ST8201-CS 900417COPPRLL PUBLIC WORKS
MEMORANDUM
April 17,
To:
From:
Re:
1990
H. Wayne Ginn, Ginn, Inc.
Steve Goram, Director of Public W)~
Terrence W. Middle, Claim Filed
Wayne, attached documentation is being submitted to your
office to review and forward to the contractor performing
the Denton Tap Road project improvements.
Staff has reviewed this, and at present the claim would
appear to be associated with the Denton Tap Road
improvements. Please request the contractor to respond
appropriately.
If you or the contractor
Vivyon Bowman or myself.
have any questions, please contact
Thank you.
SGG/ymh
xc: Vivyon Bowman, Assistant City Manager/Personnel Director
FAX (214) 352-320!
ED BELL CONSTRUCTION COMPANY
April 11, 1990
City of Coppell
P. O. Box 478
Coppell, Texas 75019
Attns Mr. Steven G. Goram
Director of Public Works
Gentlemen~
We have reviewed the attached claim and have determined
that it did not occur on any of our projects. It appears
to be related to the Denton Tap project.
Should you have any questions, please contact us.
Very truly yours,
ED BELL CONSTRUCTION COMPAN~
J. M. Albert
President
JMA/gh
AN EQUAL OPPORTUNITY EMPLOYER
MEMORANDUM
March 28, 1990
TO:
FROM:
Steve Goram, Director of Public Works
~lvyon V. Bowman, Assistant City Manager/
Personnel Director
SUBJECT: Terrence W. Middle
Claim #032690.1
Attached is a claim from Terrence W. Middle in connection with the
Bethel Road Construction Project. Please note that the accident
involving Mr. Middle allegedly occurred in January 1989.
Please forward the claim to the contractor for consideration and
handling.
Your follow-up and response would be appreciated.
WB/dj
xc: Dorothy Timmons, City Secretary
Alan D. Ratliff, City Manager
April
The City With A Beautiful Furl e
6, 1990
P.O. Box 478
Coppell, Texas 75019
214-462-0022
Mr. J. M. Albert, President
Ed Bell Construction
10605 Harry Hines
P. O. Box 540787
Dallas, Texas 75354-0787
Dear Mr. Albert:
Attached is a claim from Mr. Terrance W. Middle in connection with
the Bethel Road Project, which Mr. Middle indicates occurred
January 1989. He is a resident of Coppell, Texas, residing at 516
Hunters Ridge.
Please review this matter and respond appropriately.
Should you have any questions, please contact either Vivyon Bowman,
Assistant City Manager at 462-0022 or myself at 462-8495.
~rely~ t'/
Steven G. Goram
Director of Public Works
SGG/bb
xc:
Alan D. Ratliff, City Manager
Dorothy Timmons, City Secretary
Vivyon Bowman, Asst. City Manager/Personnel
Director
MIDDLE.SGG
The City With A Beautiful Future
April 6, 1990
Mr. J. M. ~lbert, President
Ed Bell Construction
10605 Harry Hines
P. O. Box 540787
Dallas, Texas 75354-0787
,PR
9 1990
P.O. Box 478
Coppell, Texas 75019
214-462-0022
:91NNOU
Nt^I]Vt
Dear Mr. Alberts
Attached is a claim from Mr. Terrance W. Middle in connection with
the Bethel Road Project, which Mr. Middle indicates occurred
January 1989. He is a resident of Coppell, Texas, residing at 516
Hunters Ridge.
Please review this matter and respond appropriately.
Should you have any questions, please contact either Vivyon Bowman,
Assistant City Manager at 462-0022 or myself at 462-8495.
hrely~ ~
Steven G. Goram
Director of Public Works
SGG/bb
XC S
Alan D. Ratliff, City Manager
Dorothy Timmons, City Secretary
Vivyon Bowman, Asst. City Manager/Personnel Director
MIDDLE.SGG
C~AIM NOT
City Sect,
P.O. Box
Cop~ell,
75019
cLAiM so.(','~;-)l~,q(rL I
IN MY OFFICe, THIS THE ~(~
DA~OF W~L , 19
ci~
Dear Sir:
This is my notice of claim against the City of Coppell. The
circumstances giving rise to this claim are as follows:
1. The injury or damage occurred o~ the ~d day of ~ ~_~,
loc.tion of /
2. The d~age or injury o~curred in the follow,nE ~nner:
follows
The full extent of my damages and/or injuries are as
(be soecific; ~ttach estimates, bills, etc., if available):
4. The amount of damages claimed is $
CLAIMANT /~w=~¢ e
/
I DO S~~
NOTE: ~TIC~ II, Section 11.09 of the Home Rule Charter -
D~ge Suits.
The notification shall ~ filed within lofty-five (45) days of
the date of injury or damage or, in the case of death, within
forty-five (45) days of the date of death. The failure to so
notify the city within the time and ~nner s~cified shall
exonerate, excuse and exempt the city from any liability
whatsoever. No action at law shall be brought against the city
until at lea~t sixty (60) days have elapsed following the date
of notification.
26 March
1990
CLAIM NOTICE - ATTACHED SHEETS
Terrence W. Middle
2. The damage or injury occurred in the following manner:
I was struck in the rear by a car while waiting at a stop sign
for the traffic to clear. This was a difficult Job because
of the bad condition of the roads and because of obstructions to
the view, It was necessary for me to get into a awkward position
to see ~raffic which caused my back to twist when I was hit.
3. The full extent of my damages and /or injuries are as follows:
I have a damaged facet in my lower back and pain in my neck.
I have lost my Job last year largely as a result of this accident.
This lost me access to insurance and, thereby, any further
treatment.
The pain persists and my activities are now limited.
As complete a set of my medical expenses as possible is
included.
Terrence W. Middle
516 Hunters Ridge
Coppel~, Texas 75019
Feb 20, 1989
City Manager
Alan Ratliff
P. O. Box 475
Coppell, Texas
75019
Dear Mr. Ratliff:
On ~7'~/~20, 1989 I was involved~in an accident at the corner
of Bethel Rd. and Denton Tap Rd. due to extreme visual impairments
caused by construction signs for a car entering Denton Tap Rd.
I was standing still and hit in the rear. I am undergoing
physical therapy for multiple back injuries. There are still
many danger points in this construction area ( Denton Tap ) due
to a lack of flag men or other control in the evening. Should
there be any disability incurred on my part, the city will be held
accountable.
I received your letter dated July 16, 1987 in response to my letter
dated June 15, 1987. I complained about rocks blocking drainage
deposited by my neighbor to the north and you assured me that
they would be removed from the street right-of-way within 30 days.
the drainage is still blocked and the cost has been considerable to
me. Please see included pages. If this condition continues I
will again hold the city accountable.
Sincerely,
Terrence W. Middle
HO. Box 478
CoppelI, Texas 75019
214-462-0022
March 15, 1989
Mr. Terrence W. Middle
516 Hunters Ridge
Coppell, TX 75019
Dear Mr. Middle:
Having received your letter, the information regarding your
claim has been forwarded to our risk manager and insurance
company for their handling. We have also asked the city
engineer to again review all safety measures being utilized
on this construction project. I am extremely sorry to hear
that you were involved in an accident and hope that you are
recovering.
In your letter you made me aware that we have failed to
follow-up in having your neighbor remove the rocks within
the drainage ditch in front of their home and which you
had brought to our attention in July of 1987. You are
correct that we failed to pursue this matter and ensure that
the rocks were removed from the drainage ditch within the
30-day period we stated. I have attached a copy of the
letter that we mailed to your neighbor asking him to remove
this accumulated debris so you will at least know we did
contact him. However, as stated, we did not follow-up to
see that the rocks and debris were removed. I have again
directed the street departmen% personnel to initiate action
to remove this gravel and to personally follow-up to see
that it is done. I will also ask that the Public Works
Director contact you to discuss this matter.
Sincerely,
Alan D. Ratliff
City Manager
ADR/dgc
Attachment
xc: Mayor and City Council
Steve Goram, Public Works Director
COPPELL
'!', ~OLE TERRENCE
516 HUNTERRIDOE
393-0025
COPPELL ]'X
PH.462 0411
TX 75019
137497 07/01/B9
NAPROSYN 500HG TABLET 30 TA
OR. BUTTS JOSEPH
AMOUNT DU~28.99~'
R TAX OR INSURANCE
PH.462 0411
L TX 73019
MIDDLE TERRENCE 137498 07/01/89
516 HUNTERRIDGE FLEXERIL IOMG-TA~LET MSD
393-0025 60 TA
THANK YOU FOR SHOPPING AT MINYARD AMOUNT DU
THIS IS YOUR RECEIPT. P~EA, SE R~"rAIN FOR TAX OR INSURANCE
Dcte of Birth Mar, Sra.
~ Brief Ortho. 90024
90010 ~0040
90012
WIG exam
S.c~/neck/h
)ATE OF ACC/DENT:
Fu W/C-BI N
Primary ICDA Code
DiAG~J~IS:71--~ CONTINUING TRE,~'MENT OF PREVIOUS OIAGNOSIS
~,(~' ~.: .., ~- .... < ~-~.'~ ...... <~, )
#. Date / "~' ~'7 ....... ( '~ '"'
# Date /__ /
//
STITUTE SPORTS MEDICIN!
Soc. Security No.
AND IIEHAliUTATION
1735 KELLER ~IIRINGS ROAD
SUITE 100
CARROLLTON, TEXAS 75006
(214) 242..8535
JOSEPH A. BUTTS. M.D.
ROBERT G, JOHNSON, M,D,
OFFICE HOURS BY APPOINTMENT
I.D. # 75-2214267
Acct. No. Bal.
NEXT APP~O, INT
large M TU TH F
~on~
Adj.
cl.. (2)
71104) P3'bs (2}
73510 H~
73550 F~r (2]
73~0 K,,e,,
73562 ,.... {3)
73564 ~ (4)
735,15 Knee S~,~s (~)
73630 F~ (3}
7~s!
OFFICE COPY - White
[] 29065 Adult
SPLINTS:
[] 9NC5 Fmeom~WMI
[]
[]
[]
[]
[]
[]
[]
D
n
BRACES:
O 2g080 Adul~
O 2g0~1 Child
[] 29135 Adult
29346 Child
[] 29110 A~t,
29755 Casl Ilem~ k~m
[]
INSURANCE COPY - Yellow
PATIENT COPY - Pink
~V SOLUTZg~S
YOUR I~)U~E HA~ M~N
THIS STATEMEI~ I$ FOR YOUR RI
Ic, TAL
~CORDS
! 13'~
APPROVED OMB NO.
