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/ AOL File Library: 4,101 to 4,200 / aol-file-protocol-4400-4101-to-4200.zip / AOLDLs / Business Management / MEDISOFT_ V4.14a Medical Patient / MEDI414A.exe / MATRNH.TUT < prev next >

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Text File | 1996-02-07 | 64KB | 503 lines

501 0 12800 0 11 8 41 8 521 8 00 0 0AGADW010060193060193930601 1 11715.9 Degenerative Joint Disea99212 CA40 060193070593 1 1 99A 0AGADW010060193060193930601 1 1100000001 Cash CASH SA-1.6 1 1 99A0 NAGADW010060193 930601 1 Blue Cross/Blue Shield was billed. 0ANALO010060293060293930602 1 11724.2 Low Back Pain 99213 CA60 060293 1 1 99A 0ANALO010060293060293930602 1 11724.2 Low Back Pain 97260 CA30 060293 1 1 99A 0ANALO010060293060293930602 1 11724.2 Low Back Pain 97010 CA10 060293 1 1 99A 0ANALO010060293060293930602 1 11724.2 Low Back Pain 97128 CA15 060293 1 1 99A 0ANALO010060293060293930602 1 11724.2 Low Back Pain XRAY CA25 060293 1 1 99A 0ANALO010060293060293930602 1 1100000200 Cash COPAYCASH HA-10 1 1 99A0 NANALO010060293 930602 1 Cigna Health Plan was billed. 0ANALO011060193060193930601 1 11034.0 Strep Throat 99213 CA60 060193 1 1 99A 0ANALO011060193060193930601 1 11034.0 Strep Throat 87072 CA15 060193 1 1 99A 0ANALO011060193060193930601 1 1100010000 Cash COPAYCASH HA-10 1 1 99A0 NANALO011060193 930601 1 Cigna Health Plan was billed. 0BRADO010060193060193930601 4 11995.3,989.5 99213 CA60 060193 1 1 99A 0BRADO010060193060193930601 4 11995.3,989.5 J0490 CA10 060193 1 1 99A 0BRADO010060193060193930601 4 11Patient Check #2500 COPAY10 OA-10 1 1 99A0 NBRADO010060193 930601 4 FHP Health Care was billed. 0BRIJA010060293060293930602 3 11737.30 Scoliosis, Acquired Pos99212 CA40 060293070593 1 1 99A0 0BRIJA010060293060293930602 3 1100010000 Cash COPAYCASH HA-10 1 1 99A0 NBRIJA010060293 930602 3 FHP Health Care was billed. 0BRIJA011060393060393930603 3 11052.9 Chicken Pox 99213 CA60 060393 1 1 99A0 0BRIJA011060393060393930603 3 1100010000 Copay Cash COPAYCASH HA-10 1 1 99A0 NBRIJA011060393 930603 3 FHP Health Care was billed. 0BRIJA012060393060393930603 3 11052.9 Chicken Pox 99213 CA60 060393 1 1 99A 0BRIJA012060393060393930603 3 1100010000 Copay Cash COPAYCASH HA-10 1 1 99A0 NBRIJA012060393 930603 3 FHP Health Care was billed. 0BRIJA013060193060193930601 3 11052.9 Chicken Pox 99213 CA60 060193 1 1 99A0 0BRIJA013060193060193930601 3 11Patient Check #103 COPAY10 OA-10 1 1 99A0 NBRIJA013060193 930601 3 FHP Health Care was billed. 0BRIJA014060193060193930601 3 11052.9 Chicken Pox 99213 CA60 060193 1 1 99A 0BRIJA014060193060193930601 3 11Patient Check #103 COPAY10 OA-10 1 1 99A0 NBRIJA014060193 930601 3 FHP Health Care was billed. 0BRUTO010060193060193930601 1 11461.8 Sinusitis, Acute 99211 CA25 060193 1 1 99A 0BRUTO010060193060193930601 1 11461.8 Sinusitis, Acute 95115 CA7 060193 1 1 99A NBRUTO010060193 930601 1 Humana Health Care was billed. 0BRUTO010060193060193930601 1 1100000100 Copay Cash COPAYCASH HA-5.00 1 99A0 0CHOCL010060193060193930601 2 11487 Influenza 99214 CA65.00 060193 1 1 99A 0CHOCL010060193060193930601 2 11Patient Check #788 CHECK PA-13.00 1 1 99A0 NCHOCL010060193 930601 2 Champus was billed. 0DOVBE010060293060293930602 3 11110.4 Athlete's Foot 99212 CA40 060293070793 1 1 99A 0DOVBE010060293060293930602 3 1100000001 Cash CASH SA-1.2 1 0 99A NDOVBE010060293 930602 3 Medicare was billed. 0DUDST010060193060193930601 2 11845.00 Sprain Ankle 99202 CA40.00 060193 1 1 99A 0DUDST010060193060193930601 2 11845.00 Sprain Ankle 73610 CA55.00 060193 1 1 99A 0DUDST010060193060193930601 2 11Patient Check #2301 CHECK PA-19.00 1 1 99A0 NDUDST010060193 930601 2 John Hancock Insurance was billed. 0ESTPO010060193060193930601 1 11V700 Exam Routine Health (Adul99211 CA25 060193 1 1 99A0 0ESTPO010060193060193930601 1 11V700 Exam Routine Health (Adul86585 CA7.5 060193 1 1 99A0 0ESTPO010060193060193930601 1 11Patient Copay-Check #432 COPAY10 OA-10.00 1 1 99A0 NESTPO010060193 930601 1 Intergroup was billed. 0FARJA010060193060193930601 6 11346.9 Headache-Migraine 99214 CA65.00 060193 1 1 99A 0FARJA010060193060193930601 6 11346.9 Headache-Migraine 70250 CA55.00 060193 1 1 99A 0FARJA010060193060193930601 6 1101000004 Cash CASH SA-24 1 1 99A NFARJA010060193 930601 6 John Hancock Insurance was billed. 