[104-10218-10009.pdf — page 136]
# MENT OF CLAIM| MIMNILS NUMBER SEA | CODE  | VOUCHER BUMPER | CLIINDENT RELATIONSHIP | LATE CLAIM HACORRED || ------------------ | :---: | :------------: | :--------------------: | :-----------------: || 1902               | 39505 |     Golfes     |        5-10-05         |                     |## AUDIT BREAKDOWN|                                                                                          |      AMOUNTS      |        AMOUNTS         || ---------------------------------------------------------------------------------------- | :---------------: | :--------------------: || 1 Hospital Admission Date -5-10-05                                                       | OF ACTUAL CHARGES | PAYACLUINDER BASE FLAN || 2 Hospital Admission Cour-las Per                                                        |                   |                        || 3 Hospital Room 6 Days@ $22,02                                                           |      132422       |         280.00         || 4 Hospital Last                                                                          |                   |                        || 5 laiptint Hosp, Misc Unciade Ambulance                                                  |       21025       |         217006         || 6 Oull.cat Misc.                                                                         |                   |                        || 7 Surgeon                                                                                |       1332        |         200000         || 8 Anesthetist (Other than hospital)                                                      |       01005       |         10000          || 9 Physician (O her than Surgeon) 5-10-05-5-01-05                                         |       7000        |                        || 10 Drugs (Omer Hapa Hospitull                                                            |                   |                        || 11 Other Cor Experse                                                                     |                   |                        || 12 TOTAL CASE PLAN LENcils This WOKOCET                                                  |       70635       |         177.06         || 13 Total Acul Charges                                                                    |       30109       |                        || 14 Show Any, Locess of Line 13 over Line 12                                              |                   |                        || 15 Add Amy Amulation of Deductible Applia                                                |                   |                        || 16 Totes Lore 1 and Line 15                                                              |       30109       |                        || 17 if line 16 Lacreds Deduci.Lie ($100, Flus Aly Private Foun Charge Exceeding $25 a Day |      207002       |                        || inter Aroul of Excess                                                                    |                   |                        || 18 PAYALLE 60%                                                                           |      207602       |                        || 19 PAYALLE 50%                                                                           |                   |                        || 20 TOTAL MAJOR MEDICAL LENEFITS TriS WORKSHEET...                                        |       30057       |         165.67         || 21 TOTAL SENCES Hills WCくられた (Lino 12 Fes Line 20)                                       |       0221        |         6.2.21         |ACCUMULATION OF DEDUCTIBLEFROM IREVIOUS CLAMSPrevious Cule Car YeanVoucher ho Amt.Voucherいて。 Amt.Voucher Na Am.Current Calendar Year.Voucher tis. Amt.Voucher it AVoucher No. AmTOTAL >Show any excess ca in, claim which may be appre roward sunsiaction of the deductible in the:Current Calendar YearFalloning Calendar YearMAJOR MEDICAL MAXIMUMPAID CONTROLel Major Medicalire..caly laidAmount Major AlevicalFord This Ciola 165.67Less Ang ReitstelerientCread Nol Previously TakenIcial AccumulatedMaar Mediral Faid 1607ITEM 8 BREAKDOWN,Arst. SurgeoOthersITEM 11 EFEAKDOWN:AppliancesNurseOthers (Expicin)REMARKS:Date Cetober 27 , 19 65