~T ,,~T- TX 7~t~)
,- --'--P-~,,~m oe mmic, · r~und ghe~k will tm
e,e~ HCFA-
and Memorial Medical Center
MIDDLE TERRENCE W
516 HUNTERS RIDGE
COPPELL TX
75019
07/07/89
Re: MIDDLE TERRENCE W
Account Number: 4228730
Admit Date: 5/15/89
Current Balance: 1,138.00
Discharge Date: 5/16/89
As stated previously, it is our policy to file insurance claims
as a courtesy to our patient.
If, however, your insurance company does not pay within thirty
(30) days from this date, we must look to you for payment in full
for this account.
Sincerely,
ROBERT KROLIK
8 4:30
214 888-7135
FUS/105-BCOUR
LI~.I I:recwa)' a~ '%g/ebbs Chapel · I~O, 1{o× 81909.1 · Dalhls. '[i:xas 75581-9094 · 214-247-1000
Memorial Medical Center
MIDDLE TERRENCE W
516 HUNTERS RIDGE
C0PPELL TX
75019
05/27/89
Re: MIDDLE TERRENCE W
Account N~mber: 4122057
Admit Date: 1/27/89
SECOND NOTICE
Current Balance:
Discharge Date:
191.50
1/27/89~
This is to remind you the above referenced account is past due.
Your immediate attention to this matter is requested.
Sincerely,
KIMBERLY HUGHES
8:30 5:00
214 888-7144
FUS/109-CSCL2
1.1~1 I:r,:t'way al ~Xzcbbs Chal~cl · I'.0. Box 819()9i · Dali:ts, 'li_'×;is 75.~81-909-i · 21-i-2.i7-10(10
Memorial Medical Center
MIDDLE TERRENCE W
516 HUNTERS RIDGE
COPPELL TX
75019
07/14/89
Re: MIDDLE TERRENCE W
Account Number: 4122057
Admit Date: 1/27/89
Current Balance: 38.30
Discharge Date: 1/27/89
FINAL NOTICE
Because our previous efforts have not resulted in the resolution
of the referenced account, we must proceed with further action.
Consider this your final notice. If this account remains unpaid,
it will be referred to our collection agency - Central Financial
Control.
Sincerely,
KIMBERLY HUGHES
8:30 - 5:00
214 888-7144
FUS/ll0-CSCL3
33 I:rccwav :tt Wel)l)s Chapel · I~0. I{()x 819()9.i · I):lllas.' i.-x s 75%8 -9()94 · 2i.t-2,|7-1000
PHYSICAL THERAPY CLINIC
OF NORTH DALLAS. INC.
Your insurance company~
$ ~'~'~ towards your total expenses of $ ~t~o The
rem~inin~ balance due is $ / ~ 0 -- Please remit this amount.
Thank you for your prompt attention to this matter.
Sincerely,
TOTAL 8~;N J~i:'J T J .... /~2..~(
Dire of Birth
Addm~
rnplo¥lr City, State, Zip
Mar. StB.
OF SPORTS MEDICINE
· -- AND IIEHABIUTATION
~oc. Security No. 1735 KELLER SPRINGS ROAD
SUITE 100
CARROLLTON, TEXAS 75006
Home Phone (214} 242-8535
JOSEPH A. BUTTS, M.D.
ROBERT G. JOHNSON, M.D.
OFFICE HOURS BY APPOINTMENT
I.D. # 75-2214267
IA TE OF ACCIDENT:' TPrimery ICUA Code
DIA~GNOSIS:*/[] CONTINUING TREATMENT OF PREVIOUS DIAGNOSIS
Date / , /
Date l, /
Secondary
73000 Cl~k~e [] 29135 Adult
73010 Scapule SPLINTS: [] 29136 Child
73111 Na~sr [-1 99650 Fredd~Fmg MISC I-1 ~42S Adult
73130 ~ [] 99655 Sleck [] 29426 Child
73140 ~ [3) ~6~
[] 29436 Adult
71020 Chest ~2) ri 29436 Child
INSURANCE COPY - Yellow PATI;~,IT r'mv m.~.
MedJOuir)-
I
Page
ACCOUNT NUMBER STATEMENT DATE
': ~ :1.~!:: (', .;.
TERMS
:L,;; ,. ,3',.:;/ LO
89 0007'5.1.90
It",,S!.! ['¢J',10£ COi~PANY 'BILLED
Y[ IR EST!i"',Lr~3'Eg¢,I'¢,~.OUItT D. LIE~I
."' 39s'I '.
TO AVOID ADDITIONAL CHARGES, PAY BY CLOSING DATE OF
xplanati, on of Benefits
Claim Questions Please Call
~a~ oncC-~-~-Administrators
$) 364-7000
o) 827-7177
TERRENCE RZgDLE
516'HUNTER$:RZD6E
COPPELL;TX 75019
Employee
Patient
Plan
Group No.
Group Name
I.D. No.
Claim No.
Provider
(X)
:)escription of Service
C-EON
Date of Service Amount Amount
From To Billed Allowed Code
Q5115 05115189~1138'00;1138.00'
TERRENCE RZDDLE
TERRENCE
OUCH/COSTCUREIZNA
TEKNEKRONCORPORATZON
89016781~16
R H D*REROR~AL~NOSPZTAL
NON-~ART/CZPATZN6
PROVZDER
Inaiig. Amount Amount Amount
Amount ~ % @ % ~ 100%
1138,,00
Totals
1138.00' 1138,00
Less Deductible
Balance
Co-Payment %
Benefit
: Responsibility: $ : · 00'
~r Respom,ibility: $
:ription of Remarks / Benefits
fOUR 1989 DEDUCTZBLE;'HAS I)EEN SATZSFZED=.
1138.00
1158.00
~ ~ 100~
1138.00
Total Benefit 1138 · 00
Other Insurance Payment
Total Paid I~ 1 1 3 8 ,~ 00
D ~IEROR'[AL HOSp'rTAL
Check Issued Amount Date
25989 1~'1 38.00 08~02~89
Preferred Providers have aDreed to accept Lincoln Nalionai / Family Health Plan Scheduled Aflowances as paymen n u except when Prov der Par-
ticipation is not a benefit oz your group plan. if you wish to appea the amount paid on your claim, you should first review your coverage provisions,
then call or write to us within sixty (60) days after receiving this explanation.
R'H*D ~EIqORZAL HOSpTTAL
PO 80X 819096'
DALLAS TX 75381
INSUREC COPY
,~LL ~.>
APPROVED OMB NO, O~3&O~Z{
I'
The hoepilll is mcttng Iol~Y''ira dn Igent lot U~ i)~ienl in filing tot inlurlncl Ima~lts
~ I0 it, however. ~ hol~illl CArs M flo illpOfl~l~llly lot guifill~hlg plyml~
d covered chlrgll II Ihowfl on I~e ~ M ~ bill, ~ il Ihowfl ~nly wt~ml N h~ll
COPPELL FAMILY PHYSICIANS
600 DENTON TAP at MEADOWCREEK
COPPELL. TX 75019
214-462-0762
TERRENCE W MIDDLE
516 HUNT~RS RIDGE
COPPELL, TX 75019
002112
01/21/89
D~tor: J. MIDOL' ~THUR:N.D? 75-2072792
~'.
924.5 ~CK PAIN
Charae Pavment
~35.00 S35.00
TOTAL CHARGES / RECEIPTS"TNZS MONTH: $35.00 S35.00
477 lest
P.O, Box
(210
AKTSSB r. TEl01, Il, ?. A.
2515 Sctiotm Smut
Suite 100
Ofltou, bxos 7i~1-2391
(817) 382-1577
ITYEIOllS PIISZCIAIS STATEIEI!
0)/I1-0]-00
I1DOL~, TSBKICE S iCCOOlT I0. 0)1605
516 ]lUSTERS IIDGE
75019
AS ~ O)-2]-RS
DATE lCD ICD.DRSC OPT CP~.D~SC AIOOIT
03-23-89 724.2 LUll&GO 090050 OFFICE'VISIT, LIIITED 40.00
03-23°# 724.2 LOIBAG0 900910 KRSOIJIL CS-OVEI Tn! COflTES 40.00-
L~SlCIMI - i1~00 L~, ~ZlBI, ID, P. A,
!~.10 ' 751777402
~ ! ' 17517774026000
T00A]'S ACTIVIT!
0.00
bsigmut of benefit, roleesu of uedical records, and authorization to
~s bdieilt and/or lusuraneo cIuiu:
I ~gn all ~iul ~lor surgical ~u~its to incl~e
dial ~tb to which l n citified, i~l~i~ ndicere, ~iviLe
~dauT othr ~alth ~ln to
~ ~ uill rmls Il effect uutil revolkd
h ~ ~ ~ ~icil st~las ate peid~ this assigmat vill
b.~db th relean of udtcal in[ot~t~on a~ discussion of
PA~HI~ SI~IITU00 % DAT~
nploye~ ~ity, et~le, Zip
Soc. Security No.
~ee~e Cedi ~efvlee C~de
Brief Ortho. 90024 Post-Dp Fu.
~0 Pre~lFu. 2~
Ce~ ~ Foll~p~ ~10
~c~hip FU ~kln~k
~0 Fu ~/N
~TE OF ACC/DENT: . [Priory ICDA C~
Date /__ /
Date / /
INSTIlIITE OF SPOITS IIEBICINE
Ail IrdlAIIUTATIOl
173S KELLER S~RINGS ROAD
SUITE 100
CARROLLTON. TEXAS 75006
(214I 242-8535
JOSEPH A. BUTTS, M.D.
ROBERT G. JOHNSON, M.D.
OFFICE HOURS aY APPOINTMENT
I.D. # 75-2214267
MTUWTH F
O x-~ nc~t
Adj.
rom ~ (2)
¢.~ (41.
Co~d, C.S~ (6)
~ (2)
7~11o t.s~ (5l
~ E~ (2)
~ 731ll ~ {4)
O~ ~ ~).
~ 7~ T~
OFFICE C~ - ~ite
0 ~SOS C,~ C~(Sd4
[] ~ c~ Bom
HEEL PAD~:
0 ~9~5 Ad. It
Child
(~tild
Adult
C~ild
0 29135 Adult
O 29136 Child
0 29346 Adult
0 29~4~ C~tild
29365 Adult
1'~ 29366 Child
0 29425 Ao~JIt
O 29426 Child
[] 29435 Ad]ul!