0GONIB010060193060193930601 4 11487 Influenza 99201 CA30.00 112493 1 1 99A 0GONIB010060193060193930601 4 11Patient Check #450 CHECK PA-30.00 112493 1 1 99A0 0GOOHE010060393060393930603 6 11716.94 Arthritis-Hand 99214 CA65.00 070793060393 1 1 99A0 0GOOHE010060393060393930603 6 11716.94 Arthritis-Hand 73130 CA45.00 070793060393 1 1 99A0 0GOOHE010060393060393930603 6 11Credit Card Payment CRCDPAY RA-22 070793 1 1 99A0 NGOOHE010060393 930603 6 CC# 4324555561010021 Exp date: 1194 Name: Goodman, Hesa NGOOHE010060393 930603 6 Blue Cross/Blue Shield was billed. 0GOORI010060193060193930601 1 11372.30 Conjunctivitis 99212 CA40.00 060193070693 1 1 99A0 NGOORI010060193 930601 1 John Hancock Insurance was billed. 0HYNHE010060293060293930602 5 11005.9 Food Poisoning, Unspecif99214 CA65.00 060293070793 1 1 99A 0HYNHE010060293060293930602 5 11005.9 Food Poisoning, Unspecif91105 CA50.00 060293070793 1 1 99A 0HYNHE010060293060293930602 5 1100000003 Cash CASH SA-3.60 1 1 99A NHYNHE010060293 930602 5 Medicare was billed. 0KLICA010060393060393930603 3 11492.8,716.9 99204 CA65.00 060393 1 1 99A0 0KLICA010060393060393930603 3 11Patient Copay-Check#378 COPAY10 OA-10.00 1 1 99A0 NKLICA010060393 930603 3 Cigna Health Plan was billed. 0MARMA011060293060293930602 4 11Well Child Exam 99392 CA50.00 060293 1 1 99A0 0MARMA011060293060293930602 4 11Well Child Exam 90707 CA10.00 060293 1 1 99A0 0MARMA011060293060293930602 4 11Patient Copay-Check #023 COPAY10 OA-10 1 1 99A0 NMARMA011060293 930602 4 Intergroup was billed. 0OHAPA011060193060193930601 4 11034.0 Strep Throat 99201 CA30 060193 1 1 99A 0OHAPA011060193060193930601 4 11034.0 Strep Throat 87072 CA15.00 060193 1 1 99A NOHAPA011060193 930601 4 Aetna was billed. 0OHAPA011060193060193930601 4 1100000105 Copay Cash COPAYCASH HA-10 1 0 99A0 0RODES010060393060393930603 3 11V2509 Family Planning 99213 CA60.00 060393 1 1 99A 0RODES010060393060393930603 3 1100010000 Copay Cash COPAYCASH HA-10.00 1 1 99A0 NRODES010060393 930603 3 Aetna was billed. 0SHAIM010060193060193930601 5 11719.46 Pain, Knee 99213 CA60.00 060193 1 1 99A 0SHAIM010060193060193930601 5 11836.1 Tear, Torn Knee Lateral 73562 CA45.00 060193 1 1 99A 0SHAIM010060193060193930601 5 1100010000 Cash COPAYCASH HA-10 1 1 99A0 NSHAIM010060193 930601 5 Intergroup was billed. 0YOUMI010060193060193930601 3 11401.9 Hypertension 99213 CA60.00 060193 1 1 99A0 0YOUMI010060193060193930601 3 1100010002 Cash CASH SA-12 1 1 99A NYOUMI010060193 930601 3 Champ VA was billed. 0AGADW010070593070593930601 1 Insurance Check #0001 BP IA-32 070593 1 0 0 1 NAGADW010070593 930705 1 Mutual of Omaha was billed. 0AGADW010070693070693930706 1 11715.9 Degenerative Joint Disea99212 CA40 070693081093 1 2 99A 0AGADW010070693070693930706 1 1100000001 Cash CASH SA-1.6 1 2 99A NAGADW010070693 930706 1 Blue Cross/Blue Shield was billed. 0ANALO010070793070793930707 1 11724.2 Low Back Pain 99212 CA40 070793 1 2 99A 0ANALO010070793070793930707 1 11724.2 Low Back Pain 97010 CA10 070793 1 2 99A 0ANALO010070793070793930707 1 11724.2 Low Back Pain 97128 CA15 070793 1 2 99A 0ANALO010070793070793930707 1 1100000200 Copay Cash COPAYCASH HA-10 1 2 99A0 NANALO010070793 930707 1 Cigna Health Plan was billed. 0ANALO010070793070793930602 1 Insurance Write-Off CIGWROFF BA-130 1 0 0 1 0ANALO010070793070793930602 1 Insurance Check # CIG IA0 1 0 0 1 0ANALO011070693070693930601 1 Insurance Write-Off CIGWROFF BA-65 1 0 0 1 0ANALO011070693070693930601 1 11Insurance Check# CIG IA0 1 0 99A1 0BRADO010070693070693930706 4 11Truck Physical 99214 CA65 070693 1 2 99A 0BRADO010070693070693930706 4 11Truck Physical 93000 CA45 070693 1 2 99A 0BRADO010070693070693930706 4 11Truck Physical 99000 LA8 070693 1 2 99A 0BRADO010070693070693930706 4 11Truck Physical DS CA40 070693 1 2 99A 0BRADO010070693070693930706 4 1100000200 Copay Cash COPAYCASH HA-10 1 2 99A0 0BRADO010070693070693930601 4 Insurance Write-Off FHPWROFF BA-60 1 0 0 1 NBRADO010070693 930706 4 FHP Health Care was billed. 0BRADO010070693070693930601 4 11Insurance Check# FHP IA0 1 0 99A1 0BRIJA010070693070693930602 3 Insurance Write-Off FHPWROFF BA-30 1 0 0 1 0BRIJA010070693070693930602 3 11Insurance Check# FHP IA0 1 0 99A1 0BRIJA011070593070593930705 3 11692.71 Sunburn 99212 CA40 070593 1 2 99A 0BRIJA011070593070593930705 3 1100010000 Copay Cash COPAYCASH HA-10 1 2 99A0 NBRIJA011070593 930705 3 FHP Health Care was billed. 