURG HOSPITAL Plaintiff No. 96-3128 CIVIL TERM VB. CIVIL ACTION - LAW DONALD W. SHEPHERD and AMY C. SHEPHERD, Dafandants JURY TRIAL DEMANDED CERTIFICATE OF SERVICE I, Douglas R. Bare, EBqulra, of the law firm of FRANKEL. BARE. ASSOCIATES, attornays for DafendantB, do heraby cartlfy that I am this day Bervlng a copy of the foregoing Notlca upon the counsBI of record In the following manner. BY CERTIFIED MAIL-RETURN RECEIPT REQUESTED: Pioneer Life Insurance Company ATTN: Attorney Lisa A. Day, Associate Counsel 304 North Main Street, P.O. Box 120 Rockford, IL 61106-6000 BY REGULAR MAIL: Arthur A. Kuslc, Esquire 4201 Crums Mill Road P,O. Box 67016 Harrisburg, PA 17112 Dated: August 21, 1996 FRANKEL, BARE . ASSOCIATES " ,"1 , " -'~'-- ~-:gl~-e~=;ti{;~fl~b~ ~' Attorney for Defendants 14 West King Street PO Box 1389 York, PA 17406,1389 (717) 864,3836 '"AHKIL, .AI.. . A..OCIAT,. AtTO"~IY' AT LAW ,.. WI" KINO l"tllT laNK PIN""lVANIl\ 17401 c__ e ~ :{. . , . , % f; f f I l- i J ~ I; i~~1 ~ n ~ i ~ ... .I~ i!~ i : ii · Ii J R I! I! .~III , III . r~~ ., . ,. . .' 'I . , . f. ..' ; -4' . . -' ., ... .. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HARRISBURG HOSPITAL, Plelntiff No. 96-3128 CIVIL TERM VB. CIVIL ACTION - LAW DONALD W. SHEPHERD and AMY C. SHEPHERD, Defendants JURY TRIAL DEMANDED vs. PIONEER LIFE INSURANCE COMPANY OF ILLINOIS, Additional Defendant DEFENDANTS' COMPLAINT AGAINST ADDITIONAL DEFENDANT (.I +~ AND NOW, this \ day of November, 1996, come the Defendants, Donald W. Shepherd and Amy C, Shepherd, by end through their attorneys, Frenkel, Bere & Associates, Douglas R. Bere, Elqulre, and file the following Complaint against the Additional Defendent: 1. Defendants, Donald W. Shepherd and Amy C. Shepherd, are adult merrled Individuals residing at 3824 Mountain View Road, Mechanlclburg, nANKIL, 8AIII . U80CIATU _"O"HIV. AT LAw "wier KING ITAIIT '0"" 'IHNW"LVANIA 17401 Cumberlend County, Pennsylvania 17066. 2. The Additional Defendant, Plonear Life Insurance Company of illinois, Is a Corporation authorized to IBsue health Insurance policies in the Commonwealth of PennBylvanla, having one of Its principle places of bUllnele at 304 North Main Street, Rockford, illinois, . " 3. The Plaintiff instituted this action against the DefendantB alleging that certeln monies were duo the Plaintiff for having provided health care servlceB to the Defendant, Donald W, Shepherd, on or ebout June 21, 1994. A copy of Plaintiff's Complelnt Is attached aB Exhibit A, 4. The Defendant had tondered to the Additional Defendant the sum of thirteen hundred sixty dollars ($1.360.001 which was accepted by tha Additional Defendant for Policy No. NG0187589A and which Insured the Defendants agalnet 1088 by reason of expendlturee for surgical procedures and hOBpltel relldence Incurred by the Defendant. 6. While the above doscrlbed policy was In full force and effect the Defendent Incurred hospital expenses In the sum of twenty-one thousend seven hundred forty-nine doll ere and ninety-six cents ($21,749.96). 6, Under the terms of the policy (a sample duplicate copy of which Is attaohad hereto and marked Exhibit BI, the Addltionel Defendant IB liable to the Defendent for his hospltel ex pen see of twenty-one thouBand seven hundred forty-nine dollers and nlnetY'Blx cBnta ($21,749,961. .,. The Additional Defendant has rejected the Defendant'B claim for paymBnt and although due demand therefore has been mede by the Defendant, the Additional Defendant fal/ed and refused and etlll faUB and refuses to pay '''ANKlL .A"l . A..eCIAtu Defendant's hospital claim or any part thareof, .nONHIYI AT LAW '4 WIlT NINO 1f"lIt \'0"" ".NJiIII'fL'IAH'A 17401 " . . WHEREFORE, the Defendants, Donald W. Shepherd and Amy C. Shepherd, demand: 1. Judgment In their favor together with COStB. 2. Judgment that, if there Is any liability to tho Plaintiff, the Additional Defendant, Pioneer Life Insurenca Company of IIl1nolB, Is solely liable to the Plaintiff. 3. In the event that a verdict Is recovered by Plaintiff against the DefendantB, that Defendents, Donald W, Shepherd and Amy C. Shephard, may have Judgment over and against Additional Defendant, Pioneer Life Insurance Company of illinois, by way of Indamnlflcatlon and/or contribution for the amount recovered by Plaintiff against Defendents together with cOltS. 'NANKIL, IAN I . AUDelAnl AnO"Nna AT LAW 14 WI.' KINO ''''IIT ,"O"IC 1I.I'l"'IVI.VANrA 1'401 Respectfully Submitted, FRANKEL, BARE. ASSOCIATES ~r~~ ~ (( 1S~ DougleB . Bare, Esquire 1.0. #43871 Attorney for Defendants 14 West King Street P.O. Bo)( 1389 York, PA 17406- 1389 (7171864-3836 J VERIFICATION I verilv that the statoments made In this COMl'LAIN'r are true and corroct, I understand thaI false slatemontB heroin are made subject to penalties of 1 B PA C,S. !i4904. rolaling 10 unsworn falsification to authorities, ~'ft; v~ (, , Date If?~ ---- /1 . l /' (\ J--; 71 .~ ~A. y '.,({'" u' Donald Shepherd , /JJ , / /9'1<'- :.JJ..<1~:_L.i ...:..J__L, Datl.' U21~'I~ \ /;t2,J~ki_,_ l\fj1v ~Pi?8rd .. , . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HARRISBURG HOSPITAL Plaintiff No, 96-3128 CIVIL TERM vs, CIVIL ACTION - LAW DONALD W. SHEPHERD and AMY C. SHEPHERD, Defendants JURY TRIAL DEMANDED VS. PIONEER LIFE INSURANCE COMPANY OF ILLINOIS .Q,ERTlfICA TE OF SERVICE I, Douglas R. Bare, EBqulre, of the law firm of FRANKEL, BARE. ASSOCIATES, attorneys for DefendantB, do hereby certify that I am thiB day Bervlng a copy of the foregoing Notice upon the counsel of record In the following manner. BY REGULAR MAil: Pioneer Life Insurance Company ATTN: Attorney Lisa A. Day, ABsociate CounBel 304 North Main Street, P.O. Box 120 Rockford, IL 61106-6000 '''.NHIL .."1. "..OCIATlle AnONNIU AT l.AVW ,.. WI.' KINO I'''IIT YO"" 'I"'''''YLVAN'A 11401 Arthur A, KUBic, EsqUire 4201 Crums Mill Road P.O. Box 67016 HarriBburg, PA 17112 Dated:~~ q ~- FRANKEL, BARE & ASSOCIATES -I' -'') )--::> -\-t' v ~<;..,.... \ - , f-.... . Douglas R. Bare, Esquire 1.0. #43877 A ttorney for Defendants 14 WeBt King Street PO Box 1 389 York, PA 17406-1389 (717} 864-3836 IIARRISBURO 1I0SPITAL, Plaintiff IN THE COURT OF COI~I~OI~ PLEAS CUMBERLAND COUIHY PENI~5YL VAN I A DONALD AMY C. V. N. SHEPPARD and SHEPPARD, Defendant s CIVIL ACTION - LAW 1m. q(j - 31"J.~ C~~k..l~Y'- I'iQ 11 CJ; You have been sued In court. If you wish to defend against the claims set forth in the following pages, you must take action within tWBnty (~O) days after this Complalnt and Notlce are served. by entering a written appearance personally or by attorney and filing in wrltlng with the court your defenses or objectIons to the claims set forth against you. You are warned that if you fa i 1 to do so, the case may proceed without you and j udgmellt may be entered against you by the court without further notice for any money claimed In the COmpla1Jlt for any other claim or ,.ellef requested by the Plaintiff. You may lose money or prC'pert:1 or other rIghts important to you, YOU SHOULD TA~E THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU 00 NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT W~ERE YOU CAN GET LEGAL HELP. LA\~YER REFERRAL Cumberland Co. Court Admin. Fourth Floor One Courthouse Square Carlisle, PA 17013-3387 (717) 240-6200 Resoectflll"'y sllbm1tted: ~'~ ....... ;<'1"-, , ~ ' ~'"."I Jilc,' "ESOUIRE 4201 Crums Mill Road Post Office Bo. 67015 HarrlSbJrg, PA 17112 (717) 54(1-5610 SUPREME COURT NO. 07207 ATTORIIEv FOR PLAIllTIFf: Dated :~\~t~( ~vd ~ {p-It.; EXIIIOI'l' ^ - HARRISBURG 1I0SPITAL, PlaIntIff IN THE COURT OF COMMON PLEAS aMlDUl~v COUNTY PENNSYLVANIA CIVIL ACTION - LAW V. DONALD W. slIEPPARD and AMY C. SHEPPARD. Defendantl tJO. tJ_QnG.H~ Le han demand ado a usted en 1 a corte. S 1 usted qu i ere defenderBe de estas demandas expuestaB en las paginas s1gu1ente8, usted tlene Vlenta (20) diu de plazo al partir preBentar una aparlenCla escrlta 0 en persona 0 por abogado Y arch1var en la corte en forma escrlta sus defensas 0 sus objeclones a laB dBmandaB en contra de su persona, Sea aVlsado que S1 usted no sa def1ende, la corte tomara mealdas Y puede entrar una orden contra uBted sin prevIa aV1S0 0 nat1flCaclon y Dor cualquler queja 0 allvlo Que BB pedldo en la petlC10n ae den13nda. usted pUlice perder dlnero 0 sus proPledades a otros nerechos lmportantes para usted. LLEVE ESTA OEt.\ANDA A UtI ABOGADO INI~EDIATAI~ENTE. 51 NO TIEtlE ABOGAOO 0 SI I/O T1EIJE EL OINERO SUFICIEtHE DE PAOAR TAL SERvlCIO, vAYA Eli PERSONA 0 LLAME POR TELEFO~O A LA OFICINA CUYA DIRECCION sE EliCUEflT~A ESCRITA ABAJO PARA AVERIGUAR CONDE SU PUEDe CONSEGUIR ASlSTEf,~IA LEGAL: Respectfully submitted: LAWYER IIEFERRAL Cumberland Co. Court Admin, Fourth Floor One courthouse Square carlisle, PA \701 )-)]87 (7171 HO-6200 -' ARiHUR . l<.US 4201 Crums MIll Roed Post office Box 67015 4arr1sburg. PA ,7112 (717) ~40-!:-6'O SlJPREI~E COURT NO. 01207 ATTDRIlEY FOR PLAINTIFF lJHec.JU~~~,\ - ' " HARRISBURG HOSPITAL/ Plaintiff IN TilE COURT OF COKMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA I I I I I I I I NO. V. CIVIL ACTION - LAW DONALD W. SHEPPARD and AMY C. SHEPPARD, Defendants h COM P L A I N T AND N01~ comes Plaintiff by and through its attorney, Arthur A. Kusic, Esquire, and respectfully represents the following I 1. Plaintiff, HARRISBURG HOSPITAL, is a hospital facility organized and existing under the laws of the Commonwealth of Pennsylvania located at South Front street, Harrisburg, Dauphin County, Pennsylvania. 2. Defendants, DONALD W. SHEPPARD and ~1Y C. SHEPPARD are adult married individuals residing at 3824 Mountain View Road, Mechanicsburg, Cumberland County, Pennsylvania 17055. 3. On or about June 21, 1994 through June 29, 1994, Plaintiff, at the request of the Defendant Donald l~. Sheppard, did provide health care services to said Defendant. 4. Plaintiff in good faith provided the necessary health care services to the Defendant, Donald l~. Sheppard and thereafter billed Defendants its usual and customary charges for the services rendered. As evidence thereof, a copies of the billing for services render':.~ to Defendant, Donald I~. Sheppard are attached hereto, made a part hereof and marked Exhibit "A". 5. Plaintiff did credit Defendants' account with all ;/<J" payments made on the account and there now remains a balance dUe and owing of $21,749.96. 6. Plaintiff avers that the amount due and owing does not exceed the jurisdictional amount requiring arbitration referral by local rule. COUNT I. (Plaintiff v. Donald W. Sheppard) (Quantum meruit) 7. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 6. B. Plaintiff did render health care services to Defendant with the reasonable expectation that payment for such services would be made by the party benefitted. 9. Should Defendant not be required to pay for the balance'due for the servicee rendered, Defendant would be unjustly enriched at Plaintiff's sXpense. 10. Plaintiff avers that the amount due and owing does not excesd the jurisdictional amount requiring arbitration referral by local rule. WIIEREFORE, Plaintiff pray your Honorable Court to enter Judgment in its favor and against Defendant Donald W. Sheppard in the amount of $21,749.96, al~hg with interest at the rate of 6\ per annum and the coats of thie proceedin~. COUNT II. (Plaintiff v. Amy C. Sheppard) (Doctrine of necessaries) 11. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 10. 12. Plaintiff believes and therefore avers that the health care services rendered, upon request, to Defendant Donald W. Sheppard, husband of the Defendant Amy c. Sheppard, were necessary for his benefit and welfare. 13. Plaintiff believes and therefore avers that pursuant to the "doctrine of necessaries", Defendant Amy c. Sheppard, as spouse of the recipient of health care services, is liable to Plaintiff for the balance due. 14. Should Defendant Amy c. Sheppard not be held liable to Plaintiff for payment of services rendered her husband, she would be unjustly enriched as the services were necessary to benefit the health and welfare of her spouse and their marital union. 