Exhibit 28

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 1 of 28 Pg ID 313
NUCC Inatnictlon Manual available at www.nucc.org

WCMS-1 500CS

STATE FARM INSURANCE

r.o Box 2361

BLOOMINGTON IL 61702

HEALTH INSURANCE CLAIM FORM

4PPROVED BY NATiONAL UNIFORM CLAIM COMMITIEE 08/05

T11Pt PICA rfi fl MEDICARE MEDICAID TRICARE CHAMPvA GROUP FECA OTHER is INSUREOS l.a NUMBER For Program In Item

CHAMPUS HEALTH PLAN ELK LUNG

MedkAres SponscflSSN EM.IDSEIiSNottD ESSM 22C415636 --

PATiES NAME ikemó First Nuns Mtofl IntosO PATIENTS BIRTh DATE SEX INSUREDS NAME st Name Firm Name Middle Iclual uti nfl vv IMIXFCl PATIENTS ADDRESS No Street PATIENT RELATIONSiIIPTO INSURED INSUREDS ADDRESS No Street

Sejf1use CItd other

PATIENT STATUS

singieE Married Other

ER INSUREDS NAME Uame

ErrJfl StodeM Stodenl

Full-TIme jfl Part.Ttrner

IL

Mcli Inhlal 10 IS PATIENTS CONDITION RELATED TO 11 INSUREDS POLICY GROUP OR FECA NUMBER

OTHER INSUREDS POLICY OR GROUP NUMBER EMPLOYMENT Current or Previous INSUREDS DATE OF BIRTh SEX it

Ia

flYES FEJ OTHER INSUREDS DATE OF BIRTH SEX AUTO ACCIDENT PLACE State EMPLOYERS NAME OR SCHOOL NAME

MM1 DD1 YY

FE END LMJ EMPLOYERS NAME OR SCHOOL NAME DNER ACCIDENT INSURANCE PLAN NAME OR PROGRAM NAME

flYES STATE FARM INSURANCE

INSURANCE PLAN NAME OR PROGRAM NAME lOd RESERVED FOR LOCAL USE IS ThERE ANOTHER1IEALIWBENERT PCAN aEYES__kI NO tt return to end complete item a-cl

READ BACK OF FORM BEFORE COMPLETING SIGNING This FORM 13 INSUREDTbR AUTHORIZED PERSONS SIGNATURE authorize

12 PATIENTS OR AORIZED PERSONS SIGNATURE authothe the release ci eny mestoal or other Infoadon necessa peenI ci medIcal beneibs to the undegned phtoIan or eIer lot

to process this claim elso request paprrant ol government benefits either to myseil or to the party wiro accepts assignment services described below

below

SIGNED SIGNATURE ON FILE DATE 02/25/11 SIGNED SIGNTPE_QN FILE

14 DATE OF CURRENT IU.NESS first symptom OR ItS IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS

MM1 DD YY IIvAoR GIVEF1RSTDATE MM1 OD YY

10 PREGNNCYLMP_INJuRY

11 NAME DF REFERRING PROVIDER OR OTHER SOURCE na

SAUL WEINGARDEN t1ThtPi 1760459994

19 RESERVED FOR LOCAL USE

16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

MM1 DD1 MM1 DD1 YY

FROM TO

18 NOSPITALIZATtON DATES RELATED TO CURRENT SERVICES

MMi ODu YY MM1 DD YY

FROM TO

20 OUTSIDE LAB CHARGES

21 DIAGNOSIS OR NATURE OF ILlNESS OR INJURY Relate Items 123 cr4 to1imiE bjUrii

47...0..

zd-iIQ-2- 4.L._

JJYES Ek 22 MEDICAID RESUBMISSION

CODE ORIGINAL REF NO

23 PRIOR AUTHORIZATION NUMBER

From To tRACE ccl Explain Unuousl Circumstances DIAGNOSIS DAYS kreo ID RENDERING

24 DATES OF SERVICE PROCEDURES SERVICES OR SUPPLIES

MM DO YY MM DD vv SERYCE EMIl MODIFIER _ppjgR CHARGES Fpm DUAL PROVIDER ID

12 10 10 12 10 10 GO 12 225.00 MEGANRVTLEDG. 11 97003

i._L If1J

12 10 10 12 10 10 11 97535 GO 12 70.0

.4EGAftVILPi3._ NPII

12 10 10 12 10 10 11 97110 GO1 12 75.00

NPI

fin

12 10 10 12 10 10 11 97140 GO1 12 65.00 .GAN.RUTLEDGE it

NPII

12 iq 10 12 10 10 11 97014 GO 12

25 FEDERAL TAX ID NUMBER 55K ElM 26 PATIENTS ACCOUNT NO 127 ACCEPT ASSIGNMENT

IFagtwtansoetsc3

271033080 EE CHAJ0000 1286 END 31 SIGNATURE OF PHYSICIAN OR SUPPLIER ERtEAIClLITV1OCATION INFORMATION

INCLUDING DEGREES OR CREDENTIALS POINTE PHYSICAL THERAPY Icertllythatthostatememtsonthareveme

55.00 ......ttjEGAN.RUTLEDGE..

NPII

28 TOTAL CHARGE 29 AMOUNT PAID 133 BAL.AX4CE DUE

550L0QJ$ 550.00

33 BlUiNG PROVIDER INFO PH 5867745006

POINTE PHYSICAL THERAPY epplytothlabtflandarenladeapartthereol

02/25/It

MEGAN RUTLEDGE OWDATE

17200 E.1O MILE RD

ERSTPOINTE MI 48021

17200 10 MILE SUITE 165

EASTPOINTE MI 48021

154107 lb

12 10 10 12 10 10 11 970351

GO 12 60.00

i._i

..MEGANRUTLEDGE.

--

Arrrnjvttj 0MB 0938-0999 FORM CMS-1 500 06/05

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 2 of 28 Pg ID 314
STATE FARM INSURANCE

P.O BOX 2361

BLOOMINGTON IL 61702

HEALTH INSURANCE CLAIM FORM

PROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 0805

Til PICA PICA

MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER is INSUREDS ID NUMBER For Program In Item

CHAMPUS HEALTH PLAN BLI LUNG

flMecuceaiI flspoouoeessN DjMemLwlDstfltssNorlo 1SSN4I b0 22c4 15636

PATIENTS NAME I.asI Name Fit Name Mldde ISis PATiENTS BIRTh OATS SEX INSUREDS NAME tat Name Riot Nams MIddle InIIIe

IM PATIENVS ADDRESS No SIres PATIENT RELATIONSHIP TO INSURED INSUREDS ADDRESS No Street

SeIf spouse Chldfl ottier

PATIENT STATUS

Emoyed Stedi StodenI

Mated fl otherfl

FuII.TIme fl Part-TIme r1

OilIER INSUREDS NAME Last Name FIrst Name Middle InIllel 10 IS PATIENTS CONDITION RELATED TO 11 INSUREDS POLICY GROUP OR FECA NUMBER

OThER INSUREDS POLICY OR GROUP NUMBER EMPLOYMENT Current or Previous

Ui

OTHER INSUREDS DATE OF BIRTH SEX

EYES RNO rIfI.orno

nsn SEX

AUTO ACCIDENT PLACE Slate EMPLOYERS NAME OR SCHOOL NAME

MM1D01 YY

ME ENO LMI

EMPLOYERS NAME OR SCHOOL NAME OThER ACCIDENT INSURANCE PLAN NAME OR PROGRAM NAME

EYES STATE FARM INSURANCE

INSURANCE PLAN NAME OR1ROGRAM NAME iod RESERVED FOR LOCAL USE IS THERE ANOTHER HEALTH BENEFIT PLAN

YES NO READ BACK OF FORM BEFOPE COMPLETlNu SIGNING ThIs FORM 13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE euthorlue

to procees thle claim also request payment of government benellti sIllier to myself or 10 the petty who accepts esslgnmenl servlcee deecilbed botow

12 PATIENTS OR AUTHORIZED PERSOWS SIGNATURE eodzs the release Of any midlas or other InloaUon necessity parent of medIcal beneflle to the undersIgned phIaian or apIIer br

below

SIGNED

SIGNATURE ON FILE DATE02/25/11 SIGNEDSIGNATURE ON FILE

14 DATE OF CURRENT ILLNESS First evmptorrr OR 15 IF PA1IfWHAä HAD SAME OR SIMILAR ILI.NESS 16 DATES PAI1ENT UNABLE TO WORK IN CURRENT OCCUPATION

MM 00 Ti INJURYAcclderitOR GIVE FIRSTDATE MM DO YY MM1 DD1 YY MM1 DD YY

lii 08 10 PREGNANCYUIP INJUR FROM TO

17 NAME OF REFERRING PRO V1DER OR OThER SOURCE IS HOSPITAliZATION DATES RELATED TO CURRENT SERViCES

SAUL WEINGARDEN ri6o MMi DDj MM1 DO 459994 FROM TO

19 RESERVED FOR LOCAL USE k.oUfi5iLkB CHARGES

DIAGNOSIS OR NATURE OF 1LLNESS OR INJURY Relele Items 123 or 410 Item 24E by LIne

aL__

2.L..iP9 4.L......_.___.._

EYESLk4OI 22 MEDICAID IRESUBMISSION

CODE ORIGINAL REF NO

23 PRIOR AUTHORIZATION NUMBER

24 DATES OF SERViCE PROCEDURES SERVICES OR SUPPUES

From To PUCE OF EIIakI UnIsusI stancea DIAGNOSIS OS Ig ID RENDERING

MM DO VY MM DO YY SERVICE EMO CPTMCPCS MODIFIER POINTER CHARGES ea GUALJ PROVIDER ID

12 10 10 1Q 10 11 97010 GO 12 55.00 MEGIONRUTLEDGE il _NPIl

121i10 12 17 10 11 97010 GO 12 55.00 RUThEDGE

III

12 10 12 17 10 11 97014 GO1 12 55700 MEGANRUTLEDGE U_I

12 10 12 17 10 11 97035 GO 12 60.60 tERUTLEDGE IIIIiI 1f 12 17 10 12 17 10 11 7140 GO1 65.00 MEGJRUTLEDGE LT4IEGAN RUTLEDGE 12 171 10 12 17 10 11 97110 GO 12 75.00 iT 25 FEOEAKL TAX 10 NUMBER SEN EIN 26 PATIENTS ACCOUNT NO 177 ACCEPT ASSIGNMENT 28 TOTAL CHARGE 29 AJIIOUNT PAID 130 BALANCE DUE

qowt deans see ben

27-1033080 CHAJ0000 12863c55 flio 36500I$ 365100

31 SIGNATURE OF PHYSICIAN OR SUPPUER 32SERVICEFACILIfl LOCATION INFORMATION 343 BIWNG PRDV1DhR INFO PH

INCLUDING DEGREES OR CREOENTIAI.S POINTE PHYS ICAL THERAPY lcertlfythstthststarnenteonthsreveree POINTE PHYSICAL TIERAY

epgtywdttiQIeasecrflapasithereot 17200 E.10 MILE RD 17200 10 MILE SUITE 165 02/25/li

EASTPOINTE MI 48021 EASTPOINTE MI 48021 MEGAN RUTLEDGE OTR T28sg54To7 SIGNED DAlE

NUCC InStr CtIDR ManUal aVallablo at www.nucc.org

WCMSi 500CS

nrrnjvcU 0MB 0938-0999 FORM CMSI500 DB/O5

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 3 of 28 Pg ID 315
STATE FARM INSURANCE