I"1 29436 Child
I~ 29110 A.
INSURANCE COPY - Yellow
[]
0
[]
PATIENT COPY - Pink
No.
tient Na~e
. £ ~' (*.. ~ ,.~ I~ , ,:~,.~.~
sible Party Name
'~ployer
Date of Birth
Addrett
City,State, Zip
Soc. S~urity No.
INSTITUTE OF DFODTS MEDICINE
AND BENABILITATION
1736 KELLER SPRINGS ROAD
SUITE 100
CARROLLTON, TEXAS 75006
(214} 242-8535
JOSEPH A. BUTTS, M.D.
ROBERT G. JOHNSON0 M.D.
OFFICE HOURS BY APPOINTMENT
I.D. J~ 76-2214267
ATE OF ACCI DEN T:
)tAONOSIS:~/C] CONTINUING TREA
Date /
Date /
1 2
C] 9961o w~
SPLINTS:
D
D
BRACES: []
D~O ~, ~.~a~ []
[] 99675 Ab' Leg ~.up
D 99697 Long ~g Hinged 8~
~LIN~BRACES: ~ ~7~ Ca~ R~ ~
INSURANCE COP~. Yellow
0 ~2~)~1 Child
0 29135 Adult
D 29136 Child
n 29345 Adult
0 2~34~ Child
[] 29365 Adult
[] 293~6 Child
[] 29425 Adult
0 29426 Child
[] 29435 Adult
I"1 29436 Child
[] 2~110 All
0
0
0
/ PATIENT COPY - Pink
[CCOUNT NO: 289021734
)ATIENT:
fIDDLE TERRENCE
DETAIL BILL
HCA LEWISVILLE MEMORIAL BILLING DATE PAGE
500 W MAIN 03/23/8~ £2:£0
LEWISVILLE TX 750&7-3&99 DATE OF SERVICE
FROM TO
03/23/89 03/23/8~
DILL TO:
MIDDLE TERRENCE
5£6 HUNTERS RIDGE
COPPELL
TX 750£9
DATE OF
SERVICE
HOSPITAL
REFERENCE CODES
03/25/89 8&8925 300
~/23/89 86J3£7 JO0
FACTORS
SERVICE
DESCRIPTION
EXECUTIVE FOUR
SED RATE
TOTAL CHARGES
CHARGES
£2.50
4.50
~7.00
05123/89
0000£0
PATIENT PAYMENT
TOTAL PAYMENTS
17.00
17.00
BALANCE .00
.. CO. NCEPT ADMINISTR/V"~RS INC.
P.O. Box 7090 PO Box ~,,)29
Sacramenlo, CA 95826 Bellevue, WA 98004
(916) 364-7000 (206) 827-4050.
(800) 223-2107 (In C/~) (800 426-3070.. ¢
(800) 824-4692 (out CA)
TERRENCE NZDDLE
516 HUNTERS RZDGE
COPPELL TX 75019
EMPLOYEE: TERRENCE Mt'DDLE
PATIENT: TERRENCE
PLAN: OUCN/COSTCURE/TNA
GROUP #: GEX-9104
GROUP NAM~EKNEKR0N C0RPORATZ0N'
~a .: 524-'44-864~
CLAIM. 89016781--06
PROVIDER: PHY THPY CLZNZCIN0 DALLAS
~ ) NON-PARTZCZPATZN6
PROV~DEE
)ESCRIPTION OF SERVICE DATE OF SERVICE BILLED ALLOWED INELIG. AMOUNT AMOUNT AMOUNT
FROM TO AMOUNT AMOUNT CODE AMOUNT @ % , 1oo %
)'L. ACCZDENT BE )2/17 )21~7-~-8-~--4-~-~-.20 402,.20 ~55.00
LESS DEOUCTIBLE
BALANCE 35~.00
CO-PAYMENT % % 1 O0 % 80
BENEFIT 35~e00
TOTAL BENEFIT
PATIENT RESPONSISILITY: $ 9 · ~ · OTHER INSUfiANCEPAYMENT
PROV~DE~ RESPONSm~UTY: $ TOTAL PA~D 59
DESCRIPTION OF REMARKS / BENEFITS
YOUR 1989 DEDUCTZBLE HAS 6EEN SATZSFZED.
FABLE TO CHECK ISSUED AMOUNT DATE
Y TNPY CLZNZC/NO DALLAS 6Z1228 392.76 '05112189
Participating Providers have agreed to accept contracted allowances as payment in full, except in cases of dual health insurance coverage.
As provided by the Employee Re tkemant Income Security Act of 1974, you or your authorized representative may request a review of your denied claim described above.
Suc~ request must be made in writing and submitted to the Plan Administrator within 60 days after you receive this notice. You may include any issues or questions
you wish answered and comments you feel are pertinent to this cf aim.
PHY THPY CLZNZC/N0 DALLAS
2925 LBJ FRWY STE 230
DALLAS TX 75234
KEEP THIS STATEMENT FOR TAX
REDORDS.
NO OTHER RECORDS WILL BE PROVIDED.
2925 LBJ FREEWAY SUITE 230
DALLAS. TEXA.~ ?$234
(214) PH. 241.2334
PLEA$~ GIVE 24 HOUR NOTICE
TO CHANGE OR CANCEl-
your RECEIPT for the amount
t
PHYSICAL TH£1~APY CLINIC
~ NORTH DALI.~ INC
292S LBJ FREEWAY SUITE 7~
DA~. TEX~
~14) PH. 241-23~
~ Gei~mtl, LPT
PLEA.SE GIVE 24 HOUR NOTICE
TO {:MANGE OR CANCEL
TAX I.D. · 75-1628549
PROVIDER ~ 650147
PHYSICAL THERAPY CLINIC
ef NORTH DALI.AS, INC.
2925 LBJ FREEWAY SUITE 23O
OALLAS. TEXAS 75234
{214) PH. 241-2334
LaDawn S~even~on. LeT
Drama GHnnell. LPT
D~AGNOSIS: ,~'/,~ /'~.V',/~-
PLEASE GIVE 24 .HOUR NOTICE
TO CHANGE OR CANCEL
Tk. b lm~ RECEI~T f~ ~ ~mmm~
PHYSICAL 1~EP. AP~ CZJNIC
a[ NO~12~I D~ INC.
2925 LBJ FREEWAY ~dlTE 230
DALLAS. TEXAS 75234
(214) PH. 241-2334
SERVICES PROVIDED
Grinnell, I. PT
PLEASE GIVE 24 HOUR NOTICE
TO CHANGE OR CANCEL
COPPELL FAMILY PHYSICIANS
600 DENTON TAP at MEADOWCREEK
COPPELL. TX 75019
214-462-0762
TERRENCE W MIDDLE
516~ HUNTERS RIDGE
COPPELL,~TX 75019
i .' ~== 002112
Date Patient Charge Code and DescriPtion
01/21 TERRENCE MID 90050 OFFICE CALL '.I 10 'MINS. 0
No ] Charade, Payment
$35.00 $35.00
Doctor: J. MICHAEL ARTHUR;M.D. 75-2072792 . .. ..'..' . .,i.~ '.; ~'
724.5 BACK PAIN . · "?<',? '.~ b~',-- ='~
...... '~:"~ ~ .=';'..
., ~', .-, .~.~.~ :, ~* ~.~:~',~.~.,,'.~'- :.'%,~'a. ,~ ,.. ~'~,;.;[~3~. ~,:,t ::,}') .%~,;', ?{ '~ ,: ':, ,~"% '2~, ·
. ,.. ~ .... ~.,.,., .-..~.-, ..... ,,..... :=}.. . . ~....: . . .... ~
TOTAL CHARGES / RECEIPTS 'CHIS MONTH:
$35.00
$35.00
COPPELL FAMILY PHY~S-ICIANS
600 DENTON TAP at MEADOWCREEK
COPPELL, TX 75019
214-462-0762
TERRENCE W MIDDLE
516 HUNTERS RIDGE
COPPELL, TX 75019
002112
01/26/89
~te Patient CharQe Code and Descriotion
./26 TERRENCE MID 90040 FOLLOW UP VISIT
Doctor: STEVEN P. GELLMAN:M.D. 085-38-1582
724.5 BACK PAIN
728.9 CERVICAL SYNDROME
No
CharQe
.~25.00
Payment
$25.00
TOTAL CHARGES / RECEIPTS
'PHIS MONTH:
$25.00
2 .oo
Acct. No.
Em~4oyer
Code ~iee
90000 Brief Ortho.
g0010 Ortho. Exam
Knee exlm
g0015
Back/mck/h
9O020
DA TE OF ACC/DENT:
# _ Date / /
#, Date / /
C~de . ~ewiie v Fie
Mar. Etl.
Code
INSTITUTE OF SPORTS MEDICilII
,. ,-.='. : .... AND IIEIIRBIUTATION
So~. Security No, j~',l 7~E KELLER ~PRING$ ROAD
SUITE 100 ' .'"
.... ': ~RROLLTOI4.,., TEXAS 75006 ~,
· . ~_...,.. ,:,;.~,.~ .'~ . ~_~.~;~ ~,~ .~,~, ~+... ~%.?~:~'~
'.~ ~ "~IEPH A. lU~, M.D. ' ~'
ROBERT G. ~HN~. M.D.
OFFICE ~URS BY ~IN~ENT
.' I.D. ~ ~t4~7
Fu W/~*BIN
Primiry ICDA Code
Fie
BRACES:
~:~0.~ e..Ik A. Ib ~0~ '
HElL PA~
0 ~1 T~
C]~.. '
0
0
D
0 ~ Adult
0 2~76 Child
[] 29366 Child
0 20425
0 2942~ Ch#d '
02~q6 ~lkl.