15. Plaintiff has made demands for payment upon Defendant, which demands remain unheeded. 16. Plaintiff avers that the amount due and owing does not exceed the jurisdictional amount requiring arbitration referral by local rule. WHEREFORE, plaintiff prays your Honorable court to enter Judgment in its favor and against Defendant Amy C. Sheppard in the amount of $21,749.96 along with interest at the rate of 6\ per annum and the costs of this proceeding. COUNT II I . (plaintiff v. Amy C. Sheppard) (statute) 17. plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 16. 18. pursuant to 23 Pa.C.S.A. 4321, married persons are liable for the support of each other. 19. pursuant to 23 Pa.C.S.A. 4102, where debte are contracted for necessaries by either spouse, a creditor may institute suit against the husband and wife for the price of the necessaries. 20. plaintiff did render necessary health care eervices to Defendant Donald W, Sheppard with the reaBonable expectation that such servicss would be paid for by the persons bsnefitted, which in the inBtant case includs said Dsfendant and hiB epouse, Defendant AmY c, Sheppard as partner in ths marital union. 21. Plaintiff has made demands for payment upon Defendant, which demands remain unheeded. 22. Plaintiff avers that the amount due and owing doe. not exceed the jurisdictional amount requiring arbitration referral by local rule. WHEREFORE, Plaintiff prays your Honorable Court to enter Judgment in its favor and against Defendant Amy C. Sheppard in the amount of $21,749.96 along with interest at the rate of 6% per annum and the costs of this proceeding. COUNT IV. (Plaintiff v. Donald W. Sheppard & Amy C. Sheppard) (Total) 23. Plaintiff incorporates herein by reference thereto the averments hereinabove set forth in paragraphs 1 through 42. 24. Plaintiff has made demands for payment upon the Defendants for the balance due of $21,749.96, which demands remain unheeded. 25, Plaintiff avers that the amount due and owing does not exceed the jurisdictional amount requiring arbitration referral by local rule. WHEREFORE, Plaintiff prays your Honorable Court to enter Judgment in its favor and against Defendants in the amount of $21,749.96 along with interest at the rate of 6% per annum and the costs of this proceeding. DATEDl RESPECTFULLY ,/,~' ....,:;i Arth r A,'Kusic, E quire 4201 Crums Mill Road Post Office Box 11585 Harrisburg, PA 17108 (717) 540-5610 Supreme Court No. 07207 Attorney for the Plaintiff ..... HARRISBURG HOSPITAL, Plaintiff IN 'rilE COURT OF COKMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW V. I I I I I I I I NO. DONALD W. SIIEPPARD an4 AMY o. SHEPPARD, Defen4ants y E R I F lOA T ION I, HARRY PARK I the SUPERVISOR. OF CREDIT & COLLECTION of HARRISBURG HOSPITAL verify that the statements made in the COMPLAINT are true and correct and that I am authorized to make this Verification on behalf of HARRISBURG HOSPITAL. I understand that false statements herein are subject to the penalties of 18 Pa. C. S. Section 4904, relating to unsworn falsification to authority. HARRISBURG HOSPITAL ~. ~ BYI ~ TITLEl SUPERVISOR DATEl 5/18/95 -- ~ . \ - " " , . B:X:II:D1 I:T .. l\ .. T'J!lO;-!~l-fll~",,:'}:~.t- 1 ,r" 'I't=:., 1 ~~~~~ ~:I,~_l()O,~(Jfl_~S_:O_~_ --'-- _ I .::~". .:: 0 Cii~E~~~Cffc~~i-- --~~~~- - I\d;[~~j3~89i" "II ~o "'II "0 ----------- '---" .-------- ~e r -, , t I " ~. , o L DONALD W SHEPHERD 3824 MTN VIEW RD MECH PA 17055 . " '-,/ 942816080 SHEPHERD DONALD W CUCA''!,O'' o MfoIO 1001-02 27,00 1610: 00 88' 00 27: 50 16' 50 7: 50 6' 50 13: 00 143' 00 148 50 i 31,00 I 36' 50 36: 50 30' 00 28: 00 28' 00 31: 00 56: 00 27' 00 61: 50 36 50 ! 34: 50 47' 50 , 27,00 36: 50 114; 00 134: 00 88' 80 18: 72 4' 00 , 2,00 5: 00 5,58 5' 58 liJ GARMANS 1-~.i~J HARR I SBURO HOSP IT AL HARRISBURG, PA. 17101 717 - 782-3680 I,R.S.23.0676.330N 00 T01"L c~,VIOI 'IT CO\"".t..QI 11,i0 CO\'IJUGI 2,A:) covtlVoQI ..W', "MOUNT -.-J "' 1610: 00 88' 00 27: 50 16' 50 7: 50 6' 50 13: 00 143' 00 148, 50 I 31: 00 36' 50 36: 50 30 00 28: 00 28: 00 31,00 56: 00 27, 00 61: 50 36' 50 34: 50 47' 50 , 27,00 36: 50 114,00 134: 00 88' 80 18: 72 4' 00 , 2,00 5' 00 , 5, 58 5' 58 , ' 14, 41. _....! , TOTALS ~ -1iEE.l.As See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms 27, 00 , , , , , , , , , , , , , , , , , , , , , , , , , , , , .. _ KU~ ,.... 'OIHIO'~ '0" YOUR PoleoAtS .. _ _ . _ _ .. .. .. _ _ _ _ _ .. _ _ .. ~ - .. . - "cpitH "-",,5 .-'"rrUR-~ tl'~' pCl=:rioi; \,:::T;..;.;,/(I":; - - - - - .. ~ N . .. - - .. .. - .. - .. .. .. .. .. .. .. .. .. .. ' ...."" I ...." ,," Il~';""':' 11'i"''.~O'~1'CI' ',e ."OIJl< MAKE CIlECKS~~T~~'L · ; ''''''h'''' PAYABLE TO:d ' .,! - PRE-CERTifICATION ROOM CCU I EMER MED VISIT III 02 EMER CARDIAC MONITOR 02 02 SET-UP - E.D. 02 IV CATHETER 02 HEHATEST 02 I V ADH-EO 02 EO VISIT IV 02 I !lVAC SET-ED 02 PHOSPHOROUS 10 CALCIUIi STAT 10 MAGNESIUM STAT 10 CBC AUTO Dlff STAT 10 PTT STAT 10 PRO-TIME STAT 10 LOll SERUH/URINE 10 LDH ISOENZ 10 BUN STAT 10 CK-HB STAT 10 CPK STAT 10 CREATININE STAT 10 ELECTROLYTES STAT 10 GLUCOSE STAT 10 SGOT/AST STAT 10 EKG 12 PORTABLE EXAli SURCHG 20 CIIEST SINGLE PA 23 ORAL MEDS 40 ORAL ME OS 40 ORAL HEDS 40 INJECTABLE MED 41 INJECTABLE HED 41 INJECTABLE HED 41 N IrrTABLE...liEU__..__--.-li. IF lAll CKARelU '0" IE~VICU "'E~O("lD CCCU". "OU WI~\. "'ICIIVI "OortIOt;l~ 8IlLI~Q elTI 06.21 06:21 06'21 06 :21 06'21 06:21 06 '21 , 06,21 06 :21 06,21 06,21 06'21 06 :21 06 '21 , 06,21 06 '21 , 06,21 06 :21 06 '21 06 :21 06 '21 06 :21 06'21 , 06.21 06 :21 06 ,21 06 :21 06121 06 :21 06'21 06:21 06 :21 06,21 06'21 , .. ~ ~ - ~ 'ClIil,l,UH ,.;,. o'~'.-;~'L-,f' --"\,'I"3.:,.."_i:, ___ _",,_ 'l~?,::J OTSCiI--6rOI'~S - (JO 'ou j 05'01 , , , JNP. l' t , IINlrtt' uaot' .-- ~~.:~~~c-iCO.:lIUGi, '_j_ Q"O~P""=' VII _0 COKMERC I AC-A=Z--u ------ "'11 ,",0 VII NO -------.------ --, ,------~-_..- "0 ---,-- r'-- , t DONALD W SHEPHERD 3824 KTN VIEW RD KECH PA 17055 I o L GARKANS I~~~~l~ "CO.'C" ~o NGOTS75S9A '-1 HAlIRlSBURG 1I0SPlTAL HARRISBURG, PA. 17101 717 - 782-3680 _J , ' U ," , 1t[~~~~~~~~~';71:~41 0-6 ,;9 ~94 I.R,S, 23.0676.330N 942816080 ISHEPHERD DONALD W f'TlI'" D.UI OIIC":"IO'~ TOULC'",1.A31 'IT CO\'I"GI INO coyt"-'GI ~A.J CO~'IlVt.G' I,I.OUfiT 06 :21 - 29: 70 , 0 INJECTABLE KED 41 29,70 , , , 06 :21 INJECTABLE KED 41 5: 58 5: 58 , , , , , , 06 ,21 INJECTABLE KED 41 4452, 80 4452' 80 , , , 06 :21 INJECTABLE KED 41 5: 00 5: 00 , , , , , , 06 '21 INJECTABLE KED 41 8' 10 8' 10 , , , 06 :21 INJECTABLE MED 41 10: 08 10: 08 , , , , , , 06 '21 IV SOL GENERAL 0931 70 45' 00 45' 00 , , , , 43: 00 43: 00 , , 06,21 IV ADHINISTRATION 80 i , 06 :21 IV TWIN CATII 80 14 50 ' 14' 50 , 1610 00 I 1610 00 I i , I 06,22 ROOM CCU I 06 :22 PTT 10 22: 50 I 22: 50 I , , I , , 06'22 PTT 10 U 50 I 22 50 I , , I 06:22 CBC PROF AUTO DlFF 10 24' 50 24: 50 , , , , 06 '22 GLUCOSE 10 21' 50 21' 50 I , , , 31: 00 , , , , 06,22 'CALCIUM SER 10 31,00 , , 06 '22 CREATININE SERUM 10 29: 00 29: 00 , , , , , 06,22 CPK 10 31,00 31,00 , , 06 :22 PHOSPHOROUS 10 31: 00 31: 00 , , , , , 06 '22 BUN 10 21' 50 21, 50 , , 06 :22 KAGNESIUM SERUM 10 31 00 31: 00 , , , , , 06'22 CPK ISOENZYME MB 10 56' 00 56' 00 , , , 06 :22 ELECTROLYTE PRofIL 3 10 42: 00 42: 00 , , , , , , 06'22 CAlIDIO-LIPID PANEL 10 48' 50 48' 50 , , , , , , , , 06,22 PTT 10 n 50 22, 50 , , , 06 :22 PTT 10 22: 50 22: 50 , , , , , , 06 ,22 PTT 10 22< 50 22, 50 , , , 06 :22 PTT 10 22: 50 22: 50- , , , , , , 06 '22 CPK 10 31' 00 31' 00 , , , 06 :22 CPK ISOENZYME MB 10 56: 00 56: 00 , , , , , , 06 '22 EKG 12 114' 00 114' 00 , , , 06 :22 18: 72 , , , , ORAL MEOS 40 18, 72 , , , 06:22 ORAL HEDS 40 2' 00 2: 00 , , , , , , , 06,22 ORAL HEDS 40 7, 74 7, 74 , , , ~~:~~ ORAL HEDS 40 4' 00 I,' no , , , I ~lEr.UIU.E MED__ , , , , , ____,__,,11 L -," 2!. 24, 2L 211 ~ -.-. .,._,-j--_.~ . P^' n I~ I , III 1'11,11 11',1 " \.All CI''''R~II 'c' lI"o',CII "J"O "00 CUR, VOUI'II I TOTALS.... I I': CI '....Ob :O,,""lIILLtl,ti ".- _,.5Et.LAS IJAGE..: .....1._.._._ ",___._.._J.~,__ See Reverse Side 1f You Have Not Furnished Us Your Health Insurance Information and/or Forms . ~ ,. ~l(tl~'~'t.'.~'A}19'i!~"!oy~II!C..C~::! '. _ _ . _ _ _ _ M _. _ _ ~ _ _ .. _ _ _ _ .. .... ... ... ... ... .. :;(l~C" "',0 ''In.''.. 1111 'CIl' C~ \',"~>1 ,..'1.'('.1 "'1',' ""1 II ! !1;';Hi;L':'::~,2.::~~::l,1~=C - :"MI Del , , '.H-!~" hO M,\KE CHECKS I'^V^RI F TO' T'l'JlI 0' .'.L - -'~"~~;'Q-c".'i" r .----ii~-~;; __,~.~+...--- ---.- --t--- DISCH 05 01 95 00 00 " , INP. IINI"" "'D'O Ilil.JR,A"C:1 CO'.["AQI ,." vII VEl ',C 5 ,"0 COIIIIERCIAL A-Z NO ,"0 I , DONALD W SIlEPHERO t 3824 IITN VIEW RO I IIECH PA 17055 o L NUW U'E" ~l'" 942816080 SHEPIlERD DONALD II Dm CIIC~,JI'TIO~ .C:> 'Oral , N:;i.,,;O"'l "I G~OJJI"O GARHANS r-'::;;;'l IlARRISBURG HOSPITAL HARRISBURG, PA. 17101 717 - 782-3680 -1 1I.00lJ ~o 06,29,94 ''"II. 0 I,R,S.23.0875.330N rOlllAA TQT.lL C..,....31 liT CO.IIY-Gt ;11,0 COVlAAGI ,A:l CO'vlllJ.al 21, 24 5: 00 5' 58 63: 72 20' 00 29: 70 34' 47 , I 63,72 I 6 57 : 213, 00 ' 213: 00 i 1610 00 I n 50 24 50 29: 00 21' 50 42: 00 22: 50 22' 50 73: 00 73' 00 , 31,00 56' 00 114: 00 134: 00 88, 80 18: 72 2' 00 4: 00 29' 70 , 63,72 63' 72 20: 00 2), 24 5: 00 5' 58 63; 72 20' 00 29: 70 34' 47 , ' 63, 72 I 6' 57 : 213, 00 ! 213: 00 I 1610; 00 I 10 22, 50 I 10 24' 50 10 29:001 10 21' 50 10 42: 00 10 22: 50 10 22' 50 10 73: 00 10 73' 00 10 31: 00 10 56' 00 , 12 114,00 20 134: 00 23 88' 80 40 18: 72 40 2' 00 40 4: 00 41 29' 70 , 41 63, 72 41 63: 72 41 20,00 41 59' 40 59' 40 , , --!I.L .iI~ __JOJf3 TOTALS ~ E L See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms 06,22 INJECTABLE liED 06:22 INJECTABLE liED 06'22 INJECTABLE liED 06:22 INJECTABLE liED 06'22 INJECTABLE liED 06:22 INJECTABLE liED 06'22 INJECTABLE HED , 06,22 INJECTABLE liED 06:22 EXTERNAL HED 06,22 OXYGEN TIlERAPY 06:22 OXYGEN THERAPY 06'23 ROOM CCU I 06:23 PTT 06'23 CBC PROF AUTO DIFF 06:23 CREATININE SERUH 06:23 BUN 06,23 ELECTROLYTE PROFIL 3 06 :23 PTT 06.23 PTT 06:23 BLOOD CULTURE 06'23 BLOOD CULTURE 06 :23 CPK 06:23 CPK ISOENZYIIE MB 06,23 EKG 06:23 PORTABLE EXAH SURCHG 06,23 CHEST SINGLE PA 06:23 ORAL HEDS 06'23 ORAL HEOS 06:23 ORAL IIEDS 06'23 INJECTABLE MEO , 06,23 INJECTABLE MED 06:23 INJECTABLE MEO 06.23 INJECTABLE MEO 06:23 INJECTABLE MED J.2 UFO 'I' LATl CH"~QII 'eA Il~v;cn "I"D "10 OCCUII. '00 V^" R ClIVI ACOltlONAL 'ilLl~a JIA'TIIt.j1t\C 'OA... '"u. MAKE CHECKS PAYABLE TO: . .. .. .. .. .. .. .. . .. _ .. .. _ _ ~ _ _ _ _ _ _ _ _ ~ _ ~ _ _ _ _.v:'~ '~;Il"~R.."'2t.,j!t:2.":!c_..~p.Jc_c~::! - - - . - - .. .. .. - - - .. .. - .. .. - .. .. .... .... .. .. .. .. .. . C['H.C'" 1..'1.0 "[1~',"t.,j TM I PCll~-C~ \','.,.... '''''Jl'l.;T W,,, "..', I[~~~~~~_~j 'O~":O"I:CI l--=~~~~__ 41 41 41 41 41 41 41 41 41 92 92 , , , , , , , , I , , , , , , , , , , , , , , , , I I , , . , , , , , , , , . , , I , , , , , , , IC AJiOV Dv 'M ";.~;&Ci+.+.~ i ..~'.Gt"~'l l' eo.. I"'::; DISCIl - 05 'Or-95 00 'cio -05 '0-1 . IN'E] ~~- ---;--- L___~__ -- ' .- -- I '~;:"1I ':: 0 co;~';~Tft~~O; - OOM 1,0, NG~6%'-il-89^ vn NO vII NO ---*- I , , " o IJ ~O - ~5WffiO ." I I.R,S.23.0676.330N 942816080 SHEPHERD DONALD W 'II 1001-02106,21 ,94106,29~94 1 'OW" D."I CI'C~'"lO~ 'TCU,L C.,..1I;31 \ IT COVEAAaI '11I0 C0\1",",01 aAO CO."Icv.ClI " DUm 06,23 IV PUHP-RENTAL 70 59,00 59,00 , , , 06:23 IV PUHP-RENTAL 70 59: 00 59: 00 , , I , I , 06'23 IV PUHP-RENTAL 70 59' 00 59' 00 , , , 06:23 IV SOL GENERAL 0931 70 45: 00 45: 00 , , I , , , 06'23 IV SOL GENERAL 0931 70 45' 00 45' 00 , , , 06:23 IVAC 20DRP SEC-3705 70 34: 50 34: 50 I , , , , , 06 :23 IBABY POWDER 70 2' 00 2' 00 , , , , , , , , 06,23 I HOUTIlWASH 70 I 00 1,00 , , , i 06 :23 IPARTIAL FILL IV-4461 70 Ii 00 17: 00 I , , , . , 0623 ,076100645 92 141 00 141, 00 , , 06 :23 I Il-IPPB 92 54: 00 54: 00 I , , I , 06 '23 IOXYGEN TIlERAPY 92 213' 00 213' 00 I , , , 06:24 IROOM 1001 J 920; 00 I 920: 00 , , , , , , 06'24 IPH 10 22' 50 22' 50 , , , 06 :24 IPTT 10 22: 50 , , , , 220 50 . , , 06'24 I PTT 10 22' 50 I 22: 50 , , , , , . , 06.24 CBC PROF AUTO DIFF 10 24, 50 24, 50 , , , 06:24 PH STAT 10 28: 00 , 28: 00 , , , , , , 06'24 SHEAR ONLY 10 15' 00 I 15' 00 . , , 06:24 ROUTINE CULTURE 10 31: 00 31: 00 , , , , , , 06'24 BUN 10 21' 50 21' 50 , , 06:24 ELECTROLYTE PROFIL 3 10 42: 00 42: 00 , , I , , , 06'24 SENSITIVITY 10 29: 50 29' 50 , , , , , , , , 06,24 ORAL HEDS 40 18, 72 18, 72 , , , 06:24 ORAL HEDS 40 2: 00 2: 00 , , , , , , 06,24 ORAL HEDS 40 18, 72 18' 72 , , , 06:24 ORAL HEDS 40 2: 88 2: 88 , , , , , , 06'24 ORAL HEDS 40 2' 00 2' 00 , , I 06:24 ORAL HEDS 40 4: 00 4: 00 , , , , , , 06 '24 ORAL HEDS 40 4' 00 4' 00 I , , , , , , , , 06,24 INJECTABLE HED 41 20, 00 20,00 , , , 06'24 INJECTABLE HED 41 29: 70 29' 70 , , , , , , , I 06,24 IV PUHP-RENTAL 70 59,00 59,00 , , , 06:24 IV PUHP-RENTAL 70 59' 00 59' 00 , , , J16...0.2.LUV"l'IlliP:RfJHAL _,,, ..