Exhibit 13

2:14-cv-11700-PDB-MJH Doc # 1-14 Filed 04/29/14 Pg 1 of 9 Pg ID 187
STATE FARM

P0 BOX 2361

BLOOMINGTON IL 61702

HEALTH INSURANCE CLAIM FORM

AIPIOVED BY NATIONAL UNIFORM CLAiM COMMI1T EB 0805

PICA PICA

MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OThER Ia INSUREDS ID NUMBER Fos Poglttm Item

CHAMPUS HEALTh PLAN

.DMam .J tpoasoes ss.vl DotetcfctQissN arID 22 127918

PATIENTS NAME Last Name Feat Name MgkJlc resell

PAI1EP4TSgIRTH TE SEX MN

fl43fl

INSUREDS NAME LaII Name

FatjName Midole iNStil

PATIENTS ADDRESS IWO Street PATIENT RELATIONSHIP TO INSURED INSUREDS ADDRESS No Stroell

Sc4$pouseCb8d oMmQ

LRATIENTETATUS

Single Merdod Other

ri FiS.Tene ri Pan-TImern

EmpIod ssent L..J SMIsIN

OIlIER INSUREDS NAME fl-oat Name Fuel Name IluodIe Initial 10.15 PATIENVS CONOITIOP4 RELATED TO

EMPLOYMENT Cuuucntor Preotoa

AUTO AC NOCIDENT P1.ACE SINaI

fJYES DHO OTHER ACCIDENT

II INSUREDS POLICY GROUP OR FECA NUMBER

OTHER INSUREDS POLICY OR OROUP NUMBER INSUREDS DATE OF BIRTH SEX

OTHER INSUREO DATE OF BIRTH SEX MM DO YY EMPLOYERS NAME OR SCHOOL NAME

EMPLOYERS NAME OR SCHOOL NAME INSURANCE PLAN NAME OR PROGRAM NAME

d.INSUTIANCE PLAN NAME OR PROGRAM NAME

YE$ END STATE FARM

lod RESERVED FOR tOCAL USE IS THERE ANOTHER HEALTh GENEFIT PLAN

READ SACK OF FORM BEFORE COMPLETING LiTGI4ING THIS FORM

YES If yes relate to and complete itemS e-d

13 INSUREDS OR AUTHORIZED PERSOTS SIGNATURE authorize

12 PATIENTS OTT AUTHORIZED PERSONS SIGNATURE Irurhoaza the release CI oay medical or other rnten eecotsoty

to process Itne darn also request payment ol gaeernrnent bereltts either to inysoll or to the party itho accepla asclgnr000l

payment sliodertI bootIes Ia 1110 undorougnod physicIan or supplEr lou

sorvEac descnbad ocloco

below

SIGNATURE ON FILE 04122010

SIONED....._ DATE

SIGNATURE ON FILE

SIGNED___________

t4.DATE OgfiURRENT

ILLNESS Feel symptomOR Its IF PATIENT HAS HAD SAME OR SIMiLAR ILLNESS

YY DO YY INJURY lAcalIJoflIi OR GIVE FIRST DATE IAN

olo62010 PREGNANCYLMPI 010 62010

17 NAME OF REFERRING PROVIOER OR OTHER SOURCE

lit.1

-I I7IINPI

18 DATES PATIENT UNABLEW WORK IN CURRENT OCCUPATION

MM DI MM 00 YY

FROM TO

MM DO YY MM DO 18 HOSPIALIZAT1ON DATES RELATED TO CURRENT SERVICES

FROM TO

19 RESERVED FOR LOCAL USE 20 OUTSIDE LAD CHARGES

21 DIAGNOSIS OR NATURE OF ILI.NESS OR INJURY tReble llama 123 01 410 Item 24E by LInoJ

i.LHJ.0___ s.LIV.1___

flM

22 9FAI0 RESUBMISSION

ORIGINAL REF ND

23 PRIOR AUTHORIZATION NUMBER

Z.LJ32

2$ DATES OP SERVICE PROEOURES SERVICES OR SUPPLIES

From To

MM DO VY MM DO YY SEAYCZ EMS

Eripteri UnueuaI Crarmstnnces lotAGNoss

CPTIHCPCS MODIFIER POINTER tCHARGES LIarS Nr

RENDERING

PROVIDER 10

01202010I 0120201.21 J.iI 99205 25 11234 400 aol 1710019.955 IIII II

.1 .1 NPI

I._ ....i_.i IIiJ Ii JNPI

25 FEDERAL TAX 1.0 NU.IBER SSN EIN 25 PATIENTS ACCOUNT HO 27 CCEPT ASSIGNMENT 28 TOTAL CHARGE 123 AMOUNT PAlO 30 BALANCE OUE