P.O BOX 2361

BLOOMINGTON IL 61702

15003

HEALTH INSURANCE CLAIM FORM

IROVED BY NATiONAl UNIFORM CLAIM COMMITTEE OV5

TT1 PICA PICA flf

MEDICARE MEDIAFO täThARE CHAMP VA GROUP FECA OThER

CHAMPUS HEALTH P1-AN ELK LUNG

.cScamflM.caW4i fltSPCnaOiI8SNI flMsrnbv1osssNorlo fl$SN

PATiENTS NAME Last Name First Name Middle Initial PATIENTS BIRTH DATE SEX

ATIENTS AISDREäS iNjjijjij PATIENT RELATIONSHIP

IMTO INSURED

It INS REDS TO NUMBER For Program In Item

22C4 15636

INSUREDS NAME Last Name Fit Name MIdd Initial

Y5UREDSADORESS No Street

8pOUee Child Other

PATIENT STATUS

singleE MamedE otharD

OTHER INSUREDS NAME tail Name First Name Middle inIttiQ

OTHER INSUREDS POLICY OR GROUP NUMBER

Full-Time Part-Time

Enwloyed Student Student

10 IPATIENTS CONDITION RELATED TO

EMPLOYMENT Current or Previous

EYES

AUTO ACCIDENT PLACE State

EYES ELMJ OTHER ACCIDENT

EYES

10d RESERVED FOR LOCAL USE

11 INSUREDS POLICY GROUP OR FECA NUMBER

INSUREDWOATEOfBIRTH SEX

OThER bEMPEOSER8 NAME OR SCHOOL NAME

INSUREO%ATEOF bIRTH SEX

LMLLFD CEMPLOYERS NAME OR SCHOOL NAME INSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE

ti IS THERE ANOTHER HEALTH BENEFIT PLAN

EYES 5J NO yea return to and complete item

INSURANCE PLAN NAME OR PROGRAM NAME

READ SACK OP FORM BEFORE COMPLETINI 5IGNINQtNISFORM

12 PATIENTS OR AUTHORIZED PERSONS SIGNATURE authorIze the release of

any medical or ether Information necesaary

to process this claim also request payment of government benefits either to myselt or to the party wtro accepts assIgnment

below

SIGNED

SIGNATURE ON FILE DATE02/25/11

ItINSUREDS OR AUTHORIZED PERBONWB authorize

payment of medical benefits to the undersigned physician or supplier for

services deacdbed below

WGNED SIGNATURE ON FILE

16 DATES PATIENT UNABLE TO WORK IN CUR1tENT OCCUPATION

MM DC YY MM DO1 YY

FROM TO

18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

FROM

MM YY

TO

MM OD VY

20 OUTSIDE LAS CHARGES

14 DATE OF CURRENT ILLNESS IFirat avmotom OR 15 IF PATIENT HARAbBAMOWStMiLAFfiLLNE5S

MM DO YY iNJURY AcddentOA GiVEFIRSTDATE MM DO YY

11 08 10 PREGNANCYLMP INJURY

It NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a

SAUL WEINGARDEN 176045999

10 RESERVED FOR LOCAL USE

at DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate hems 1.23 or to item 24E by LIne

._ 2H 4.L--.

22 MEDICAID RESUBMISSION

CODE ORIGINAL REF NO

23 PRIOR AUTHORIZATION NUMBER

24 DATES OF SERVICE PROCEDURES SERVICES OR SUPPLIES GTTH From To Iuco Explain Unusual Circumstances DIAGNOSIS tt%s IRT ID RENDERING

MM PP Vi MM PD YY SERCE EMG CPTIHEPCS MOPIFER POINTER CHARGES u1rra OUAL PROVIDER ID

12 10 10 12 10 10 11 97001 G9 225.00 MANASBAS III_ I_L.

12 10 10 12 10 10 97010 Gp 55.00 .___.LvtL.AS Iii II

12 17 10 17 10 14 97010 GF 5500 Ill .I...........i.i

12 17 10 12 17 10 11 97014 55.00

I_

12 17 10 12 17 10 11 97035 GF 60.00 III .1 l..__.._____

12 17 10 12 17 10 11 97140 65.00 ..MNAS.BASTh1...

26 FEDERAL TAX ID NUMBER SSN FiN 26 PATIENTS ACCOUNT NO 21 ACCEPT IGNME 28 TOTACARGE 29 AMLjjWk.O 3D BAt.ANCENJE

271033080 CHAJ0000 12851 515

ools

.i J1515400 31 SIGNATURE OP PHYSICIAN OR SUFF ER WSERVICflAC1DTVIeATTON1NFOR liON 33 BILUNffPROVIDER INFO PH 1586 745006 INCLUDiNGDEGREESORCREDENT1ALS POINTE PHYSICAL THERAPY Ioeitfythattheetaiemantaonthezsvarae POINTE PHYSICAL ERA

apgtyrothlabtiandaremadasportthoreof 17200 E.10 MILE RD 17200 10 MILE SUITE 165

EASTPOINTE MI 48021 EASTPOINTE MI 48021

SiGNi1 BASTHARPT DATE r-12s5954107 1285954107 jb pnflflfltlrr NUCC InStructiOn Manual aVSIIable at www.nuoc.org

WCM$ SOOCS

nrrnjvci 0Mb UQU9U FOHM CMS1 500 GD/OS

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 4 of 28 Pg ID 316
PA11ENTS ADDRESS No Sail PATIENT RELATIONSHIP TO INSURED

Self Spouse fl Chd ouerfl

INSUREDS ADDRESS No Streett

PATIENT STATUS

Single Mauled fl ottierfl

Employed

FuII.Tlrne

Sem PeztTlmaStudent

2I

STATE FARM INSURANCE

9.0 BOX 2361

BLOOMINGTON IL 61702

HEALTH INSURANCE CLAIM FORM

.PRDVED BY NATIONAL UNIFORM CLAIM COMMITTEE 03/CS

ffl PICA PICA ITT

MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER

CHAMPUS HEALTH PLAN ELK LUNG

Medicare Medicaid Spon.sore SSN Member OS sssiJ9

PATIENTS NAME Last Name First Name Mlddte InitIal PATiENTS BIRTH DATE SEX MgJFJ

is INSUREDS ID NUMBER For Program in Item

22 15636

INSUREDS NAME Last Name First Name MIddle Initial

.1

OTHER inouua NAMO Name Name Middle InItIal 10 io omi UVNUU iiv RELATED TO

EMPLOYWFNT Cunent or Prevlous

DYES JNO AUTO ACCIDENT PLACE State

flNO LM..IJ

OTHER ACCIDENT

DYES NO MId RESERVED FOR LOCAL USE

Ii iJOUntUO ruuy unvur un FECA NUMBER

INSUREDS GATE OF BIRTH SEX

nfl

ltvl

FE

OTHER INSURED POUCY OR GROUP NUMBER

.THER INSUREDS DATE OFBtRTH SEX MMDO1 YY

MJ FE

EMPLOYERS NAME OR SCHOOL NAME

EMPLOYERS NAME DR SCHOOL NAME

tI INSURANCE PLAN NAME OR PROGRAM NAME

INSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE

IS THERE ANOThER HEALTH BENEFIT PLAN

RAD 8ACI OP FORM BEFORE COMPLEflN StONING TIltS FORM

DYES JND ffyetretumtoendcomptsleItemoe4

13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE authorize

12 PATIENTS OR AORIZED PERSONS SIGNATURE euthodee the retesse of nS or other Inlomelion necesaa

to proceee thIn claim also revest payment of government benefit either to myself or to the party who aocepta assignment

below

SIGNED SISNATURE ON FILE DATE 02/25/11

peent ci medal benefite to the underaned physIan or supplier for

earvlcee described below

StGN SIGNATURE ON FILE

i4 bAtOP CURRENT IllNESS IFIrat symptom OR Fie IF PATIENT HAS HAD SAME CR SIMILAR ILLNESS

MM1 DO YY

IINJURYAcctderitOR

OIVEFIRSTDATE MM DO YY

ii oa__j...o PREGNACY LMP T.N.11URY

17 NAME OF REFERRING PROV1DER OR OTHER SOURCE lie

SAUL WEINGARDEN 60 459994

13 DATES PATENT UNABLE TO WORK IN CURRENT OCCUPATION

MM DD if MM DO if

FROM TO

18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

MM DO if MM DO if

FROM TO

tO RESERVED FOR LOCAL USE 20 OUTSIDE LAB CHARGES

EYES EkIO

21 DIAGNOSIS CR NATURE OF ILLNESS OR INJURY Rein Items 1.23 or 410 Item 24E by LIne 22 MEDICAID RESUBMISSION

CODE ORIGINAL REF NO

t1...BA7.0

23 PRIOR AUTHORIZATION NUMBER

24 DATES OF SERVICE PROCEDURES SERVJOES OR SUPPLIES

From To IPi.MIE0Explain Unusual CIrcumstances DtAGNOSIS ID RENDERING

MM_DO. MM PD if SERVICE EMO .CPTAICPCS MODIFIER POINtER .5 CHARGES GUM PROViDER ID.l

12 171 10 12 17 10 11 97535 GO 12 70.00 .MftVIPPQ. Iii ......JI

ii II iIif I_f

I__I II ..LE

.L_......L II IY

25 FEDERAL TAX ID NUMBER UN EIr4

271033080 DEI 31 SIGNATURE OF PHYSICIAN OR SIJPPUER

INCLUDING DEGREES OR CREDENTIALS

Icerulymattheetatemantsonnravorae

26 PATIENTS ACCOUNT ND 27 ACCEh ASSIGNMERW IssbachJ

CHAJ0000 l2B DNa 32 SERVICE FACILITY LOCATION INFORMATiON

PO1NTE PHYSICAL THERAPY

28 TOTAL CHARGE 29 AMC%JThAIO

jsO

BALANCE DUE

701001 7000

33 BILLING PROvIbkR INFO PH

586

7745006

POINTE PHYSICAL ERA

atylothlabmflaMemedaepanthereot

02Q511

MEGAN RUTLEDGE OTR SIGNED DATE

17200 E.10 MILE RD 17200 10 MILE SUITE 165

L_

EASTPOINTE MI 48021

1285954107

EASTPOINTE MI 48021

.48595410J Jir nnt7r1 NUGG InstruCtion Manual available at WWW.nUCC.Org n.v..aJ LiMb UJa-U9S1 runM cMb-1bUU UWUD

WCMS-ISODCS

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 5 of 28 Pg ID 317
HEALTH INSURANCE CLAIM FORM

iPROVED BY NATIONAL UNIFORM CLAIM COMMITIEE 05/05

ffl PICA

NUCO Instruction Manual available at www.nucc.org

WCMS.1S000S

STATE FARM INSURANCE

P.O BOX 2361

BLOOMINGTON IL 61702

PICA

MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OThER

CHAMPUS HEALTH PLAN BLI LUNO

Mefla fflM.cUcaAlS fl Sponsors LEN fl Member 100 fl St// Or ID El 85W ID

PATIENTS NAME Last Name First Name Mddde lrJIlaI

DSflflflMfl P110TH flA 5X

Ia INSUREDS ID NUMBER For Prcram In 11am

22 15636

INSUREDS NAME Last Name First Name MIddle InftiaI

PATIENTS ADDRE8S No Bunt PATIENT RELATIONSHIP TO INSURED

Soil Spouse 011th El other El

INSUREDS ADDRESS ND Street

11 INSUREDS POUCY GROUP OR FECA NUMBER

PATIENT STATUS

sinqtefl Msnledfl otrerfl

Employed

Futi.flrna fl Part.Time fl Student Studenl

OTHER INSUREDS NAME Lest Name FIrst Name Middle InIllal 10 iS PATiENTS CONDITION RELATED TO