__ .10_ , , , , , ___59.,00 I .19,ilil -- ..____~._J..___"._._ - ____~__J..~_. . \,'0' ~",o~!' 'oOIlO,',(iI TOTALS ~ , , , , ""rll'/llf'l Ii 0 ~O 00"00"'&' I~, . I I , III ,If" III.! C IVI "DOi lo",AL J.ll'l~ _,SEf._LAS J>AGt: I _ _ ,. +.",. M~_mJ_~__~ -- . FlO I . . 'O.I.l..", GARH/INS I-:!~i':::] I HARRISBURG HOSPITAL HARRISBURG, PA. 17101 717 - 782-3680 8 I l l , o DONALD W 3824 HTN HECH PA SHEPHERD VIEW RD 17055 .-J L _ ~..~_ J__.__ Soe Reverse Side lfYou Have Not Furnished Us Your Health Insurance Information and/or Forms ~~H..., ;"'0 ,_ _ _" . ~ ,_ ,.._ u _ _ _"..E..E~T!:1'-'flO!'Q"!~~~~:'"'~~JC5;;~::! ~ p. _ _ - ~ M ~ ~. ~ - ~ ~.. .. -. ~................- tl''!'CH ,1..1.;0 "ih.....~ 1~.. ~C...~'GI. V"h. ',1."'1,1[',1 ","T ',"11 If ":,,ijCi:! 'i2"-1~'g.,~~n _:f!==YW V"~ v ,t;;~'iq~iL. 1 '" MAKE CHECKS PAYAOLF. TO: 1"00 ) -6-rror , tylll a,-.~.r'-~';:Q:~~1l.--1---- ~;I 01 SCIl0ro195--6o'00 " , INP. IINI'I" AIO'D VII NO VII NO 'VEl NO Ole 5 Gila..' ,",0 I""SVA.&.I,C! ca.'E'\lDl COliHERCIAL A-Z I , DONALD W SIlEPIlERO t 3824 HTN VIEW RO T HECH PA 17055 o L u ,'" 1\&.',1 SHEPHERD DONALD W 942816080 CATI 06,24 06:24 06'24 06:24 06'24 06:24 06 :25 06 ,25 06 :25 06,25 06:25 06'25 06:25 06'25 06 :25 06 :25 06,25 06:25 06'25 06:25 06'26 06:26 06 :26 06,26 06 :26 06'26 06:26 06'26 06:26 06'26 06:26 06:27 06,27 06 :27 IIO.ICY 1.0 NGOI87589A- 1;,001,1 1,0 1001-02 GARHANS ,- "~I l I HARRISBURG 1l0SPlTAL IlARRISBURG, PA. 17101 717 - 782-3680 ~ CI11.aa I.R.S. 23.0675.330N rbBL~t 10 10 59, 00 21: 50 21' 50 21: 50 21' 50 54: 00 920' 00 22: 50 I 24: 50 210 50 I 42: 00 28' 00 18; 72 2' 00 4: 00 29: 70 6, 57 6: 57 43' 00 9: 00 920' 00 22: 50 22' 50 28: 00 9: 36 2, 00 18: 72 2' 00 4: 00 29' 70 , 29, 70 920: 00 22, 50 22' 50 , .L.Jl 06,29,94 a__~CC'iP,Al)1 K!(IlI rl"l I POlr.IO~ n:q 'Ol.'~ '"fCOR::S .. - ... - ... - - - ... - ... ... - - .. - - - - - ... -:i<rrc;. ;...5p.rruAi,dH i hAr-c, i'l''!;' ;";"'["'1 .. .. .. - - - ... ... ... ... ... - - .. - - ... ... ... .. .. - .. ... .. - .. ""I" '.e I "'I" ''''I --1E~'" 0';1 '0"", O'II'o',CI ',e AM""'" OVI :: ICI-I"-a on. Al,.I '''1 ------ '()qlot ,".. Cllelli"rICN rc,.,.~ C.....~JE ,IT CO\'(....QI IN::! COVI~&.QI 70 70 70 70 70 92 J 10 10 10 I 10 10 40 40 40 41 41 41 80 80 J 10 10 10 40 40 40 40 40 41 41 59,00 21: 50 21' 50 21: 50 21' 50 54: 00 920' 00 , 22, 50 24: 50 210 50 42: 00 28' 00 18: 72 2' CiO , 4,00 29: 70 6, 57 6: 57 43' 00 9: 00 920' 00 22: 50 22' 50 , 28,00 9: 36 2,00 18: 72 2' 00 4: 00 29' 70 , 29, 70 920: 00 22, 50 22' 50 , IV PUHP-RENTAL SET UP IV PUHP SET UP IV PUHP SET UP IV PUHP SET UP IV PUHP II-IPPB, ROOH 1001 PTT CBC PROf AUTO Dlrf BUN ELECTROLYTE PROfIL 3 PTT STAT ORAL HEDS ORAL HEDS ORAL HEDS INJECTABLE HED EXTERNAL HED EXTERNAL HED IV ADHINISTRATION ANGIOSET ROOH 1001 PTT PTT PTT STAT ORAL HEDS ORAL HEDS ORAL HEDS ORAL HEDS ORAL HEDS INJECTABLE HED INJECTABLE HED ROOH 1001 J PTT PTT IrTllH ~F:R I' UTI CHl..~QU ,o~ IERV;Cn "."'DEJliID DCCUA, .,.ou WILL I'lilCIf\"AOOltIOI.,"L 'ILLI"O , , ll.J.AS UG See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms TOTALS ~ MAKE CHECKS PAYABLE TO: h" 0' .-.~ t- ".l.II.G,t.".. (I, p.::.. ' DIS;II~ ~~5~~I-)5'j' UO :00 : 6~ '01 '~~1:;'ir ;;~i~~'f, . t:;"l'idi"'~'" "e G"RIiANS l'~-~ j I 5 r , t DONALD W SIIEI'IIERO 3824 HTN VIEW RD HECII PA 170~~ -1 I.R,S.23.0676.330N IIARRISBURG 1I0SPlTAL HARRISBURG, PA. 17101 717 - 782-3680 , o L FAT,"1 j.,MOUh'T , .' 0'" DONAto W crtCIV',OIi IND eovEIUGI ."0 COVlfV,.1lI 06,27 MAGNESIUM SERUH 10 J1. 00 31, 00 06:27 POTASSIUM 10 18: ~o 18: 50 06'27 IIEMODYNAli MON lTR 12 484, 00 484, 00 06:27 XYLOCAINE 12 18: 00 18: 00 06'27 IIYPAQUE 1'10 76" 12 30' 00 30' 00 06 :21 IIEART CATH TRAY 12 92: 00 92: 00 06'27 CATH LAB RM CIIOE 12 731: 00 I 73 l' 00 , , 06,27 NORMAL SALINE 250 ML 12 18 00 ! 18, 00 06 :27 NORMAL SALI~E 1000ML 12 22 00 I 22' 00 06,27 ,GUIDEWIRE DIAGNOSTIC 12 i 44, 00 I 44. 00 06:27 DIAGNOSTIC CATIIETER 12 \ 162, 00 ' 162: 00 , , 06 ,27 HEMAQUET 12 97 00 i 97' 00 , 06 :27 CARDIAC CATH LEFT 12 517 00 i ~ 17: 00 , , 06'27 HEXABRIX 50ML!OPTIRA 12 262' 00 I 262' 00 , 06:21 CHEST PA L LATERAL 20 99 90 \ 99: 90 , , 06 :27 ORAL MEnS 40 2 00 I 2: 00 I 2,00 I , 06,27 ORAL MEDS 40 2, 00 , 06:27 ORAL ME OS 40 9 36 I 9: 36 , , , 06'27 ORAL MEDS 40 2 00 2' 00 , 06 :27 ORAL MEDS 40 IS: 12 18: 12 , , 06 '21 ORAL MEDS 40 2 00 2' 00 , 06:21 ORAL MEDS 40 4: 00 4: 00 , , 06 '27 INJECTABLE MED 41 ~' 58 5' 58 , , 29: 70 , , 06,27 INJECTABLE MEO 41 29, 70 , 06:21 IV PUMP-RENTAL 70 H: 00 59: 00 , , 06 '27 IV PUMP-RENTAL 70 '9' 00 59' 00 , 06 :27 IV PUMP-RENTAL 70 ~9: 00 59: 00 , , 06'21 IV PUMP-RENTAL 70 ~9' 00 59' 00 , 06 :27 IVAC 20DRP PRIM 5373 70 9: 00 9: 00 , , 06'21 IV ADMINISTRATION 80 43' 00 43' 00 , 06 :27 ANGIOSET 80 , 9: 00 , 9,00 , 06 :28 ROOM 1001 J 920: 00 920: 00 I , 06,28 ORAL MEIlS 40 7,92 7, 92 , 06'28 ORAL MEDS 40 2' 00 2' 00 , , , , , I HFIlS.." -_..._._----~_.. _40 :Ll0 ,,~n __..___..J I' LA" C~""O!' 'OIllIl"o'ICII TOTALS ~ , "I'i "to g~ vO, '~u w'&' , I , .. C r\'. AO IIO"....l Illl'" ,. SEE. LAS P AGE_l-__ ..,____1...-_ See Reverse Side 1f You Have Not Furnished Us Your Health Insurance Information and/or Forms ~ - - ~ - . - - ~ - - . - .. _ _. _ }'{l~T~.t'~'f,a;'ft",.,c:"~o.o.J,!"'!C_D~PJ. ~ - ~ - - - ~ - - - - - - - - ~ ~.. -................- :;:,.~c.~ p..::.lIIr........ ~.-;.. 'cll..'DN W,TH '4'1'1111,' ..""",.'! II .c~~~Y!~~~_'1~~~~It~~~_~ ~_',:_ ~~OV~ ..Jlli.,\"'2~":l, ~ ", , , 'O.'} "u' I MAKE CHECKS PAYABLE! TO: .,.'!;i,," ,,(:I --.- ..._--^..,-- """'1 c., RI~~ 'II.~II.G C,oE , DISCIl O~ '0)'"95 , , INP. IINlr"s "'SO'O '" ," ," ,x: ~ 8;~ (j()~(jo , lAoC,:> r05:0r-- ')~O..lPI.O ...L~ NO NO NO 1'...ulU....CI cO'w'(JU.OI COliHERC!AL A-Z r , l 6 L DONALD W SHEPHERD 3824 HTN VIEW RD HECH PA 17055 . ,1\ "'ill 942816080 SHEPHERD DONALD W DATI OUC'llIPTlO"4 06,28 06:28 06'28 06:28 06'28 06:28 06:29 06,29 06:29 06,29 06:29 06'29 06 :22 , , TOTAL ORAL HEDS ORAL HEDS ORAL HEDS ORAL HEDS ORAL HEDS IV PUHP-RENTAL ORAL HEDS ORAL HEDS ORAL liEDS ORAL HEDS ORAL liEDS EGG CRATE MATTRESS OXYGEN THERAPY CHARGES GARHANS f ~';I I 'O.ICV 1.0 NG0187589A -, IlARRISBURG 1l0SPITAL HARRISBURG, PA. 17101 717 - 782-3680 ~ A OM" . "","1100 I.R.S. 23.0675.330N r~ll~~t 06,29,94 TCU~ C'1....~QI , IT CC\,(ilI,lOI INO CCV!IIJ.OI ,-':l CC\"EP..&.DI 40 40 40 40 40 70 40 40 40 40 40 70 92 18, 72 18, 72 2' 00 2' 00 , , 4' 00 4' 00 7: 92 7: 92 5' 40 5' 40 59: 00 59: 00 6' 00 6' 00 , , 18, 72 18, 72 2: 00 2: 00 7, 92 7, 92 5: 40 5: 40 51'00J' 51'00 213: 00 I 213: 00 ;;~~;:~~ r;;~~~:~~ ......... , , , , ........ , , , , , , , , , , , , , ______0..__ , , _____k__ , 27, 00 ........ , , ......... , , I ......... , , , TOTALS ~ FF. ; AsbF: ~ See Reverse Side TfYou Have Not Furnished Us Your Health Insurance Information and/or Forms " LATt CI1AAlJEI 'OA U"VICEIl "'NO 010 oeeu.. 'OU W", AlellVl ACOITIONAl 'II.~INO . _ .. .. .. _ _ KoHli 'HIS I'CIfTIO"4 'OR ,"0',.'''' "(CCAOS .. .. .. - - - - - - .. - - .. - .. .. - .. .. - - -cit;6i i"NCAtru"'-'II TH;-'S ;OiniCN \':;.Ti=l ;...y""'i,,i .. - .. - - .. - .. .. .. - .. .. - .. .. .. .. .. .. .. .. .. .. .. ... - I "loIN! NO I "','" """ I h'M 0'" 'OM U'O"IE~VOCI "C .uov,,", MAKE CHECKS o,c;". " · 'Oou '/1.. PAYABl E TO: ----_._.__.._~. TOTALS ..l:-- See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms . _ _ _ _.. _ .7J].: }5~-)1l5Q.,. ,,!'-"'~PF'."'!""C""'I'.C~:'. -. - ,-, -' - -" . - - - - -. -- tP'c",".: Ill.,,"'''''' I pC,Il",C" ",1""".1,11'.' - - - -' - .- 9~;~~~:~jc~~rltf.R\l"';:(~~:'~';1 W II (J;"':':~:i:~~jl '-o2-6~::"'~!-2:9i~~,f9.~;4[:'t:: I PAVAIlI.ElO: ItA~~IS8L'RG It05I'IIAl. 'F O"I.A'uu (;MMIIS ly~!.:j "'''IOf.!~L h~II~Clt"'1 f t~' 'lAC: DISCIl, ~;'~i-;~s --~O'i)O j 05~'O; IIARRIS'Il~R(j lloSI'11Al. I' I , INP. "___',__ ___,..c,._ !1~.!l,~l~~RllLI'A. 17101 .~"..~. CO~;;~'I':~":-': -!'3,C",i;i8\ ~';j i:;Ui:~;i:;~i[ :i::;l:lr~i::: FlC .- --lINTENDED FOR INSURANCE ,'URPOSES 5 I AND IS NOT TO DE PAID BY YOU. YOU , DONALD W SHEPHERD WILL RECEIVE A SEI'ARATE BILLING t 3824 HTN VIEW RD FOR ANY BALANCE DUE AFTER lHE l. HECII PA 170SS INSURANCE COHI'AllY liAS PROCESSED L_.lOUR BILL AS AUTIIORIZED BY YOU. DON~~D W ~~~~~~2:i~'~~ili:~~';~~~ I.R,S, 23'O~~'~1~30N CIICilI.,"IO"ll '1'C.....L c..,I."al '1' to\'IAJoGl ".;) CCr'llU:l1 .":J CO\llUQI AVOUN' , -..,.- SUKHAR OF CIlARGES -- :QTY DESCRIPTION INS C AHO~NT , 10 EHER VISIT t. ASSOC O'J 4S0' SO : 66 LABORATORY 10' 210S: 00 , 18 EKO, PIlYS t. CARD I~ 2819' 00 : 5 RADIOLOGY 20,22.23 545: 50 'Ill PHARHACY 40-42 5436' 96 , : 25 H t. S SUPPLIES 70-73: 104)' 50 i : 6 IV SOLUTIONS 80 161' SO . , 5 OXYGEN/RESPIRATORY n 67S' 00 I : 3 R t. C INTENSIVE CARE I: 4830,00 i I 5 R t. C SEHI PRIVATE j 4600 00 I ,J : 1 HISCELL 00.09,S8,98.991____~~~~~ I TotAL CHARGES I.::~~~~:~ I ! I i ! I ._._.J__ , .....J,___ I A 1 II 1,' ) , tIll '.1', '.' "l.A~ C"""OIl 'C""""" "1M "10 oec"",, 'ou w,,, "Ie Nt AOM10hiAL lolLING " -, , ._-1____ GARHANS l"-'''~l-~ ~~~;~~~f'- --,J~~b?~~3,' -j~66'.b,0, " , JNP. ~ _~._L._.__l._".~ .~_._.!.--- Iltd,ll, "'G'O l"'lu""'''CI. CO,"EJV.Gf COHl1ERCIACA-=Y---- 11;,-. l (is-of ",,;;0 -;i~i'''~'9'j I DONALD W 3824 HTN HECH P A SIIEPllERD VIEW RD 17055 HARRISBURG HOSPITAL HARRISBURG, PA. 17101 717 - 782-3680 -.J I,A.S.23-0675-330N P.roINT "'Mou~'T 27,00 .....'-.. , I I , , I I I , , I , .....,... , , 27' 00 , -----r-- 27' 00 I .....,... , , , , , , , I , I I I I , I , I I I , I I , , , I I I I 27: 00 vlt VII vlt NO NO NO ......... I I , , , I I , , I I , , , I I I I I I I I I i I I I _'.'. _ _ _. ,7)].__ )1l,-J~6Q,.,. _. _" .'tI~T~,pp':."g"!'<'10.u~'!c.o~O!.. -. - - -. - -. -. - - - - ----- DEUCH "".0 P,E'T\,.''''lI TM'. 'c-;;,IOl\ W,TH p,lYIJI"T I PoT"" '01 "'I" "'..E I BILL11t.,a 0171 ,I.:;t,l:II~O""iUJlliICe FIC Al.l . 942~!~Q80 .. Sllf-l'IIERD. DONALD W ,J:>~-,-Q1~5 06' H~94 5 MAKE CHECKS Q. c"..a " .... '0"""'. PAVABLE TO: IIARR ISBVRG 1I0SI'ITAL 06 , 29,94 "c 5 I , t 6 L N "1\ ,.,,, 942816080 SHEPllERD DONALD W OAt. CUCq~FTIO'-l TOTAL CllARGES , I INSUR CE ---- CQVER GE BEfORE DEDUCTIONS 'OED CTIONS .- , , TOTAL C.,U:11 ,n CO\'11\,10B 'NO COYE.....al IRO COV!IlJ,QI 22666, 96 , , -----,..-- 22666: 96 22693, 96 , , I -----....-- , , I , -----r-- , , .....'... , -----,..-- I I , , -----r-- I , -----r--- , , -----r-- TqTAL DEDUCTIONS TQTAL BENEfITS PATIENT C~ARGi NOT COVERED BY P~TIEiT RESPONSIBILITY P~TIE T BALANCE 22666: 96 22666' 96 , ----..... ......... i INSURANCE) 27 00 I j-------- ! 27: 00 r"';;:~~ ......... ......... ........ " ....Tl c".'all 'OA II"V'CII ',Ne 'Ie OCCUA, VOU WILL FIl CI . "oortIO~"l Illll"'O --"- , , TOTALS ~ _..1- See Reverse Side If You Have Not Furnished Us Your Health Insurance Information and/or Forms r'FlOF h\. "~;.;'.G CI... j l: I 05 'ot'9Tli:f()'OO " ' ,I _-!__ ."I","""'C( Cov[RJ.GE :{~:::; jus-'of- GARMANS I=='~~~ DISCII INP. ,---- 011.0,1' '.0 'O~'C' ,",0 lllil'"' "SO-o' NGOl87589A vII 'u vII ',0 5 "0 COMJiERCIAL A-Z "0 '.0 -...--.--------------- I I , t DONALD W 3824 MTN MECH PA SIlEPIlERD VIEW RD 17055 IlARRISBURG HOSPITAL IlARRISBURG, PA. 17101 717 - 782-3680 , o L .-J I,R.S.23.0675.330N "" ::...