tt5avI an cot bMI

800381054 DL._ MGM041210JB003JYEs QNO Ji 400 OOjs 000s 40000

SIGNATURE OF PHYSICIAN ON SUPPLIER 32 SERVICE FACILITY LOCATION iNFORMATION 33 BILLING PROVIDER INFO PH

INCLUDING DEGREES OR CREDENTIALS

IIccrvlyMeIIIna$atcmentscilrhrlcvclsa MICHIGAN VISITING PHYSICIANS aoplyIoIhsbAendaiemedeapattrheresl.I 25650 OUTER DRIVE RAM GUNABALAN LINCOLN PARK MI 48146-2096 SIGNATURE ON FILE

SIGNED DATE e48414335881tr

NUCC InStrUCtion Manual available 01 wwW.fluCC.Org

2:14-cv-11700-PDB-MJH Doc # 1-14 Filed 04/29/14 Pg 2 of 9 Pg ID 188
2:14-cv-11700-PDB-MJH Doc # 1-14 Filed 04/29/14 Pg 3 of 9 Pg ID 189
HEALTH INSURANCE CLAIM FORM

PcPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE US$5

TTIPICA

STATE FARM INSURANCE

POBOX 2361

BLOOMINGTON IL 61702

MEDICARE MEDICAID TRICARE CHAMPVA GROUP OTt-CR

CHAMPUS t.THPLAN SUcLlxIG.uM0414M D9P0 56N

an INSUREDS 1.0 NUMBER For Pregrem In Item

22005M305

MSUREOS ADDRESS No. SSeeII

teal

Hr Plcatfln ArM Name Maclie InrhaI

PAENV$ ADDRESS Strest

PARENfl çIRTH DATE SEX

PATIDif RELATNSP TO INSURED

ME

OTHER IH$URWS NAME t.aal tJeme1 First NameS Middle IaltI

seIIXpouse ChId OthorQ

it INSUREDS POLICY GROUP OR FECA NUMBER

PAtiENT STATUS

Sine Mactied Duet

FuJlme fl ParI.TImeri

Etnployed L.....J Student L..J Sludent

10.1$ PATiENTS CONDITION RELATED TO

-w OTHER IN$LJRED6 policy OR GROUP NUMBER

--

OTHER INSUREDS DATE OF BIRTH SEX MM DO

fl

EMPLOYMENT Current or Preyrous DYES AUTO ACCIDENT $aJ

DNO

OTHER ACCIDENT

EJNO

lOd RESERVED FOR LOCAL USE

INSUREDS DATE OFBITh

FO EMPLOYERS NAME OR SCHOOL NAME

INSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE

IS THERE ANOTHER HEALTH BENEFIT PUN

DYES__j3NO ltye relurnloerldcornpleleilem9e4

Jr

EMPLOYERS NAME OR SCHOOl NAME

INSURANCE PLAN NAME DR PROGRAM NAME

READ SACK OF FORM BEFORE COMPLETING SIGNING THIS FORM

to process lit claim lao request payment ci government bandits caner to rnyaell onto the party who accepts eslgnment

12 PATIENTS OR AUTHORIZED PERSONS SIGNATURE authorize lIre release of any medlcalor other IrderrnsIIon rceeaery

bb0w

SIGNATURE ON FILE 02/15/11 SIGNED_..._ .__ DATE

INSUREDS 6R AUThORIZED PERSONS SIGNATURE authorize

eerntcea deserted bMw payment ol medIcal benellla to lire undersIgned physician or supplIer for

SIGNATURE ON FILE

SIGNED_____________________

i4.TE CURRENt ILIJESS Rrat symptom OR 115 IF PATiENT HAS HAD SAME 88 SIMII4 ILLNESS

VY INJURY AccIdent OR GIVE FiRST DATE MM

PREGNANCYLMP

it DATESIEt%NABLQ WORK IN

CUtRNT %CUPATI41

FROM TO

17 NAME OP REFERRING PROVIDER OR OTHER SOURCE lit

JAMES SEALS Ji11Lt31693440

It HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

MM1 CD1 YY MM1 DD YY

FROM TO

IS RESERVED FOR LOCAL USE

21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate llama 123cc 410 Ilem 24E by Line

846

L_.._

7291 2.L_

20 OUTSIDE LAB CHARGES

DYESLJHOI 22 MEDICAID RESUBMISSION

CODE ORIGINALREF.NO

23 PRIOR AUTHORIZATION NUMBER

24 DATESOPSERVICE lo PROCEDURESSERVICESOA SUPPliES IN t1 From TO IPLCOF$ Erplein Utsjeuel CIrcumstances DIAGNOSIS RENDERING OR IoY MM DO VY MM 00 VY IBENCEI EMG CPTIHCPCS MODIF1ER Lpowra SONARGESI airs PROVIDER ID.e