EMPLOYMENT Currenl or PrevIous

flYES NO UTO ACCIDENT PLACE Sn

END LMJJ

OThER ACCIDENT

YE5 1URESERVED FOR LOCAL USE

INSUREDS DATE OF BIRTH SEX

FE EMPLOYEWS NAME OR SCHOOL NAME

OTHER INSUREDS POLICY OR GROUP NUMBER

OTHER INSUREDS DATE OF BIRTh SEX MM1OD1 VY

Mf EMPLOYERS NAME OR SCHOOL NAME

INSURANCE PLAN NAME OR PROGRAM NAME

INSURANCE PLAN NAME OR PROGRAM NAME ISTATE FARM INSURANCE

IS THERE ANOTHER HEALTH BENEFIT PLAN

EYES NO I/yes return to and complels torn ed

13 INSUREDS OR AUTHOilIgli10ENSoNB 8IOATURE stthortie

peymnerrl of medIcal benellte to the undersIgned physIcIan or suppler Icr

cervIces descrIbed below

SIGNED_IGNATURE ON FILE

READSACK OPPOPMSEFORS COMPLETING SIGNING THIS FORM

12 PATIENTS OR AUTNORIZED PERSONS SIGNATURE authorIze the release ol eny medical or other Intorrosdon necessary

to process this stalin also request palinnent of govemrnent bensfas eIther to mysell or to the party who acceple ssaIImerft

below

SIGNATURE ON FILE DATE 02/25/il SIGNED

14 DATEbF CURRENT IlLNESS

IFIreterngtorn

On IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS

MM1 001 VY INJURYfAccIdenIt GIVEFIRSTOATE MM1 001 YY

1.1Lft8_.1L PREGNANCY LIAP I.CLJJRX_________________________________

11 NAME OF REFERRING PROVIDER OR OTHER SOURCE

SAUL WEINGARDEN 7bc rNPfl 1760459994

19 RESERVED FOR LOCAL USE

16 DATES PATIENT UNABLE Tb WORRIEUóORREiIT OCCUPATION

MM1 DO1 rY MM1 DD vi

FROM TO

15 HOSPITALIZATION DATES RELATED TO CURRENVSERVIdES

MMi OOi yy MM1 DO YY

FROM TO

20 OUTSIDE LAB CHARGES

EYESDOl 21 DIAGNOSIS OR NATURE Of II.I..NESS OR INJURY Relate lIerns 125 cr4 10 Item 24E by LIne 22 MEDICAID RESUSMISSION

CODE ORIGINAL REF NO

L.._

23 PRIOR AUTHORIZATION NUMBER

DATES OP SERVICE PROCEDURES SERVICES OR SUPPLIES

From To IPLACE

On Expleirl Unusual CIrcumstAnces DIAGNOSIS

I%

ID RENDERING

MM DO YY MM DO YY jEIFv1CE EMO CPT/HCPCS MODIFIER POINTER CHARGES OUAL PROVIDER ID

12 17 10 12 10 11 97110 GF 75.00 MANASBASTHA lrllIlI

01 21 11 01 21 11 97010 G9 55 00

1_._1 1.i_ FL

01 21 11 01 21 11 11 97014 G9 5500 JUSTEGEORG

IIjI_l..... liI l_I.___.__..

01 21 11 01 21 11 11 97035 60.00

ii liii ii

01 21 11 01 21 11 11 97124 G9

60.001

01 21 11 01 21

ill 111 97110 G975.001 lf .JJ$JçgpftQ

-- -p

W1EOEAAL TAX 10 NUMBER SSN EIN 28 PATIENTS ACCOUNT ND 127 ACCEPT ASSIGNMENT 28 TOTAL CHARGE 29 AMOGflAIW1i0 BALAJ4CE DUE

4Fa4svmssefladç 271033080 fl CHAJ0000 1285jE/Es EN0 38010Db 380.00

31 SIGNATURE OF PHYSICIAN OR SUPPUER 32 SERVICrFACIOrn0CATION INFORMATION 33 lWN PRO VIDR INFO PH

S%7

Y4sYDC INCLUDINO DEOREES OR CREDENTIALS POINTE PI-IYS ICAL THERAPY loertlfythelthestelemerrtsonthereverse POINTE PHYSICAL ERA eppiylothlsbltandaremedeaparrtherecf

02/25/11

510WSTES GEORGE RPTDATE

17200 E.10 MILE RD

EASTPOINTE MI 48021

17200 10 MILE SUITE 165

EASTPOINTE MI 48021

1285954107 jb 85107 lb

mrriiuvtU 0MB 0938-0999 FORM CMS-1500 08/05

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 6 of 28 Pg ID 318
HEALTH INSURANCE CLAIM FORM

IPPRDVED BY NATIONAL UNIFORM CLAIM COMMITTEE OSVS

ffl PICA

STATE FARM INSURANCE

P.O BOX 2361

BLOOMINGTON IL 61702

PICA

MEDICARE MEDICAID TRICARE CHAM GROUP FECA OTHER

CHAMPUS HEALTH PLAN ELK LUNG

Madffl Medcahi JTjjSpons Wa 86W fl Mambcr IDJT 88W or ID 88W IC

flSUREDSI.DUMBER For Program In tent

22 1563

PATiENTS NAME Last Nama FIrst Name Middle InSet PATTENTSfflIRTH DATE SEX

IMJFL1I PATIENT RELATiONSHiP TO INSURED

INSURED8 NAME LaI Name FIrst Name MIddle inItIal

PATIENTS ADDRESS No 6tmot INSUREDS ADDRESS No Shot

Self 5E1 opoueo ChIdD otoerD

CI

2t

11 INSUREDS POLICY GROUP DR FECA NUMBER

INSUREDS DATE OF BIRTH SEX

--

.FD EMPLOYERS NAME OR SCHOOL NAME

PATIENT STATUS

stngofl MardodO omorQ

Employed

Full-Time Past-lime ri

Student L...J Student L......J

OThER INSUREDS NAME Lout Name First Name MIddle tnIdeI ID IS PATIENTS CONDITION RELATED To

EMPLOYMENT Current or PrevIous

flYES RND AUTO ACCIDENT PLACE State

END LMW OThER ACCIDENT

DYES

OThER INSUREDS POLICY OR GROUP NUMBER

OTHER INSUREDS DATE OF BIRTH SEX MM DD YY

MfJ

EMPLOYERS NAME OR SCHOOL NAME INSURANCE PLAN NAME ORPRöAAK

STATE FARM INSURANCE

IS ThEREANOTNER HEALTh BENEFIT PLAN

QYES 5J NO Nyu return to end complete Item e-d

13 INSUREDS OR AUTORiEDPERSOfISSIGNATURE1uthodze

eeMcee dassilbed below

payment of medical benefila to the undersigned pIclon or euppller br

SIGNED

SIGNATURE ON FILE

INSURANCE PLAN NAMEOR PRDORAM NAME lOd RESERVED FOWLOCAL1JSE

READ SACK OF FORM BEFORE COMPLET1Nu SIGNING THIS FORM

to process thIs claIm also requesi payment of government benefIts cUtler to myself or to the party wtro accepts assIgnment

12 PATIENTS OR AORID PEGS SIGNATURE Shodse the mlease of any medIcal or other imonaUon nesn

belOW

SIGNED SIGNATURE ON FILE DATE 02/25/li

14 DATE ONT ILLNESS rFIrst evnvstom OR

jIS

IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS

MM1 CD YY INJURYAedderiflOR GWEF1RSTDATE MM DO YY

1.1_ft8....J..0

PREGNANCY LMP

17 NAMEOF REFERRING PROVIDER OROTHER SOURCE

l7aTFJ_ SAUL_WEINGARDEN rT

19 RESERVED FOR LOCAL USE

16 DATES PATIENT UNABLE TCWDRgiNtURRENT OCCUPATION

MM1 OO MM DO YY

FROM TO

..I

16 HOSPffALIZATION DATES RELATED TO CURRENT SERVICES

MM DO MM DO YY

FROM TO

20 OUTSIDE LAB ItARGES

DafliO 21 OIANOSIS OR NATURE OF ILLNESS OR INJURViRi iltEniiic23 or to Item 24E by Llii

t.L..147.9

22 MEDICAID RESUBMISSION

CODE OR1GINAL REF NO

23 PRIOR AUTHORIZATION NUMBER

4.L 24 DATES ôrSERVICE PROCEDURES SERVICES OR SUPPUES

From To lPt.ACE on Expleln Unusual CIrcumstances DIAGNOSIS oe ID

MM DO MM DO VY SERVICE EMG LC2Iaj MOJINR POINTER CHARGES uvrra sto QUAL

01 21 11 01 21 11 11 97002 39 150.00

il L_

.1

RENDERING

PROVIDER ID

JGEOFQ

01 28j 11 01 28 11 ii 97010 39 55.00 USTEQRGE III hI il NPI

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01plj 28 11 01 28 11 11 97014 39 55.00 JUSTESGEORGE

II lI II NFl 1._i

01 28 11 01 28 11 JUSTESGEORGE 11 97035 39 60.00

NPI

01 28 11 0-1 28 11 97124 60.00 YGQR_QE_ liT

01 28 11 01 28 11 11 97110 GE 75S NP1

25 FEDERAL TAX .0 NUMSER SSN EIN 26 PATIENTS ACCOUNT ND 27 ACCEPT ASIGNMENT 26 TOTAL CHARGE 29 AMcJD 130 BALANCE DUE wco.bac$l 271033080 fl CHAJ0000 45500 128.E5 flNO 455 OOls

31 SIGNATURE OF PHYSICIAN DR SUPPUEIC 32 SERVICEFACUT LOCATION INFORMATION 33 BiLLING PROVIDER INFO PH 58 77 45O06 INCLUDING DEGREES OR CREDENTiALS POINTE PEWS ICAL THERAPY Icortllythmthoawlsmvnaonthereveree POINTS PHYSICAL ERAPY

epptytothbbclondaromnadeaparlthoreofj

02/25/11

SIGd6JSTES GEORGE RPlATE

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1285954107 ID

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STATE FARM INSURANCE

P.O BOX 2361

BLOOMINGTON IL 61702

JEALTH INSURANCE CLAIM FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITFEE 03105

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EMPLOYERS NAME OR SCHOOL NAME

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PS THERE ANOTHER HEALTH BENEFIT PLAN

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i3 INSUREDS OR AUTHORIZED PERSONS SIGNATURE authorIze

paymem ot medIcal broths to the underalrsd phystor or eupplter tar

servIces descrtbed below

SIGNATURE ON FILE SIGNED

EMPLOYERS NAME OR SCHOOL NAME

INSURANCWkAN NAME OR PROGRAM NAME lOd RESERVED FOR LOCAL USE

READ BACX OP FORM BEFORE COMPLETINU SIGNING THIS FORM

12 PATIS OR AORIZED PERSONS SIGNAWRE aoe the mIee of

eny medIcS or 0ther1ntoaU0n necee to Srecsss thIs claIm also request payment of government beneflta eIther to myself or to the party who accepts assIgnment

19

below

SIGNED

SIGNATURE ON FILE 03/29/11 DATE

14 DATE OF CURRENT ILLNESS lflrat ey1om OR 115 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS

INJURYAcddenlt ft SIVEFIRSTDATE MM DD YY

ii 10 PREGNANCY LMP INJURY

17 NAME OF REFERRING PROVIDER OR OTHER SOURCE -- SAUL WEINGARDEN Jim NPt 1760459994

16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATOFF

MM1 DD MM1 DOi YY

FROM TO

18 HcirrALIzATION DATES RELATED TO CURRENT SERVICES

MMi DDi YY MM1 DD1 YY

FROM TO

19 RESERVED FOR LOCAL USE 20 OUTSIDE LAB CHARGES

EYDIX_I 21 DSAGÜOSIS OR NATURE OF ILLNESS OR INJURY Relate Items 123 cr410 Item 24E by Une 22 MEDICAID RESUBMISSIO

84 CODE ORIGINAL REF NO

tL._. aL._ 23 PRIOR AUTHORIZATION NUMBER

840.9 2.L 4.L Frcvrr To PLACE DPI Explain Unusual Clrcuinslsrices DIAGNOSIS OAYS 1MW

24 DATES DP SERVICE PROCEDURES SERVICES OR SUPPUES

MM DD YY MM DD YY SERV1CE EMG CPTIHCPCS MODIFIER POINTER CHARGES us

0121 11 01 21 11 11 97010 GO 12 55.00

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01 21 11 01 21 11 lj 97535 GO1 12 MEQNJ3UiLEDGE