INSURANCE COPY · Yellow..-/
PATIENT COPY · Pink
AND REHABILITATION ·
.' -''" "~'i A,R"A.~ ' ' '"
0
0 ~'17S8
0 SI?St
0
Cede
90000 Brief Ortho.
gOOlO
Beck/neck/hip
~A TE OF ~CCIDEN~'
DIAGNOSIS:~ ~
# , Date / /
*, Date ,/ : /
· iNSTITUTE OF SPoIrr$ IEglClNE
: . ~.....: .:,.,..,'AND REHABILITATION
173S KELLER SP~INGS ROAD. ·
- Soc. Security No.,' · · "" . 'SUITE 100
,' ~r **-*-'~ ** ;..'. ..... : **,..;** * **%,' *i CARROLLTON.TEXAS 75006
. {214) 242.~536
ROBERT G. JOHNSON, M.D. '
OFFICE HOURS BY APPOINTMENT
". ,.,I.D. ~ 75-2214267
9O024
90O40 206OO m~ll
20610 M
Fu b~ck/neck
) WJC~IN
Time resulted
Next Appointffmnl
2 3 4
Code
· ' · SPLINTS:
9~10 Wild
SPLINTS:
n w~ss S~ck
[]
7355o F,~ .' L (2)
73s~ v.,,..":*;;: L-*i (2)_
129085 Adult
[] 29068 C~lld
[] 29076 Child
[] 29~1 Ch.d
I--] 29136 Child
' .-r~.~:.':. v ~ ..; ~ ....
· ~, ~o~.~,r~" ':.;.:.~'~,..~'"'
OFFICE COPY -~i~ INSURANCE C~PY - Yell~
0 2g~6 C~IM
029142 SimudtO~mk~ , ' ' '
0 ' ',.'if" ' . '
PATIENT COPY - Pink
CONCEPT ADMINISTI TORS INC.
.'P.O, Box 7090 P.O. I[ 40529
Sacramento. CA 95826 Bellevue. WA 98004
(916) 364-7000 (206) 827-4050
,(.800) 223-2107 (In CA) (800) ~26-3,0~0 .,.~
(800) 824-4692(Out CA) '
TERRENCE MIDDLE
516 HUNTERS RZDGE
C0PPELL TX 75019
EMPLOYEE; TERRENC E'..MIDDLE
PATIENT: TERREt~CE
PLAN: OUCH/CQSTCURE/TNA
GROUP #: GEX-9104
GROUP NAM1E:EKNEKRON C0RPORATZON
ID .: 524-44-8645
CLAIM s: 89016781--08
PROWOER: RHD MEMORTAL'
~ ) NON-PARTZCIPATING
PROVTDER
OF SERVICEI1,, DATE OF SERVICE BILLED ALLOWED I INELIG. · AMOUNT AMOUNT AMOt
DESCRIPTION
FROM TO AMOUNT AMOUNT CODS AMOUNT ~ % @ % (~- SC
~XL ]1127 )1127/89 191.50 191.50 191.
TOTALS 191.50 191.50 191.
LESS DEDUCTIBLE
BALANCE ,:191 ·
CO-PAYMENT % % % BO
BENEFIT 1 5 3.
TOTAL BENEFIT 153.
PATIENT RESPONSIBILITY: $ ~[8 ,. 30 OTHER iNSURANCEPAYMENT
PROVIDER RESPONSIBILITY: $ TOTAL PAID '~ .~.~e
YOUR 1989
DEDUCTIBLE HAS
DESCRIPTION OF REMARKS/BENEFITS
BEEN SATISFIED.
:~AYABLE TO CHECK ISSUED AMOUNT DATE
HEMORIAL 6;)4'~35 153.Z0 05/Z3/89
~articJpa~ng Providers have agreed to accept contracted allowances as payment in full, except in cases of dual headth insurance coverage,
As provided by the Employoe Re~iremen t Income Security Act of 1974. you or your aulhorized rep~e sentative may request a review of your denied claim described abo',
Such request must be made in wriling and submiitod to the Plan Adminisffator within 60 days alter you receive this noUce. You may include any issues or queslJo
you wish answered and comments you feel are pertinent to this claim.
P 0 a0X 81909z,
· DALLAS TX 75:~81
KEEP THIS STATEMENT FOR TAX
REDORDS.
NO OTHER RECORDS WILL BE PROVID
CONCEPT ADMINISTRATORS INC.
P,O. Box 7090 P.O. Bo. 529
Sacramento, CA 95826 Bellevue, WA 98004
(916) 364-7000 (206) 827-4050
(800) 223-2107 (In CA) (800) 426-3070
(800) 824-4692 (Out CA)
TERRENCE HZDDLE
516.HUNTERS RZDGE
C0PPELL, TX 75019
EMPLOYEE: 'TERRENcE M'rDDLE
PATIENT: .TERRENCE
PLAN: OUCH! CO STCURE! ZNA
GROUt' ,: GEX-9104
GROUP NAMETEKNEKR 0N ~. C0 RPORATZON.
CLAIM ~: 89016781~07
PROVIDER: ,HRZ~A~SO,,OF TEXASr
(X) NON-PARTZCZPATZNG
PROVZDER
DATE OF SERVICE BILLED ALLOWED INELIG. AMOUNT AMOUNT AMOU~
DESCRIPTION OF SERVICE coDE
FROM TO AMOUNT AMOUNT AMOUNT @ % ~ lOt"J: %
~(L 04/05 04105189 937,00 937°00 168.00 769..
TOTALS q~7. O~ g'{?. {30 1 AR_13~3
LESS DEDUCTIBLE
BALANCE I ~8 ~'~" ' 7
CO-PAYMENT % % '~! % 80
BENEFIT 1 ~R
TOTAL BENEFIT
PATIENT RESPONSlBILITY: $ 1 53.80 OTHER INSURANCE PAYMENT~
PROVIDER RESPONSIBILITY: S TOTAL PAID
DESCRIPTION OF REMARKS / BENEFITS
YOUR 1989~DEDUCTTBLE HAS BEEN SATTSFZED.
~.YABLE TO CHECK ISSUED AMOUNT GATE
IR*r ASSO 'OF- TEXAS:
624065 783.20 .05122189'
Participating Providers have agreed to ac, copt contracted allowances as payment in lull, except in cases ot dual health insurance coverage,
As provided by the Employee Re~rament Income Security Act o! 1974, you or your authorized rel:x'esentative may raque st a review of your denied claim described abov
Suc~ request must be made in wdlJng and submitted to the Plan Administrator within 60 days after you receive this no6ce. You may include any issues or quest~o~
you wish answered and comments you leel are petlJnent to this claim.
MR/ AS$O OF TEXAS
12840 HILLCREST'103
DALLAS 'TX .752~0
KEEP THIS STATEMENT FOR TAX
REDORDS.
NO OTHER RECORDS WILL BE PROVID
P.O. Box 7090 P/~-~ox 40529
Sacramento. CA 95826 Bt. /ue, WA 98004
(916) 364-7000
(206) 827-4050
(800) 223-2'107 (In CA) (800) 426-3070
(800) 824-4692 (Out CA)
TERRENCE MIDDLE
516 HUNTERS RIDGE
COPPELL TX 75019
DESCRIPTION OF SERVICE
FROM
EMPLOYEE: TERRENCE MIDDLE """."~ , :.
PATIENT: TERRENCE ' ..L~ :'.'~.: ~-
GROUp NAMI~EKNEKRON CORPORATION ?' '
~o .: 524'44-8645 ..,'
(X) NON-PARTIcipATiNG ..
81LLEO ALLOWED INELIG. AMOUNT
__TO __AMOUNT AMOUNT AMOUNT AMOUNT
%
AMOI
-~10(
875.
PATIENT RESPONSIBILITY: $
PROVIDER RESPONSIBILITY: $
YOUR 'J9~9 DEDUCT,rBLE
,YABLE TO
TOTALS
LESS DEDUCTIBLE 75.
BALANCE
CO-PAYMENT %
BENEFIT
· O0 TOTAL BENEFIT 75..
OTHER
TOTAL PAID
DESCRIPTION OF REMARKS / BENEFITS
HAS BEEN SATISFIED.
CHECK ISSUED .... ' ' · AMOUNT '-.", ~,':'.--,/', ..... ,
IST SPORTS MED/REHAB '
7167 8.~. ,., ,-, ..'; .-~
......... :., , ',. ,..~,~,~",,"~,~ ~ ....
Pa~pa,ng Pm~rs have ........ ' ' '
~ a~aymont i~ll~ excent i .......... ~~r~,~.~ ....
you wish answered and ~~e~'~ ~ ~ ~1~ Adminis~tor;;~P~n~vem~yre~est~re~ofyour~niedca m desc~
...-~ ,.~u~ any Issues ~ questions
'(,'~"'!~ZNST'SPORTS.MED/REHAB'~: .... ~.. .. ....... : ::. · · . ,. '',,
' " ....
1735 KELLER SPRINGS ROAD '" .
SUITE 100
CARROLLTOH TX 75006 KEEP THiS STATEMENT FOR TAX
'REDORDs.
NO OTHER RECORDS WILL BE PROVIDED
P.O. Box 7090
· . , ',Sacramento, CA 95826
(916) 364-7000
(800) 223-2107 (in CA)
(800) 824-4692 (Out CA)
TERRENCE MIDDLE
516 HUNTERS RIDGE
COPPELL TX 75019
p.o...,~.,x40529 .......
Bell[ ~.WA 98004
(206) 827-4050
(800} 426-3070
EMPLOYEE; TERRENCE MIDDLE "~'; :,.'.
PATIENT: TERRENCE "'
GROUP NAMI~'EKNEKRON CORPORATION ~"7":'""
CLA~U .: 8901 57 81-09
(X ) NON-PARTZC[PATZN6' "
PROV[DER
DESCRIPTION OF SERVICE DATE OF SERVICE BILLED ALLOWED INELIG. AMOUNT AMOUNT AMOUr.
FROM TO AMOUNT AMOUNT COOE AMOUNT @ % @ % '~ 100
URGEON 35/15 35/15/89 336.00 336.00 336.(
TOTALS 336.00 336.00
LESS DEDUCTIBLE
BALANCE 335
CO-PAYMENT % % % '100
BENEFIT
TOTAL BENEFIT 3
PATIENT RESPONSIBILITY: $ · 0 0 OTHER INSURANCE PAYMENT
PROVIDER RESPONSIBILITY: $ TOTAL PAID
DESCRIPTION OF REMARKS / BENEFITS
YOUR 1989 DEDUCTIBLE HA~ 6EEN SATISFIED·
Pa~dpa~ng Pro~s have agreed ~ a~pt ~a~ al~wan~s as payment in ~11, except in ~ses ol dual ~ insurance co~rage. '. -;: ~ ~'
As prodded by ~e Emp~yee Re~rement I~me S~d~ A~ o~ 1974, you or yo~ au~odz~ m~ s~ may re.est a renew o~ your ~ claim ~s~b~ a~ve.