01 2014j01ftWj-14 h-ftHm05 ti-H E1H aQFo i.

iI NPI r_ Iii

II lull iI Ii.i1

INPII_____ rn

1111111 Iju III--a---

iii-i

FEDERAL TAX ID NUMBER 5514 IN 23 PATiENTS ACCOUNT NO 21 ACCEPTIGPNT TOTAL CNIJ AMOUNT PAID 30 BALANCE

382264186 PRANA000 2996I.X 1öJ ILJYES LJso js Js

3000

31 SIGNATURE OF PHYSICIAN OR SUPPLIER 32 SERVICE FACILITY LOCATION INFORMAT245354..flhl 33 BILLING PROVIDER INFO PH 1Th86y26848S3 INCLUDIND DEGREES OR CREDENTIALS

Icernllythalthestalenlenlsonthe reverse MEDICAL1 EVALUATIONS PC DR JAN85 SEALS JR MD

eppfr In IbIS NA end are 110110 ir nail lIlereof DR.JAMES BEALE.M.D 17117 WEST NINE MILE ROAD 11111 HALL ROAD SUITE 101

SOUTTIFIELD MI 48076 UTICA MI 48317

02/15111

I-iI_ SIGNED DATE

NUCC IRSIrUCIOR ManUal available at www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-09380899 FORM CMS-1500 08.05

2:14-cv-11700-PDB-MJH Doc # 1-14 Filed 04/29/14 Pg 4 of 9 Pg ID 190
HEALTH INSURANCE CLAIM FORM

APR0VEO DY NATIONAL UNIFORM CLAIM COMMrrrEE 08/05

TI1PICA

STATE FARM INSURANCE

POSOX 2361

BLOOMINGTON IL 61702

PICA flT -aTRICAJIE CHAMrVA GROuP FECA OTHER Ia thSURFDS ID NOMAPS For Program lIars

CHAMPUS HEALTh PLAN ELKILIMS

Sponsors SAN itera SAN or 10 fl SAN ID 2200 SN 306

First Name MiMe Initial

Pt11ENT$IRTh

DATE

MD

IRFfl MMIP sot

fl1me

FIrst Name MiMe lottal

PATIENT RELATIONSHIPTO INSURED INSUREDS ADDRESS 4No Street

SeflDbouseDCuSdQOtherfl

PATIENT STATUS

etD

StudemUSWdentU

zi___________________ FuIke

Name First Name MIMe tOtal 10 Is PATIENTS CONDItION RELATED TO

GROUP NUMBER EMPLOYMENT Currant or Prevbus

DVESDNG BIRTH AUTO ACCIDENT PLACE State

FQ QVES Dt0 L.......J

NAME cOT$ER ACCIDENT

EYES 9No

11 INSUREIYS POLICY GROUP OR FECA NUMBER

INSUREDS DATE OF BIRTH SEX

SIOYERS NAME OR SCHOOL NAME

INSURANCE PLAN NAME OR PROGRAM NAtE

Iii STATE FARM INSURANCE

IS THERE ANOThER HEALTH BENEFIT PLAN

NO__- If yes return to and complele Ilem 9a4

PROGRAM NAME ISO RESERVED FOIl LOCAL USE

OF FORM BEFORE COMPLETING SIGNING ThIS FORM PERSONS SIGNATURE authorIze 11 release tI any medIcal or other rdorrrrauon necessary

psymesl at government banal 115 either to niysa8 or to Ills party who accepts assignment