25 FEDERAl TAX ID NUMBER SSJ EIN 25 PATIENFS ACCOUNT NO 21 ACCEPT ASSIGNMENT 28 TOTAECNAIRGE 29 AMOI31flAID 130 BALANCE DUE

27-1033080 CHAJ0000 1412Xa

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380.00

31 SIGNATURE OF PHYSICIAN OR SUPPLIER 3P0INTE PHYSCAL THERAPY

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Ioethetthestetementsonthereverse POINTE PHYSICAL HE PY

spplytothtablllsnderemacleapamlthemol 17200 E.10 MILE RD 03129/11

EASTPOINTE MI 48021

17200 10 MILE SUITE 165

MEGAN RUTLEDGE ON EASTPOINTE MI 48021

SIGNED DATE

1285954107 lb 5.__

NUCC InStrUctlOn Manual avaIlable at www.smuoc.org

WCMS-1500C5

AFVHUVLU liMb UUJb-UUitdbf PtIMM liMb-i DUU fUU/U3I

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 8 of 28 Pg ID 320
Sitastl PA11ENT RELA11ONSHIP TO INSURED

Self ESpouse fl Child Other

STATE FARM INSURANCE

Iicn P.O BOX 2361

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HEALTH INSURANCE CLAIM FORM

gPROVED BY NATIONAL UNIFORM CLAIM COMMTTTEE OB5

ffl PICA PICA flf

MEDICARE MEDICAID TRICARE CHAMP VA GROUP FECA OThER

CHAMPUS HEAI.TH PLAN BLK LUNG

j1Medkie DMedAcsid Esn1s SSN DMnbt4U95M0n1 flLSSNI ID

is INSUREDS ID NUMBER For Prcçram In Item

22CM 15636

PATIFNDR IJAMP tint Nflns Rnr Msws IAItfla 11711151

I_____________________________________________

PA11FN1S KYRTM r1ATF SEX

Mfl4 FfJ

IISURED NAME II.sst Name First Name MIddie InlIlpI

OTHER INSUREDS NAME Last Name First Name MIddle InIdaD 10 IS PATIENTS CONDITION RELATED TO

EMPLOYMENT Current or Previous

LIVES

AUTO ACCIDENT PLACE State

EXIES DNoLjI OTHER ACCIDENT

Exc

lCd RESERVED FOR LOCAL USE

11 INSUREDS POLICY GROUP OR FECA NUMBER

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ri IS THERE ANOTHER HEALTh BENEFIT PLAN

EMPLOYERS NAME OR SCHOOL NAME

INSURANCE PLAN NAME OR PROGRAM NAME

DYES__ yes return to and complete Item

READ BACK OFFORM BEFORE COMPLEUNu SIGNING THIS FORM

12 PATIENTS OR AUTHORIZED PERSONS SIGNATURE authorize the release of any medical or other InformatIon necessary

to process this clslm also request pslnent of government benefIts either to myself otto the party who accepts assIgnment

below

SIGNED

SIGNATURE ON FILE DATE

03/29/11

IS INSUREDS OR AUTHORIZED PERSONS SIONATURE authorize

paTrrent of medIcal benefits 10 the undersInatphysIcfsn or supplIer for

servIces descrIbed below

SIGNEDSIGNATURE ON PILE

iNSUREDS ADDRESS No Street

PATIENT STATUS CIT

SIngleD Manledfl otherD

jff

Emptoyad

Full-Time ri Pert-lime fl

Student_L.J_Student__L...J

INJURYIAccIden1I SIVEFIRSTDATE MM DD YY MM DD YY MM DO1

14 Its vi- vvnricrl

1LLNESS

CArat

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OR 15 IF is ron risrI HAD SAME as olrvulars iLLNESS 1151 tO i5i EN JflSOLt Iv YYUMI IN Oui-tritra OCCUPATION

1J 08 10 PREGNANCYLMP INJURY FROM TO

PROVIDER OR OThER SOURCE i7s

WEINGARDEN ir7Co459994

16 HOSPITALIZATION DATES RELATED TD CURRENT SERVICES

MMi ODi yy MM DO VY

FROM TO

USE 20 OUTSIDE LAS CHARGES

flYES_Dlx_I

OF ILLNESS OR INJURY Relate Items 123 cr4 to Item 24E by One

aL_._ 22 MEDICAID RESUBMISSION

CODE ORIGINAL REF NO

23 PRIOR AUTHORIZATION NUMBER

L.- SERVICE PROCEDURES SERVICES OR SUPPIJES

To IRAtE on ExplaIn Unusual CIrcumstances DIAGNOSIS

0A8

ID RENDERING

OD YY ISERVEEF EMS CPTJHCPCS MOCIRER POINTER CHARGES DUAL PROVIDER ID

01 28 11 11 97010 GO 12 55.00 MEGANRUTLEDGE

t._.__

01 28 11 11 97014 GO 12 55.00 MEGAN RUTLEDGE

_I

Oi28 11 11 97035 GO 12 60.00 MEGANRUTLEDGE

.Ei

01 28 11 11 97140 GO 12 65.00 MEGANRUTLEDGE

..L

01 28 11 11 97110 GO 12 75.00 MB3J31QQ IIIIIIII

01 28 11 11 97535 GO 12 70.00

NUMBER SSN EIN 26 PATIENTS ACCOUNT NO j27CCEPT ASSIGNMENT 20 TOTAL CHARGE 29 AMUJRYWsD 30 BALANCE DUE

as bark

IIJ CHAJ0000 1419ctjNO 380.OQ 380.00

OR SUPPLIER 32 rrpnvrrt rArIl TV OflATION INrnni.cxnoN 33 BIWNO PROVIDER INFO PH

.ç

774 5006 OR CREDENTIALS POINTE PHYSICAL THERAPY

POINTE PHYSICAL HE PY

03/29111

OER

DATE

17200 E.10 MILE RD

EASTPOINTE MI 48021

i2859541Q7 lb

17200 10 MILE SUITE 165

EASTPOINTE MI 48021

b07I -.- NUCC Instruction Manual available at www.nucc.org Afrrrtuvta 0MB O938-str FIJNM LM-1trUU UWUb

WCMS-1 SOOCS

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 9 of 28 Pg ID 321
Li5pJ

EALTH INSURANCE CLAIM FORM

KPPROVED BY NATIONAL UNIFORM CLAIM COMMtTFEE OBfOS

111 PICA

STATE FARM INSURANCE

P.O BOX 2361

BLOOMINGTON IL 61702

PICA

MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER

CHAMPUS HEALTH PLAN

Jere DMod/caal Sponsoe SSN Member/OS $SN or 10 EG It INSUREDS I.D NUMBER For Program In Item

22 C4 15 636

SEX INSUREDS NAME Lest Name Pint Name Middle Initial

ft PATIENTS AbDRFSS INn Straafl PATIENT RELATIONSHIP TO INSURED

Set itiictfl other

INSUREDS ADDRESS No. Street

21

11 INSUREDS POLICY GROUP OR FECA NUMBER

Lii

PATIENT STATUS

Single Mauled Other

Full-Time Part-lime l1 Employed Student Student_Li

OTHER INSUREDS NAME Lest Name First Name Middle Initial 10 iS PATIENTS CONDITION RELATED TO

EMPLOYMENT Current or Prenloue

Ex40

AUTO ACCIDENT PLACE State

ENOLJiFE

OTHER ACCIDENT

EYES

lOd RESERVED FOR LOCAL USE

OTHER INSUREDS POLICY OR GROUP NUMBER Am SEX

INSUrEDS

DATE OF

OTHER INSUREDS DATE OF BIRTH EMPLOYERS NAME OR SCHOOL NAME SEX

MM1 DDt YY

ME EMPLOYERS NAME OR SCHOOL NAME

d.INSURANCE PLAN NAME OR PROGRAM NAME

iNSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE

IS THERE ANOHER HEALTh BENEFIT PLAN

EYES ulyse return to end complete Item

13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE authorize

servIces described below

peent of mecet beneflta to the undersigned phIen or supplIer tar

SIGNATURE ON FILE SIGNED

READ BACK OF FORM BEFORE COMPLE1JNu SIGNING THIS FORM

to proceee thIs claim also request payment of government benefits eIther to rnyeeil or to the party wtro accepts assIgnment

12 PATIEPS OR AUTHORIZED PERSONS SIGNATURE stithoNse the release Of any rnedI or other Intoeneiton nece

below

SIGNATURE ON FILE 03/29/11 SIGNED DATE

14 DATE OF CURRENT ILLNESS FIrst

eyrngom

OR IS IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS

INJURY Accldentt GTVEFIRSTDATE MM1DD1 YY

111 o1e lye PREGNANCY LMP INJURY

17 NAMEOFREFERRINGPROVtDEROROThERSOURCE

SAUL WEINGARDEN 117ed

16 DATES PATIENT UNASLE TO WORK IN CURRENT OCCUPATION

MM1 00t YY MM4 DD1 YY

FROM TO

16 HOSPITALIZATIDN DATES RELATED TO CURRENT SERVICES

MM OD YY MM DD YY

FROM TO

19 RESERVED FOR LOCAL USE 20 OUTSIDE LAB CHARGES

EYESEQI 21 DIAGNOSIS OR NATURE OF ILLNESS OR iNJURY Relate Iteme 1.23014 to tern 2E by Une

84

L..._ L_...

840.9 2.L 4.L

22 MEDICAID RESUBMISSIDN

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23 PRIOR AUTHORATION NUMBER

24 DATES OF SERVICE PROCEDURES SERVICES OR SUPPLIES

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MM DO VY MM VY ISEItYICEIEMO POINTER CHARGES u2 DUAL PROVIDER ID CfTJHPPCS D209fl021i9fl 11 97010 GO 55.00 P1EA$FUTLEDGE iii ii NPI

IL 0911 02 09 11 11 91014 12 55.00 MEGANRUTLEDGE

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02 09 11 02 09 11 11 97110 GO 12 75.00 MEGANRUTLEDGE

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25 FEDERAL TAX ID NUMBER SSN EIN

27-1033080

31 SIGNATURE OF PHYSICIAN OR SUPPLIER

INCLUDING DEGREES OR CREDENTiALS

Ioertltythatthoetatamerrteontherovemo

app1ytothimadeapom5themo4

03/29/11

MEGAN RUTLEDGE ON

SIGNED DATE

26 PATIENTS ACCOUNT NO 27 ACCEPT ASSIGNMENT

pan us tee b3fl CHAJ0000 1419cES

3iQiiF PNnTvUr4TInffjNnnnuATlON POiNTE nysxca THERAPY

17200 E1O MILE RD

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1285954107 jtt

28 TOTAL CHARGE 29 AMOUNT PA1D 130 BALANCE DUU

380.00

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POINTE PHYSICAL HE PY

17200 10 MILE SUITE 165

EASTPOINTE MI 48021

128595U07 lb

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NUOC Instruction Manual aVaIJaba at www.nucc.org nrrnjviaij UM1S U93B4JS99 frUIIM UMS-1bUU UWUb

WCMS-ISDOCS

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 10 of 28 Pg ID 322
0500

EALTH INSURANCE CLAIM FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105

Jf PICA

STATE FARM INSURANCE

P.O BOX 2361

BLOOMINGTON IL 61702

PICA

TRICARE CHAMPVA GROUP FECA OTHER

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22 C4 15636

INSUREOS NAME Last Name First Name MIddle InIIIaI

INSUREDS ADDRESS Sjt

Cli

PATiENTS BIRTH DATE SEX

FIFRtN5SMIflIlft5I IM PATIENT RELATIONSHIP TO INSURED

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Iii

ilUñSS DATE OF BIRTH SEX

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EMPC6ER14AME OR SCHOOL NAME

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..