(', ""IJ osc..,r.l1iG 06,29,94 942816080 SHEPHERD DONALD W DATI OUCR.I'TION PJ"Tlf"'T ""'0101"''1 TC'r,lL c"".....31 , IT CO\'EAAGI INO eO\1IUOI ~l1iO eo.l'tJV.GI soaIAL SECURITY NO. - 283-44-8543 BlijTH ATE - 11/16/47 SEX - I:l ~ITA STATUS - H RAOE - W ADHITT NG DOCTOR - 1903 GL-BR-TY-SC-PA-Bl JO AqEND NG DOCTOR - 1033 GLUCK ~ICIlAEL: L DRG CO E - 121 ' Dl~GNO IS - P 410.41 ' I DIAGNO$IS - S 427.1 i DI4GNOSIS - S 413.9 I PROCED~RE - P 37.22 PROCEDVRE - 0 88.56 I- PROCEDVRE - 0 88.53 PROCEDVRE - 0 99.29 I PR~NCI~AL PROCEDURE DATE - 06/27/94 , PRINCI~AL SURGEON - 04005 GUTIERREZ fELlYo _ AD~INISTRATION CLASS - I-EMERGENCY I DISCH GE STATUS - ROUTINE ' PO~ICY HOLDER EMPLOYER - DIMLER TRUCKING POll ICY HOLDER - DONALD W/Z GRACE AYS - 0 CO~ERE DAYS - 000 TREATH NT AUTHORITY - AP~ROV 0 fROH - APPROV 0 T1IRU - I HD01674~E /R/99~ I'LATI tH""OU FO" lER'I'leEl "(NO "lD oCC:U", "OU \'.'\.-L "ICIIVI.A.OOITIC~"l liUI..a TOTALS ~ See Reverse Side 11 You Have Not Furnished Us Your Health Insurance Information and/or Forms _ _ _. _ _ _ _ _ ,7.1], -: )~2-)li6Q, _ _ ....,""O"',O"O.VOU..IOO.OI .. - - - -CitiCH "-"0 ,,1T:"'~ Tt"~ pci'r~o~ \';ITH P";I.'E"'; . . - - . ~ . - - - - - - - - .. .. .. .. .. .. .. . . .. .. I ''''(I,""' '.0 H. P.1 "'''','' I h~l",a t.n&: ":;l,I u,CI,'IERVICI ~ C AlJOU,", PioneerLife September II, 1995 Mr. Douglas R. Bare, Esquire Frankel, Bare & Associates 14 West KJng Street York, PA 17401.1413 REef'i '\I EO RE: Donald Shepherd Policy ING01875898 Date of Treatmellt: JUlie ,U, 1994 Healtll Care Provider: lIarrifburg Hospital SEP \" i995 0" R~ BQ Dear Mr. Bare: Enclosed please find a sample. duplicate of the policy Mr. Shepherd had with our company. Pleasc contact me if you have any questions or need further information. Thank you. Very truly yours. PIONEER UFE INSURANCEOOMPANY ( AJLUNM. _,.0 l tt1'IL.<-(, -1'- ~ Patrice Gentile Paralegal pg Enc, IlXIIIlllT II Pioneer Lde Insurance Comp,1nY 01 /IImOIS PO BOK 120' 304 Nor,n Mam S'reel nNHold IIMol,' 61105,0120 . 815:987,5000 T lUJJ~.l.L.d.L"" A STOCK COMI'ANY (He,elnafter called lhe Company. we. oor or us) SPECIMEN CERTIFICATE OF INSURANCE CATASTROPHIC HOSPITAL EXPENSE COVERAGE We agree to pay benefits according to the provisions of the Group Policy If you Incur Covered Expenses resulting from: J. INJURIES which occur anytime after the Certificate Date and while your insurance 15 In force; 2, SICKNESS. diagnosed or treated after the Certificate Date; or 3. PRE.EXISTlNG CONDITIONS. after your Insurance has been In fo,ce for 12 months, RIGHT TO EXAMINE Carefully read this certificate as soon as you receive It, If you a,e nOI satisfied. you may return It to us at our Home Office within 10 days after you receive it, We will refund all premiums you have paid, IMPORTANT NOTICE This Certificate describes the principal provisions of, but does not constitute. the contract of Insurance, The actual contract Is available for Inspection at the office of the Group Policyholder during regular business hours. This Certificate replaces all Certificates of Insu,ance that may have been Issued previously under the Group Policy, -~ ~ "\.~ (QQ"j I're Ident Secreta,y GHC.90S4.F Plae 1 PIONEER LIFE INSURANCE COMPANY OF ILLINOIS 304 Norlh Main Slreet. P.O. Box 120. Rockford. Illinois 61105.()120. (815) 987.5000 Check Ihe 8\l8ched enrollmenl 8ppllcallon, I( II II nol complele or has an error, )llease lei us kno'l" An InCGlrrecl apPUc8110rt may C8Ule your coverage 10 be voided, 01 a c1alnllo be reduced or denied, . CONTENTS DEFINITIONS BENEFITS EXCLUSIONS AND LIMITATIONS COORDINATION OF Ill:NEFITS 4,5 5,6 7 7-8 EFFECI'lVE DATE OF COVERAGE PI~EMIUMS TEI~MINATlON OF COVERAGE GENERAL PROVISIONS Any Amendments and/or Riders will (ollow Ihe General Provisions Secllon, ADDITION OF DEPENDENT ADDITION OF NEWBORN CHILD CERTIFICATE CERTIFICATE SCHEDULE CLAIM FORMS COMPLICATIONS OF PREGNANCY COSMETIC SURGERY COVERED DEPENDENT COVERED EXPENSES DEDUCfIBLE DRUG USE AND DEPENDENCY ENTIRE CONTRACf EXCLUSIONS EXTENSION OF BENEFITS GENERAL PROVISIONS GRACE PERIOD HANDICAPPED CHILDREN HOSPITAL COVERAGE INJURY INSURED PERSON 10 10 11 3 11 4 " " 5 7 7 11 7 11 11.12 10 10 5 4 " " , 0IlC,9054-I' INDEX LEOAL ACnON MAXIMUM PAYMENT MEDICARE MENTAL ILLNESS MISSTATEMENT OF AGE NOTICE OF CLAIM OTIIERINSURANCE PAYMENT OF CLAIMS PHYSICAL EXAMINATION AND AUTOI'SY PREMIUMS PREMIUM C!lANGES PROOl' OF LOSS USUAL. CUSTOMARY AND REGULAR SAME, DAY SURGERY SICKNESS TERMINATION OF YOUR COVERAGE TERMINATION OF A DEPENDENT TERMINATION OF THE GROUP POLICY TIME LIMIT ON CERTAIN DEFENSES TIME OF PAYMENT OF CLAIMS 8-9 10 10.11 11.12 12 6 " 5 12 11 7 12 12 10 10 II 5 5 5 10-11 10 11 12 12 I'agc 2 '\,\ .. . " , '. .''': !",I,,'-~' ;., '.-,it'.', .,' " ','" " , '. . :' " ',.; " CtAT I r1CA'n SnltDUlt .' MAXIMUM BENEFIT FOR tACH INJ~RY OR SICKNESSI Lift MAXIMU~ fOR A~L INJUR/ts ~ sl(K~EssESI .. : " $ 500:000 S 2.000.000 S 300 YEAII) S ' 10.000 , CAS II DED~CTIBLt AMOUNT (C~LtNDAR YEAR) MAXIMUM OUTPATIEST MEDiCAL BENEf;T (CALENDAR .' .. /. poLIn H';~DER: ~,~l~ IO~ IH,AllH C~Rr. TR~ST I ~~I:nnl 1)l)\ALll SHEI'IiER D aR T I FICA t E S~M8ER I EHECTIVf. DHE: 11-'),1-89 fiRSt RENEWAL DAttl I~ITIAL PREHI~,~,: S101.11 ISset AGEl S';O 1875891. , , 1~'01.89 4\ " NOTEI OTHER ELIGIBLE INSUREDS, IF ANY, ARt IN THt ATTACHED APPLICATION. *, , RENEWAL PREMI~MS IS~BJECT TO [H~SGE) : 581, II GHC-90S4'F PAOE 3 . SEE AIDER ATTACHED " ",' , . ,. , " ',':' ',>~_:,:':,;\':' ,I . ... .,,~:~~ ~~ :",j~~,::"~' .', " ',"I" " ,'" I t.r,' ," , , ,"'~ 'j ',S.. ,", '.I" ',.&., " ',' "'~/I ,,' " I , 'i::', '::' t,~ .. " , I ;",:J.iL."I'" , ,', ,1J'll .' ' '" "",,:,.,, ,', '"i ,...';,., " ~ I' 1'." -,\,,-", ,:,.'.'j' , ....! ....,.1....\ ...t'_ . ,r "'. ..~,., , " . ','" ...... ..~ . .,' I'"' .If '. 304 North !fain street, Rockford, I1Un01. 11101 . . ,f, . RIDER EXCEPTIHn RISK Policy No Nob187589A to which thil rider i. attached, ~nd af Which it i. .ade a part, i. continued or renewal, aubject to' it. terae, by the' co.p.ny with the undar.t.ndinq that .nythin9 which aria.. or occur., or which i. cauaed or contributad to by raa.on ofl 'Any di..... of tha h..rt .nd/or oirculatory ayah. on Oona14 s~eph.rd b...d on Infora.tIon ll.ted on the appllc~tlon, .' Thla III a rlak not i18~ullled under IIIld prhlcy, "l1ythlnq therllln to thll contrary notwlth8tandlnq. ThIa rIdar .hall a180 apply to ant la4nd..nt., rld.r. ~, oth.r .ndor....nt. attached to II d polley, and doe. Ie , walv., .ltar or .xtend In Iny reapect, oth.r than aa abo~. .xpra..lt .tatad, Int of the condition., axc.ption.. a9r....nt. or provll on. of .Iid policy. . .\ ' .. Approv.d thh lit day ot HOVOCDr." ,1919 !'IOHEIlR I.IrE IHtlUItAHl" COMI'AHY or 11.1,1"0'1 , ,~ , .. -1 ro... 5404 \ I . ' .~'..... II PAIH I . IlIWI:-iITlO:-iS A. YOU, VOUII, VOUIlS mean the glOup t,usl member named In the Certlllcate Schedule whose coverage has become ef(ectlve and has notlcrmlnatcd, D. COVEll ED OEPENllENT means an Eligible Dependenl whose cove,age has become ef(ectlve and has not terminated, C. CO~lI'I.ICATIONS OF I'llEGNANCV means: I. conditions requiring medical treatment p,lor or subsequent to the te,mlnation of pregnancy whose diagnosis are distinct (rom p,egnancy but which a,e adve,sely affected by pregnancy or caused by pregnancy, such as acute nephritis. nephrosis, ca,dlac decompensation. missed abortion, disease of the vascular, hemopolellc nervous. or endocrine systems. and similar medical and surgical conditions of comparable severity; but will not Include (alse labor, occasional spoiling. physician prescribed rest during the period o( pregnancy, morning sickness and similar conditions associated with the management o( a difficult pregnancy not constituting a classlllably distinct complication o( pregnancy; , 2, hyperemesis gravldarum and pre'eclampsia requiring hospital conllnement, ectopic pregnancy which Is terminated, and spontaneous te,minalion o( p,egnancy which occurs during a period of gestallon In which a viable birth Is not possible; and 3, conditions requiring medical treatment after the termination of pregnancy whose diagnoses are distinct from pregnancy but which a,e adversely affected by p,egnancy or caused by pregnancy, D. COSMETIC SURGERY means Ihe surgical alteration of tissue (or the Improvement of appearance but which Is not Intended to effect a substanllal improvement or restoration of bodily (unction, E. ELIGIBLE DEPENDENT means your lawful spouse; your unmarried children. adopted children and step.chlldren who are under 19 )'ears o( age, The limiting age Is extended to age 2~ I( the child Is enrolled as a fuil-tlme student and allends classes regularly at an accredited college or university, F. HOSPITAL means an Institution operated pursuant to law for the care and treatment of sick and Injured persons which: 1. maintains organized facilities for medical and diagnostic care for sick and Injured persons on an In.patlent basis for which a charge Is made that the Insured Person Is legaily obligated to pay In the absence of Insurance; 2, maintains a staff of one or more duly licensed physicians; and 3, provides twenty. four nursing care by or under Ihe supervision of a registered graduate professional nurse (R,N,), The term "Hospital" does not Include: 1. any Institution which Is used principally as a (acillty for the aged; drug addicts; alcoholics; custodial care; education care; rest; convalescence or care of mental or ne,vous disorders; or 2, any military, veteran's hospital. soldier's home or any hospital conlracted (or or operated by the Federal Government 'or any agencies thereof (or the t,eatmcnt of members or (ormer mcmbc,s of the Armed Forces, unless the Insured Person Is legally requl,ed to pay for services In lhe absence of this Insurance coverage, G. INJURV means accidental bodily Injury or Injuries sustained by an Insured Person which is the direct cause of the loss Independent of disease. bodily Inllrmlty, or any other cause and occurs after the Insured Person's coverage became effective and while the coverage Is In (orce, It. INSURED PERSON means you or a Cove,ed Dependent under this Certlflcaie, I. MEDICARE means the Ilealth Insurance for Ihe Aged Act. Title XVIII o( the Social Security Amendments of 1965, as amended, J. MEDICINES OR J>IlUGS means those medicines 0' d,ugs, used In Ihe hospital and can be obtained only upon written prescription of a physician, K. MENTAL OR NERVOUS U1S0IlDEII means a neu,osis. psychoneu,osls, psychopathy, psychosis, or mental or emotional disease or dlsorde, without demonstr able o'ganlc odgln, OHC.9054.F Page 4 l'AllI' I . IWl'INITIONS (l'lInllnued) L. PHYSICIAN meanl a legally qualified litelaed pI.ctllione, or Ihe he.llng am IIIho plovides ca'e IIIlIhln Ihe lcope of hlslher IIcenle; olhe, Ihan a membe, or Ihe Inlu.ed Person'l Immedlale r.mily, M. PRE.EXISTING CONIJITIONS means any lllnditlon ro, IIIhiLh medic.1 adviLe wal loughl horn. ,ecommended by or received horn. phYllci.n within. l)(l day peril'" preceding Ihe clleclhe d,'e or Ihe Inlu,ed Person'l co\'erage, N. SAME DA Y Sl'RGEIlY FACIUTY meal1l a licensed public 0' private eslablishmenl wllh: 1. an organized lIaH of phYllcl.ns; and 2, permanenl facllllles Ihal a,e equipped and ope'aled prima'ily ror the purpose or pe,rormlng lu'glcal procedu,el, Such ellabllshmenl nHlII p' o\'lde contlnuoul physician lerviLel and legillered p,olelllonal nursing lervicel whene\'er a patlenlllln Ihe racllllY, The lerm "Same-Day Surge.y Facility" 11I111 include lacllltiel ope"led by a hOlpllal IIIhlch p,ovlde Icheduled, non-emergency, oUI'pallenllurgle.1 ca,e, The lerm "Same-Day Surge,y Facillly" doel nOllnclude: 1. hOlpital emergency 'oom; 2, Irauma cente,; 3, phYllclan'l olllce; 0' 4, cllnle, O. SICKNESS meanl Ilckness or dlleale l" an Inlu,ed Perlon \/ohich wal dlagnoled 0' treated aher Ihe Inlured Person'l coverage became eHectlve .nd while Ihe co,...a8e II in roree, P. USUAL. CUSTOMARY AND REGULAR CIIARGES, ~-EF_'i OR EXI'EI'iSES mean Ihe normal and prevailing charge, fee or expense for Ihe lervlce rende,e" or Ihe malerlal furnished In Ihe