Su~ re.est must be ma~ in wdfing ~d su~i~d ~ ~e PI~ Adminis~a~r wi~ 60 ~ys a~r y~ m~ive ~is no~. Y~ may inclu~ any issues or ques~ons
you wish answer~ and comments you ~eel are ~nent to ~is claim·
JOHN MUELLER MD
10 MEDICAL PARKWAY
SUITE 202
DALLAS TX
75234-7840
KEEP THIS STATEMENT FOR TAX
REDORDS.
NO OTHER RECORDS WILL BE PROVIDED.
,nployer
Addmt~ . IH°me Phone
City, ~tatl,,Zip
I
INSTITUTE OF SPriTS MEDICINE
AND REHABILITATION
1735 KELLER SPRINGS ROAD
SUITE 100
CARROLLTON, TEXAS 75006
(214) 242-853S
JOSEPH A. BUTTS, M.D.
ROBERT G. JOHNSON, M:D.
OFFICE HOURS BY APPOINTMENT
I.D. # 75-2214267
DA TE OF ACC/DENT:
DIAGNOSIS:V[-[ CONTINU~J~;
#. . Date
# Date
Service F. C.de
7300o Cio,kb (I)
73010 ~(o~x~lo (2}
73OOO Sl,~
73O31 ~ {3)
7~ ~ (2)
OFFICE COPY - White
: [::] ~,sos o. cdb. it,,~l
r-L ~SS0 A.C ~i~
D~0
O~
O
O
[]
O
[]
O
(:3
[]
Code
029068 Adult
O 290~8 Child
29~ Ad. It
O 290~1 Child
O 2913~
[] 29136
Ad~h
Child
O 2g34B ~t
[] 29346 Child
SPLINTS:
996~6
BRACES:
HEEL PADS:
[] 99771 Tu&HHICUp~
29365
[] 29366 Child
[] 29425 Admt
O 29426 Child
[] 29435 Adult
[] 29436 Child
[] 2~110
INSURANCE COPY - Yellow '
[]
[]
O
PATIENT COPY - Pink
IIAGNO~S: ,/r'l CONTINUING I~F. ATMENT O~
DATE I I.
M TU W TH F
Time Requimd
1234
New Balance
O g7530B
0 9713~A
Thempe~c Exe~c~e
30 Minule~ (Lower)
'Therapeutic Exe~ise
3O ~,,ir, ut.
*ddia:.~ 'is Miout.~
~ 15 Minutes (Lower)
[] ~?1~4 Ma.age 0-
[3
0 ggO?OV Neu~-~de (8~l-Adhe~ive)
0 990'7'0W ileum-Ice pak:h~
0 99o7oY SImtM
~ 15 Minute~ ('['~ur,~)
30 Mlr, u~ (Lower)
~' ~nlih4e Party Name
Employer
INSTITUTE OF IPORTS MEDICINE
AND REHABILITATION
1735 KELLER WRINGS ROAD
SUITE 100
CARROLLTON, TEXAS 75006
(214) ~42-853E
JOSEPH AolIUTTSo M.D.
ROBERT G. JOHNSON° M.D.
OFFICE HOURS BY APPOINTMENT
I.D. # 7E-2214267
t Ch~roe.
's Peyment
Adj.
[] 71020 ~ (2)
[] 71100 Ribs (2)
Code Fee
[] ~o w~,
r-I ~ Vdcm F.,reer
[] ;~6S5 S~ck
D
[]
[]
[]
0
[]
[]
029O66 Child
29076 Child
2g0~0
[] 29081 Child
[] 29135 Adult
[] 29136 Ch#d
I-I 29346 A~JIt
[] 2034~ Child
Ty P nt
II
IIRACES:..
[] 99751
HEEL FADS:
[] 2~3~ C~id
[] 2042E Gh~ld
0 29435
[] 29436 Child
29110 Ag
[]
[]
INSU RANGE COPY - Yellow
PATIENT COPY - Pink
10 Medical Parkway 202
Dallas Texas 75234--7840
(214) 247-9000
TERRENCE W. MIDDLE
516 HUNTERS RIDGE
COPPELL, TX. 75019
CONCEPT ADMIN.
(JOHNSON)
ACCOUNT NUMBER # ~.'~9-? 741
DATE PROFESSIONAL SERVICE CHARGE PAID BALANCE
5-15-89 ANESTHESIA 336 00 £ 336 30
$-75-R9 INS. FIIFD
5-25-Rg STMT.
.~,i~:,.'.,.~.. .~.+,,~.,~. ~.~..,. ,~. . . ,.
~:Concept Administrators
~~~;~,,~;~'.~"'"'~SE~'-NT.ACCOUNT ..,. ~.~: ..... . '.~... 0~O 0 0 6 3 3 2
...... . ..~, .. ...... .~ ,': 't~:: -
~'~'~". '-:' ~' 9~2 TEOH CENTER DR., SUITE 600 .
'~.t:'~'.r';'`'~' ;: ::~?~ ':P:O;"BOX 7090 '
SAC~MENTO, CALIFORNIA 95826 $ ~ ] b · O0
.. ~... (916) 364-7000 OR %800-827-7171
S335 OOLLARS ANO O0 CENTS
TO .MUErLER MD/ JOHN
THE ,10,.MEDZCAL PARKWAY
ORDER *'"~'~ "~
,,'.~ ~,$ U:~T,E ~ OZ ,,,>
ACCOUNTS ARE DUE 30 DAYS FROM DATE OF SERVICE.
THANK YOU.
PREV. BAL: 628.U0
:kO/2~/,= ..
Stuart B. Black, H.I).
THIS'STATE~NT ~FLECTS YOUR TOTAL BALANCE TO
DATE. I~$NOT TO BE U~D FOR FILI~IHSURAtI~.
FORENG, EVOIEO ESPONSE, EEG, MD HOSPITAL
CHkR6E$, HE IL4VE FILED YOUN PRIORY INSURAJIE;..
NO PAYNENT HAS BEEN RECEIVED. THIS AHOUNT IS NOW
DUE AND PAYABLE NY YOU. PLEASE REflIT IN FULL Ar
THIS TINE.
PLEASE RESPOND USING THE ENCLOSED PRE A~)DRESSED REPLY ENVELOPE
(HD M~qOR[ AL
~0 ~OX 8Lgogq'
)ALLAS
~[03LE
)gOb39
APPROVED OMB NO. 0938-0219
[ERREN;6 a M[3OLE
>16 HUflTE,qS RIDGE
:OPPELL TX
750L9
.[ADIDLOGY 3 [ A3 hr':.) ST [ C
' TOTAL
^ TEKNE~,RON :
,MIDDLE TERRENCE W
8
SPRAIN Off NESK
8~.70
; TXRF399J. GELLMAN
52~86~5
E
AEMO~IAL PO BOX 819096 ¥
~RRE~ICE W MIODLE PT~ O0~12ZO57 F/C 20
AOM[TTED O[/Z7/B9 DISCHARGED OL/Z?/S9
C~ARGE~
~932050 7ZOSO00
~932070 7207000
DESCRIPTION QTY DATE CHARGE
SP[NEgCERV CCMPL L O127 58.50
SP/NEgTHORACZC L 0L27 6Oe50
SP[NE~L/S CORPL L 0L27 72.50
]
I
s.c.~P~Ii{~RMACY L;OPPELL
PH.4~2 0411
TX 75019
MIDDLE TERRENCE 147018
516 HUNTERRIDGE ANSAID IOOMG TAB
393-0025 60 TA
COPPELL TX DR.WILLS, K.
10/12/89
THANK YOU FOR SHOPPING AT MINYARD AMOUNT DUE $4B.99
NEUROLOGY ASSOCIATES OF DALLAS
8230 WAL~q3T HILL IAN., SUITE 600
DALI2%S, TX 75231
214-696-3383
TAX ID: 75-2193858 SUPPLIER NO: 87E226
%ME OF PATIENT: MIDDLE,
[6 HUNTERS RIDGE
)PPELL, TX 75019
TERRENCE W
POSTING DATE:09/08/89
b. OF SERVICE(ACCORDING TO FORM HCFA-1500): 3
DIAGNOSES:
.) LUMBAR SPONDYLOsIS
:) 721.3 (2)
(4)
TOS _ PROCEDURE CO ...... '
BAU cE FOR
Stuart B. Black, M.D.
NEUROLOGY ASSOCIATES OF DALLAS
8230 WALNUT HILL LN., SUITE 600
DALLAS, TX 75231
214-696-3383
TAX ID: 75-2193858 SUPPLIER NO: 87E226
NAME OF PATIENT: MIDDLE,
516 HUNTERS RIDGE
COPPELL, TX 75019
TERRENCE W
POSTING DATE:09/15/89
PL. OF SERVICE(ACCORDING TO FORM HCFA-1500): 3
LUMBAR SPONDYLOSIS
721.3
DIAGNOSES:
(2) CERVICAL SPONDYLOSIS
(4)
721.0
TOS' PROCEDURE
DESCRIP.LLE
CODE FROM TO
195860WPI
24D:
INCv-MOTOR
DESCRIP:L MEDIAN
?V-MOTOR
DESCRIP.L ULNAR
[NCV-F WAVE
DESCRIP.L MEDIAN
INCV-F WAVE
DESCRIP:L ULNAR
INCV-MO~O~
DESCRIP:R PERONEAL
!NOV-MOTOR
DESCRIP.L PERONEAL
195900WP
24D:
195900WP
24D:
195935WP
24D:
195935WP
24D:
195900WP
24D:
195900WP
24D:
I INCv-MOTOR 195900WP
DESCRIP:R POSTERIOR TIBIAL 24D:
I INCV-MOTOR 195900~
DESCRIP:L POSTERIOR TIBIAL 24D:
I INCV-F WAVE
DESCRIP:R PERONEAL
195935WP
24D:
~ !NCV-F WAVE
DESCRIP.L PERONEAL
195935WP
24D:
09/15/89109/15/89
09/15/89109/15/89
09/15/89109/15/89
09/15/89109/15/89
09/15/89109/15/89
09/15/89109/15/89
09/15/89109/15/89
09/15/89109/15/89
09/15/89 109/15/89
09/15/89 109/15/89
09/15/89 109/15/89
UNIT AMT
185.00 C
50.00 C
50.00 C
50.00 C
50.00 C
I
50.00 C
50.00 C
50.00 C
50.00 C
50.00 C
50. O0 C
I
TOT AMT
185.00
50.00
50.00
50.00
50.00
50.00
50.00
50.00
50.00
50.00
50.00
I' I~CV-F WAVE 195935wP og/15/s~lo~/15/s~
ESCRIP:R POSTERIOR TIBIAL 24D:
~ I INCV-F WAVE 195935WP 09/15/89~09/15/89
~SCRIP:L POSTERIOR TIBIAL 24D: '
~ I I TYPE OF PAYMENT(i=CASH;2=CK;3=CC): CHECK
~SCRIP:PT CK #3377
BALANCE FOR THESE SERVICES:
TOTAL BALANCE:
50.00 C 50.00
50.001C 50.00
157.00 P
628.00
628.00
Stuart B. Black, M.D.