ON FILE DATE 04/17/11

13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE authodse

payrnenl of nactcal benefits to the undersIgned physlalos or super br

seMees deserted below

SIGNATURE ON FILE

SIGNEO

INURYACCICIGnUOR GIVEFIRSTOATE MM

PREGNANCYLMP

First symptom OR IF PATIENT HAS HAD SAME OR SIMILAILLNESS

OR OTHER SOURCE tm.1

PROM TO

IS DATES NASI.E TO WORK IN CURRENT PATEFJTQ MB CUPATI

18 HOSPITtZATI DATESRELATEO TO CURRENT SERVICES

MB1 Do1 YY

FROM TO

20 OUTSIDE LAS CHARGES

DvESEOI_---.._I ILLNESS OR INJURY Relate Items 23 or to Item 245 by Line

.I

4___

22 MEDICAID RESUBMISSION

CODE ORISINALREFNO

23 PRIOR AUTHORIZATION NUMBER

PROCEDURES SERVICES OR SUPPLIES

IPLCGI Explain UnuttatCtrcurnslancaa IDIASNOSIS

ISEFPACELEMG OPT/HOPOS MODIRER POINTER CHARGES tRAYS an

II RENDERING

oust PROVIDER ID II

iii 99214 I1 isooqi

I0

NPI 1316934409

...__ SI

0-

I.j_

J_______ 1_ I_ L.NPI

lIlt III

J_

NPI

NFl

SAN EIN 28 PATIENTS ACCOUNT NO 127 ACCEPT ASSIGNMENT

cenit daaee seem

ttj PRAMA000 31EcLPES L.J

SUPPLIER 3t SERVICE FACIUTYLOCAT1ON

CREDENTIALS INFORMATK4S3M liii

P4EDICPj EVALUATIONS PC

17117 WEST NINE MILE ROAD

SOUTIIPIELD 141 48076

04/17/11 DATE

28 TOTAL CHARGE 129 AMOUNT PAID Iso BALANCE DUE

150.00J 15000

EILLVIGPRDVIDER INFO PH 5862684833

DR JAMES BEALE JR MD

11111 BALL ROAD SUITE 101

UTICA MI 48317

1316934409 lb

62

NUCC InStruCtion ManUal available at WWW.nUCC.Org PLEASE PRFNT OR TYPE APPROVED OMB-0938OSS FORM OalS-1 500 08-05

2:14-cv-11700-PDB-MJH Doc # 1-14 Filed 04/29/14 Pg 5 of 9 Pg ID 191
HEALTH INSURANCE CLAIM FORM

PPPROVED BY NATIONAL UNIFORM CLAiM COMMITTEE 08/05

PCA

PROCEDURES SERVICES OR SUPPLIES

lutE CI Explan Unusual Circumstances DIAGNOSIS

JRa1.g.G LCPTmHCPC$ MODIFIER

1709 111 99205 23

p9 1409 E1 j_ 99214 F23 1...

22 w.EoCAD RESUBMISSIDN

CODE ORIGINAl REF NO

23 PRIOR AU11-IORIZATION NUMBER

F- I-I

ID RENDER1NG

CHARGES L\DSJ2 DAjQ_ PROVIDER ID L__

_..I jNPII

___i Li NP1

._I fN

LEEDERAL TAX NUMBER 55W EN

264300636 UfJ 31 SIGNATURE OF PHYSICIAN OR SUPPLIER

26 PATIENTS ACCOUNT NO 27 CCEPT.ASSIONENT

CAMLA000 431f.tflN 32 SERVICE FACILIfl LOCATION INFORMATION

3-

JNPI

28 TOTAL CHARGE 29 A.ICUNT PAID 30 BALANCE DUE

500.00 500.00

33 BILUNG PROVIDER INFO PH Z49 35ZT1T1

MEDICAL EVALUATIONS P.c

20411 TWELVE MILE ROAD 103

SOUTHFIELDS MI 48076

G2

IXCLUDNO DEGREES OH CREDENTIALS

eerily tat tam ctticrrcnts en tim raveree

10123/09

EGNED DATE

STATE FARM INSURANNE

FOBOX 2361

BLOOMINGTON IL 61702

PICA

TRICARE CHAMPVA GROUP FECA OTHER

CHAMPUS HEALTh PLAN ELK LU.t

Sponsors SSN SSNor /0 ID

Ia INSURED SIC NUEER For Praqrnm in 11cm 14

22 019 145

Narmis MSe tmttzi4 PAll ENTFI El NTH DATE SEX

IM Fal PATIENT RELAT1ONSHIP TO INSURED

scj Spoirre Cl- ilEl otcrfl

4INSUREDS 4AE 1. -c I.titclmm InJI

7INSUREDS ADDRESS INn Street

PATIENT STATUS

Siagle Marnnd Other

Fu.Tmnc PtrtTana

Emnp.oyed Stuminni SLidmnI

Name FIrst Name MlddIe Initial 10 IS PATIENTS CONDITION RELATED TO 11 INSU REDS POLICY GROUP OR FECA NUMBER