Ileogr.phle a'ea whele rendered or furnllhed, PART II . DEI'iEFITS We will pay Ihe Covered Expenle Incurred for lervlces and lupplles IIIhlch exceed Ihe Calh Deductible Amounl, All benefits are limited 10 Ihe Maximum Benefll for Each Injury or Sickness and Ihe Lirellme "i..imum Amounl for ALL InjurIes and Slcknmes which. along with Ihe Cash Deducllble Amounl, a,e shown In Ihe Certlflcale Schedule, Covered Expenses are Ihe usual. euSlomary and regular leel charlled ror cove,ed lervlcel and lupplies, A. HOSPITAL EXPENSES DEN~:FIT Seml-p,lvale hOlpllal room. board. and general nursing care lu,"llhed by Ihe hOlpitalwhen you or one of your covered dependents II neeeSlarlly confined 81 an overnlghl bed pallent In B hOlpllal, up 10 Ihe amounl Ihown In Ihe schedule, Benefits for conflnemenl In Inlenslve ca'e 0' ea,dlac ca,e faclllllel in Ihe hospital will be payable al 100% of Ihe Covered Expense, Mlscellaneoul hOlpital chargel for medically necenary lervlcel and lupplles, fur nllhed by Ihe hOlpitalwhen confined u Ita led above, for eumple: operaling '00011; recovery ,oom; anellhella; lurglcal dresllngl; cent,al luppllel; culs and spllnls; medlclnel or drugl uled In the hOlpllal; x'ray photog ,a phs; laboralory lervlce; and oxygen equlpmenl and lervlees, Chargel for personal and convenience Itellll like lelephone. radio or lelevislon; guest meals or COli; take-home drugs 0' other Items nOI cllnlumed 0' uled while cnnfined a,e nol Co,eled ;:'pemel, D. SECO:-';U SUIHac,\L OJ'INION If a physician recommendllu'gery, Ihe Insllred I'etsnn may ~el a lewnd opinloll by anal her I'hYllclan, We will pay Ihe ulual and eullomary charge lor Ihe 'mured Pc,,,,,, In oblain IlIch ..mnd opinion, If Ihe lecond opinion Ihollll Ihal lurge,y II nol advllable, lIIe will pay Ihe IIsual and cuuoma,y chat ge lor Ihe IllIorel! Person 10 oblaln a Ihlrd oplnllln, The,e Is no deduclible applicable In Ihll benefll, 0IlC.9054-F I'.ge ~ PAIlT II ' 1lI':I"~:H(,S (Contlnutd) c. SURGEON AI"D ASSISTANT SURGEON FEE The fen cha'ged by physicians, Including necessary assl!lant surgeons' fees, for surgical p,ocedu,es pe,formed when confined as an nl'ernight bed patient In a hospllal, 0, IlENEFIT FOR SAME.lJA Y Sl'RGEIl\' The feel charged for su'ge,y. ane!lhesla admlnlst,allnn. and olher associated medically necessary services provided al a Same-Day Surge,y Facility, E. IlENEFIT FOil ANESTHESIA ADl\lIl1OlSmATION Feel charged by an aneSlheslologbt fo, the administ,atlon of anesthesia while unde'golng a covered surgical operation, .'. IN,HOSPITAL PHYSICIAN'S VISIT The feel charled for Ihe services of a licensed pathologist while Ihe Insured Person Is confined as an overnlghl bed patlenlln a hOlpllal. G.IlENIWIT mR PATHOLOGIST The feel cha'led for the services of a licensed pathologist while Ihe Insured Person Is confined as an overnlghl bed pallenlln a hOlpllal. H. BENEFIT FOR RAlJlOLOGlST The feel charled for the le,vlces of a licensed radlologlSl while Ihe Insured Person Is confined as an overnlghl bed patient In a hOlpllal, I. ORGAN TRANSPLANTS Benefits BI evidenced by this Cerllflcate are payable for charges for organ transplants or charges for organ donors, We will nOI provide bendils for orlan Irani plants conslde,ed to be experimental by Ihe United Stales Departmenl of Health, Education and Welfare or Ihe American Medical Association, J. FAMILY SECURITY BENEFIT Upon due proof of your death occurrlnl while your cove,age Is In force. we will waive further premium for any of your ellllble dependenll who were Insu,ed under the O,oup Polley as your dependents on Ihe date of your death, The waived premium will begin on Ihe monthly anniversary date and continue 10 be waived for Iwelve months, During Ihls period, we will provide all of Ihe benefits for whlcr l'our eligible dependents were Insured at the time of your dealh; provided that coverale will te,mlnate If the Group Policy te,mlnates, K. RK'fURN OF I'Rltl\lIUI\J FOI( ACCIllENTAL DEATII If. while thll coverage Is In force, an haUled luffers an Injury and dies solely ps a ,esult of such Injury. the Company will pay to Ihe Imured'. estate. an amount equal In all p,emlums paid under the Group Policy prior to the date of the Inlured'l death, No payment will be made under this lectlon If death ,esults from: 1. ptomaines or hacte,la! Infection ucept pyogenic Infection which occurs wllh and as a result of an acclden"l cUI or wound; or 2, hodlly "' mental disease or dllo,der. "' medica! or surgical treatment therefore, OllC,90H,I' Page 6 l'ASIIIlEIlIll'T1I1I.E The Cash Deductible AmoulII Ii~ll'd In Ihe Celllllrate S,hedule 11'111 he dedu[te\lullly III1<e during any line <lIlendal )elll (January I . December ,11) fll' each 11I\\lIed I'el~oll, lIuwele,. IIIKe thlee family melllhelS hale IlIel their Calh Deductible Amounts In one calend,,. ye.,., IIU fUlthel deduclibl\'~ IllUlt be mellhi~ )elll. Any amount o( Coveled E'peme, IlIllllled hl' all In\\"ed I'ellun dUlill~ Ihe la,llhll'e n""'II" Ilf a [aklIlLII )eal, whid. are applied toward a Ca,h lJedu[libl,' Amllunt fOI 11"11 ye.1I, will al~u be applied tll\lald Ihe Calh Ill'd",tihle ,\mllunt IIf the (ollowlng calendar year, I'AIIT III . EXCI.l'SI01'\S A"'1l l.I~lIrArl()"'S A. Claims 11'111 not he paid (or allY Ill" le"I!tlllg di,eell) UI ilHlIleclly hum: I. any act o( war. declaled or undc"a,cd; 2, any Inlentlonally sel(.lnflicled inJu,); 3, menial or nervous disorders withouI delllonlt,able organic oligln; 4, hospltallzallon for which Ihe rlillclpalpulpme is phy'ical elamlllatioll; 5, loss cove,ed hy any Worke,'s Compensation ArlOI' any IIceupaliun.11 dlu'ase law; 6, cosmetic surgery unless due 10 all accldelll occulling while Ihe pulicy Is III fllll'e and while the Inluled pel.lInll Insured hereunder and rel(o,med withlll two years hOIll Ihe a[cidelll; 01 tll leralr lOlIlenltal defecl IIf a newborn child and pe,(ormed wlthill one )ea' frolll Ihe dale of hillh and \I III Ie (Ovenge Is III (ulce; 7, Pre-E,istlng Conditions unless 1011 oeculs after the Imuled I'e,son's roverage has heenln fOlce (0' 12 mOIHhs; 8, pregnancy or childblrlh (elcept complications of plegnancy) unless p""lded hy supplemenlall ider; 9, care which halnol been applol'Cd hy Ihe Secrela,y of Health and Ihllnan Sell ice,; 10, experimental or Investigallonal or,~n transplants; 11, hernia or hem<l,rholds. unle~s hm 15 Inculled II, /Il<lnlhs aile, Ihe h""1t'.1 1""""1 be,,"nCl CllI'eled uflllrr Ihe Group Policy; 12, any loss to which a conl,ibullng cau,e \I'a, the I 11111 red Person's heing en~aged In an illegalo\'cul,atlon; 13, any loss suslalned or cont,acted \lhlle an Imuml I'el,on Is unde, Ihe Influence of Inhnkanl' ur ulldel Ihe Influence o( any narcotic unlel8 admlnlslcl ed on the adl ice of a I'h)sicldll, 14, charges (or which benefllS are nOllreclflrally pll1llded he,elll B. Dental care. trealmenl or su"ery is covered \lhen IIece,sltaled hy InJII'y 10 .ound naturalleelll which occun while Insured hereunder, The expense /IlUII he incurred \llthln one yea, (111m Ihe dale o( injury, C. Coverage (or a no,mal p,egnancy will only be plovlded hy a supplementalllder. i( atladled, CO/llplicallonl o( pregnancy 11'11I be covered as a sickness i( the Insuled I'enon's coyerale is In (orce at the lime Ilf lou, D. Beneflla 11'11I not be paid (or Iou covered by .1n auwmobllc policy Illued to comply \/.-Ilh the Molor Vehicle Financial Responsibility Law. T,75 I'a, C, S. Subchaplel n. Secllon 171'1, PART IV . COmmiNATION WITII 01'lllCll IIENnTr I'I.ANS Benefits payable unde, othe, health In,uran[e pian, thai )'\lll 0' 1'0111 Cove,ed Ilepellllenl' have may allccl Ihe henlf"l payable unde, this plan, Becau,e benefits payable hy [..tain Il<'alth plans y"u may have IIlll/ht ellecd Ihe Amount of Covered Expen.es. Ihe benefit, of Ihls plan IIllghl be It'dured 'I he following e'plallls how Conltlinallon u( lIen,(lII' wo,ks: IIENEFITS S\!II.1El'T TO TIllS 1'110 VISION All o( the health in,uraoce benefits plovlded linde, Ihe (JIllIlP I'oltry ale .ubJ.'1 III Ilnl I',"vj,j"ll fOI Cooldlnallon of Benefits, Coordination u( !leneflts fIlay 1101 be applied In "alms Ie" than filly dnllall ($~II), hilt If .,"lItlunal lI.blilty I, Incurred to raise the smail claim above (ifly doll,lIs (~~II). lhe enllre liabilily may he inclnde\l In the ('llOldlntllun of Beneflls computallon, GIIC.9054.F I'll' 1 UHINI'1'I0NS A. "Plan" means any plan pluvldlng benefits or services for or hy lea\on of hospital. medical or dental cale or treatment. which beneflls or suvlees ate provided by: (a) group or blanket insurance eove,age. excepl blanket student accident and heaith Insurance; (b) group Blue Cross. Blue Shield and olhe, p,epaymenl cove, age provided on a group basis; (c) any coverage under labor-management trusleed plans, union welfal e plans, employe, organlzalloo plans. employee benefit organlzalion plans 0' any othe, arrangemenl of benefits fur Individuals of a group; and (d) any coverage under govern menIal prog,ams, and any coverage requl,ed or provided by any statule. except Medicaid and Pennsylvania no-fault auto insulance, The te,m "plan" will be cOllSl,ued sepalalely with 'espect to each polley. contract. or olher arrangemenl for benefits or se,vlces and separately wllh 'espect 10 that portion of any such policy. conlract, or other arrangemenl which reserves the righlto take the beneflu 0' lCIvlces of other plans Inlo conslde,allon In determining Its benefits and thai portion which does not. B. "This plan" means that portion of the Group Policy "hleh provides benefits Ihat are subjeclto this provision, C. "Allowable Expense" means any necessary, leasonable, and customary Item of expense al least a portion of which is covered under at leasl one of Ihe plans covering Ihe person for whom claim Is made, An allowable expense to a "secondary" plan includes the value or amounl of any deductible amount or co-insurance percenlage or amounl of otherwise allowable expellles \\hleh \\'as not paid by Ihe "p,lmary" or first paying plan, When a Plan provides benefllS In the fo,m of servlees ,ather Ihan cash paymenls, Ihe reasonable cash value of each servlees rendered will be deemed to be both an Allowable Expense and a benefit period, O. "Claim Oelermlnallon Period" means a calendar year or any portion thereof during which a person subject to Ihls provision is insured under this pian, EFFECT ON BENEFITS This provision will apply In delermlnlng the benefits for a person cove,ed under this plan during any Claim Delermlnallon Period If, for Ihe Allowable Expemes Incurred by such person during such period, the sum of: 1. Ihe benefits thai would be payable under this plan in the absence of Ihis provision; and 2, Ihe benefits Ihal would be payable under all other plans In Ihe absence Ihe,eln of provisions of similar purpose to Ihls provision, exceeds such Allpwable Expenses, During any Claim Determination Pel iod to which this provision applies. the beneflls that would be payable under this plan In the absence of Ihis pruvislon fur Ihe Allowable Expenses Incuned by such pe,son during such Claim Determlnsllon Period will be leduced so thai the sum of such reduced benefits and all the benefits payable for such Allowsble Expenses under all olher plans, exec pi as provided In the nexl paragraph. will nol exceed the lotal of such Allowable Expenses, Ueneflts payable under anolhe, plan Include the benefits thai would have been payable had claim been duly made Ihe,efore, If another plan which 15 illvol\'Cd in the above pa,agraph contains a p,ovlslon coo,dinallng Its benefits with those of Ihl. plan and woold, accolding to Its rules. deter mille III benefits afte, the beneflls of Ihls plan have been delermlned, and the rules set forth In Ihe next paraglaph lequlte Ihls I'lan to determine lIS be,neflts before such olher plan, Ihen the beneflls of luch olher plan will he IgnOled fOI Ihe pOI pmes of dele,mlning benefits under Ihls plan, For Ihe pu'poses of the plecedlng paragraph, Ihe lilies eSlahHshlng the orde, of benefit delermlnatlon