0BRIJA011070793070793930603 3 Insurance Write-Off FHPWROFF BA-50 1 0 0 1 0BRIJA011070793070793930603 3 11Insurance Check# FHP IA0 1 0 99A1 0BRIJA012070793070793930603 3 Insurance Write-Off FHPWROFF BA-50 1 0 0 1 0BRIJA012070793070793930603 3 11Insurance Check# FHP IA0 1 0 99A1 0BRIJA013070793070793930601 3 Insurance Write-Off FHPWROFF BA-50 1 0 0 1 0BRIJA013070793070793930601 3 11Insurance Check# FHP IA0 1 0 99A1 0BRIJA014070793070793930601 3 Insurance Write-Off FHPWROFF BA-50 1 0 0 1 0BRIJA014070793070793930601 3 11Insurance Check# FHP IA0 1 0 99A1 0BRUTO010070693070693930601 1 Insurance Write-Off HUMWROFF BA-27 1 0 0 1 0BRUTO010070693070693930601 1 11Insurance Check# HUM IA0 1 0 99A1 0CHOCL010070693070693930706 2 11780.7 Fatigue 99213 CA60.00 070693 1 2 99A 0CHOCL010070693070693930706 2 11269.2 Vitamin Deficiency 85023 KA18 070693 1 2 99A 0CHOCL010070693070693930706 2 11Patient Check #832 CHECK PA-15.60 1 2 99A0 NCHOCL010070693 930706 2 Champus was billed. 0CHOCL010070793070793930601 2 Insurance Check #00015 CH IA-52 1 0 0 1 0DOVBE010070593070593930705 3 11785.1 Palpitations 99214 CA65.00 070593081193 1 2 99A 0DOVBE010070593070593930705 3 11785.2 Heart Murmur 93000 CA45.00 070593081193 1 2 99A 0DOVBE010070593070593930705 3 1100000003 Cash CASH SA-3.60 1 2 99A NDOVBE010070593 930705 3 Medicare was billed. 0DOVBE010070793070793930602 3 Medicare Write-Off MCA BA-10 1 0 0 1 0DOVBE010070793070793930602 3 Insurance Check #00019 MP IA-24 081093070793 1 0 0 1 NDOVBE010070793 930707 3 Blue Cross/Blue Shield was billed. 0DUDST010070593070593930705 2 11780.7,783.2 99214 CA65.00 070593 1 2 99A0 0DUDST010070593070593930705 2 11780.7,783.2 85023 KA18.00 070593 1 2 99A0 0DUDST010070593070593930705 2 11780.7,783.2 81000 CA11.00 070593 1 2 99A0 0DUDST010070593070593930705 2 11783.0 Anorexia 80050 LA45 070593 1 2 99A0 0DUDST010070593070593930705 2 11Patient Check #2333 CHECK PA-27.80 1 2 99A0 NDUDST010070593 930705 2 John Hancock Insurance was billed. 0DUDST010070693070693930601 2 Insurance Check #2301 JH IA-76 1 0 0 1 0ESTPO010070693070693930706 1 11845.00 Sprain Ankle 99213 CA60.00 070693 1 2 99A 0ESTPO010070693070693930706 1 11845.00 Sprain Ankle 73610 CA55.00 070693 1 2 99A 0ESTPO010070693070693930706 1 1100000200 Copay Cash COPAYCASH HA-10.00 1 2 99A0 0ESTPO010070693070693930601 1 Insurance Write-Off INWROFF BA-22.5 1 0 0 1 NESTPO010070693 930706 1 Intergroup was billed. 0ESTPO010070693070693930601 1 11Insurance Check# IN IA0 1 0 99A1 0FARJA010070793070793930707 6 11346.9 Headache-Migraine 99214 CA65.00 070793 1 2 99A 0FARJA010070793070793930707 6 11346.9 Headache-Migraine 90900 CA40.00 070793 1 2 99A 0FARJA010070793070793930707 6 11Patient Check #1321 CHECK PA-21.00 1 2 99A0 0FARJA010070793070793930601 6 Insurance Check #00026 JH IA-96 1 0 0 1 NFARJA010070793 930707 6 John Hancock Insurance was billed. 0GONIB010070593070593930601 4 11Returned Check DANSF AA30.00 112493 1 99A 0GONIB010070593070593930601 4 11Returned Check Charge DANSFCHG AA15.00 112493 1 99A NGONIB010070593 930705 4 Standard Statement was billed. NGONIB0100706934 930706 4 Promises to pay next week. 0GONIB010070693070693930706 4 11723.1 Neck Pain 99213 CA60.00 112493 1 2 99A 0GONIB010070693070693930706 4 11723.1 Neck Pain 70360 CA45.00 112493 1 2 99A 0GONIB010070693070693930706 4 1102000100 Cash CASH SA-45.00 112493 1 2 99A NGONIB010070693 930706 4 Standard Statement was billed. 0GOOHE010070793070793930707 6 11716.94 Arthritis-Hand 99213 CA60.00 070793070793 1 2 99A 0GOOHE010070793070793930707 6 11716.94 Arthritis-Hand 73130 CA45.00 070793070793 1 2 99A 0GOOHE010070793070793930707 6 1101000001 Cash CASH SA-21.00 070793 1 2 99A0 0GOOHE010070793070793930603 6 1188.00 applied to DED DED IA0.00 070793 1 99A1 NGOOHE0100707936 930707 6 Standard Statement was billed. Patient owes 88.00 on 930603 NGOOHE010070793 930707 6 Blue Cross/Blue Shield was billed. 0GOORI010070693070693930706 1 11535.5 Gastritis 99212 CA40.00 070693081193 1 2 99A 0GOORI010070693070693930601 1 Insurance Check #00018 JH IA-32 070693070693 1 0 0 1 NGOORI010070693 930706 1 John Hancock Insurance was billed. NGOORI010070693 930706 1 Cigna Health Plan was billed. 0HYNHE010070693070693930706 5 11780.7 Fatigue 99214 CA65.00 070693081193 1 2 99A 0HYNHE010070693070693930706 5 11780.7 Fatigue 82947 CA25.00 070693081193 1 2 99A 0HYNHE010070693070693930706 5 11780.7 Fatigue 36215 KA8 070693081193 1 2 99A 0HYNHE010070693070693930706 5 11780.7 Fatigue 99000 LA8 070693081193 1 2 99A 0HYNHE010070693070693930706 5 1100000003 Cash CASH SA-3.00 1 2 99A NHYNHE010070693 930706 5 Medicare was billed. 0HYNHE010070793070793930602 5 Medicare Write-Off MCA BA-25 1 0 0 1 0HYNHE010070793070793930602 5 Insurance Check #00019 MP IA-72 080993070793 1 0 0 1 NHYNHE010070793 930707 5 Aetna was billed. 