GUARAWI'OR NAME AND ADORF.~S
8230 Wulnut Hill Lane, Suit~ 818
(214) 987-2393
K.HNNETH L. REED. M.D. i,D. //75-2227087
I~111~1'f NO. P~UflqT I&ldd~
04957
BILL
FILE
"5'[ ~, i'tLJl',i FL:fi'E-; ;". [ ,)[.:,[:i
GOF'FEI_L i'× '?~:~Oi V
P~ ~~ CENTER OF I)/I~T.T.~
',, ' 8Z~O 'Wa]nm Hill lane, $.ite 818 '~ ~ /
DIIIm, Tellm 7~231
(214) 9~7-2393
KENNETH g REED. M.D. I.D. # ~-2227987
BIRTH
~ Dp NOT ~
STAPLE'(N
mml
TDfi$ ARFA
HEALTH INSURANCE CLAIM FORM
(CHECK APPLICABLE PROGRAM BLOCK BELOW.~080
PATIENT AND INSURED (SUBSCRIBER) INFORMATION
TERRENCE N MIDDLE
S16 HUN,ER= RIDGE
L-OPPELL TX ~
~-.0~9
~.~o SIGNATURE ON FILE
TERREN;-E W. I'IIDE'LE
HUNTERS RIDGE ; .......
COPPELL TX 7~019
SIGNATURE ON FILE
PHYSICIAN OR SUPPLIER INFORMATION
RHE, MEMORIAL HOSP,' DALLAS
N~JMSERS ,. ~. 3. ETC. OR OX C~E '
~THIS ~:LAIH FOR PROFESSIONAL COMPONENT
4-1OSPITAL BASED PH,SI_I~N" ~' *' - P~ADIOLOGIST
DATE O~ SERVICE
FROM
01-27-89 72110 SPINE~ LUMBA;i~ COMPL,
01-27-89 r2070 SPINE~ THORACIC
01-:27-89 72~S2 SPINE¢ CERVI,ZAL~
FLE~/E~T~
AUTHORtZATION N
2':" .~,~0
20, Do
20, Do
I
62, ~o
B -k~ l
APPROVED BY AMA COUNCIL Form HCFA-1500 (C-1) (1-84) Form OWCP-1500
O~,.~EO~C,~LS~RwCES-e3 Form CHAMPUS-501 Form RRB-1500
MIDDLE, Terre~ce
516 Hunters Ridg~
Coppell, T× 75019
ACCOUNT NUMBER
6515
TERMS
10.0%/ 10
Page
STATEMENT DATE
07/~0/89
05/31/89 00075190
06/30/89 00075190
IN 196.93 , ,.
PY 9514 157~ ~4'
PROMF'T F~AYMENT WILL BE AF'PRECIATED.
. 00 39.39 . ~]0 · 00 · O[i'~
TO AVOID ADDITIONAL CHARGES, PAY BY CLOSING DATE OF
39.39
09/08/89 OFF]CE CHARGES 150.00
Og/lS/Og OFFICE CHARGES 78S.O0
::;i J ] I i
'."): 0 0 to
Stuart B. B3. ac:k, H.D
rA~ AD3S 8AL THIS STATE~HT REFLECTS Y~R TOTAL BALANCE TO
J50.O0 .~ .00 ~ATE: iT IS NOT I0 8E U~D FOR FILI~
J57.00 .00 .~8.00 FOR EHG, EVOIED ~ESPO~E, E[6: ~B HOSPHAL
C~RGES, NE H~VE FILED YOUR PRI~RY INSUR~CE.
PAY THIS AHOUNT:
628.00 ) - Assigned Charges( .00 ))
I I..RI'?i:.I',iL;L ~,,) ti i
L:t d: ['[ [ .I. , J ,': ) 5l ~ J '..~
PLEASE RESPOND USING THE ENCLOSED PRE ADDRESSED REPLY ENVELOPE
' - ~ 8230 Walnut Hill Lane, Sui~ 818
Dallas, Texas 75231
(214) 987-2393
KENNETH L. REED, M.D.
09/!'),/'..~ :}? 62"(K)7 !
I,D. #75-2227987
PATIB~-IIAlilE ·
~'JNCE~T. ADMINISTRATORS
~' PO BOX 7090
SACRAMENTO CA 95826
TEKNEKRON CORPORATION
~MPLOYEE
CLAIMANT
TERRENCE MIDDLE
5!~ HU~!TER? RIDGE
TERRENCE
CLA I ~'NO. 8c~016781-01
DATE: OS / 1 ~,/90
PAGE: 1
.ECEIVED: 'TO:
PROCESSED: 03/15/.~
CLAIM TYPE: MEDICAL
COPPELL TX 75019 CD .SEX BIRTHDAY ADdUSTER: K. BELDEN
TOTAL INELIGIBLE ~---DEDUCTIBLE---~ BENEFIT *CO-INSURANCE~ PAI
,~,un ~EDICAL ~ENEFiTS
02/10-02/15/89
253.20
724
ALLAS 42.5.
53.20 80
53.20 42.5.
~OTAL i
3HK NO CHK I
597c~43 03/15~
[NT NO ~F. E. I. N.
75-1628549
_C;,i 4C~-PT. ADMINISTRATORS
PO BOX 7090
SACRAMENTO
CA ~5826
CLAI~ 40.
DATE:
PAGE:
890167~1-02
03/14/90
1
~OijP:
TEKNEKRON CORPORATION
TO:
RECEIVED:
O~/U~/~
04/04/~
04/07/~
~I~T~
TERRENCE MIDDLE
TERRENCE
CLAIM TYPE: MEDICAL
COPPELL TX 75019
CD. SEX BIRTHDAY ADdUSTER: N. ANOER$
TOTAL
~HAR~E
~ ~ U¥/U6/~Y LU~AI iUN: U/
INELIGIBLE *---DEDUCTIBLE---* BENEFIT *CO-INSURANCE* PAl
GHAEBES BENEFIT CO-INS AMuONT AMOUNT % AMOU~
iC 04/04-04/04/8~ ~5 848 INST SPORTS HEDZREHAB
70.00 70.00 70.¢
'OTAL 70.00 70.00 70.0
;HK NO CHK DATE PAID TO CHECK AMOUNT PATIENT NO F. E. I. N.
,14377 04/27/89 TERRENCE MIDDLE 70.00
516 HUNTERS RIDGE
~O~"JCE,~T .~DMINISTRATORS ~ CLAIM -~J. 8901~781-03
PO BOX 7090
DATE:
~ACRAMENTO CA 95826 PAGE:
GEX-~iO4
TEKNEKRON C0RPORATION
~PLOYEE CLAii-iANT
TO:
RECEIVED:
03/14/90
1
~i~/~
03123/8
04/07/8
04i2~i~
TERRENCE MIDDLE
COPPELL TX 75019
TERRENCE
CLAIM TYPE: MEDICAL
CD. SEX BIRTHDAY ADdUSTER: N. ANDERS
TOTAL INELIGIBLE *---DEDUCTIBLE---* BENEFIT *CO-INSURANCE* PAI
03/23-03/23/8~ 3~ 848 UNIDENTIFIED
17.00 17.00 17.0
3TAL 17.00 17.00 17.0
JK NO CHK DATE PAID TO CHECK AMOUNT PATIENT NO F. E. I.'N.
14380 04/27/89 TERRENCE MIDDLE 17.00
516 HUNTERS RIDGE
..uu~E~ TX 7~0i~
,O!NC~P?,ADMINISTRATOR$
PO BOX 7090
SACRAMENTO CA 95826
~--~IV~
TEKNEKRON CORPORATION
TERRENCE MIDDLE
COPPELL TX 75019
CLAI: 4r_. 89016781-04
~LAI~ANI
TERRENCE
DATE: 03/14/90
PAGE: 1
TO: 03/23/~
RECEIVED: 0~/17/~
CLAIM TYPE: MEDICAL
CD. SEX BIRTHDAY ADdUSTER: N. ANDERS
TOTAL INELIGIBLE ~---DEDUCTIBLE---* BENEF. IT *CO-INSURANCE* PAI
E ~M~6~ CH~ u~Erl~ uu-lN~ ~MOU~: ~nuu~; i A~OUN
C 03/23-03/23/89 95 724 TERRY, ARTHUR F MD
40.00 40.00 40.0
OTAL 40. O0 40. O0 '
40.0
HK NO CHK DATE PAID ~0 CHECK AMOUNT PATIENT NO F. E. I.. N.
= = ===== = ~ ===-=======-- ===~= === === = == === ==,.,=.===~== ==
20628 05/11/89 TERRENCE MIDDLE 40.00
516 HUNTERS RIDGE
:
£07iCEPT~'ADMINISTRATORS
PO 'BOX 7090
~ACRAMENTO CA 95826
GEX-~i04
TEKNEKRON CORPORATION
~ CLAIM'--h3. 89016781-05
DATE:
PAGE:
INCUR~U F~On:
TO:
RECEIVED:
03/14/90
1
04/11/8
04/17/8
TERRENCE MIDDLE
COPPELL TX 75019
TERRENCE
CLAIM TYPE: MEDICAL
CD .SEX BIRTHDAY ADdUSTER: N. ANDER$
TOTAL INELIGIBLE ~---DEDUCTIBLE---~ BENEFIT *CO-INSURANCE~ PAI
;~iuEN'r BEN~Pil
04/11-04/11/89 95 724 INST SPORTS MED/REHAB
35.00 35.00 35.0
)TAL 35.00 35.00 35.0
IK NO CHK DATE PAID TO CHECK AMOUNT . PATIENT NO .F. E. I. N.