are: I. The benefits of a plan which covelS the person Oil whose expense claim is based olher than as a dependent will be determined hefore the benefits of a plan which Cll\'r.rs sllch penon as a dependenl; 2, When rule (1) ahove, .lOCI 1101 ellablllh an Older of benefit dete,mlnallon, Ihe benefits of a plan which cover. the person ,In whllse cx!'ellSes <lalm is ha,ed al J dependent of a pelion whnse date of birth. excluding year of hltth. (ICCUIS ('allie, In a (alcndat y,'al, Ihall he delellnlned befure Ihe benefits of a plan whleh covers luch !'enun as a dependent uf a 1"'1""1 w h,,,,, "'lie of billh, e\(ludlng year of hillh, "CCIlIS later in a calendar year. OIlC-90~4-I: Page 8 EFFECT ON IlENEFITS (Contlnllrd) If either plall does 1I0t have the provisions 01 Ihls pa,ag','ph 'egaldlllg dependellls. which leslllls ellher III e'.llh plan delermlnlng lis beneflls belo,e Ihe olher. or In each plan dele'mlnlllg lis belleflts arter Ihe Illher. Ihe provisions 01 Ihls pa,agraph shall nOI apply, and Ihe rille lei Illrth III Ihe plall which dnes IInl hAle Ihe provisions 01 this paragraph shall dele,mlne Ihe o,der 01 benefits; e>lepl Ihal III Ihe ease 01 a persnn 10' \Iohnrn claim Is made as a dependenl child: a, When Ihe pa'enls are leparaled or dlvo,ced and Ihe palelll with cUllody 01 Ihe ehlld has lint lemarrled, Ihe benefits 01 a plan which cove,s Ihe child as a depelldelll 01 Ihe I'alenl wllh cllllndy 01 Ihe ehlld will be determined belo,e Ihe benefits 01 a plan which covers Ihe child as a dependelllol the p:lIe'lIl wllholll ellllody; b, When Ihe pa,ents are divorced and Ihe parent with Ihe clI'lody 01 Ihe ehlld has lern.",I.d, Ihe benellls 01 a pia II which covers Ihe child as a dependenl 01 Ihe parenl wllh cllslndy Ih.,1I he de'lerrnllled hefm e Ihe henellls of a plall which covers the child as a dependent 01 Ihe Mep'palellt will be delermlned belme Ihe bellellls 01 a plan which cove's Ihal child as a dependellt of the pa'elll \Io'lthnlll cllllody; c, NOlwllhstandlng subparagraphs (a) and (h) of this paraglaph. whell the p.'lellu 3Ie IIIVUlced 0' separnted Alld Ihere Is a courl decree which would olhe,wlse eltabll,h flnallclal rC5pol1llhillty IIlI th~ medlclIl, IlenlAI, III other health care expenses with respect 10 Ihe child. Ihe beneflu III a plall \10 hleh wl'e" Ihe ehlld B! a dependenl of Ihe parent with such financial such financial relponsihlllly ,hnll be delerrnlllell hdole Ihe beneflls of any olher plan which covers Ihe child as a dependent child, 3, When ,ule (I and 2) above. docs not eSlabllsh an orde, or bendlt delermlllallon, Ihe bellerllul A plnll which hB! covered Ihe person on whose expense c1airn Is based as a lald,oll or rellred employee. 01 dependelll III .lIeh person, shall be determined after Ihe beneflu of any other plan cOl'erlllg Ihe persulI 'IS alle'mployec. olher than a laid off or retired employee, or dependenl of such person; 4, When rule (I, 2. aud 3) above. docs nOI eSlabllsh an o,der ul benellt detcrmlnnlllln. the hellefllol a plan whleh has covered Ihe person on whose expense claim is based for Ihe 10llger pellod III lime \10111 be deterrnlnClI belllre Ihe benefits of a plan which has covered such person Ihe shorter pe,lod 01 time, When this provision operates 10 reduce the 10lal amounl 01 benefits otherwl,e payahl. \Io'llh lelpeel 10 II pc 110 II roverell under this plan. during any claim determlnallon period, Ihe bene fils Ihal wuulel be 1'111',,111. III Ihe ah.ente of Ihl. provision will be reduced. and only the ,educed beneflu Ihal arc pa)'ahle after Ihe "pelalloll III Ihls I"OII.IIIII \10'111 he charged against any applicable benefit limits 01 Ihis plan, RIGHT TO ImCEl\'E AND IlEJ.EASE NEn:~SAIl\' ISFOlfMATION For Ihe purpose of determining the applicability of and Irnplementlng the lellllS 01 Ihl. l''''l'lslon or any I'rovl.ltlll 01 similar purpose In any olher plan, We may. wllhout Ihe consenl of or nOllce III any pellnn. Itlease to Ilr uhl~ln frum any olher Insur~nce company. or other organization or person. any IlIlorlll.,tion which We "eelll lu he lIecrualY lor such purposes, Any person claiming beneflls under this Plan will lu,nlsh III US lueh 111101 Illntinn al ma)' he nerruary to Implement Ihe terms of Ihls provision, FACILITY m' PAYMENT Whenever paymenls which should have been made under this Plan In accn,dann' wllh the t.rml of Ihls plnvllllln have been made under any olher plans. We will have Ihe ,Ight. .,erclsable alolle and III nlll .nle "11t'letion, In pay ewer to any organizations making such othe, payments any amoullt We ma)' "el.llnln. In he 110';11 I anI"" In ul".r hI utilly Ihe Inlent of Ihls provision, Amounts so paid will be "eellled henefils 11"1 IIn"" Ihll Plan and, hi Ihe ..lelll 01 luch payments. We will be fUlly discharged from liability under Ihls plan, I!lGm' OF IIECO\'EIlY Whenever payments have been ma"e by Us ..llh ,e'pelt In allowahle f'P"II\l" In a lolal ;lIllIlIlnlo al any Ilme'o In excess of the maximum amounl necessary at Ihat tillle 10 sati.fy the IlItenlnr Ihll 1"11\ III\ln, We \10111 have Ihe Ilghl to recovel such payments. 10 Ihe extenl of such excelS, I,om among olle 01 1ll0le 01 Ihe followlllg. ,(\ We shall "eterllllne: an' persons to or lor 0' with respect to wholll sueh paym.nts \loere Illa"e; any olh!'1 In'1I1alll'e companies; any othe organization, GJIC.90S4.F Page 9 . , TI~m LIMIT FOIlI'A\'M~:NT Payment of henellls mUSI be made wllhin Ihlrty (30) calendar days after submlllal of a p,oof of loss. unless We p,ovlde the c1almanl a c1ea, and concise statemenl of a valid reason fa, funh., delay which is in no way connected wllh or caused by Ihe exlslence of this Coo,dinalion of Benelits provision nor olherwise allr ibulahle 10 the Company claiming delay, We will furnish any Informalion neceslary for coo,dinalion of henefilS to a ,equesting company whhln 15 calendar days of Ihe requesl. I'Aln V . EFFECTIVE DATE OF COVEIIAGE Vou and Vour Covered Dependenls: We requill' ,,,dellll "f inlur.hlliry helo,e coverage Is provided, Once we have approved your emollment appllcalion. coverage la, you ","l you, covered dependents will begin on Ihe Cenlllcale Dale shown In the Certillcate Schedule, Newborn Children: You, newborn children will be provided coverage after Ihe Certillcate Dale and erfectlve from the momenl of birth for 31 days, Coverage will nol be subject 10 any evidence of Insurability 0' acceptance by Ihe Company and will Include coverage for congenhal birth defects, binh abnormalities. p"mature birth. and routine nursery care, Afler the Inhlal 31 day pe,lod. cove,age will continue only if we I ecelve wrillen notice of birth !rom you before Ihe next premium due date or whhin Ihe grace period and any lequi,ed p,emlum Is paid fo, such dependenl, Addlllon of Dependents: You may add addirional dependents by providing evidence of eligibility and Insurability I8llsfacto,y to us and upon payment 01 the p,emium ,equired lor such addirlonal dependenlS, The acceptance 01 new Covered Dependents will be shown by endorsement and the date of the endorsement will be Ihe erfeellve date of coverage for Ihe new Cove,ed Dependents, PART VI . PREMIUMS Paymenl of Premiums: Premiums are payable to Us at our Administrative Office, The premium II payable monlhly, quarterly, seml.annually or annually, I'aymenl of any premium will not malnlaln the policy In force beyond Ihe nexI premium due date. excepl as provided by the Orace Period, Any Indebtedneu of the Insured Person 10 UI arising oul or prior claims may be deducted In any selllement under the Group I'allcy, Grace Period: A g,ace pe,lod of thlrty,one days. measu,ed from Ihe premium due date, will be allowed for paymenl of all premiums due. olher Ihan Ihe first, Ou,lng this lime, Ihe coverage will remain In fa,ce. unless we receive prevloul wrlllen nOllce Ihallhe coverage Is 10 be terminated prlo, to the grace period, Premium Changes: We will nOI Increase Ihe premiums solely on the basil of your claims or any change In your health; however, we reserve Ihe rlghllo change the premiums becoming due under the Group Polley at any lime alter your coverage has been in fo,ce fo, one year; p,ovlded we have given the Group I'olicyholder wrltlen notice of al lea51 3\ daYI prior to Ihe eHectlve dale of Ihe new rates, 1',\ln VII . TERMINATION Oi' C()V~:RAlJE In.ured, Your Insurance wllllermlnate on: t. the dale the Group Polley lelmlnales; 2, upon nanpaymenl of premium, subjccllllthe g,ace peliod; 3, Ihe dale you cease 10 be a member In gLlod standing of Ihe Hust to whLlIll.lhe GIllUp Policy Is luued; ur 4, the date you qualify fllr Medicare, at any age, 0' leach age 65; ullleu benelllS are p,ovlJed by supplemenlal rider. Covered I)ependents: You, Cllvered Depende"t'sl"sura"re willtellllinate nn: t. the date your Cllve'age lermlnales; 2, Ihe date such dependent cea.e, to be a" Eligible Ilel'endenl; 3, Ihe date your spouse bettllllcs diwlred flOIll YLlll; 4, the date a dependent eblld lIlarrl,',: or 5, Ihe dale a dependenl 'i"alifies, at 'lilY aKc. ton ~ledirale, or Icarhn a~e 65. unless beneflls are provided by supplemental rider, OIlC,9054.J' l'alC 10 "AllT \'11 . TEltMINA'[JON CW CO\'EItAGE (Conllnned) The allalnment of Ihe IImlllng age fo, a Coyered Dependenl \\'111 nnl cau~e coye,age to te,mlnate while Ihal per~on I~ and continues 10 be both: (a) Incapable of ~elf-~u~talnlng employmenl by 'ea~on nf menial ,clardatlon or phy~lcal handicap; and (b) chiefly dependent on )'nU fn, support and malntenante "Chleny Dependent" mean~ the Covered Dependent receive~ the majollty of hl"he, finandal ~upport from you, We wllllequire that you provide proof thai the dependent is In fael a disabled and dependent pe'~on alleaS! 30 day~ prior to the dale upon which the dependent \\'ould othe,wl~e re.lth the Iimillng age and. Ihe,eafter, \\'e may ,equl,e ~uch proof no more f,equently Ihan annually, In the absence of such ploof, \\'e may te,minate Ihe cOV'e'age of such person after the allalnment of the limiting age, Group Polfc)', The Q,oup Policyholder or the Company may terminate the O,oup Policy. provided \\'rillen notice Is given to the other parly at leaS! 31 day~ p,lo, to Ihe date of tc,minallon, Exlenllon of BeneWs. We allow for the extension of benefits If the G,oup Polley te,mlnates, If an !n~u'ed Pe'~on 1& totally disabled at the time the Group Policy te'mlnates, benefll~ will be payable subject to the ,egular benefit IImils of the Group Policy. for expense Incurred due to the ~Ickness of Injury which caused such total dl~ablllty, This extension 01 benefits will cease on the earllcst of: (a) the date on which the total disability ceases; or (b) the end of the 12 month pe,iod Immediately following the date on \\'hich his/her Insurance terminated, For the pu'pose of this section. Ihe te'm~ "lIltal disability" and "totall)' disabled" mean your continuous Inability to pc, form all of the substantial and material duties and functions of )'our occupallon, PAin \'111 . GENERAL pRO\'151Ol'i5 Entire Contract; Changes: The Entl,e Contract will consist of: 1. the Oroup Policy. the application of the Group Policyholder, which "'III be attached to the Q,oup Polley; and 2, any enrollment appllcatlon~ of the propo~ed Insured Individuals. Including your own, Allltatementl made by the Group Policyholder or by you will, In the absence of fraud. be deemed representations and not warranties, Only an officer of the Company has the power on behalf 01 the Company to execute or change the Group Policy, No other person will have the authorily to bind us In any manne" Any change In the Group Policy will be made by amendment approved by the Group Policyholder and ~Igned by the Company, Such amendment will not require the consent of any Insured Person, Indh'ldual Certificates. We Is~ue a Certificale to each Insu,ed !ndiyldual unde, Ihe G,oup Policy, It summarlzCI thc benefits for which you arc Insu,ed by the Group Policy. to who III payable and your rights. If any, upon termination 01 Insurance 0' termination