0KLICA010070793070793930603 3 Insurance Write-Off CIGWROFF BA-55 1 0 0 1 0KLICA010070793070793930603 3 11Insurance Check# CIG IA0 1 0 99A1 0MARMA011070793070793930602 4 Insurance Write-Off INWROFF BA-50 1 0 0 1 0MARMA011070793070793930602 4 11Insurance Check# IN IA0 1 0 99A1 0OHAPA011070693070693930706 4 11078.1 Wart 99212 CA40.00 070693 1 2 99A 0OHAPA011070693070693930706 4 11078.1 Wart 17110 CA15 070693 1 2 99A 0OHAPA011070693070693930706 4 11Patient Copay-Check #453 COPAY10 OA-10.00 1 2 99A0 0OHAPA011070693070693930601 4 Insurance Write-Off APWROFF BA-35 070693 1 0 0 1 NOHAPA011070693 930706 4 Aetna was billed. 0OHAPA011070693070693930601 4 11Insurance Check# AP IA0.00 1 99A1 0RODES010070693070693930706 3 11V2509 Family Planning 99213 CA60.00 070693 1 2 99A 0RODES010070693070693930706 3 11V2509 Family Planning 84702 KA25 070693 1 2 99A 0RODES010070693070693930706 3 11Patient Copay-Check #1204 COPAY10 OA-10.00 1 2 99A0 NRODES010070693 930706 3 Aetna was billed. 0RODES010070793070793930603 3 Insurance Write-Off APWROFF BA-50 1 0 0 1 0RODES010070793070793930603 3 11Insurance Check# AP IA0.00 1 99A1 0SHAIM010070693070693930706 5 11726.71 Achilles Tendonitis 99213 CA60.00 070693 1 2 99A 0SHAIM010070693070693930706 5 1100010000 Copay Cash COPAYCASH HA-10.00 1 2 99A0 0SHAIM010070693070693930601 5 Insurance Write-Off INWROFF BA-115 1 0 0 1 0SHAIM010070693070693930601 5 11Ins. Refund for overpayment INSREF BA20 1 0 99A NSHAIM010070693 930706 5 Intergroup was billed. 0SHAIM010070693070693930601 5 11Insurance Check# IN IA0 1 0 99A1 0YOUMI010070593070593930705 3 11401.9 Hypertension 99212 CA40.00 070593 1 2 99A0 0YOUMI010070593070593930705 3 11Patient Check #638 CHECK PA-8.00 1 2 99A0 NYOUMI010070593 930705 3 Champ VA was billed. 0YOUMI010070693070693930601 3 Insurance Check #000023 CHV IA-48 1 0 0 1 0AGADW010080993080993930601 1 Insurance Check #000002 MU IA-6.4 1 0 0 2 0AGADW010081093081093930706 1 Insurance Check #00003 BP IA -32.00 081093 1 1 NAGADW010081093 930810 1 Mutual of Omaha was billed. 0AGADW010081193081193930811 1 11786.50 Chest Pain 99214 CA65 081193091593 1 3 99A 0AGADW010081193081193930811 1 11422.9 Heart Disease 93000 CA45.00 081193091593 1 3 99A 0AGADW010081193081193930811 1 1100000004 Cash CASH SA-4.40 1 3 99A0 NAGADW010081193 930811 1 Blue Cross/Blue Shield was billed. 0ANALO010081093081093930810 1 11724.2 Low Back Pain 99212 CA40.00 081093 1 3 99A 0ANALO010081093081093930810 1 11724.2 Low Back Pain 97010 CA10.00 081093 1 3 99A 0ANALO010081093081093930810 1 11724.2 Low Back Pain 97128 CA15.00 081093 1 3 99A 0ANALO010081093081093930810 1 11Patient Copay-Check #358 COPAY10 OA-10.00 1 3 99A0 NANALO010081093 930810 1 Cigna Health Plan was billed. 0ANALO010081193081193930707 1 Insurance Write-Off CIGWROFF BA-55 1 0 0 1 0ANALO010081193081193930707 1 Insurance Check # CIG IA0 1 0 0 1 0ANALO011081093081093930810 1 11Well Child Exam 90762 CA50.00 081093 1 2 99A0 0ANALO011081093081093930810 1 11Patient Copay-Check #358 COPAY10 OA-10.00 1 2 99A0 NANALO011081093 930810 1 Cigna Health Plan was billed. 0BRADO010081193081193930706 4 Insurance Write-Off FHPWROFF BA-148 1 0 0 1 0BRADO010081193081193930706 4 11Insurance Check# FHP IA0 1 0 99A1 0BRIJA011081093081093930705 3 Insurance Write-Off FHPWROFF BA-30 1 0 0 1 0BRIJA011081093081093930705 3 11Insurance Check# FHP IA0 1 0 99A1 0BRIJA012081193081193930811 3 11373.11 Stye Eye 99213 CA60.00 081193 1 2 99A 0BRIJA012081193081193930811 3 1100000200 Copay Cash COPAYCASH HA-10.00 1 2 99A0 NBRIJA012081193 930811 3 FHP Health Care was billed. 0BRIJA014081093081093930810 3 11487 Influenza 99214 CA65 081093 1 2 99A 0BRIJA014081093081093930810 3 1100010000 Copay Cash COPAYCASH HA-10.00 1 2 99A0 NBRIJA014081093 930810 3 FHP Health Care was billed. 0BRIJA01W080993080993930809 3 11354.0 Carpal Tunnel Syndrome 99212 CA40.00 080993 1 1 99A 0BRIJA01W080993080993930809 3 1100010000 Copay Cash COPAYCASH HA-10.00 1 1 99A0 NBRIJA01W080993 930809 3 FHP Health Care was billed. 0BRUTO010081193081193930811 1 11782.1 Rash 99212 CA40.00 081193 1 2 99A0 0BRUTO010081193081193930811 1 1100000100 Copay Cash COPAYCASH HA-5.00 1 2 99A0 NBRUTO010081193 930811 1 Humana Health Care was billed. 0CHOCL010081093081093930810 2 11269.2 Vitamin Deficiency 99211 CA25.00 081093 1 3 99A0 0CHOCL010081093081093930810 2 11269.2 Vitamin Deficiency 81000 CA11.00 081093 1 3 99A0 0CHOCL010081093081093930810 2 11Credit Card Payment CRCDPAY RA-7.20 1 3 99A0 NCHOCL010081093 930810 2 CC# 350024245571228 Exp date: 0494 Name: Mr. Clam Chowder NCHOCL010081093 930810 2 Champus was billed. 