GROUP NUMBER EMPLOYMENT Current or Prev.oti

UYES rnNo

$EX AUTO ACCIDENT PLACE State

MU FEt UNO

NAME OThER ACCIDENT

YES ftNO

Ui

NSURED DATE OF BIRTh SEX

EMPLOYER NAII.E OR SCHOOL NAME

INSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANNE

PROGRAM NAME lCd RESERVED FOR LOEAL USE IS THERE ANOTHER I-IEALTH BENEFIT PLAN

YES NO if yea return to end complete tern 9-d

OF FORM BEFORE COMPLETING SIONINO THIS FORM 13 INSUREDS OR AUThORIZED PERSONS SiGNATURE authoaze

PERSON SIGNATURE authorize Il-a rclraic at en-j mi-mi cat Cr ether nt1armramton ncccaary

payment ol government bemletta either to niysei or to the party who accepts ascrgnrncrit

payment of rcadzal benefits tote underagned ptiyracr.ia or Supp.er Ion

cerareca dracraed below

ON FILE 10/23/09 SIGNATURE ON FILE

DATE

.--. SIGNED

16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

ELI DO YY MM CD YY

FROM TO

First yrnptorn OR 15 IF PATiENT HAS NAO SAME OR SiMILAR ILLN ESS

INJURYAce1deat GIVEFIRSTOATE MEt 01 YY

PREGNANCYLM4NJURY

OROTHER SOURCE 17T

17SINPIT

18 HOSPITALIZATION DATESRELATEDTOCURRENTSERVICES LILt CD YY MM DO is

FROM TO

20 OUTSIDE LAB CHARGES

UYESE1NO 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items 1.2.3 or 410 Item 24E by Late

.723_4 ______ 796

2.00_9 ______ _______ _____

24 DATES OF SERVICE

From To

MM DC YY MM DO

PS 08 17 09

209 14 09

.1

2000011 JNP

C/

NUCC nSWCion Manua available at www.nUcC.Org PLEASE PFIINT OR TYPE APPROVED OWB-0938.0999 FORM CMS-1500 08-05

2:14-cv-11700-PDB-MJH Doc # 1-14 Filed 04/29/14 Pg 6 of 9 Pg ID 192
1500

HEALTH INSURANCE CLAIM FORM

REPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE QH/05

r T T pica

STATE FARM INSURANCE 

POBOX 2 3 6 1

BLOOMINGTON I L 6 1 7 0 2 - 9 7 3 8

pic a (

CHAMPVA GROUP FECA

 i---- 1 CHAMPUS ,— , r-~ l HEALTH PLAN r— 1 B1KLUNG r v -,

(Medicare * )__(Med&itd 0) (Sponsor's SSN) QJ (Member tDft) F J ($SN or 10) r j (SSN) [Xj (ID)

1 MEDICARE MEDICAID TRICARE 

, CHAMPUS

1a INSURED'S I.D. NUMBER

22012N185

(For Program in Item 1)

2 f’A l l E t r r s , ^ Middle Initial) 3 £ATI6N33SiB(HniDA.1I E

L o

SEX

£ L

4. jN.S.UHED’.S ..^ Middle India!)

5 PATIENTS ADDRESS (No , Street} 6 PATIENT RELATIONSHIP TO INSURED

XT

7. JDD8ES.S,iNo,-Sltafttl

8. PATIENT STATUS

Single □ Married □

dD

o,her EZJ

 Fuel-Time |— | Part-Time 

_________ Student I___| Student |___|

9 OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)

0. OTHER INSURED'S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH 

MM , DO , YY

c. EMPLOYER'S NAME OR SCHOOL NAME

MP f D

10 IS PATIENTS CONDITION RELATED TO 

a, EMPLOYMENT? (Current or Previous)

PLACE (State) 

I______ ,

11 INSURED’S POLICY GROUP OR FECA NUMBER

□ YES □ no

b AUTO ACCIDENT?

[x * |y es □ no

C. OTHER ACCIDENT?

y e s QZ

o

a INSURED'S DATE OF BIRTH ^

< □ riO

b. EMPLOYER'S NAME OR SCHOOL NAME

c. INSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE

d INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d IS THERE ANOTHER HEALTH BENEFIT PLAN?

[ [ y e s | NO tfyes. return to and complete Hem 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.

12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I oulhonio the release o! any medical or other Information necessary 

to process this claim. I also request payment of govomment benefits either to mysell or to the parly who accepts assignment 

below

SIGNED,

SIGNATURE ON F IL E

DATE

0 5 /1 8 /1 1

13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I aulhodze 

payment of med.cal bonetits to the undersigned physician or supplier lor 

6enncee described below.

SIGNATURE ON F IL E

1A DATE OF CURRENT: A ILLNESS (First symptom) OR

04' 0 6 ° 2 0 I t <1 INJURY (Accident) OR 

! N PREGNANCY(LMP)

15. IP PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 

GIVE FIRST DATE MM , DD . YY

16. DATES PATIENT ABLE T£> WORK IN CURRENT OCCUPATION 

FROM > TO ' |

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 16. HOSPITALIZATION DATES REIATEO TO CURRENT SERVICES 

MM , OD YY MM , 0 0 , YY

FROM ! ; TO ; J ________

19, RESERVED FOR LOCAL USE 20 OUTSIDE LAB? t CHARGES

□ y e s 0 N O

21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1 ,2, 3 of 4 to Item 24E by Line)

, 8 4 7 0____ | 719 41____ 1

22. MEDICAID RESUBMISSION 

CODE . ORIGINAL REF. NO

2. L

846 9

24. A DATE(S) OF SERVICE 

From To

MM DD YY MM DD

4 L

784 0

23. PRIOR AUTHORIZATION NUMBER

YY

B.