!0&29 05/11/89 TERRENCE MIDDLE 35.00
516 HUNTERS RIDGE
· ~Ut"l"b:.L&. TX 7.5015'
-CC,N~E. PT 'ADM I N I STRATOR$ PO BOX 7090
CLAI~
~0 · 8~016781-0~,
~ACRAMENTO
CA 95826
~Ex-gi04
TEKNEKRON CORPORATION
TERRENCE MIDDLE TERRENCE
COPPELL TX 7501~
CD. SEX BIRTHDAY
DATE: 03/14/90
PAGE: 1
TO: 02/27/E
~ECEIVED: 04/21/R
CLAIM TYPE: MEDICAL
ADdUSTER: N. ANDERG
TOTAL INELIGIBLE ~---DEDUCTIBLE---* BENEFIT *CO-INSURANCE~ PA1
02/17-02/27/89 95 724 PHY THPY CLINIC/NO DALLAS 392.7
402.20 355.00 47.20 80
ITAL 402.20 355. O0 47.20 392.7
K NO CHK DATE PAID To CHECK AMOUNT PATIENT NO F. E. I.. N.
1228 05/12/89 PHY THPY CLINIC/NO DALLAS 392.76 4067 7~-1628549
2925 LBd FRWY GTE 230
L,,~LLA~ -i'X ~0234
CO~EPT'~DMINISTRATORS PO BOX 7090
~ACRAMENTO CA 95826
~Ex-~Iu4
TEKNEKRON CORPORATION
TERRENCE MIDDLE
COPPELL TX 75019
CLAIM
TERRENCE
3. 8901~781-07
DATE: 03/14/~0
PAGE: 1
~ TO:
RECEIVED:
~U~U:
CLAIM TYPE: MEDICAL
CD SEX BIRTHDAY ADJUSTER: N. ANDERS
04/0~/8'
04/27/8"
~/i//~'
TOTAL INELIGIBLE ~---DEDUCTIBLE---* BENEFIT ~CO-INSURANCE~ PAI~
~ CH~GE~ ~E~E~iT CO-i~ ~nO~i~T AHO~] ~ ~nuum'
04/05-04/05/8~ 36 7222 MRI ASSO OF TEXAS 783.2:
~37.00 168.00 769.00 80
TAL ~37.00 168.00 769.00 783.2c
K NO CHK DATE PAID TO CHECK AMOUNT PATIENT NO F. E. I. N.
4065
05/22/8~ MRI ASSO OF TEXAS
12840 HILLCREST 103
783.20 04894912 75-2036590
-~E r4~,EP1 'AOM I N I STRATORS
PO BOX 7090
CLAI~ O.
$9016781-08
SACRAMENTO CA 95826
GEx-~lu4
TEKNEKRON CORPORATION
TERRENCE MIDDLE
COPPELL TX 7501~
TERRENCE
CD. SEX BIRTHDAY
DATE: 03/14/90
PAGE: 1
. TO: 01/27/8
REC~IVEDr 05/08/8
CLAIM TYPE: MEDICAL
ADdUSTER: N..ANDER$
.......... ~ M 0~/0~/3~ LUCATI~N: OZ
TOTAL INELIGIBLE *---DEDUCTIBLE---, BENEFIT *CO-INSURANCE~ PAI
: ~H~L ~HAK~ ~ll UU--LN~ RRUUN1 AMOUN1 % AMOUN
01/27-01/27/89 36 848 RHD MEMORIAL 153.2
191.50 191.50 SO
~TAL 191.50
191.50 153.2
4K NO CHK DATE PAID TO CHECK AMOUNT PATIENT NO :F. E.. I. N.
05/23/89
RHD MEMORIAL
P 0 BOX 819094
153.20 4122057
95-3720659C
COi'4CE~=T 'ADM I N I S TRA TORS
PO BOX 7090
SACRAMENTO CA 95826
6EX-~i04
TEKNEKRON CORPORATION
MPLOYEE
TERRENCE MIDDLE
COPPELL TX 75019
[~AIMAN"I'
TERRENCE
CLAIr ;0. 89016781-09
DATE: 03/14/90
PAGE: 1
TO: 05/15/8
RECEIVED: 05/30/8
CLAIM TYPE: MEDICAL
CD .SEX BIRTHDAY ADdUSTER: N. ANDERS
TOTAL INELIGIBLE *---DEDUCTIBLE---* BENEFIT ~CO-INSURANCE* PAl
M 05/15-05/15/89 19 724 MUELLER MD, JOHN 336.0,
33&.00 336.00 100
OTAL 336.00 336.00 336.0
HK NO CHK DATE PAID TO CHECK ¢d~OUNT PATIENT NO :F. E. I..N.
6332 06/12/89 MUELLER MD, JOHN 336.00 189-2741~ 75-1580415
10 MEDICAL PARKWAY
'" ;DALLAS TX 75234-7840
CONCE~T ~DMINISTRATORS
PO BOX 7090
CLAIM J. 89016781-10
SACRAMENTO
CA 95826
TEKNEKRON CORPORATION
i'iPLoYE~
TERRENCE MIDDLE
5i° HUNTE~G ~iDGE
COPPELL TX 75019
C~iM~N¥
TERRENCE
CD .SEX BIRTHDAY
DATE: 0~/14/90
PAGE: 1
. TO: 05/15/8
RECEIVED: 06/02/~
CLAIM TYPE: MEDICAL
ADJUSTER: N. ANDERS
.---- ~ I~ ~J~/¢J~/;d'~ I_F..II..;A I IUI~-' ii/
TOTAL INELIGIBLE ~---DEDUCTIBLE---* BENEFIT *CO-INSURANCE* PAl'
r I~,MAEbmr'. ~,MRI'~t~_5 Ub.~- I- I I I,.,U-- J,N.5 APIUUN I APIUUN I 7. API~mUN
05/15-05/15/89 19 724 INST SPORTS MED/REHAB 875.0,
875.00 875.00 100
)TAL 875.00
875.00 875.0
IK NO CHK DATE PAID TO CHECK AMOUNT PATIENT NO .F.E. I. N.
7167 06/13/89 INST SPORTS MED/REHAB 875.00 89124~00 75-2214267
173~ KELLER SPRINGS R0AD
,, C~RROLLTON TX 75006
CLAI~O.
~oN~EPT~DMINISTRATORS PO BOX 7090
SACRAMENTO CA 95526
;ROUP; ~EX-~i04
TEKNEKRON CORPORATION
89016781-11
DATE: 03/14/90
PAGE:
TERRENCE MIDDLE
TERRENCE
TO: 05/22/8~
RECEIVED: 06/02/8~
CLAIM TYPE: MEDICAL
COPPELL TX 75019 CD .SEX BIRTHDAY ADJUSTER~ N. ANDER$
TOTAL INELIGIBLE ~---DEDUCTIBLE---* BENEFIT ~CO-INSURANCE* PAIl
E CH~E ~,H~R~ ~EbiEr i i ~0- i N~ ~OUN ~ ~MOUN ~ /. ~IOuN
:C 05/08-05/22/89 95 724 INST SPORTS MED/REHAB
80.00 80.00 80 64.0,
OTAL 80.00 80.00 6~.0.
:HK NO CHK DATE PAID TO CHECK AMOUNT PATIENT NO .F. E.. I. N.
7743 06/14/89 64.00
TERRENCE MIDDLE
516 HUNTERS RIDGE
-CC~N~EPT~ADMINISTRATORS
PO BOX 7090
CLAI, NO. 89016781-12
SACRAMENTO CA 95826
TEKNEKRON CORPORATION
TERRENCE MIDDLE
COPPeLL TX 75019
DATE: 03/14/90
PAOE: 1
: TO: 05/31/:
RECE I VED: 06/05/C
TERRENCE CLAIM TYPE: MEDICAL
CD. SEX BIRTHDAY ADUUSTER: N. ANDER$
TOTAL INELIGIBLE ~---DEDUCTIBLE---. BENEFIT ~CO-INSURA~4CE~ PA'~
C 05/31-05/3I/S9 95 72~ MEDIQUIP
196.93 157.~
19~.~3 80
OTAL 1~6.93
157.,,
HK NO ~HK DATE PAID TO CHECK AMOUNT PATIENT NO F. E. I. N.
~514 06/20/89 MEDIQUIP 157.54 75-1827213A
1865 SUMMIT DRIVE
PLANO TX 75074
cO~CEPT '~DMI N I STRATORS ~'~ CLAIr ~-~i0. 87016781-13
PO BOX 70?0
SACRAMENTO
CA ?5526
GEX-~i04
TEKNEKRON CORPORATION
TERRENCE MIDDLE
TERRENCE
DATE: 03/14/70
PAGE: I
TO:
RECEIVED:
04/26/8
06/23/8
CLAIM TYPE: MEDICAL
5i~ HUm~i~ ~l~
COPPELL TX 75017
CD ,SEX BIRTHDAY ADdUSTER: N. ANDERS
TOTAL INELIGIBLE ~---DEDUCTIBLE---* BENEFIT *CO-INSURANCE~ PAI
CHA~E CH~OE5 ~EN~rl~ Cu-i~ ~nOUN~ ~muu~ ~ ~nuu~
:C 04/17-04/26/87 ?5 7231 PHY THPY CLINIC/NO DALLAS 234.0
2?2.60 2?2.60 80
'OTAL 2?2.60 2?2.60 234.0
,HK NO CHK DATE PAID TO CHECK AMOUNT PATIENT NO F. E.' I.'N.
13520
06/28/8? PHY THPY CLINIC/NO DALLAS
2?25 LBd FRWY STE 230
234.08 4067 75-162854?
C)NCEPT- ADMINISTRATORS
· PO'BOX 7090
ACRAMENTO CA 95826
GEX-~i04
TEKNEKRON CORPORATION
PLO¥~E
TERRENCE MIDDLE
CL~IM~N~
TERRENCE
CLAIM
89016781-22
DATE: 03/14/90
PAGE: 1
INCURRED
TO:
RECEIVED:
10/12/8
10/16/8
CLAIM TYPE: MEDICAL
5i~ HUNTers ~iD~E
COPPELL TX 75019
CD ~SEX BIRTHDAY ADdUSTER¢ N. ANDERS
TOTAL
CHA~E
E H 0')/0~z.39 LOCAT~0N: 07
INELIGIBLE ~---DEDUCTIBLE---~ BENEFIT *CO-INSURANCE*
CHAR~'ES BEN£Pi T CO- i iNS AHOUNT AHOUNT % AHOUN
dOR--MEIlFI~AL--~!~-NE-FiTS
10/12-10/12/89 78 780 PRESCRIPTION DRUGS
48.99 48.99 i00 48.9'
TAL 48.99 48.99 48.9'
K' NO CHK DATE PAID T° CHECK AMOUNT PATIENT NO F. E. I. N.