0CHOCL010081193081193930706 2 Insurance Check #4520 CH IA-62.4 1 0 0 1 0DOVBE010081093081093930810 3 11785.2 Heart Murmur 99213 CA60.00 081093091593 1 3 99A0 0DOVBE010081093081093930810 3 1100000002 Cash CASH SA-2.40 1 3 99A0 NDOVBE010081093 930810 3 Medicare was billed. 0DOVBE010081093081093930705 Medicare Write-Off MCA BA-20 1 0 0 1 0DOVBE010081093081093930705 3 Insurance Check #13004 MP IA-72 091593081193 1 0 0 1 0DOVBE010081193081193930602 3 Insurance Check #00004 BP IA -4.80 091593081193 1 2 NDOVBE010081193 930811 3 Blue Cross/Blue Shield was billed. 0DUDST010081093081093930705 2 Insurance Check #00042 JH IA -111.20 1 1 0DUDST010081193081193930811 2 11783.0 Anorexia 97540 CA30.00 081193 1 3 99A 0DUDST010081193081193930811 2 11Patient Check #2365 CHECK PA-6.00 1 3 99A0 NDUDST010081193 930811 2 John Hancock Insurance was billed. 0ESTPO010081193081193930811 1 11719.47 Pain, Ankle 99213 CA60.00 081193 1 3 99A0 0ESTPO010081193081193930811 1 11Patient Copay-Check #589 COPAY10 OA-10.00 1 3 99A0 0ESTPO010081193081193930706 1 Insurance Write-Off INWROFF BA-105 1 0 0 1 NESTPO010081193 930811 1 Intergroup was billed. 0ESTPO010081193081193930706 1 11Insurance Check# IN IA0 1 0 99A1 0FARJA010081093081093930810 6 11346.9 Headache-Migraine 90900 CA40.00 081093 1 3 99A 0FARJA010081093081093930810 6 1100000103 Cash CASH SA-8.00 1 3 99A0 NFARJA010081093 930810 6 John Hancock Insurance was billed. 0FARJA010081193081193930707 6 Insurance Check #00148 JH IA -84.00 1 1 0GONIB010080993080993930809 4 11Phone Call to Patient COMMENT E 0 112493 1 0 99A 0GONIB010080993080993930809 4 11Patient says didn't get stmt. COMMENT E 0.00 112493 1 99A 0GONIB010080993080993930809 4 11statement COMMENT E 0.00 112493 1 99A NGONIB010080993 930809 4 Standard Statement was billed. 0GOOHE010081193081193930707 6 Insurance Check #1305 BP IA -84.00 1 1 0GOORI010080993080993930809 1 11535.5 Gastritis 99212 CA40.00 080993091493 1 3 99A NGOORI010080993 930809 1 John Hancock Insurance was billed. 0GOORI010081093081093930601 1 Insurance Write-Off CIGWROFF BA-8 1 0 0 2 0GOORI010081193081193930706 1 Insurance Check #1308 JH IA -32.00 091593081193 1 1 NGOORI010081193 930811 1 Cigna Health Plan was billed. 0GOORI010081093081093930601 1 11Insurance Check# CIG IA0 1 0 99A2 0HYNHE010080993080993930809 5 11250.01 IDDM Diabetes Mellitus 99213 CA60.00 080993091593 1 3 99A 0HYNHE010080993080993930809 5 11250.01 IDDM Diabetes Mellitus J1820 CA20.00 080993091593 1 3 99A 0HYNHE010080993080993930809 5 1100000003 Cash CASH SA-3.20 1 3 99A0 NHYNHE010080993 930809 5 Medicare was billed. 0HYNHE010081093081093930602 5 Insurance Write-Off APWROFF BA-14.4 1 0 0 2 0HYNHE010081193081193930706 5 Medicare Write-Off MCA BA-31 1 0 0 1 0HYNHE010081193081193930706 5 Insurance Check #3405 MP IA -60.00 091393081193 1 1 NHYNHE010081193 930811 5 Aetna was billed. 0HYNHE010081093081093930602 5 11Insurance Check# AP IA0.00 1 99A2 0KLICA010081093081093930810 3 11492.8,786.09 99214 CA65.00 081093 1 2 99A 0KLICA010081093081093930810 3 11Patient Copay-Check #432 COPAY10 OA-10 1 2 99A0 NKLICA010081093 930810 3 Cigna Health Plan was billed. 0MARMA011081093081093930810 4 11692.6 Poison Ivy 99212 CA40.00 081093 1 2 99A 0MARMA011081093081093930810 4 11Patient Copay-Check #037 COPAY10 OA-10 1 2 99A0 NMARMA011081093 930810 4 Intergroup was billed. 0OHAPA011081193081193930811 4 11737.30 Scoliosis, Acquired Pos99214 CA65.00 081193 1 3 99A 0OHAPA011081193081193930811 4 11737.30 Scoliosis, Acquired Pos72052 KA80 081193 1 3 99A 0OHAPA011081193081193930811 4 11Patient Copay-Check #487 COPAY10 OA-10 1 3 99A0 0OHAPA011081193081193930706 4 Insurance Write-Off APWROFF BA-45 1 0 0 1 NOHAPA011081193 930811 4 Aetna was billed. 0OHAPA011081193081193930706 4 11Insurance Check# AP IA0.00 1 99A1 0RODES010081193081193930811 3 11V221 Pregnancy 99213 CA60.00 081193 1 3 99A 0RODES010081193081193930811 3 1100000200 Copay Cash COPAYCASH HA-10.00 1 3 99A0 0RODES010081193081193930706 3 Insurance Write-Off APWROFF BA-75 1 0 0 1 NRODES010081193 930811 3 Aetna was billed. 0RODES010081193081193930706 3 11Insurance Check# AP IA0.00 1 99A1 0SHAIM010081193081193930706 5 Insurance Write-Off INWROFF BA-50 1 0 0 1 0SHAIM010081193081193930706 5 11Insurance Check# IN IA0 1 0 99A1 0YOUMI010081093081093930810 3 11401.9,535.5 99213 CA60.00 081093 1 3 99A 0YOUMI010081093081093930810 3 1100010002 Cash CASH SA-12.00 1 3 99A0 0YOUMI010081093081093930705 3 Insurance Check #5403 CHV IA-32 1 0 0 1 NYOUMI010081093 930810 3 Champ VA was billed. 