PlACEOf

SERVICE

c

EMG

D. PROCEDURES, SERVICES, OR SUPPLIES 

(Explain Unusual Circumstances) 

CPT/HCPCS I MOOIFIER

E,

DIAGNOSIS

POINTER

F

$ CHARGES

G.

DAYS

Qfl

UNITS

99205 | ; j ; 1 2 3 4 3 0 0 00 l

K

EPSOT

Ferity

Pfc*

-l'G'

RENDERING 

PROVIDER ID «

NPI 1 1 4 4 4 2 9 7 6 2

NPI

NPI

FJ5 FFDERAI TAX I.D n u m b e r

260594435

31. SIGNATURE OF PHYSICIAN OR SUPPLIER 

INCLUDING DEGREES OR CREDENTIALS 

(i certify thai the statements on the reverse

s ’e t l n ' ' h o b a n ' ^ d ® m °">,e0' 1

0 5 /1 8 /1 1

SSN EIN I 26 PATIENTS ACCOUNT NO. ' 27, ACCEPT ASSIGNMENT?

r—Df—. WILHA000 647

□ l J _________________________________\ Z \ m

28 TOTAL CHARGE

„ 3 0 0 , 0 0

! 3 2 SERVICE FACILITY LOCATION IN ('810.) 2<3 2 - 980 0 

iMUNDY PAIN CLINIC PC 

6240 RASHELLE DRIVE SUITE 103 

FLINT MI 48507

29 AMOUNT PAID

S

30 BALANCE DUE

„ 3 0 0 . 0 0

SIGNED DATE

33 BILLING PROVIDER INFO & PH # ^ 86 J 68 4 83 3

MUNDY PAIN CLINIC P.C .

6240 RASHELLE DRIVE SUITE 103 

FLINT, MI 48507 

TT4 4-429762—

NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE APPROVED OMEt-0938-0999 FORM CMS-1500 (06-05)

PHYSICIAN OR SUPPLIER INFORMATION ------------------------------------------M -<------------------ PATIENT AND INSURED INFORMATION CARRIER

2:14-cv-11700-PDB-MJH Doc # 1-14 Filed 04/29/14 Pg 7 of 9 Pg ID 193
1500

HEALTH INSURANCE CLAIR/} FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

_____________

STATE FARM INSURANCE 

POBOX 2361

BLOOMINGTON IL 6 1 7 0 2 - 9 7 3 8

t

DC

Ui

DC

OC

<

o

PICA' n n l

1. MEDICARE MEDICAID OTHERTRICARE CHAMPVA GROUP FECA

. , t-----| (J ,i— | CHAW PUS |-----, |-----, HEALTH PLAN, , BU<.UNG p— r

(Medicare *)\___(Medicaid * | (Sponsor's SSN) ^ (Member £») (SSN or IQ) (SSN) |X |flD )

la, INSURED’S 1,0. NUMBER

22B094111

{For Program hi Item 1) A

2 PATIENTS NAME (Last Name. First Name, Middle Initial)

5. PATIENTS ADDRESS (No,, Street)

S o H p ^ Spouse[ | Childf | Other] |

CITY S PATIENT STATUS CT

ZIPC

Single | | Married | | Other [ |

ZIF

-

I— | Full-Time |— | Part-Time |— i 

Employed |__ | student L I Sludent I___ I

3. R^TI.EMT.SjRLRTM.O.A

J Q

SEX

6. PATIENT RELATIONSHIP TO INSURED

lE L

LURED:aNAJMEXLas!.Nexne...,Rrst Name, Middle Initial)

7 INSUREDS ADDRESS (No ., Street)

9. OTHER tN$UR£D*S NAME (Last Name, First Name, Middle Initial)

a. OTHER INSUREDS POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH 

MM t DD ( YY

_L_

c EMPLOYER'S NAME OR SCHOOL NAME

SEX

o D ____£ L

10. IS PATIENTS CONDITION RELATED TO:

a. EMPLOYMENT? (Current or Previous)

□ y e s [ ^ N O

b. AUTO ACCIDENT?

Q y es

c. OTHER ACCIDENT?