9229 11/16/89 TERRENCE MIDDLE 48.99
516 HUNTERS RIDGE
,COPPELi_ TX 75019
. CQNO~PT . ADM I N I STRATOR$ ~ CLA I '~ ~-~
PO BOX 7090 ~lO. 89016781-14
SACRAMENTO
CA 95826
DATE: 03/14/90
PAGE: 1
G~X-~Iv4
TEKNEKRON CORPORATION
TO: 0&/28/~
RECEIVED: 07/07/(
~U~U: V//~/~
TERRENCE MIDDLE
COPPELL TX 75019
TERRENCE
CLAIM TYPE: MEDICAL
CD. SEX BIRTHDAY ADdUSTER: N. ANDER$
TOTAL INELIGIBLE *---DEDUCTIBLE---* BENEFIT *CO-INSURANCE~ PA~
C 0~/28-06/28/89 ~5 780 INST SPORTS MED/REHAB
70. O0 70. O0 80 5~. (.
OTAL 70. O0 ': 70. O0 5~. 0
HK NO CHK DATE PAID TO CHECK AMOUNT PATIENT NO .~:F;::=!E.:I..N.
,,== , = ! =- = ,,.. = ==,~ =
.===== = ====?====.,======= ======-:,= ======== ~- ==== ~=.=. =====.,-=======
22234 07/24/89 TERRENCE MIDDLE
516 HUNTERS RIDGE
~ CO~E~L
CONCEPT ~DMINISTRATORS
. PO BOX 7090
~ACRAMENTO CA 95826
CLAIM~.
89016781-15
DATE: 03/14/90
PAGE: I
GEX-~i04
TEKNEKRON CORPORATION
IP~O~EE CL~i~ANT
" IN~RRED FRON~ 07i0ii~
' TO: 07/01/8'
RECEIVED: 07/07/8"
PRuC~$ED:
TERRENCE MIDDLE
~o H~i~TER$ RIDGE
COPPELL TX 75019
TERRENCE
CLAIM TYPE: MEDICAL
CD .SEX BIRTHDAY ADJUSTER: N. ANDERS
TOTAL INELIGIBLE *---DEDUCTIBLE---* BENEFIT *CO-INSURANCE~ PAI
CHARGE CHARGES BENEFIT CO-iNS A~OU~T A~G~T ~ A~O~N
~u~ n~uiC~L bE~l~
07/01-07/01/89 98 780 PRESCRIPTION DRUGS
~9.9G ~9.98 80 55.9:
]TAL 69.98 ~9.98 ' 55.9.
4K NO CHK DATE PAID TO CHECK AMOUNT PATIENT NO F. E. 'I. N.
- ==================- _ .
:~2235 07/24/89 TERRENCE MIDDLE 55.98 516 HUNTERS RIDGE
-C~NCEPT~MINISTRATORS
.'PO BOX 7090
CLAIM
;ACRAMENTO
CA 95826
'TEKNEKRON CORPORATION
i~LU¥CC
TERRENCE MIDDLE
COPPELL . . TX 75019
TERRENCE
89016781-16
DATE: 03/14/~0
PAGE: I
, ~: ~ TO: O5/1~/E.
RECEIVED: · · 07/11/F
.~. CD. SEX BIRTHDAY
CLAIM TYPE: MEDICAL
ADJUSTER:
=========== ................ = .... ~ M 0~/06/)~ LUCATION: O/
TOTAL INELIGIBLE ~---DEDUCTIBLE---* BENEFIT *CO-INSURANCE* PAI
05/15-05/15/8~ 19 7244 R H D MEMORIAL HOSPITAL.
1138.00 . 1138.00 100
'' ' ' ' ':' 1138.00
1138.0
113G.0
~O~CEPT~DMINISTRATORS
· PO BOX 7090
3ACRAMENTO CA 95826
TEKNEKRON CORPORATION
TERRENCE MIDDLE
5i6 HUNTE~ ~E
COPPELL, TX 7501~
G~iH~N'~
TERRENCE
CLAIM 3. 8~01~7~1-20
DATE: 03/14/90
PAGE: 1
RECEIVED: 0~/28/8
P~OCE~ED:
CLAIM TYPE: MEDICAL
CD . .SEX
E ii
BIRTHDAY ADdUSTER,: N. ANDERS
0~/0~/3~ LOC~¥iON: 07
TOTAL INELIGIBLE ~---DEDLICTIBLE---* BENEFIT *CO-INSURANCE* PAI
I 07/22-0~/22/87 1~ 7242 WILL MD, KELLY 38~.0
389.00 387. O0 100
ITAL '?'389.
'2444 11/08/89 WILL MD, KELLY
8230 WALNUT HILL LANE
, 38<~. O0 890604
75-2227~87
~CGNCEPT ADMINISTRATORS -
PO BOX 7090 CLAII JO. 89016781-21
SACRAMENTO CA 95826
TEKNEKRON CORPORATION
TERRENCE MIDDLE
OGPPELL TX
TERRENCE
: CD .SEX BIRTHDAY
DATE: 03/14/90
PAGE: 1
RicEiVED: TO: 10/Og/E
10/13/~'
CLAIM TYPE: MEDICAL
ADJUSTE~: N. ANDER$
:::=====:=== ............ ~ M OY/O~/~y LOCAIIUN:
TOTAL INELIGIBLE *---DEDUCTIBLE---* BENEFIT *CO-INSURANCE* PAI
UH~ UHA~ UEN~DII ~O--IN~ AMOUNT AMOUNT ~ AMOUN
U 10/09-10/07/8!? 19 724 WILL MD, KELLY 326.0
326.00 326.00 100
3TAL ' 326,00 : ; : ,' :
· 326. O0 326.0
tK' NO CHK DATE PAID TO ; ' , CHECK AMOUNT PATIENT NO
F8375 11/15/89 WILL MD, KELLY 326.00 890604 75-2227987
8230 WALNUT HILL LANE
~;DALLAS : ;:i;: TX 75231 ~:~:
-.J~EP~ ADMINISTRATORS
· PO'BOX 7090
;ACRAMENTO CA 95826
~EX-~i04
TEKNEKRON CORPORATION
IMLL~Y~
TERRENCE MIDDLE
HUNTERS AiDGE
COPPELL TX 75019
ULAIM~N~
TERRENCE
CD .SEX BIRTHDAY
CLAIM ). 8901~$781-22
DATE: 03/14/70
PAGE: 1
-° ~NCURAED FAOH: i0/i2/~
TO: 10/12/8
RECEIVED: 10/1~/8
CLAIM TYPE: MEDICAL
ADdUSTER¢ N. ANDERS
E H 09i0~i3~ LOC~¥iON: 07
TOTAL INELIGIBLE ~---DEDUCTIBLE---* BENEFIT *CO-INSURANCE* PAl
C H A R~E--'---'--C'MA RGE'S"~-BEN£P i T CO- i NS AHOUNT AHOUNT g AHOUN
10/12-10/12/89 98 780 PRESCRIPTION DRUGS
48.99 48.99 100 48.9'
TAL 48.99 48.99 48.9'
K'NO CHK DATE PAID T° CHECK AMOUNT PATIENT NO F. E. I. N.
9229 11/16/89 TERRENCE MIDDLE 48.~9
516 HUNTERS RIDGE
,COPpEii
CO'CE?', ~DMINISTRATORS
'PO BOX 7090
~ACRAMENTO CA
~OuP:
TEKNEKRON CORPORATION
IKLUY~
TERRENCE MIDDLE
5i~ MUNTE~ ~IuGE
COPPELL TX 75019
CLAIM 3.
C LA~MAN i
89016781-23
TERRENCE
DATE: 03/14/~0
PA~E: 1
TO: 10/20/8'
RECEIVED: 10/27/8'
MRuCE~u: ll/~l/~'
CLAIM TYPE: MEDICAL
CD .SEX BIRTHDAY ADJUSTER.: N. ANBERS
~ ~ U¥/U6/~¥ LUGAIIUN: VI
TOTAL INELIGIBLE ~---DEDUCTIBLE---* BENEFIT ~CO-INSURANCE* PAl'
UMA~ UHA~ ~N~II ~O--INS AMOUN] AMOUNT ~ AMOUN~
10/20-10/20/89 19 724 WILL MD, KELLY 32~.0~
326.00 326.00 100
ITAL 326.00 326.00 326.0~
IK NO CHK DATE PAID TO CHECK AMOUNT PATIENT NO F. E. I. N.
:2698 11/21/89 326.00 890~04
WILL MD, KELLY
8230 WALNUT HILL LANE
' ,,. DALLAS TX 75231
75-2227957
FiO ~E.q'T ADMINISTRATORS
.PO BOX 7090
CLAIM r'-, 89016781-25
ACRAMENTO CA 95826
GEX-~i04
TEKNEKRON CORPORATION
FERRENE:E MIDDLE
5i~ HUNTE~
~OPPELL TX 75019
DATE: 03/14/90
PAGE: 1
i~4CU~ED F~GFi; 12/05/8'
TO: 12/05/8'
~ RECEIVED: 12/27/8"
CL~iHANT ~uC~$ED:
TERRENCE
CLAIM TYPE: MEDICAL
CD SEX BIRTHDAY ADJUSTER~ N. ANDERS
:==:==- ............ E Fi O)/06i~f LOt~TiON: ZOi
TOTAL INELIGIBLE ~---DEDUCTIBLE---* BENEFIT ~CO-INSURANCE* PAil
CHA~GE CHA~GE~ B~NEF i T CO- i NS AHOUNT AiiOUNT ~ ~HOU~:
12/05-12/05/89 19 7242 PRESBYTERIAN HOSPITAL 1369.2~
1369.25 13~9.25 100
'AL 1369.25 1369.25 1369.?~
NO CHK DATE PAID TO CHECK AMOUNT PATIENT NO F. E, I. N.
469 01/24/90
PRESBYTERIAN HOSPITAL
PO BOX 843115
DALLAS# Ti 75284
1,369.25 4504762826 75-1047527