0AGADW010091493091493930706 1 Insurance Check #45003 MU IA -6.40 1 2 0AGADW010091593091593930811 1 Insurance Check #456 BP IA -84.48 101993091593 1 1 NAGADW010091593 930915 1 Mutual of Omaha was billed. 0ANALO010091593091593930810 1 Insurance Write-Off CIGWROFF BA-55 1 0 0 1 0ANALO010091593091593930810 1 Insurance Check # CIG IA0 1 0 0 1 0ANALO011091493091493930914 1 11052.9 Chicken Pox 99213 CA60.00 091493 1 3 99A 0ANALO011091493091493930914 1 1100000200 Copay Cash COPAYCASH HA-10.00 1 3 99A0 NANALO011091493 930914 1 Cigna Health Plan was billed. 0ANALO011091593091593930810 1 Insurance Write-Off CIGWROFF BA-40 1 0 0 1 0ANALO011091593091593930810 1 11Insurance Check# CIG IA0 1 0 99A1 0BRIJA010091393091393930913 3 11737.30 Scoliosis, Acquired Pos99213 CA60.00 091393 1 2 99A 0BRIJA010091393091393930913 3 11737.30 Scoliosis, Acquired PosXRAY CA25.00 091393 1 2 99A 0BRIJA010091393091393930913 3 11Patient Copay-Check #312 COPAY10 OA-10 1 2 99A0 NBRIJA010091393 930913 3 FHP Health Care was billed. 0BRIJA012091493091493930811 3 Insurance Write-Off FHPWROFF BA-50 1 0 0 1 0BRIJA012091493091493930811 3 11Insurance Check# FHP IA0 1 0 99A1 0BRIJA013091593091593930915 3 11463.0 Tonsillitis 99213 CA60.00 091593 1 2 99A 0BRIJA013091593091593930915 3 1100000105 Copay Cash COPAYCASH HA-10.00 1 2 99A0 NBRIJA013091593 930915 3 FHP Health Care was billed. 0BRIJA014091493091493930810 3 Insurance Write-Off FHPWROFF BA-55 1 0 0 1 0BRIJA014091493091493930810 3 11Insurance Check# FHP IA0 1 0 99A1 0BRIJA01W091393091393930913 3 11354.0 Carpal Tunnel Syndrome 99212 CA40.00 091393 1 2 99A0 0BRIJA01W091393091393930913 3 11Patient Copay-Check #312 COPAY10 OA-10 1 2 99A0 0BRIJA01W091393091393930809 3 Insurance Write-Off FHPWROFF BA-30 1 0 0 1 NBRIJA01W091393 930913 3 FHP Health Care was billed. 0BRIJA01W091393091393930809 3 11Insurance Check# FHP IA0 1 0 99A1 0BRUTO010091393091393930913 1 11461.8 Sinusitis, Acute 99211 CA25.00 091393 1 3 99A0 0BRUTO010091393091393930913 1 11461.8 Sinusitis, Acute 95115 CA7.00 091393 1 3 99A0 0BRUTO010091393091393930913 1 11Patient Copay-Check#2048 COPAY5 OA-5 1 3 99A0 NBRUTO010091393 930913 1 Humana Health Care was billed. 0BRUTO010091593091593930811 1 Insurance Write-Off HUMWROFF BA-35 1 0 0 1 0BRUTO010091593091593930811 1 11Insurance Check# HUM IA0 1 0 99A1 0CHOCL010091593091593930810 2 Insurance Check #5670 CH IA-28.8 1 0 0 1 0DOVBE010091593091593930915 3 11465.9 Upper Respiratory Infect99214 CA65.00 091593102093 1 4 99A 0DOVBE010091593091593930915 3 1100000002 Cash CASH SA-2.00 1 4 99A0 0DOVBE010091593091593930810 3 Insurance Check #3017 MP IA -48.00 091593091593 1 1 0DOVBE010091593091593930705 3 Insurance Check #00080 BP IA -14.40 091593091593 1 2 NDOVBE010091593 930915 3 Medicare was billed. NDOVBE010091593 930915 3 Blue Cross/Blue Shield was billed. 0DUDST010091393091393930913 2 11783.0 Anorexia 97540 CA30.00 091393 1 4 99A0 0DUDST010091393091393930913 2 11Patient Check #2422 CHECK PA-6.00 1 4 99A0 NDUDST010091393 930913 2 John Hancock Insurance was billed. 0DUDST010091593091593930811 2 Insurance Check #00078 JH IA -24.00 1 1 0ESTPO010091593091593930811 1 Insurance Write-Off INWROFF BA-50 1 0 0 1 0ESTPO010091593091593930811 1 11Insurance Check# IN IA0 1 0 99A1 0FARJA010091393091393930913 6 11346.9 Headache-Migraine 90900 CA40.00 091393 1 4 99A 0FARJA010091393091393930913 6 11Patient Check #1432 CHECK PA-8 1 4 99A0 NFARJA010091393 930913 6 John Hancock Insurance was billed. 0FARJA010091593091593930810 6 Insurance Check #000085 JH IA -32.00 1 1 NGONIB010091393 930913 4 Standard Statement was billed. 0GOOHE010091493091493930914 6 11464.0 Laryngitis, Acute 99212 CA40.00 091493 1 3 99A 0GOOHE010091493091493930914 6 1100000103 Cash CASH SA-8.00 1 3 99A0 NGOOHE010091493 930603 6 930603-paid 40.00 today, will pay remainder before 10/20/93 0GOOHE010091493091493930603 6 11Credit Card Payment CRCDPAY RA-40.00 1 99A0 NGOOHE010091493 930603 6 CC# 4324555561010021 Exp date: 1194 Name: Goodman, Hesa NGOOHE010091493 930914 6 Blue Cross/Blue Shield was billed. 0GOORI010091493091493930809 1 Insurance Check #345 JH IA -32.00 091593091493 1 1 0GOORI010091493091493930706 1 Insurance Write-Off CIGWROFF BA-8 1 0 0 2 NGOORI010091493 930914 1 Cigna Health Plan was billed. 0GOORI010091593091593930915 1 11535.5 Gastritis 99214 CA65.00 091593102093 1 4 99A 0GOORI010091593091593930915 1 11535.5 74246 LA80.00 091593102093 1 4 99A 0GOORI010091593091593930915 1 11535.5 99000 LA8.00 091593102093 1 4 99A NGOORI010091593 930915 1 John Hancock Insurance was billed. 