Q yES f * ] N O

11. INSUREDS POLICY GROUP OR FECA NUMBER

a. INSURED’S DATE OF BIRTH

M

□ C D

PLACE (State) 

NO , ,

b, EMPLOYER'S NAME OR SCHOOL NAME

c INSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE

d. INSURANCE PLAN NAME OR PROGRAM NAME 106. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

□ YES T l N O ti yes, return to and complete Item 9 a-d

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.

12 PATIENT'S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other Information necessary 

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment 

below,

SIGNED _ SIGNATURE ON FILE

DATE 0 4 /2 4 /1 1

13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 

payment of medical benefits to the undersigned physidan or supplier for 

services described below,

SIGNATURE ON FILE

1 A, DATE OF CURRENT: A ILLNESS (Ffrst symptom) OR

m ! D f P if ) < INJURY (Accident) OR 

U i N PREGNANCY(LMP)

(5. JJ= PATIENT HAS HAD SAME OR SIMILAR ILLNESS 

GIVE FIRST DATE MM I DD I YY

16, DATES PATIENT^NABLE Tp WORK IN CURRENT OCCUPATION 

FROM I ! TO | |

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

17b. NPI

10, HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 

MM , DD , YY MM , DO , YY

FROM | I_______________TO I I

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB?

| | YES □ NO

$ CHARGES

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1 .2 .3 or 4 to Item 24E by Une)

I. L 723 4 718 81 1

22. Mgg^AIO RESUBMISSION ORIGINAL REF. NO.

Z L

847 9

23. PRIOR AUTHORIZATION NUMBER

24 A DATE(S) OF SERVICE B C. D. PROCEDURES, SERVICES, OR SUPPLIES e. F g’

From To puceof (Explain Unusual Circumstances) DIAGNOSIS OR MM 0 0 YY MM 0 0 YY SERVICE EMG CPT/HCPCS 1 MODIFIER POINTER $ CHARGES UNITS

ID

DUAL

— r

RENDERING 

PROVIDER ID. If

03! 1 5 i l l

_____ i _ ......

03 15 11 1 1 99214 1 2 3 150 100 | 1 NPI

J___ I

J__ L

NPI

25. FEDERAL TAX 1 D NUMBER SSN EIN

260594435

26. PATIENTS ACCOUNT NO | 27. £ C C E P 1 ^ G N g ^ T * '

MORLEOOO 5 1 7 | P ] yes Q no

28 TOTAL CHARGE

$ 150 .|00

29 AMOUNT PAID 30. BALANCE DUE

s j * 1 5 0 . pO

31. SIGNATURE OF PHYSICIAN OR SUPPLIER 

INCLUDING DEGREES OR CREDENTIALS 

<1 certify that the statements on (he reverse 

apply to this bill and are made a Bait thereof.)

SEAN HOBAN M.D

0 4 /2 4 /1 1

SIGNED DATE

32. SERVICE FACILITY LOCATION I N F q r g ^ ip g 3 2 - 9 8 0 0

MUNDY PAIN CLINIC PC

6240 RASHELLE DRIVE SUITE 103

FLINT MI 48507

33 BILLING PROVIDER INFO& PH 4 ^ > 8 6 4 8 0 0 

MUNDY P A I N C L I N I C P . C .

6240 RASHELLE DRIVE SUITE 103 

FLINT, MI 48507

a jb. a b.

NUCC Instruction Manual available at: www.nucc.org

t

PLEASE PRINT OR TYPE APPROVED OMB-0938-0999 FORM CMS-1500 (08-05)

2:14-cv-11700-PDB-MJH Doc # 1-14 Filed 04/29/14 Pg 8 of 9 Pg ID 194
HEALTH INSURANCE CLAIM FORM

a f F r o v e d b y n a t io n a l u n if o r m c la im c o m m itte e a m s

•p P IC A

(1500)

STATE FARM INSURANCE 

POBOX 2361

BLOOMINGTON I L 6 1 7 0 2 - 9 7 3 8

PICA

t

cc

UJ

£

cc

<

o

n o t

I MEDICARE MEDICAID TRICARE _

h— I , . , _ I 1 r— i CHAMPUS ,— , , .HEALTH PLAN i— , BLK LUNG r t n

(Medicare *) jMedicatd #j | | (Sponsor's SSN) \ \ (Member/D#J (SSN or ID) \ j (SSN) [ X ] (iq)

CHAMPVA GROUP OTHER Is. INSURED'S I D NUMBER

22012N185

(For Program in Item 1)

2. kiifoal)

5.