YES If yes return to end complete Item a-ti

13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE authorize

GROUP NUMBER EMPLOYMENT Currenl or Previous

DYES

SEX AUTO ACCIDENT PLACE Sate

IMLI DNOLJJ NAME OTHER ACCIDENT

DIVES

CR1ROGRAM NAME lOd RESERVED FOR LOCAL USE

BACK OF FORM BEFORE COMPLETINu SIGNING ThIS FORM

PERSONS SIONAThRE authodse the reIe ot medS or other inIoaton necossa

payment of government benefits eIther to mysell or to the party who accepts asalgnmenl

paenI al medIcal benefIts to the underelgned physicIan or euppllar Icr

setccas described below

ON FILE 03/29/11

DATE______________________

SIGNATURE ON FILE SIGNED

ILLNESS FIrst

smgtont

OR 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS

INJURYAcddentl GIVEFIRSTDATE MM1 DO1 YY

PREGNANCYLMP INJURY

16 DATES PATiENT UNABLE TO WCRI IN CURRENT OCCUPAI1ON

MM1 DD1 YY MM1 DD1 YY

FROM TO

OR OTHER SOURCE lie 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

MM1 DDi TI MM1 DD1 YY

FROM TO

20 OUTSIDE LAB CHARGES DDxI ILLNESS OR INJURY Relate Items 12.3 or to Hem 24E by LIne 22 MEDICAID RESUBMISSION

CODE ORIGINALREF.NO

23 PRIOR AUTHORIZATION NUMBER

L__ PROCEDURES SERVICES OR SUPPLIES

Ft.ACEOFI EtaIn Unusual CIrcumstances OIAGNOSIS tD RENDERING

YY SEttIlCE EMO CPTIHCPCS MODIRER POINTER CHARGES wrre PI OUAL PROVIDER ID

11 11 97010 GP 55.00 JUSTESGEORGE

.E1

11 11 97014 GP 55.00 JUSTESGEORGE

lILA

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11 11 97124 GP 60r00

I.____.I ..L_

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11 11 97110 11111 OP 75.00 .U$5E.SJ3E.O13Gg

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SUPPLIER 39 ccnvIrE FAflI IT IATIfllliNFRIAKTtW 33 BIWNO PROVIDER INFO 14f 586 771 5006 CREDENTIALS POINTE PHYS sCAL THERAPY

POINTE PHYSICAL THERAPY

17200 E.1O MILE RD 03/29/11

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EMPLOYERS NAME ON SCHOOL NAME

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STATE FARM INSURANCE

.1

an

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iooJ P.O POX 2361 114 BLOOMINGTON IL 61702

HEALTH INSURANCE CLAIM FORM

PPROVED BY NATiONAL UNIFORM CLAIM COMMITTEE 08/05

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22 C4 15636

PATtNVS NAMP lint N. Fine Mwn

MIrIe1

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NAME Lost Name fret Name MIddle InItIal

inounfln. riJvi tevao ott rnvurtsrwr rcnwo tOri nnorrtvcO FOR LOCAL USE

--

IS THERE ANOThER HEALTH bucaru nan

EYES EXNO yoo return to end complete horn

READ BACK Off FORM BEFORE COMPLETINU S1GNJNG THIS FORM

PATIES OR AUTHORIZED PERSONS SIGNATURE eodte the retasse at any methcat or other SoatIon neussu

ttrcees

this claIm ales requeet payment at government benefIts eIther to myeelt or to the petty who accepte assIgnment

StONED

SIGNATURE ON FILE DATE

0329hl

13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE euthorlze

pent at med/cat benetIta to the underened phIc/cn or euplar for

servIces descrIbed below

SIGNED IGNATUREON IL

OThER INSUREDS NAME Last Heme Rret Name Mlddte Inttlel

OTHER INSUREDS POLICY OR GROUP NUMBER

011tH novncuc DATED BIRTH

MM1 DD

IMfl Ffl

SEX

EMPLOYERS NAME OR SCHOOL NAME

14 LIAIE or OUNNENI ILLNESS

GIVERRSTDATE MM00 VY MM1 DO1 YY MM1 DO1 YY fi INJURY eçnm OR 115

II- PAl lENt NAb IIAQ bAME UN SIMILAR ILLNESS 16 DATES IAIIENI LINAULU 10 MOult IN I.UNNENI OCCUPATION

FREGNANCY L1AP INJURY FROM TO

MErx FE

17 NAME CF REFERRING PROViDER OR OTHER SOURCE 1170

SAUL WEINGARDEN dT7Eo4s999c

18 HOSP1TALIZATtON DATES RELATED TO CURRENT SERVICES

MM DD YY DD

FROM TO

19 RESERVED FOR LOCAL USE 20 OUTSIDE LAB CHARGES

EYES_CJ 21 DtAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items 123 or to Item 24E by Line 22 MEDICAID RESUBMISSION

847 CODE ORIGINAL REF NO i.L._ s.L._ 23 PRIOR AUTHORIZATiON NUMBER

8409 2.L .. 24 OATES OF SERVICE 1Cl PROCEDURES SERVICES OR SUPPLIES

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MM DO YY MM DO Vt 5ER1CE EMO CPT/HQ3$ MOJ3IFWR POINTER CHARGES UN GUAL PROVIDER ID IS

02 17 11 02 17 11 11 97010 GO 12 55.00 MEGAN RUTLEDGE

0217 11 02 17 11 11 97014 GO 55.00

ii

MEGANRUTLEDGE

.1 I_

02 17 11 02 17 11 11 97035 GO 12 60.00 IIII 111 .ftMEGANRUTLEDGE

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II .I_

MEGANRUTLEDGE

02 17 11 02 17 11 11 97110 GO 12 75.00 iIII tI

MEGANRLJTLEDGE

02 17 11 02 17 11 97535 GO 12

25 FEDERAL TAX 1.0 NUMSER SSN E1N 28 PATIENTS ACCOUNT NO j27 ACCEPT ASSIGNMENt

ctujns coo bock 27-1033080 CHAJ0000__1412JXcJ 31 SIGNATURE OF PHYSICIAN OR SUPPLIER 32 crclVlrc FAI ITY INIATION INFORMATION

INCLUD1NG DEGREES OR CREDENTiALS POINTE PHYSiCAL THERAPY

Icthattheatatamcntsontherovoreo

appfytolhisbGauidarernadoapsrtthoreot 17200 E.1O MILE RD 03/29/11

EASTPOINTE MI 48021

MEGAN RUTLEDGE OTR

SIGNED DATE i1TTJT

70.00

2A TOTAL CHARGE 29 AMOUNT PAlO 30 BALANCEDUE

380.OQ 380.00

33 BILLING PROViOhR INFt PH csyrr71rott

POINTE PHYSICAL THERAPY

17200 10 MILE SUITE 165

EASTPOINTE MI 48021

285954107 lb

NUCU InStructIOn MOrIUSI aVaIlable at www.nucc.org /krri-tuv/cu 0MM 0935-0959 10MM CMS-1SOU 05105

WCMS-1S000S

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 12 of 28 Pg ID 324
MEALTH INSURANCE CLAtM FORM

PROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105

ffl PiCA

STATE FARM INSURANCE

P.O BOX 2361

BLOOMINGTON IL 61702

PICA rn

MEDICARE MEDICAID TRICARE CHAMP VA GROUP FECA OTHER is INSUREDS ID NUMBER For Program In Item

CHAMPUS HEALTH PLAN DLX LUNG

MedIcare Medlcaid gms4 .5511 MairbatItfl Li 5511 or ID 0Xioj 22 C4 15636

osrwwrc Ia M.. uWdla SEX nIttalO.orna

nattfl

tflCflO MA tIC t1.etAIsn fret Mw.s MIMI

DATICJrQ annarog III Ctn.tI PATIENT RELATiONSHIP TO INSURED INSUREDS ADDRESS No Street

SellLXSpouse Chid Other Li

PATIENT STATUS Cli

SfrigtefJ ManladLi ottier

Employed

FuIP.TImeCl Pad-lime fl

Student__L..J__StudllpLL_j

OTHER INSUREDS NAME Last Name FIrst Name MIddle InitIal tO IS PATIENTS CONDITION RELATED TO 11 INSUREDS POLICY GROUP OR FECA NUMBER

OTHER INSUREDS POLICY OR GROUP NUMBER EMPLOYMENT Current or Previous INSUREDS ATEOF BIRTH SEX

Li Exo TMDX Ffl

OThER INSUREDS DATE OF BIRTH SEX AUTO ACCIDENT PLACE State EMPLOYERS NAME OR SCHOOL NAME

MM1 DDt YY

MJ FO EXES LjjI

EMPLOYERS NAME OR SCHOOL NAME OThER ACCIDENT INSURANCE PLAN NAME DR PROGRAM NAME

flYES STATE FARM INSURANCE

INSURANCE PLAN NAME OR PROGRAM NAME tOd RESERVED FOR LOCAL USE IS THERE ANOTHER HEALTh BENEFIT PLAN

YES ENO yes return 10 and complete Rem a.d

READ BACK OF FORM BEFORE COMPLETiNG SIGNING ThIS FORM 13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE authorIze

to orocaaa thIs claIm also request payment of govammant benefits elthar to myself or to the party who accepts assIgnment aervlces described below

12 PATIENTS OR AORIZED PERSONS SIGNATURE authorize the rataua ot any medIcal or other tnfonaflon nacaesa payment of medIcal banatita to the undersIgned phyetctan or supplIer for

barow

SIGNATURE ON FILE 03/29/11 SIGNATURE ON FILE SIGNED -- DATE SIGNED

GIVEF1RSTDATE MM DO1 YY MM1 DD1 YY MM1 DO YY

14 DATE OF CURRENT

lLLNESSjt ertom OR Its IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATiON

IP INJUR

lii 08 10 PREGaCYt15PR INJURY FROM TO

17 NAME OF REFERRING PROVIDER OR OTHER SOURCE f5f 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

t760 45999 SAUL WEINGARDEN MM DO YY MM DO VTFROM TO

19 RESERVED FOR LOCAL USE 20 OUTSIDE LAB CHARGES

YES Thd .. 21 OtAGNOSISWNATURE OF ILLNESS OR INJURY Rotate Items 1.23 or 4to Item 24E by LIne 22 MEDICAID RESUSMISSION

847 CODE ORIGINAL REF NO t.L._ 3.L- 23 PRIOR AUTHORIZATION NUMBER

2.L_ 4L 24 DATES OP BERVICE PROCEDURES SERVICES OR SUPPLIES iT

Front To IPLICE cc Explain Unusual Circumstances OtAGNOSIS ID RENDERING

MM DD VT MM DO VT I$ERKCEI EMO

CPift1QP..L........

.MODIFIER POINTER $CHARGES GUAL PROV1DERID.I

02f7Thi02i7 11 11 97 GP 55.00 JUSTESGEORGE

21711 02 17 11 11 a7o35 OP 60.00 JUSTESGEORGE3 iIII1 I.