0GOORI010091493091493930706 1 11Insurance Check# CIG IA0 1 0 99A2 0HYNHE010091393091393930913 5 11455.6 Hemorrhoids 99212 CA40.00 091393101993 1 4 99A 0HYNHE010091393091393930913 5 1100000001 Cash CASH SA-1.60 1 4 99A0 NHYNHE010091393 930913 5 Medicare was billed. 0HYNHE010091493091493930706 5 Insurance Write-Off APWROFF BA-12 1 0 0 2 0HYNHE010091593091593930809 5 Insurance Check #00089 MP IA -64.00 102093091593 1 1 NHYNHE010091593 930915 5 Aetna was billed. 0HYNHE010091493091493930706 5 11Insurance Check# AP IA0.00 1 99A2 0KLICA010091593091593930915 3 11492.8,780.4 99214 CA65.00 091593 1 3 99A 0KLICA010091593091593930915 3 1100000200 Copay Cash COPAYCASH HA-10.00 1 3 99A0 0KLICA010091593091593930810 3 Insurance Write-Off CIGWROFF BA-55 1 0 0 1 NKLICA010091593 930915 3 Cigna Health Plan was billed. 0KLICA010091593091593930810 3 11Insurance Check# CIG IA0 1 0 99A1 0MARMA011091493091493930914 4 11782.1 Rash 99213 CA60.00 091493 1 3 99A 0MARMA011091493091493930914 4 11Patient Copay-Check #048 COPAY10 OA-10 1 3 99A0 NMARMA011091493 930914 4 Intergroup was billed. 0MARMA011091593091593930810 4 Insurance Write-Off INWROFF BA-30 1 0 0 1 0MARMA011091593091593930810 4 11Insurance Check# IN IA0 1 0 99A1 0OHAPA011091593091593930811 4 Insurance Write-Off APWROFF BA-135 1 0 0 1 0OHAPA011091593091593930811 4 11Insurance Check# AP IA0.00 1 99A1 0RODES010091493091493930914 3 11V221 Pregnancy 99213 CA60.00 091493 1 4 99A 0RODES010091493091493930914 3 11V221 Pregnancy J0210 CA20.00 091493 1 4 99A 0RODES010091493091493930914 3 1100000200 Copay Cash COPAYCASH HA-10.00 1 4 99A0 NRODES010091493 930914 3 Aetna was billed. 0RODES010091593091593930811 3 Insurance Write-Off APWROFF BA-50 1 0 0 1 0RODES010091593091593930811 3 11Insurance Check# AP IA0.00 1 99A1 0YOUMI010091593091593930915 3 11401.9,535.5 99214 CA65 091593 1 4 99A 0YOUMI010091593091593930915 3 11574.2 Gallstones 74246 LA80 091593 1 4 99A 0YOUMI010091593091593930915 3 11574.2 Gallstones 99000 LA8 091593 1 4 99A 0YOUMI010091593091593930915 3 11Patient Check #669 CHECK PA-30.60 1 4 99A0 0YOUMI010091593091593930810 3 Insurance Check #000067 CHV IA-48 1 0 0 1 NYOUMI010091593 930915 3 Champ VA was billed. 0AGADW010101993101993930811 1 Insurance Write-Off MUWROFF BA-4.22 1 0 0 2 0AGADW010101993101993930811 1 Insurance Check #45029 MU IA -16.90 101993112293 1 2 0AGADW010101993101993931019 1 11422.9,715.9 99213 CA60.00 101993112293 1 4 99A 0AGADW010101993101993931019 1 1100000002 Cash CASH SA-2.40 1 4 99A0 NAGADW010101993 931019 1 Blue Cross/Blue Shield was billed. 0ANALO011101893101893931018 1 11463.0 Tonsillitis 99213 CA60.00 101893 1 4 99A 0ANALO011101893101893931018 1 11463.0 Tonsillitis 87072 CA15.00 101893 1 4 99A 0ANALO011101893101893931018 1 11Patient Copay-Check #471 COPAY10 OA-10.00 1 4 99A0 NANALO011101893 931018 1 Cigna Health Plan was billed. 0ANALO011102093102093930914 1 Insurance Write-Off CIGWROFF BA-50 1 0 0 1 0ANALO011102093102093930914 1 11Insurance Check # CIG IA0 1 0 99A1 0BRADO010101993101993931019 4 11531.90 Gastric Ulcer 99213 CA60.00 101993 1 3 99A0 0BRADO010101993101993931019 4 11Patient Copay-Check#2566 COPAY10 OA-10 1 3 99A0 0BRADO010101993101993931019 4 11531.90 Gastric Ulcer 43246 CA60.00 101993 1 4 99A 0BRADO010101993101993931019 4 11531.90 Gastric Ulcer 74283 CA110.00 101993 1 4 99A NBRADO010101993 931019 4 FHP Health Care was billed. 0BRIJA010101993101993930913 3 Insurance Write-Off FHPWROFF BA-75 1 0 0 1 0BRIJA010101993101993930913 3 11Insurance Check# FHP IA0 1 0 99A1 0BRIJA013101993101993930915 3 Insurance Write-Off FHPWROFF BA-50 1 0 0 1 0BRIJA013101993101993930915 3 11Insurance Check# FHP IA0 1 0 99A1 0BRIJA01W101993101993930913 3 Insurance Write-Off FHPWROFF BA-30 1 0 0 1 0BRIJA01W101993101993930913 3 11Insurance Check# FHP IA0 1 0 99A1 0BRUTO010101993101993930913 1 Insurance Write-Off HUMWROFF BA-27 1 0 0 1 0BRUTO010102093102093931020 1 11461.8 Sinusitis, Acute 99211 CA25.00 102093 1 4 99A 0BRUTO010102093102093931020 1 11461.8 Sinusitis, Acute 95115 CA7.00 102093 1 4 99A 0BRUTO010102093102093931020 1 1100000100 Copay Cash COPAYCASH HA-5.00 1 4 99A0 NBRUTO010102093 931020 1 Humana Health Care was billed. 0BRUTO010101993101993930913 1 11Insurance Check# HUM IA0 1 0 99A1 0CHOCL010101993101993931019 2 11269.2 Vitamin Deficiency 99212 CA40.00 101993 1 4 99A 0CHOCL010101993101993931019 2 11269.2 Vitamin Deficiency 81000 CA11.00 101993 1 4 99A 0CHOCL010101993101993931019 2 11Credit Card Payment CRCDPAY RA-10.20 1 4 99A0 NCHOCL010101993 931019 2 CC# 350024245571228 Exp date: 0494 Name: Mr. Clam Chowder NCHOCL010101993 931019 2 Champus was billed. 