ZIP

3. PABM S.JIBXH..QAIE. SEX

i........................ J " D > a

4. (NSUHED:SNAMEi,toNaroa.XiiSLNaij«. Middla Initial)

S. PATIENT RELATIONSHIP TO INSURED 

S e w f^ l Spousej I Cnidj I Ollier I j

lNSUBER'S.A.DDB.E3S.ma.,JML

8. PATIENT st a t u s

Single □ Married | | Other | |

_ I— | Fuli-Timai— i Pan-TImei— i

Employed | | studani | | Sludent I I

9 OTHER INSURED'S NAME (Last Name, First Name, Middle Inlfial) 10. IS PATIENT’S CONDITION RELATED TO' 11 INSURED'S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED'S POLICY OR GROUP NUMBER

b. OTHER INSURED'S DATE OF BIRTH Qry 

MM DD . YY , SEX

_ ... i ! I « n

T1

C EMPLOYER’S NAME OR SCHOOL NAME

d INSURANCE PLAN NAME OR PROGRAM NAME

a EMPLOYMENT? (Current or Previous) 

I 1YES □ NO

a INSUREOS^,AIESL.B)MH sex

L.... . . . . . j 0 * □

b, AUTO ACCIDENT? PLACE (State) b. EMPLOYER’S NAME OR SCHOOL NAME

| ^ J y es □ N0 i______i

c OTHER ACCIDENT?

□ y es lx> °

c. INSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE

lOd. RESERVED FOR LOCAL USE d IS THERE ANOTHER HEALTH BENEFIT PLAN?

□ y e s ^ Q n o II yea . return to and complete item 9 a-d.

HfcAU HACK UF FORM BEFORE COMPLETING & SIGNING THIS FORM.

12. PATIENTS OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other Information necessary 

to process this claim. I also request paymont of government benefits either to myself or to the party who accepts assignment 

below

SIGNATURE ON FILE

13, INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 

payment of medical benefits to the undersigned physician or supplier for 

services described below

SIGNED. DATE.

0 6 /2 7 /1 1 SIGNATURE ON FILE

SIGNED

14. DATE OF CURRENT A

m04; Or6(20vLrl \

ILLNESS (First symptom) OR 

INJURY (Accident) OR 

PREGNANCY(LMP)

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 

GIVE FIRST DATE MM I OD i YY

16 DATES f^TfENT UNABLE T<? W0RK tN CU mmEWT DO UPAT,?Y

FROM ------ 1 ? TO I I

-L17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 1B HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 

M M, OD , YY MM { DO , YY

FROM I I TO I

• J ------------

19. RESERVED FOR LOCAL USE 20. OUTSiOE LAB?

□ y e s Q n o

$ CHARGES

21 - DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1. 2 .3 or 4 to Item 24E by Line)

1,1___ 9 4 7 0 n | 719 41 1

22, Wgg^AIO RESUBMISSION

ORIGINAL REF. NO

846 9

23 PRIOR AUTHORIZATION NUMBER

784 0

24, A. DATE(S) OF SERVICE C, D. PROCEDURES. SERVICES, OR SUPPLIES 1 E. F. G.

From To PLACE Of (Explain Unusual Circumstances) DIAGNOSIS

MM DD YY MM DD YY ISSHYCE EMG CPTyHCPCS 1 MODIFIER ! POINTER S CHAF1GE3 urars

Ftmty

Pan

06j 02 jll 06 jO2 l l 11 99213 112 34 100 00

10.

(XML

~ n r

NPI

J.

RENDERING 

PROVIDER ID #

! I I

NPJ

25. FEDERAL TAX I.D. NUMBER

260594435

SSN EIN

□0

26. PATIENTS ACCOUNT NO.

WILHA0O0 752 □ y e s Q NO

28. TOTAL CHARGE

s 1 0 0 . 0 0

2fl. AMOUNT PAID

.

S

30. BALANCE DUE

* 100.00

31. SIGNATURE OF PHYSICIAN OR SUPPLIER f t s t t

INCLUDING DEGREES OR CREDENTIALS 

(I eaitdy that Uw •latomanti on the revarso 

apply to thla bD and ora made a pad thereof.)

MARTIN QUIROGA D.O.

0 6 /2 7 /1 1

32, SERVICE FACILITY LOCATION 2 - 9 8 0 0

MUNDY PAIN CLINIC PC

6240 RASHELLE DRIVE SUITE 103

FLINT MI 48507

33. BILUNG PROVIDER INFO a PH If 6

MUNDY PAIN CLINIC P.C.

6240 RASHELLE DRIVE SUITE 103 

FLINT, MI 48507

SIGNED DATE

NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-0938-0999 FORM CMS-1500 (08-05)

2:14-cv-11700-PDB-MJH Doc # 1-14 Filed 04/29/14 Pg 9 of 9 Pg ID 195