02 17 11 02 17 11 11 97140 OP 65.00 .J_PIORGE ailailli 1o I1L

02 24 11 02 24 1II111 97010 OP 55.00 JUSTESGEORGE .I I.i 10

Iz

02 24 11 0224 11 3. 97014 OP 55.00 JUSTESGEORGE

02 24 02 24 11 11 97035 OP 60.00 IJJSTESGEORGEx t1IJl 25 FEDERAL TAX ID NUMBER SSN EIN 26 PATIENTS ACCOUW NO 27 ACCEfl ASSI6NME 28 TOTAL CHARGE 29 AMUUAID 30 BALANCE DUE govt na sea bath 27-1033080 DEI CUAJ0000 1413XES LJNO 350.00 350.00

31 SIGNATURE OF PHYSICIAN OR SUPPUER ArI 1TV flrATIQNINCtIRMATIQN 33 BILLING PROViDER INFO PH 7745006 INCLUDING DEGREES OR CREDENTIALS PCYLNTh PHYSICAb THERAPY

Icarlafythattheatatemaritacntheraveree

POINTS PHYSICAL HE PY

applytothtabfllsndemmadeaparttharnol 17200 E.1O MILE RD 0329111 17200 10 MILE SUITE 165

EASTPOINTE MI 48021 EASTPOINTE MI 48021 JUSTES GEORGE RPT

SIGNED DATE

r1285954107 1107

NUCC InStruCtion Manual available at W.nUCC.Org APPROVED DM13 0938-0999 FORM CMS-1 500 08/05

WCMS-1 500CS

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 13 of 28 Pg ID 325
1500

JEALTH INSURANCE CLAIM FORM

XPPROYED BY NATIONAL UNIFORM CLAIM COMMITTEE 06/OS

f_fl PICA

NUCC Instruction Manual available at www.nucc.org

WCMS-1 50005

STATE FARM INSURANCE

P.O BOX 2361

BLOOMINGTON IL 61702

PICA

TRICARE CHAMPVA GROUP FECA DINER

CHAMPUS HEALTH PLAN BU LUNG

Sponsos SSN DM DSSNOrD DiSSNI DXn/

it INSUREDS 1.0 NUMBER For Program In Item

2C4 15636

rSURFDS

NAME Name RiM Name Wddle

I1Uafl

INSUREDS ADDRESS No. Sliest

11 INSUREDS POUCY GROUP OR FECA NUMBER

Iii

INSUREDS DATE OF BIRTh SE

TMEX Ffl

EMPLOYERS NAME OR SCHOOL NAME

INSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE 1st

IS ThERE ANOTHER HEALTH BENEFIT PLAN

DYES NO yes return to end complete tern

13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE authorize

eendcee described below

paent of mecaI benefits to the coderetgned Iclen or avpIer tr

SIGNATURE ON FILE SIGNED

Mtae SEX 1flM

flI nstr

PATiENT RELATIONSHIP TO INSURED

Sen fl ChIld Other

PAT1ENTSTATUS

5IneD M54D OtherD

Full lime r-i Pen-lime fl

EmpIoyed Student L_J Student L..J

Name First Name MIddle InItIal 10 IS PATIENTS CONDITION RELATED TO

GROUP NUMBER EMPLOYMENT Current or Prevtoue

DYES Ex4

SEX AUTO ACCiDENT PLACE Stats

MD FD DES DNO Liii

NAME OThER ACCIDENT

flYES LXo

PROGRAM NAME tOd RESERVED FOR LOCAL USE

BACK OF cORM BEFORE COMPLETING SIGNING ThIS FORM

payment ot government benattts eIther to myself or to the party who accepts assIgnment

PERSOS SIGNATURE authorize me release St

any madtost or

ON FILE 03/29/11 DATE

FIrst

symgtom

OR 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS t6 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

4INJURYAnddentt

GIVERRSTCATE MM DO YY MM DD YY MM DD

PREGNANCY LMP INJURY FROM TO

OR OTHER SOURCE 18HOSPITAIJZATION DATES RELATED TO CURRENT SERVICES

MMi DO yy MM DO1 YY 176045999 FROM TO

20 OLJTStDE LAB CHARGES

._DYES

ILLNESS OR INJURY Relate llama 12.3 or to Item 24E by LIne 22 MEDICAID RESUBMISSION

CODE ORIGINAL REP NO

23 PRIOR AUTHORIZATtON NUMBER

-- PROCEDURES SERVICES OR SUPPLIES

PLCE OFI ExplaIn Unueual Circumstances DIAGNOSIS Iattt ID RENDERING

YY ISERV1CEI EMG CPIIHQPP J_... MODIFIER POINTER CHARGES uãa IL GUAL PROVIDER ID

11 11 97010 GO 12 55.00 MEGAN RUTLEDGE

NPI

IS 2g11 97014 GO 12 35.O0 MEGANRUTLEDGE trill

11 11 97035 GO

liii

12 60.00

IE

MEGANRL.JTLEDGE

11 97140 GO 12 65.00

11 97110 GO 12 75.00 MEG JDGES NPI

11 97535 GO 12 70 00 MEGAN RUTLEDGE ill ii SSN EIN 26 PA11ENTS ACCOUNT NO 121 ACCEPT ASSIGNMENT 28 TOTAL CHARGE 29 AMOU AID so BALANC DUE

CHAJ0000 gaIt dahlia badl

1412XEs DNC 380.OQ 380.00

SUPPLiER cnotpro trru -ru nrallcwj

IPJCflDUATIOPY

33 BIWNG PROVIDER INFO PH cSW67 74 500k CREDENTIALS POINTE PHYSTCAt THERA

POINTE PHYSICAL FHERAPY

17200 E.1O MILE RD 17200 10 MILE SUITE 165

EASTPOINTE MI 48021

om EASTPOINTE MI 48021

r1285954107 lb

--

12859541 OZJbc DATE

MrrnuvL rvic utroo-0999 FORM CMS-1500 08/05

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 14 of 28 Pg ID 326
STATE FARM INSURANCE

P.O BOX 2361

BLOOMINGTON IL 61702

flEALTH INSURANCE CLAIM FORM

IPPROVED BY NATiONAL UNIFORM CLAIM COMMITTEE 08/05

Jfl PICA PICA

--ti..

MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OThER

CHAMPUS HEALTH PLAN DLX LUNG Medftsm fl Member 1D.flSSN or ID ES$N QX9D

Is INSUREDS ID MJMBER For Program In Item

22 C4 15636

INSUREDS NAME I.asr Name First Name Middle Initial

INSUREDS ADDRESS No Street

CIT

PATIENTS NAME Last Name First Name Middle initial SEX

3.ENTSRIRTHDAT

PATIENTS ADDRESS No Street PATIENT RELATIONSHIP TO INSURED

Self Spouse Child Other

PATIENT STATUS

Singiefl Merrted OtherD

ZIP

Full-Time Part-Timer

Employed Studenl Student

OThER INSUREDS NAME 11 INSUREDS POLtCY GROUP OR FECA NUMBER Last Name First Name Middle InItial SQ 15 PATIENTS CONDITION RELATED TO

EMPLOYMENT Current or Previous

flYES EXo AUTO ACCIDENT PLACE State

Exs ENO Ls OTHER ACCIDENT

flYES

105 RESERVED FOR LOCAL USE

UI

INSUREDS DATE OF BIRTH SEX

MDX FE EMPLOYERS NAME OR SCHOOL NAME

INSURANCEThLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE UI

IS THERE ANOTHER HEALTH BENEFIT PLAN

YES It yes return to end complete Item a-u

13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE authorize

servlcea described below

payment ot medical benettie to the undersigned physialan or aupplier or

SIGNATURE ON FILE StONED

16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

MM PD yy MM DD VT

FROM TO

18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

MMi DDi VT DD1 VT

FROM TO

20 OUTSIDE LAB CHARGES

OTHER INSUREDS POLICY OR GROUP NUMBER

OThER INSUREDS DATE OF BIRTH 5x MM1 DO1 VT

FE EMPLOYERS NAME OR SCHOOL NAME

INSURANCE PLAN NAME OR PROGRAM NAME

READ BACK OF FORM BEFORE COMPLETIN SIGNING THIS FORM

to process this claim also request payment of government benetits eIther to myself or to the party wire accepts assIgnment

12 PATIENTS OR AORIZED PERSONS SIGNATURE aalldze the release olany mediast or other inbaUon necessa

below

SIGNATURE ON FILE 03/29/11 SIGNED DATE

14 DAtE OF CURRENT ILLNESS IPlrst synrotom OR tS IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS IIN OIVEFIRSTDATE MM DD TV

ii o-s PREGNANCY LIAPI INJURY

17 NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a

FNPII

SAUL WEINGARDEN 1.7 60 4.5.9 9.94

19 RESERVED FOR LOCAL USE

DYESEI 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items 123 or4 to Item 24E by Une 22 MEDICAID RESUBMISSION

847.9 .4

CODE ORIGLNALREF NO i.L._ 23 PRIOR AUTHORIZATiON NUMBER

2L............. 41

VS ItISIIT ID RENDERING

24 DATEISi OP SERVICE PROCEDURES SERViCES OR SUPPUES

From To IPLtCE oft EspIaln Unusual Circumstances IDIAGNOSIS

MM DO VT MM DD VT JSMMCEI EMG irCDIFIER POINTER CHARGES OUAL PROVIDER ID CPTJHQPQ5 02Th4t102 24 11 11 97140 65 00 JUSTESGEORGE2 ---J Ii .F 12

02 24 11 02 24 11 11 g7110 GP 75.00 JUSTESGEORGE 1IIIII NP -..l Its

02 25 11 0225 11 ii 97010 GP 55.00 JUSTESGEOROE lift 1_ IL

02 25 11 02 25 fI ii 97014 GP 55.00 JUSTESGEORGE iIFII 11111 i.1

02 25 11 02 25 11 11 97035 GP 60.00 JUSTESGEORGEC

.1

02 25 11 02 25 11 11 97140 GP 65.00 JUSTESGEORGE IJIIII .1

11 IiEii 25 FEDERAL TAX t.D NUMBER SSN BIN 26 PATIES ACCOUNT NO 27 ACCE ASSIGNMENT 28 TOTAL CHARGE 29 AMdNT FD 130 BALANCE DUI port csthn eee 27-1033080 CHAJ0000 tack

1413E5XES flNO 375.OQ 375.00

INCLUDING DEGREES OR CREDENTIALS POINTE PhYSICAl THEPAY 31 SIGNATURE OF PHYS1C1AN OR SUPPLIER 000vIrc cprI ITS flraTIrIN 33 DIWNO PROVIDER INF6 PH C5677401Jt

tcerttythattheatatamenlaontherenrae POINTE PHYSICAL HEIdPY

epplytatlJabelanderemadaapaflltleraol 17200 E.10 MILE RD 03/29/11 17200 10 MILE SUITE 165

EASTPOINTE MI 48021 EASTPOINTE MI 48021 JUSTES GEORGE RPT t1285OS4lO7 1285954107 lb

-.--

SIGNED DATE

NUOC InstrUctIon ManUaJ available at www.rrucc.org

WCMS-15DOCS

rrnuvtu 0MB 0935-0999 FOHM UMS-i bOO 05/OS

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 15 of 28 Pg ID 327
Ia INSUREDS ID NUMBER For Program In Item

22C4 15636

33 tsrwnurnuvjuwqlNFOPH.e 5S774-5OO6

POINTE PHYSICAL tHERAPY

17200 10 MILE SUITE 165

EASTPCINTE MI 48021

1285954107

STATE FARM INSURANCE

BOX 2361

HEALTH INSURANCE CLAIM FORM

BLOOMINGTON IL 61702

PPROVED BY NATIONAL UNIFORM CLAIM COMMiTTEE 0WC5

ffl PICA

____________________________________________

PICA

Jr

MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER

CHAMPUS HEALTH PLAN ELK LUNG

Jjedicsra tfl MedIcaid fl Sponsors SSN Member IDa SSN or /0 fl SSN

PATIflWC MAIAr n.t Jan flnt i.mn iIb InitIal

PATIENTS ADDRESS No Street

PATIENTBLRTH DAT SEX

iMEX FO PATIENT RELATIONSHIP TO INSURED Sef 01010 oirreC

INSUREDS NAME Last Name FIrst Name MIddle InitIal H.