0DOVBE010102093102093930915 Medicare Write-Off MCA A -15.00 1 1 0DOVBE010102093102093930915 3 Insurance Check #4507 MP IA -40.00 112493102093 1 1 0DOVBE010102093102093930810 3 Insurance Check #1475 BP IA -9.60 112493102093 1 2 NDOVBE010102093 931020 3 Blue Cross/Blue Shield was billed. 0DUDST010101993101993930913 2 Insurance Check #00104 JH IA -24.00 1 1 0DUDST010102093102093931020 2 11465.9 Upper Respiratory Infect99213 CA60.00 102093 1 5 99A 0DUDST010102093102093931020 2 11Credit Card Payment CRCDPAY RA-12.00 1 5 99A0 NDUDST010102093 931020 2 CC# 5162008543212300 Exp date: 1094 Name: Stephanie Dude NDUDST010102093 931020 2 John Hancock Insurance was billed. 0ESTPO010101893101893931018 1 11346.9 Headache-Migraine 99212 CA40 101893 1 4 99A 0ESTPO010101893101893931018 1 11Patient Copay-Check #649 COPAY10 OA-10.00 1 4 99A0 NESTPO010101893 931018 1 Intergroup was billed. 0FARJA010101893101893930913 6 Insurance Check #000125 JH IA-32 1 0 0 1 NGONIB010102093 931020 4 Standard Statement was billed. 0GONIB010102093102093931020 4 11No answer at phone #s COMMENT E 0 112493 1 0 99A 0GOOHE010101993101993930914 6 Insurance Check #23001 BP IA -32.00 1 1 0GOOHE010102093102093931020 6 11716.94 Arthritis-Hand 99213 CA60.00 102093 1 4 99A 0GOOHE010102093102093931020 6 11Credit Card Payment CRCDPAY RA-12.00 1 4 99A0 NGOOHE010102093 931020 6 CC# 4324555561010021 Exp date: 1194 Name: Goodman, Hesa NGOOHE010102093 931020 6 Blue Cross/Blue Shield was billed. 0GOORI010101893101893931018 1 11535.5 Gastritis 99214 CA65.00 101893112393 1 5 99A0 NGOORI010101893 931018 1 John Hancock Insurance was billed. 0GOORI010102093102093930915 1 Insurance Check #451 JH IA -58.40 102093 1 1 NGOORI010102093 930915 1 74246-MRI denied, pending justification of procedure. Sent requested info. 10/20/93. 0GOORI010102093102093930809 1 Insurance Write-Off CIGWROFF BA-8 1 0 0 2 NGOORI010102093 931020 1 Cigna Health Plan was billed. 0GOORI010102093102093930809 1 11Insurance Check# CIG IA0 1 0 99A2 0HYNHE010101993101993930913 5 Insurance Check #000304 MP IA -32.00 102093101993 1 1 0HYNHE010101993101993930809 5 Insurance Write-Off APWROFF BA-12.8 1 0 0 2 NHYNHE010101993 931019 5 Aetna was billed. 0HYNHE010102093102093931020 5 11250.01 IDDM Diabetes Mellitus 99211 CA25.00 102093112493 1 5 99A 0HYNHE010102093102093931020 5 11250.01 IDDM Diabetes Mellitus 82954 KA10 102093112493 1 5 99A 0HYNHE010102093102093931020 5 1100000001 Cash CASH SA-1.00 1 5 99A0 NHYNHE010102093 931020 5 Medicare was billed. 0HYNHE010101993101993930809 5 11Insurance Check# AP IA0.00 1 99A2 0KLICA010102093102093931020 3 11696.1 Psoriasis 99212 CA40 102093 1 4 99A0 0KLICA010102093102093931020 3 1100000100 Copay Cash COPAYCASH HA-10.00 1 4 99A0 NKLICA010102093 931020 3 Cigna Health Plan was billed. 0KLICA010101993101993930915 3 Insurance Write-Off CIGWROFF BA-55 1 0 0 1 0KLICA010101993101993930915 3 Insurance Check # CIG IA0 1 0 0 1 0MARMA011101993101993931019 4 11989.5 Insect Bite 99213 CA60 101993 1 4 99A 0MARMA011101993101993931019 4 1100000200 Copay Cash COPAYCASH HA-10.00 1 4 99A0 NMARMA011101993 931019 4 Intergroup was billed. 0MARMA011102093102093930914 4 Insurance Write-Off INWROFF BA-50 1 0 0 1 0MARMA011102093102093930914 4 11Insurance Check# IN IA0 1 0 99A1 0OHAPA011101893101893931018 4 11708.9 Hives 99213 CA60.00 101893 1 4 99A0 0OHAPA011101893101893931018 4 1100010000 Copay Cash COPAYCASH HA-10.00 1 4 99A0 NOHAPA011101893 931018 4 Aetna was billed. 0RODES010101893101893931018 3 11V221 Pregnancy 99213 CA60.00 101893 1 5 99A0 0RODES010101893101893931018 3 11V221 Pregnancy 76818 CA37.00 101893 1 5 99A0 0RODES010101893101893931018 3 11Patient Copay-Check #433 COPAY10 OA-10.00 1 5 99A0 NRODES010101893 931018 3 Aetna was billed. 0RODES010102093102093930914 3 Insurance Write-Off APWROFF BA-70 1 0 0 1 0RODES010102093102093930914 3 11Insurance Check# AP IA0.00 1 99A1 0SHAIM010102093102093931020 5 11816.00 Fracture, Finger 99214 CA65.00 102093 1 3 99A 0SHAIM010102093102093931020 5 11816.00 Fracture, Finger 29130 CA30.00 102093 1 3 99A 0SHAIM010102093102093931020 5 11Patient Copay-Check #789 COPAY10 OA-10.00 1 3 99A0 NSHAIM010102093 931020 5 Intergroup was billed. 0YOUMI010102093102093931020 3 11574.2 Gallstones 99214 CA65.00 102093 1 5 99A 0YOUMI010102093102093931020 3 1100010003 Cash CASH SA-13.00 1 5 99A0 0YOUMI010102093102093930915 3 Insurance Check #0578 CHV IA-122.4 1 0 0 1 NYOUMI010102093 931020 3 Champ VA was billed.