of lhe G,oup Policy, The Cerllflcate does not constitute a part of the G,oup Policy nor does It In any way change any of the condltlon~ and p,ovlslons of the Group Policy, ^ copy nf the enrollment application Is allached to the Certificate, Nollce of Claim. Wrlllen notice of claim mu'l be glyen to the Company as soon as possible, Written nOllce 01 claim given by or on behalf of the Insu,ed I'e'~on to us with Info,mallon sufficient to Identify such person will be consldcred notice 10 u~, Claim Form$; Upon ,eceipt of wrillen l"'lice of claim, we will furnish the forms we lequlle for filing p,oofs of lo~~, If we do not send the lo'ms within 15 d3)~, you can meet ou, Icqullements by glYlng u~ a w,llIen statement. This &Iatement should Include the nalu,e and eXlent of the claim and be ~cnl to u~ within the lime lIated In lhe Proof ollos~ provi~lon, 01lC-9054,F Page 11 I'AII'I' \'11I . GI':I'OEIlAL 1'lWVISlOl'OS (Collllllued) Proof of Loss: Wrlllen proal 01 lolS mu,t bc IUllllshed III \IS wilhlll ')0 days aileI' Ihe date 10' whkh <lalm is made, If Ills shown lhal II is not leasonably 1'""lble to 1011li,h wll\lell 1'1' 0,,1 01 I",s wilhill thai lime. Ihe <laim will 1101 be Invalidated or ,educed as long as we lecei\e such I"oof as SOOIl as lea,,,"ably possible and in no nellt ill Ihc absence of legal Incapaclly, later Ihan one year flam Ihe time proof is olhelwlsc Il'quired, Time of l'a)'l11eUI of Claims, We will pay all bellelll, ,llle \lnde, Ihc conllncl I'loml'tly ol'on recell'l of d\le proal of loIS, Pa)'ment of Claims: All beneflls .,e I'ayablc 10 )'OU, II any loch benellll lemaln unpaid al your death, or. il you are, In the opinion 01 Ihe Company, Incapable "I giving a legally binding Icceipt lor paymcnl 01 any benefll, we may. al our option, pay such benefll to anyone or mOle 01 the lollowing lelntive,: you, Ipouse, mOlhel', lalher, child 0' chlldlen. brolhe, or b,olhers. sister or sisters, Any paymenl <II made will cOlIstilule a com pie Ie discharge 01 our obligations to Ihe extent of such payment, Physical Examlllatlons and Autops)', We will. al au' OWII expense. have Ihe ,Ight and oppo'tunity 10 examine Ihe person of any Individual whose Injury or sickness is Ihe basis of a claim when and as olten as we may realonably require du,lng the pendency of a claim, We may have an aulopsy made in case of dealh where It is oot prohiblled by law, Legal Actions: No action at law or in equity will be hI ought to recover on Ihe G,oup Policy p,lor 10 Ihe explralion of slxly (60) days afler p,ool of loss has heen filed as lequlred by Ihe G,oup I'oliey; 1I0r will any anloll be broughl alte, three (3) years Irom Ihe expl,allon 01 Ihe lime wllhln which prool 01 loss is required hy the G,oup Policy, Mlsstatemenl of Age: II Ihe age of any Insu,ed I'crson has been misstated, 0\11' records will be changed \0 show the correct age, The benefits provided wlllllot he alfecled II the lnsu,ed I'erson continues 10 be eligible lor coverage allhe correcl age, However. premium adjustments will he made 50 that we ,ccelve lhe p,emlums due at the correct age, Time LImit on Certain Defenscsl I. Alter three years from the cffecllve date 01 an Insured I'erson's cO\'eraae under Ihe Group Policy, no mlsslatemenls. except fraudulenl misstate menU, made by Ihe appllcanl In Ihe en,ollmenl application for the coverage will be used to void Ihe cove,age, 2, 1'00 claim lor Iou incurred alte, 12 monlhs lrom Ihe effecllve dale of an Insured Person's coverage will be reduced 0' denied on Ihe grounds Ihal a disease 0' physical condition had existed p,lor 10 Ihe elfectlve date 01 the Insu,ed I'erson's cove,age, Conformity with Slate Stalules. Any provision 01 Ihe O,oup Policy which, on Its effective dale, Is In conlllct with the stalutes of Ihe stale In which Ihe Insured resides on such dale is hereby amended to conlOlm 10 lhe minimum requlremenls of such statules, PART IX . CONVERSION I'RIVILEGE If an Insured Person's coverage ends 10' any reBson olher than fallu,e 10 pay requi,ed plemlul1l.You may apply on your behalf. and, If desired, your cove,ed dependents 10' an Individual polley of Insurance 01 a kind Ihen beina Issued by Os for group conversion pu'poses, This conversion p,lvilege Is also provided 10' you, cuve,ed dependent who ceasCl 10 qualify for dependent's cove,age due to a valid decree 01 dlvolCe, No evidence of good health will be require,I, Howcver. wllllen appllcalion lIlu\1 he made and Ihe filst quallerly (or II Ihe option of the appllcanl, semi-annual or anllual) r,emlum raid within Jl days following tell1llllallon fir Ihe Insured Person'slnsurance under Ihe rollcy (60 days for an Individual whose LOve,age ~ell1llnaled because 01 divorce. 90 dayllf we have not flrsl given you wrillen nOlke 01 your light 10 converl), The individual policy will he issul'd plo\ld('d it doel oot relull hI overiusurance, at ou' publl.he.llale applicable 10 Ihe age of Ihe Individual and \0 Ihe lorl1l and an",unl 01 insulance provided under lite ('OI1\ell.,II,,,II<Y The Individual polley l1Iay provide [O(leduclion of ilS bellellls hy lite al1lount "I any henefits pa)a"", by this plan, G11C'90S4-F Page I ~ "ART IX . CONVERSION I'RIVIL..:G1, (Contlnued) . . AI an Insured Person yoo will receive wrillen notice of your conversion privileges and the durallon of soch conversion privileges within flfleen (15) days befo,e or after the dale of lermlnation of the grouJl coverage, If this notice Is nOI given more than fifteen (15) days bUlless than ninety (90) days after the dnle of le,mlnatlon of the group coverage, Ihe time allowed for the exercise of such privilege of conversion shall be exlended for fifteen (15) days after the giving of such nOllce, If such notice Is not given within ninety (90) days after the date of termination of g'oup coverage. Ihe time allowed for the exercise of such conversion privilege shall expl,e 31 Ihe end of such ninety (90) days, Wrltlen notice by the policyholder or us given 10 the Imu,ed Person 0' mailed III the 'mured Person's last known address will sallsfy our obllgallons as to such w,llIen nOllce, Afler an Individual policy becomes effective lor any person. Ihe polley will be In exchange for all benefits and privileges under Ihe polley for the person, GUARANTEEO CONVEllSION AT AGE 65: When an Insured Person's coverage ends due to becoming eligible for Medicare at any age. or reaching age 65. we will issue a new polley 10 such person, TIle new polley will be one which II then Issued by us \0 supplemenl Medicare, No proof of insurability will be required, OIlC.9054' r PIONEER !.IFE INSURANCE COMPANY 0." ILLINOIS 304 Norlh Moln Sir..., R".krurd, IlIIn,,1o 61101 OUTI'ATIENT MEIlICAL U.:NHIT RIIlER In con.iderolion oflhe poymenl of p,emium fur Ihis ,ide,. Ihis ride, is .no.h.d 10 ond m.de 0 I'orl of Ihe policy or ccrtilic.'o 10 which iI il .nlched, UENEFIT If you requi,e mediell t,eolmenl on oceounl of injury 0' sickness. ond soch treolmenl occurs at 0 physician'. ornce. clinic, ho'pllol. hOlpitl1 oUlpotient deportment. hOlpilol emergency mom. 0' on .mbulalury surgical cenler. .ner your deducliblo hOI been mel from eovered expen,el, we will p.y 80% of Ihe u,uol and customary chorgel fo, Ihe following ,ervicel: . Phy"iei.n'. Vilils II orncc 0' Clinic · Phy,iciln feel for emergency room lervice or ,urgery · Emergency Room Feel · ""Ihology (Llbo'"lory) Service · Rldlology (X,,"y) Servico · Elecl'oelrdiogrlm · E1eelroencephllogram · Pneumoencephalogram · Anglo grIm · I'yelogrlm · Ambullne. Expen'el . Spinll Mlnipullllon, not 10 exceed 2S pe, e.lend.. yeo, · Myelogrlm . Inldiltion Therapy · Chemolheropy · Anesthe.i. · Cenlrol Supplies · Costl, Splinls ond Ilrlces . lIypodennicI . P,escriplion Drugs . P,escriplion Medicines In Iddilion, we will I'"l' 80% of the usuol ond customary eho'ges, fa, ony olhe, neceuory medical expensel fo, Icrvic.. not Ii.ted lbovo II I phy"ieiln'l om co or elinio. hospillll. hospilll outpltienl dep"rtment. ho'pitll emergency room, or In Imbulllory ourglcll ccnler, Covered upenoel ineuned for .ervice. Ind .upplie. for Ihe Boso Pion Ind thil Rider mol' be used 10 '"lisfy Ih. Cuh Deductible, For purpo.el of II,lsfying Iho Cosh Deductible Co\'ered Expenses Ire thOle usuII. customary, Ind regullr Fee. ehllged for Covered Expen.el for both the Policy Ind Rider, Expens..lneuned for trlnsportltion. personll. comfort or cOll\'enienee lIeml Ire not cove,ed, Benolill plYlble under thil rider sholl not exceed $10.000 pc, colendsr ye.., Benelill will not be poyoblo under Ihis Rider if .uch benelils duplicole benelil. poyoble under ,ho bose pion, Thl. rider i, .ubjeetlo oil of Ihe condilions, limilotions ond delinitions of the policy nol ineon.islenl herewilh, In III olher ro.peetl your cove,ogo remoinl Ihe Slme, PIONEER LIFE INSURANCE COMPANY OF ILLINOIS Pre.idenl OllR9070 I'IONElm UI'Jo: ISSlIJlANCI, Cmll'ANY OF II.I.INOIS ,\dlllllllwalile Offire: I'D, II,.. (dY075, Dallas. Te,", 75261,'J075 II IJ) Ell (Fur I'elllll) Ivanla I~clidcnll Ollly) The polley or certlflcale to which Ihls Illllendlllcnl is Illlarhed II amcllded 10 Include Ihe lollowlng: ,\I.COIIOI. ABUSE ANIl DEPENDENCY BENEFIT A. Benefits a,e p,ovided 10' inpatient detoxlfiration ellher In a hOlpltal 0' In an Inpallent non.hospltal laclllly which has a w,llIen affiliation ..llh a ho'pital lor emergency, medical and psychlat'lc 0' plychologlcallupport lervlces, meets minimum lIanda,ds 10' cllent'lrl'ilaff ratios alld lIaff qualificalions which shall be eitabllshed by the Department 01 Ilealth. and Is IIcenled as aa alcohollsllI trealmellt plogram, The Following lervlcelshall be covered unde, Inpatient detoxification: I. lodging and dietary wvlces; 2, l'h).I<lan. plychologlst, nune. certified aJ.linlons counselor and lIalned lIaff lervlces; ), Dlagnolllc X,ray; 4, Psychiatric. plychologlcal and medlcallabo,alllry lelllng; and 5, Drugs. medicines. equipment ule and lupplles, Treatment under this lecllon Is IUbJect to a lifetime limit, 10' any covered Individual. of four admllllons for detoxification. snd reimbursement per adml..lon Is limited to leven (7) days of treatment or an equivalent amount, B, Benefits are provided for non. hospital relldentlal alcohol services In a facility which meets minimum standards for ellenHo-staff IItlol and lIalf quallflcatlonl which shall be established by the Office of Drug and Alcohol Programs and Is approprlalely Il<enled by the Department of lIealth 81 an alcoholism trealment program, Berore an Inlured may qualify 10 receive benefits under thll section, a IIcenled phyllclan or licensed psychologist mUll urtlfy tho Insured as a penon suffering from alcohol abUle or dependency and refer the Insured for the appropriate Ireatment, The following servlceslhall be covered under this see lion: 1. lodging and dietary services; 2, PhYllclan, plychologlll. nurse, certified addictions counlelo, and trained Ilaff lervlces; ), Rehabllllallon Iherapy and counseling: 4. Family counlellng and 1t1lelVenllon; " Psychiatric. plychologlcal and medlcallahotalory lesU; and 6, DruIS. medicines, equipment use and IUl'pllel, Rl067 (Ilev 2/92) The lIeatment under Ihls section Is <over cd fur a minimum uf thirty (30) days pe' )'ear fur ,esldentlal ca,e, Additional days a,e available as provided In section C. Treatment is subJecl tu a lifetime limit. for any covered Individual of nlnely (90) days, C, Benefits a,e provided for oUlpallent alcohul services provided in a faclllly appropriately licensed by the Department of l1ealth as an alcohollsmlrealll1enl p,og,am, Before an Insured may qualify to ,ecelve benefits under this section, a licensed physician or licensed psychologist must certify the Insured as a person suffering from alcohol abuse or dependency and refer lhe Insu,ed for the approprlale treatment, The following services shall be cOl'ered under this seellon: t. Physician, psychologlsl, nurse. certified addictions counselor and trained slaff services; 2, Rehabilitation therapy and counseling; 3, Family counseling and