INSUREDS ADDRESS No Street

Cn-4 PATIENT STATUS

SIngle fl MarrIedE Other

FuIVflnie PartTIme

poye Student Student

OThER INSUREDS NAME Last Name Rnst Name MIddle InItIal ID IS PATIENTS CONDITION RELATED TO

EMPLOYMENT Current or PrevIous

EYES ECD AUTO ACCIDENT PLACE Se

EXIES DNOLJ OTHER ACCIDENT

EYES Do

11 INSUREDS POLICY GROUP OR FECA NUMBER

INSUf1EDS

DATE OF BIRTH SEX

MEX FE

OTHER INSUREDS POLICY OR GROUP NUMBER

OTHER INSUREbt DATE OF BIRTH SEX EIXPLOYERS NAME OR SCHOOL NAME

Dr

MD rE a- EMPLDYEFVS NAME OR SCHOOL NAME INSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE

INSURANCE PLAN NAME OR PROGRAM NAME lad RESERVED FOR LOCAL USE IS THERE ANOTHER HEALTH BENEFIT PLAN

DYES__ Ityn return to and complete tern a-ct

READ BACK OF FORM BEFORE COMPLETIN SIGNING THIS FORM

12 PATIENTS OR AUTHORIZED PERSONS SIGNATURE etiltiodse the tetanus of any medIcal or other lrrtonrntattcn necessary

to process thla delm Mao request payment ot government benetits eIther to myself or to the party wtro accepts asslgnunent

below

SIGNED

SIGNATURE ON FILE DATE

03/29/11

13 INSUREDS OR AUTHORIZED PERSONS SIqNATIJRE authorize

payment of medical benefits to the unrderelgrted physIcian or aupptler for

servIces descrIbed below

SIGNED

SIGNATURE ON FILE

14 DATE OF CURRENT ILLNESS FIlet swrrotom OR 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS

flj 88 4tI21IR INJURY GIVEFIRSTDATE MM DD YY

17 NAME OF REFERRING PROVIDER OR OTHER SOURCE tm.t

SAUL WEINGARDEN 3ffT70459994

18 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

FROM

MM OD

TO

MM DO

lB HOSPiTALIZATION DATES RELATED TO CURRENT SERVICES

FROM MM DD yy MM PD YY

19 RESERVED FOR LOCAL USE 20 OUTSIDE LAB CHARGES

21 DIAGNOSIS ON NATURE OF ILLNESS OR INJURY Relate Items 123 or to Item 24E by Une

34 3.._

840.9

JYES_Dlx 22 MEDICAID RESUBMISSION

CODE ORIGINAL REF NO

23 PRIOR AUTHORIZATION NUMBER

24 DATES OP SERVICE

From To PlACE

MM DO MM DD YY SERVICE 225 11 0225 11 11

022511 02 25111

4L

PROCEDURES SERVICES OR SUPPLIES

ExplaIn UnueusJ CIrcumstances DIAGNOSIS 0t ysjy ID RENDERING

5MG CPTftIQIQ MOOIRER POitflft CHARGES uKffe OUAL PROVIDER ID

97010 GO 12 55.00 MEGANRUTLEDGE

r___j NPI

97014 GO 12 55.00 MEGANRUTLEDGE

..____iiiii .11 i97035 00 12 60.00 MEGJANRUTLEDGE

I...._

97140 GO 12 65.00 MEGANRUTLEDGE

NPI

02 25 1III 11 02 25 11 11

02 25 11 02 25 11 11

02 25 11 02 25 11 97110 GO 12 75.00 MEGANRUTLEDGE

Ii. vs

02 25 1III 02 25 11 97535 GO 12 70.00 MEGANRUTLEDGE l..i 25 FEDERAL TAç to NUMBER SSN ElM

27-1033080 DEl

26 PATIENTS ACCOUNT NO 27 ACCEPT ASSIGNMENT 28 TOTAL CHARGE 29 AMOUNT PAID 30 BALANCE DUE

389.00

31 Sauaamaurac cr9 Fnyzsiuaan cm SUPPUER

INCLUDING DEGREES OR CREDENTIALS

aertity that the statements on the reverse

apply to thIs bfi and ate made part thereof

03/29/11

MEGAN RUTLEDGE OTR

SIGNED DATE

ÔTh1Üi1tAt INj4Uy

17200 E.1O MILE RD

EASTPOINTE MI 48021

NUCC InstructIon Manual avaIablo at WWW.flUCC.Or9

WCMS-1 SOOCS

ILOJYttUf lb

AFFHUVtL UMb 0935-0999 UNM cMs-1500 0505

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 16 of 28 Pg ID 328
HEALTH INSURANCE CLAIM FORM

PPROVED BY NATiONAL UNIFORM CLAIM COMM1TEE CBV5

PICA

STATE FARM INSURANCE

P.O BOX 2361

BLOOMINGTON IL 61702

PICA flf

TRICARE CHAMPVA GROUP FECA OThER

CHAMPUS HEALTH PLAN BU LUNG

fl ovrsore S5N Marab.tiDIfl$SNoFID ETh flA tWarna SEX

MiMtsIjtIaI 131DatlCskFrihI

ME3C rp

Ia INSUREDS ID NUMBER For Program In Item

22 C4 15636

INSUREDS NAME lust Name First Name Middle In

PATIENT RELATiONSHIP TO INSURED

PATIENT STATUS

san otherD

SIngle Merited fl other fl

EnWIOYad

FuIIllme fl Part-TIme fl Strident_U__Student__L.J

Name Rat Name MIddle InItIal to IS PATIENTS CONDITiON RELATED TO

INSUREOS ADDRESS No Street

10

ZIP

II

11 INSUREDS POLICY GROUP OR FECA NUMBER

Mi

INSUREDS DATE OF BIRTH SEX

TMDC

GROUP NUMBER EMPLOYMENT Current or Previous

9YES Exo

SEX AUTO ACCIDENT PLACE State

IMD FD DIES ENOL_jjjt

NAME OTHER ACCIDENT

DYES Exo

EMPLOYERS NAME OR SCHOOL NAME

tNSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE Mi

IS THERE ANOTHER HEALTH BENEFIT PLAN

DYES__4o If yes return to end complete Item

13 INSUREDWOt AUTROIED PERSONS SIGNATURE authorize

seivlcee described below

paant of medIcal benefIts to the undersIgned physIcIan or auppller for

SIGNATURE ON FILE SIGNED

PRtIGRAM NAME lEd RESERVED F0R LOCAL USE

BACK OF FORM BEFORE COMPLETiNG SIGNING ThIS FORM

payment ot government benefits etther to myself or to the pasty who accepts asslgonient

PERSONS SIGNARE authorize the eleaa of eny medIcal or other Hfoeton necaasa

ON FILE 03/29/11 DATE

Rat atFöR P5 IF PATiENT HAS HAD SAME OR SIMILAR ILLNESS

IMJIJRYAcctdarjflOfl GIVEFIRSTDATE MM DO VY

PREGNAMCYLMP INJURY

OR OTHER SOURCE

60 4.59 9.9 4_____I lim

18 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPAT1ON

MM1 DD MM DO

PROM TO

HOSPITALIZATION OATES RELATED TO CURRENT SERVICES

MM1 COi MM1 DCI YV

FROM TO

I_._............._ 1_..._.___ I_I 20 OUTSIDE LAB CHARGES

DYESDI LLNESS OR INJURY Relate llama 123 or to Item 24E by LIne 22 MEDICAID RESUBMISSION

CODE ORIGINAL REF NO

23 PRIOR AUTHORIZATION NUMBER

FCPRb18ERVIE3ORSUPPUET1

OIAGNOSIS .L_

J....

IPUCE OF1 ExplaIn UnusraI Clrournstancfl ID RENDERING

YY IsERflfil EMQLCPTfrJQP$tJ__ POj DUAL PROVIDER IOU

11 11 97110 GP 75 00 iUSTESGEORGE iI 11111 I_ r1_I

lrlI II

i._ ..

SSN LIN 26 PATIENTS ACCOUNT NO 127 CCEPTIGNM 28 TOTAL CHARGE 20 AIOIJRTAJD 13o EAIAHCFDUE

DE5 CHAJ0000 l4l DNO 75.00 75.00 Is

BUPiUER 32 CAtS flY nrAriwI 33 BIWNG PRbVIbkR INFb PH 58cY77Tr50O6 CREOEWT1ALS tOINTE PHYSICAL THE

rovoras

POINTE P1-ifS ICAL THERAPY

17200 E.1O MILE RD 03/29/11 17200 10 MILE SUITE 165

EASTPOINTE MI 48021 EASTPOINTE MI 48021

ri2859541O7 2Y1J ---. DATE

FICC natruotlon Manual avaIlable at www.nuoC.org F\rVrIUvItU LMU UWJbUIdid runrvi IAAS-1DUU UaeUD

WCMS-1 SOOCS

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 17 of 28 Pg ID 329
NUCC Instuaton Manual available at www.nucö.óig

WCMS-JSODCS

OW

HEALTH INSURANCE CLAIM FORM

BY NATIONAl UNIFORM AJM COMMrrTEE DaMs

rrrcA

STATE FARM INSURANCE

PD BOX 661023

DALLAS TX 75266

MEDICARE MEDICAID TIUCARE CHAMPVA GROUP FECA Dm511

JMotta tfllMatftól tomn sstq Mse WI ELAWNG1

PAtIENTS NAME Lest Mane flit Name titHe Vt4 J3 PA1IENISEIRTh DATE SEX

lie INSUREOS ID NUMBER Fcc Pogian Item

J22C457642

Ji IN$UREfl NAME Lest Name flit Name MISS lrcisiII

PATiENTS ADDRESS Na Steel PAT1EUY RELATIONSHIP TO INSURED

so4IJaaDothwLJ

INSUREDS ADDRESS sib SItS

OTHER INSUREDS NAME Il..t Mane flit Name MISi baSal r.nas W%

PATIENT STATUS DsD oD

EWCIOI.dEJ

prn pan.mner

Swdwi L.LSrsidon LU ID IS PATIENIS CONDITION RELAYED TSr

OTER INSUREDS POLICY OR GROUP NUMBER EMPLOYMENT lCtaranI as Prenlotis

Li

no cooen PLCE Sate

IXFta tUZj

OTHER ACCIDENT

DYES

NM RESERVED FOR LOOM I/SE

C1ThEiIREOS 011 OP BIRTH SEX MMDO

K6TE3rTñEiiI HOOLMAME

IN

OTHER INSUNEDS DATE OP BIRTH

WA00i YY

INSURAtCrnAN NAME OR PROGRAM NAME

SPATE FARM INSURANCE

15 T1CREMIDTHER IEAUH BENEI1T rtnn

EMPLOYERS NAME OR Sti400L NAME

SIMWRA$CCPIMFMME OR PROGRAM NAME

READ BACK Cc FORM BEFORE OOtAPtENO SIGNiNG THIS FOR

ogcosa

bib clan also request paymse ci cuensnant boots sWan to mysaS tO the pariy ales amapa aselyne$

12 PAIlENrS OR AUTHORIZED PERSONS SIGNATURE atittoiW the rebate cA wty medical or Sin ktlamatstgo necessary

SIGNED

SIGNATURE ON FILE DATE_P41

pA rabn lastS c0r7t5 hasp 9.4

13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE aHlostza

earAni described Eslaw

paynisnl ci metal becalM to the urtsaargsst pisysiclas or sapplier for

EIGNEO.SIGNAURC_ON FILE

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6000 foIst

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375D0 375100 33 8IUNQ PROVIDER $NF81 PH wi 02300444

NEW ERA PT SERVICE cc tU

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SONI

DATE

FLINT MI 48532 FLINT MI 48532

1336489139 lb

...- APPROVEIJ tnnu voQauarl FORM LMIrIDUU UWUD

KMRPPTOO6657I

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 18 of 28 Pg ID 330
2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 19 of 28 Pg ID 331
HEALTH INSURANCE CLAIM FORM

IBPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE OS/OS

PICA

NUCC Insizuction Manuat avafIaba at www.nucc.org

WCMS.IS000S

STATE FARM INSURANCE

90 BOX 661023

DALLAS IX 75266

rrr TRICARE CHAMPVA GROUP FECA OUtER

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INSUREDS OR AUTHORIZED PERSONS SIGNATURE CISIIonz

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saynlarU ol medNal bqnaIIM 10 the undoiclgnod

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PERSONS SIGNATURE eathorla the release t4 any nNAcS or SOlar hiHrntbon nacanary

ON FILE

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23 PRIOR AUTHORIZATION NUMBER

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CREDENTIALS

NEWERAPTSERVICES NEWERAPTSERVICES cC thruST

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FLINT MI 48532

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nrrrI.cc.d .nn I-uuuaq .i lit amuIa/v