Intervention; 4, Psychiatric. psychological and medical laboratory teSlS; and S, Drugs. medicines, equipment use and supplies, Trealment under this section shall be cOl'e,ed for a minimum of thirty outpatient. full-session visits or equivalent partial visits per year, Treatment Is subject 10 a lifetime limit. for any covered Individual. of one hundred and twenty outpatlenl. full-session visits or equivalent parllal visits, In addition, treatment under this section shall be cOl'ered for a minimum of thlrly separate sessions of outpatient or partial hospitalization services per )'ear, which may be exchanged on a Iwo-to-one basis 10 secure up to fifteen additional non-hospital residential alcohol treatment days, 0, The following definitions will apply to terms used In this amendmenl, "Alcohol abuse," Any use of alcohol which produces a paUern of pathological use causing Impairment In social or occupallonal functioning or which produces physiological dependency evidenced by physical tolerance or withdrawal. "Detoxification," The process whereby an alcohol-Intoxicated or alcohol dependent person Is assisted, In a facility licensed by Ihe Departmenl of Ilealth. through the pe,lod of time necessa,y 10 eliminate. by metabolle or other means, the Intoxicating alcohol. alcohol dependency factors or alcohol In combination wllh drugs as determined by a licensed physician. while keeping Ihe physiological risk to the pallenl at a minimum, "Hospllal." A facility licensed as a hospital by the Department of l1ealth. the Department of Publle Welfare. or operated by the Commonwealth and conducting an alcoholism trealment program licensed by the Department of Health, "Inpatient care," The provision of medical nursing. counseling or therapeutic services twenty-four hours a day In a hospllal or non-hospllal facility, according to Individualized I,eatmenl plans, "Non-hospllal facility," A facility, licensed by Ihe Deparlment of l1ealth. for the ca,e or treatment of alcohol dependenl persons. except for transitional living facilities, "Non-hospital residential care," The p,ovlslon of medical. nursing, counseling ur the,apeutlc services to patlenls suffe,lng from alcohol abuse or dependency In a ,esldentlal envl,onrnent, according to lhe Individualized treatment plans, Rt067 (Rev 2/92) Page 2 "Oulpatlent cale," The plovlslon 01 medlc.11. nu"ln&. lOllmcllng 01 Iheropcllllr selvices In a hospllal or non,hospllal laclllly on a legllla' ond predelermlned schedule, 8llllldlng to Individualized HeMment pions, "I'artlal hospllallullon," The provision 01 medical. nlllling. l'llonsellng 0' Ihelopeutlr servlcel on a planned and regularly Icheduled basil In a huspllal or non,holpllal lacillly licensed as an ailohllllsm Heatment program by Ihe Department 01 lIeallh. designed lor a patlenl or client \Io'ho \Io'ould benefit horn more Inlenslve servlcel than a'e oHered In outpallent treatmenl hUl \Io'ho doCl not lequlre Inpalienl care, E, The benellls 01 this rider are subJecl wlhe deducllble and colnlu,ance ,,<!Celllage. II any. lIaled In lhe schedule, This ride, II eHectlve on the erlelllve dale 01 lhe policy 0' certlficale 10 which il Is attached, It Is lubject to all the condltlonslitnllatlons and exclusions III the policy nol Inconsistent hele\lo'llh, Signed at our Admlnlstrallve Olliee un the effective date 01 the policy u' certlllrale, PIONEER I.II'E INSURANCE COMI'ANY 01' ILLINOIS President RI067 (Hev 2/92) r.le 3 1'lONnR Lln: INSURANct: CO~lI'ANV ot. IU.INOIS VANISIIIN!: llt:l>IJCTllIl.t: Rlut:lt Thi. rid., is OIlDChod to 8",llIIode 0 pori of tho puliey 0' eeltifieole lu IIhieh it i. olloehcu, IIt:NF.nf Tho o..h dedueliblo ollluunl .huwn in Ihe Schedole fur eDch in.med por.un \\111 ho reduced 25% 01 Ihe end uf Ihe fi..l yeor of oO"erolle if eoch insured person incurs no covered o'pc'15es unue, the puliey UI ils ulluchod rhle,", The deductihle will be reduced In addilionul 2SIIA. each yeDr IhcrcuClcr lIS lOllS 01 each insured person has incurred no co\'crcll expenses ulu.ler tho contrDct sinea eOVo'OIlO bOllon, Tho maximum roduelion is 100% I'or purpo.o. of Ihis provision. euvered e.penses oru incurred on thu dole service is Iliven ur supplies 010 u.od, Tho provi.ion opplius .opuruloly fa, ooeh insured person, PIONEER LIFE INSURANCE COMPANY m" ILLINOIS OHR.9076 I'IONE.:R 1....E INSURANCE CllMl'ANY IW InlNOIS lI"mo Off',cc: 30.. N Main Slleel. Il"ckf"rd, IlIin"i. (01101 Admini'lrative Office: 1'0 JI". (d')01l. Dalla.. Te.a. 7llCd.Y07l AnlCndnlent (Penn.)'I\'anl' Il..,denl. Onl)') Thi, amendment i. 8ttactlclllo and Illode II pari uf your \:011118C," MAMMOGRAPHY SCREENING DENU'IT w. will pay all co.I.. .uhjcel 10 any deductihlc and cOl'a)'mcnl. associaled wilh a mammogram o\'cl}' yea, for women 40 ycall uf agc 0' older and wilh any maounogram ha.cd on a phy.ician'. recommcndation for W"nlcn under 40 yoara of ago P,ior 10 paymonl 1'0' a .crccning mammogram. wc w,lI I'c,ify Ihal the .crcening mamm"graphy lC\\'ice pro\'ider i. properly licensed by Iho Departmenl of In.urance in accordance wilh Ihe act of July 9. 1992 (1',1.. 449. No, 93). known II Ih. "Mammog,aphy Qoalily Anorancc Ac\." Tlu. amendment i..objcctlo all of lh. exception.. dcrmili"n. and condllion. or Ih. policy, In.1I olher ,upcel.. your eonlract remain. Ih. .ame, PIONEER I.IFE INSURANCE COMPANY OF I1.LlNOIS Presidenl R.22H '. ,'-- ~ //001075139" . t ull ~lrrw ) a. ~1C4~-S IIO\4E 4DOIF.\S """', ").. 00/ ~ ~ b IJ A ~ 1L-h~ l.,iT.J ~ C..",,--i'.c.AK ,______________'- -~ ,. r.. .~4JL~----------!>lat,j~-- l~rll3JJ .,.,~ ~U/ll,," I)/) I '! J';.., .1. C' -S..) IHIlIHG "1>/111,\\ HI '1'1 \\ ""\l~_ ,__ Omrl'll_ _,_ /{,' ~ It. l',1~ I" 1/' --~'..._- I IOn,,,m ~prllllllf\R \tHIIII ,"'~..., fn,m , r.: ~ 0... f\rd~"Nt '"",~l'\: . J ~ f ' ",,',1/ '.J ""''''''1 ~I '"11' ." ..J, II --.m wum I III '1'1\\ ~IlIlRESS ,,"It "DEJhIFR:'Tkvt'-A:IAJi:-- \.1""" .~, /1 !3{fv.3}' 1- . ( .'1'1) _':"U HnF~~/J1) I 'II j,)/JIlF""AAJ'i 7"<' ...'jJ SU..EL- Z/pnf}jl ..__1,1";.,0,,", 'umt-<. OD-..I_2'1. - () WI', I, ..'''' /Jl;//'JI...~ Ij_JiRlI~>>c-. H(l\IlonllZ.),,~'!>lIrjl; r;;..:.;';--T \'N So : j,) I \"", I"' memNl 11' tot III\utt\1 rft'Wnll~ fr(CI\f In~ ' t,Htll'ltt1,nl <lht '\h~ .I., \leJl\',llJ ," 'Itdl'UC'~ i' \,~ ...~..h ,Irrh\Jnl ,'IIJ ...tll\'h rf[\iranl '5/ /) \6<"'h"..., r".."" )f I~, '.~ll"lf\i'''''' \41"J,," n,....". f ..,.,#...... , ~'r..llt1 .... W''' Ivrr 1'.'N''''f\lf~lIl.''''1 ~ ".'~"" \ I....,.. ',f 1";'"'" ,.. \,,1 I' 'f""'I~r..t\ fVnt,., 1.tllln ' '0., lhrrllr,'. ~fW'flf"~"1 . I '''''/r Tn", I,', (~'If ",.ll .: '.",,11 .t '. '.... ,1 'j !j .7 ''''''',t , .-' '-r. , ' '/" 1/ ""., r",,,,"rYW \, .t--_"r.1 In ,.x . "t.1Wlft~'r__.__ . . ~l>lk"\I~lr__,___,_.__ , II..., \I'll t"\C'1 'rrhhlll'l In'lIlJlht 'IIlllh th'" rOmp'")' i' 'n. "'\11 II\lJt\I' , !, h.....h.1 1\ ,,'llh.'JI, III J"llh~ n\l"l~t't I: '" ,:1 'r"ltt""~' 4rrllC'd fl\l 't'rl,," I" trrn."I ,'hln.c o( H" ''''\l''"~' ..lfh Ih" \'f'lmpln)' or In) OIht, \omf'.n) 1 ~ I) I ,-, An. I" \I'U n,'''' h"t hn\rllllliulIOn In,ur.ncc? ' .A . I' \C,.' I' II (,Ii'ur ... or Indl\ldu.1 J. nlm"" of com,.u". ,rll,fldl!t "",11'1 "umllf',.mounij Ind l)pn uf \'O\tralf' . ,-,-,-1~:~ EA ~__ ,. ,,' 14 II,' ". 1',' ra\l I,n \'1'\, hl\ In) fl(r~R 10 bt I"Iured .. ,.' "".1' ,", C' tlf\ 1t""J. fllN. f1dtfN Uf ~.I" , '. "'fl"J', . Q:lV ' II h<' -"hh 'rr",'.nl~ I OtiC? ~r..,,'n' _____~ f. d I ( ""'rAnl' .. . ___.. _._. ._.__....~____. II 1\ '''' .('rl".nl IU'ftn,') rft.n'n'~ . . ., "'''U p.- II 'f\;'" hi, h "rrll,.nl' _ , . .....~ '. ' , 't1lm.lr..J "hit Ilf dch\"f1)' · . .'" " ' " I" ''''('I ""1 m,mhc,.IC\bf IRIUtfd 'nil' In: Pa'lChullnl, ;~ '; .... <, h.., ,h~,"" ,.h" I. '"~Inl. ,Un or \Cub. dIYln.l:.. ;',., ,t] ~ II "\":~ ~hl(h Arr'liu';ll (: '. , . <II .';IY~ '~.~, .., :..< What 'filii 01 IC1I\IIt1 f . . ,';,,, "t..,';;: ," 1H1llh __ ,f!~~"'ii4,~"".,;,,,,,:1 ~ . I. "p/1t4 IOf I. .01411101 10 ""'I' CO'fR" '" " , '. ' 0-"" 'IIl11I be ,",urf1J unl". olhtr.... ~l"td here . 'J,,\\!',., ':";.liV-'.,;'.': ~__~_+____._ , 1.t1 ; '-.'~'\l.-,".' ',. , I'MI l.ll\'~t,~ P^\'^IIlI', Amo,u~isubm,ll.,.tr,' , . 11'~[, MO."I"" :11)uIllllly " ~ \(ml AnnUli t.:; Annu.1 ,~",~': "." ,.,- I ,r, ",,"\mum moJ,"11O MONTlllf PAC. -';"'" ' :1 \ . .....~.:j.... '. l,.' I , ~. " I..':, '. . I Q ...' ... ".I :') 0'. " " . , .- . " LD " , , . " llROl'I' CATASTIIOl'IIIC 1l0SI'ITAL IlXI'KNS~: COVF.IIAnK OltC,905H PIONEEIt LIFE INSURANCE COMPANY OF ILUNOIS 30. North Mill! Street. P,O. nux 120. RorkCord,lIl1l!lJl1 61101l.{)120. (8111) 987.1\000 ,.. .,' ~...' -..... I ~ jl~'; Q,. .~ ~ 9;" "'f> ~.* l w -~ m ~ EiJ~ b m a . 1 j. BCKERT SHAMANS CHHRIN .. MELWIT ~ IIn DrIoW.4.. . HARRISBURO HOSPITAL, Plaintiff v. DONALD W. SHEPHERD and AMY C. SHEPHERD. Defendant. v. PIONEER LlFB INSURANCE COMPANY OF ILLINOIS, Additional Defendant IN THE COURT OP COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION. LAW JURY TRIAL DBMANOIlO NO. 95-3I2A JIIlAECIPE TO ENTER ~PPEARANCE TO THE PROTHONOTARY: PIeue enter the IppClIr&nCCl of the undenl.ned 011 behalf of the Additional Defendant, PIoneer Ufe InlUrance Company of 11I1001.. DATED: December I, 1995 SEAMANS CItE.1N " MELLOn BI'IICCl J. War.haw.ky, Eaqulre Supreme Ct. 1.0. 158199 One South Markel Square Bulldl". 213 Markel Street Harrbbur., PA 11101 (111) 231-6000 Attorney. for Addlllonal Defendant Pioneer Life In.urance Company of IIIlnob . CF..RTlflCATE OF S~IIVICE I, Bruce J. Wanhawlky, Elquire, hereby certify thlt 11m this dlY servin. I copy of the foreaollll document upon the person and In the manner indicated below. which service ..tllne. the requlrementl of the Pennsylvanil Rule. of Civil Procedure, by depositln. I copy of the aarne In the United State. MliI. Harrisbur.. Penn.ylvanll. with first-class poltqe prepaid, u follow.: Arthur A. KUllc. Esquire 4201 Crum. Mill ROllI Po.t Office Box 67015 Harrisbur.. PA 17112 (Attorney for Plaintiff) Dou.lu R, Bare, Elqulre Frankel. Bare" Alloclltes 14 We.t Kin. Street Polt Office Box 1389 York. PA 17405-1389 (Attorney for Defendants) / Bruce J. Warshawsky. Esquire Supreme Ct. I,D. #58799 One South Market Square Building 213 Market Street Harrisburg, PA 17101 (717) 237-6000 Attorneys for Additional Defendant, Pioneer Life Insurance Company of Illinois DATED: December I, 1995 '" IN THE COURT OF COMMON PLEAS OF CUMIERLAND COUNTY, PENNIVLVANIA HARRISBURG HOSPITAL Plaintiff No. 95.3128 CIVIL TERM vs. CIVIL ACTION. LAW DONALD W. SHEPHERD and AMY C. SHEPHERD, Defendants JURY TRIAL DEMANDED vs. PIONEER LIFE INSURANCE COMPANY OF ILLINOIS Additional Defendants PRAECIPE TO THE PROTHONOTARY: Please mark the above-captioned matter sattled, satisfied end discontinued with praJudlce. / . 4201 Crums Mill Rood P.O. 80K 67015 Harrisburg, PA 17112 ( '''ANK.~, .A". . A..OCIATIS ATTORHIYI AT LAW " WilT KINa ""IIT 'to"" '........"LVAN'... 11.01 Douglas R. are, 1.0. #43877 Attorney for Defendants 14 West King Street PO BOK 1389 York, PA 17405-1389 DATE: IIARRISIlUR<l I/osPITAL, /'1 a '" t Iff IN lIif: COUU I 01 CV/tlMON 1'1 E. AS : CUMBERLAND COUNTY. PF.NNSYL VANIA CIVIL IICTlUN - LAW : NO. 95-3128 v. : octWD W. SHEPHERD and Am C. SHEPHERD, Defendants : v. : : PIONEER LIFE INSURANCE tUlPANY OF ILLIOOIS, Additional Def.CERTIFlCATE OF SfRVICE 1. Arthur A. KlISIC. ESQUIre. do hereby certIfy that on th IS 18th da,v of January . I!J 96, I p laced In tile Un /ted States Ma, I true and correct cop le~; of Praecipe to Settle" Satisfy and Discontinue. addressed to followIng: Frankel, Barel Associates 14 Welt King Street P.O. Box 1389 York, PA 17405-1389 Douglas R. Bare, Esquire Eckert, Seamans, Cherin I Mellott one South Market Square Building 213 Markst street Harrisburg, PA 17101 Bruce Warshawsky, Esquire ~~ 420' Crums 101111 Road P.O. Box 11585 HarrISburg, PA ,7',2 (717) 540-5610 Attorney for the Plaint Iff Supreme Court I.D. 07207 C! \I) ,') h~ WI . , .. . ~nl.;.1 . i:..!.1 ttJtL' '.. .,', ("to) ''1/ ; j,'; f') I,~ f-: t~j .... ! :IJ ~::Cj , , '., ., { t:. (~, - '.I" -. ...:0..... .. :., ~j r.- ~j.f ~. r" ....