KM RPPT0066573

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 20 of 28 Pg ID 332
it

LisN1

HEALTH INSURANCECLAIM FORM

PROVED BY NATIONAL UNIFORM ClAIM COMMITtEE 06/OS

STATE FARM

P0 BOX 661023

DALLAS TX

INSURANCE

75266 Lu

JfPICA PICA

MEDICARE MEDICAID TRICARE CHAMP VA GROUP

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FECA omm It INSUREDS l2 NUMBER For Progrern In liars

CHAMPUS HEALTh PLAN BLK LU.G

JMsdcremjMstcowfl memwwtfltsstoruv JJsst 12 2C4 57642

PATiENTS NAME Last Name FIrst Name WJdsce InitIal PATiENTS BIRTH DATE SEX 14 LNSUREDS NAilS Last Name First Name Middle Initial

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S4JSpouae Otherfl

PATIENT STATUS

sinoteD MsmIIedfl Otherjj

ErrqttoyedJ

Psnibnafl

Sttsilna L.J

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Lu

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MD FI DI

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EMPLOYERS NAME OR SCHDOL NAME OThER ACCIDENT INSURANCE PLAN NAME OR PROGRAM NAME

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INSURANCE PLAN NAME OR PROGRAM NAME lEd RESERVED FOR LOOAL USE IS ThERE ANOTHER HEALTh BENEFFr PLAN

NO If yea return to and complete Mm ed

READ BACK OF FORM BEFORE COMPI.ETINL SIGNING ThIS FORIL 13 INSUREOi OR AUTHORIZED PERSONS SIGNATURE euthorize

12 PATIENTS OR AUTHORIZED PERSONS SIGNATURE authorize the release of any medical or other Worrnellen nesessety payment of methcel benefits to the undersIgned phyeldsn or suppllet for

to Drocese this staIrs also request paiswu of goverrenenl benfls either to mysell or to the petty who acceple esslgnmerd services descreted below

below

SIGNATURE ON FILE 12/29/11 SIGNATURE ON FILE SIGNED DATE______________________ SIGNED

14 DATE OF CURRENT

ILLNESSt

en1olore OR 115 IF PATIENT FlAB HAD SAME OR SIMILAR ILLNESS 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

NPIIEGN CYLJIfNJURY GIVEF1RSTDATE Pat DO YY MM1 DO YY PAt DD YY QMQ4D YY 1INJURY tIe

FROM TO

ii NAME OF REFERRING PROVIDER OR OTHER SOURCE tie

tAll DOt YY MM1 OD1 TERRY REZNICK D.O

16.NOSPITAIJ7AI1ONDATESRELATEDTOCURRENTSERVICES

FROM TO

19 RESERVED FOR LOCAL USE 20 OUTSIDE LAB CHARGES

EYES__ 21 DIAGNOSIS OR NATURE OF ILLNESS OR NJURY Relate Items 123 oc4 to Ilem 24E by Line 29 MEDICAID RESIJBMISSION

8470 CODE ORIGINALREF.NO

23 PRIOR AUTHORIZATION NUMBER

847.1 4.L.... 24 DATES OF SERVICE PROCEDURES SERVICES OR SUPPUES

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tnt DD YY tAt DO YY I$BWCE EMG CPT/HCPQ$ MODIFIER POINTER CHARGES u% I%$-4 PROViDER ID

4511 08.1511 11 97535

GO Rt.TrLEDGE

l12 65.1001

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197010

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--

ceebed

25 FEDERAL TAX 10 NUMBER SUN EIN 26 PATIENTS ACCOUNT NO 127 ACCEPfASSIGNMENT 26 TOTAL CHARGE 29 AMOUNT PAID ISO BALANCE DUE

80-0503391 DRJ SCOPA000 1430 JfJYES flMO 380.130 IS 380400 Si SIGNATURE OF PHYSICIAN OR SUIPUER 32 SERVICE FACILITY LOCATION INFORIATIDN 33 BIWNG PROViDER INFO PI

INCLUDING DEGREES OR CREDENTiALS 81o3o.04.t ersertaitheteveree NEW ERA PTSERVICES NEW ERA PT SERVICES apply to thIs us and era made pall thereof

11/11/10 4007W COURTS1 SUITE G2 04007W COURTST SUITE G2

RUTLEDGE FLINJMI 48532 FLINT Ml 48532

SIGNED DATE 1336469139 lb va ntIv

NtJCC InStruGilon Manual available at www.nucC.Drp

WCMS.1500CS

nrrnljvca isivicl 0933-13999 FVrIM UMD-iDUM çUUDJ

KMRPPTOO665I3

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 21 of 28 Pg ID 333
2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 22 of 28 Pg ID 334
STATE FARM INSURANCE

P0 BOX 2361

BLOOMINGTON XL 61702

HEALTH INSURANCE CLAIM FORM

JPROVEO BY NATIONAL UNiFORM CLAIM COMMITTEE 08105

111 PICA PICA flT

ii

MEDICARE MEDICAID TRICARE CNAMPVA GROUP FECA OiliER

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12 2C4 49-799

j4 INSURE NAME Name Name Me liM

INSUREDS ADDRESS No Stint

ii INSUREDS POLiCY GROUP OR FECA NUMBER

INSUREDS DATE CF BIRTH SEX R1OI NAME

INSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE Mi

IS THERE ANOTHER HEALTh BENEFIT PLAN

YES if yeah retum to and cneIete lent ad

13 INSUREDS OR AUThORIZED PERSONS SIGNATURE Isuthodse

aerykes descried below

payment of medIcal benefits to the undersIgned physctan or supplier for

SIGNATURE ON FILE

SIGNED_______________________________

IS DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

MM DO MM GD FROIM ro

._

18 HOSPITALIZATION DAlES RELATED TO CURRENT SERVICES

MM DO VY MM

FROM TO

20 OUTSIDE LABI CHARGES

PATIENTS NAME tsat Name Fme Name MidRe Inec 9T SEX

PATIENTS ADDRESS No Steel PATIENT RELATIONSHIP TO INSURED

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SIngIe reaznect otner

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FtS1itne fl PaitTbne ri Student L.J Student

OThER INSUREDS NAME Last Name Fist Name MIMe hilts 10 IS PATIENTS CONDITION RELATED TO

OTHER INSUREDS POUCh OR GROUP NUMBER EMPLOYMENT Owrenl or Preotcue

9YSS NO OTHER INSUREDS DATE OF BIRTh AUTO ACCIDENT PLACE State MM DD YY

ME FE 1KJ END JyJIJ

EMPLOYERS NAME OR SCHOOL NAME OTHER ACCIDENT

ND it INSURANCE PLAN NAME OR PROGRAM NAME tEd RESERVED FOR LOCAL USE

READ BACK OF FORM BEFORE COMPLERNU SIGNING THIS FORM

to proceas tWa claIm also retiesI payment of governrnenl lienatlta ether to myself or to the patty who accepts assIgnment

below

it PATIENTS OR AUTHORIZED PERSONS SIGNATURE aithorlze the release of any medIcS or other Inforrealton

necessary

SIGNATURE ON FILE 07/15/11 SIGNED DATE

14 DATE OF CURRENT n.e.rIESS flat eymptcnr OR Its IF PATIENT HAS HAD SAME15R SIMILAR ELNE MM DI YY MJURYAcclderittOR PREGNANCYLAPINJURY1 GIVEFIRSTDATE MM DD YY

17 NAME OF REFERRING PROVIDER OR OTHER SOURCE fla

JOHN HOBAN M.D d-riA-5i2

19 RESERVED FOR LOCAL USE

21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items 123 or to tent 24E by Line

.iZ9 LQ2_

CVESJXHOI 22 MEDICAID RESUSM1SStON

CODE ORIGINALREF NO

23 PRIOR ALII1IORIZATION NUMBER

4.L. 24 DATES OF SERVICE PROCEOURESSERVICES ORSUPPIJES 1FL

From To IPLCE Or Exptahi Unusual Orctanstnces IDIAGNOSIS pays 1epsor

MM DO YY MM DO VY tRIVEt EMG CPT/HCPCS .WOOIFIER POINTER CHARGES tes

05i02t 97010 GP1

11105 02 lii llj i23 60100j .1

05 02t 11 05 02 lii llp 197032

GP 123 60

.OOp

ii

ID RENDERING

OUAL1

PROVIDER ID

SHAH

0502 11105 02 h1 111 197035

OP 1123 60

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NH

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SHAH- 0502 llj 05 02 11 llj

97140 10P 1123 60001

SRAH 0502 11j05 02 lip 11 197110 p123 7500p

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25 FEDERAL TAX ID NUMBER SEN EIN 28 PATIENTS ACCOUNT NO 12Z ACCEPT ASSIGNMENT 28 TOTAL CHARGE 29 AMIUNT PAID 130 BALANCE DuE

IFur gevi clause eee uackt

80-0503391 BONTE000 1O45IR1YES flNO 375J001$ 375400

31 SIGNATURE OF PHYSICIAN OR SUPPLiER 32 SEhV1CE FACIUTY LOCATION INPOIATION 33 BILLING PROVIDER INFO PP

INCLUDING DEGREES OR CREDENTIALS 81023o.o4.uw

Icetiltyttiattheatatemafleonthemvarae NEW ERA PT SERVICES NEW ERA PT SERVICES apply to tile bat end are made part thersut

01/03/il G4007W COURTST SUITE 02 04007W COURTST SUITE 02

SHAH FLINT MI 48532 FLINT MI 48532

SIGNED DATE 1336469139 1336469139

-. I. NLJCC Insimolion ManUal available at www.nucc.org

WCMS-1500CC

hrrn.sv ..L Uced 09384IStfM 1-UMM UMS-ThUD 05/1Th

KM RPPTOO654I

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 23 of 28 Pg ID 335
STATE FARM INSURANCE

U500 P0 BOX 2361

HEALTH INSURANCE CLAIM FORM

kPROVED BY NATIONAL UNIFORM CLAIM COMMI1TEE 0805

ET1

BLOOMINGTON IL 61702 LII

PICA Jr

MEOCARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER

CHAMPUS HEALTH PLAN BLK LUNG

peaicwu MedIcaid Bpevtsorg S$N LI MwaberID fl S$N or ID 558 ID

is INSUREDS NUMBER For Program In Item

INSUREDS NAME Last Name Fist Name MIddle Irdtlal

INSUREDS ADDRESS No Street

12

toII

ii INSUREDS POliCY GROUP DR FECA NUMBER

Mi

INSUREDS DATE OF BIRTH SEX

MM1 DO1 YY MK F0

PATIENTS NAME Last Name RrM Name Melds Irelial PA11EN1S BIRTH DATE SEX

PATIENTS ADDRESS NO Street PATIENT RELATIONSHIP TOINSIJRED

sesC spouse Other

segtefl Mamedfl Otherj

PATIENT STATUS

OTHER INSUREDS NAME .eat Name Firat Name Melds hIllel 10

trEflrU IS PA11ENVS CONDITION RELATED TQ

EMPLOYMENT Current or Prevtoua

ND AUTO ACCIDENT PLACE

JVES flND 4J OTHER ACCIDENT

flVES JND

OTHER INSUREDS POliCY OR GROUP NUMBER

OThER INSuREDS DATE OF BIRTH EMPLOYERS NAME OR SCHOOL NAME

MM1001

MD Ffl

EMPLOYERS NAME OR SCHOOL NAME INSURANCE PLAN NAME CR PROGRAM NAME

STATE FARM INSURANCE Mi

IS ThERE ANOTHER HEAlTH BENEFIT PLAN

flms ND It yes return to awl complete Item a-It

13 INSUREDS DR AUTHORIZED PERSONS SIGNATURE authorIze

eeivlcea rleacrthed below

payrneril of meilcal benefits to the unrieralgned pliyalclan or auppller for

SIGNATURE ON FILE SIGNED

INSURANCE PLAN NAME OR PROGRAM NAME lCd RESERVED FOR LOCAL USE

READ BACK OP FORM BEFORE COMPLEI1N..I SIGNING THIS FORM

jrrocesa

tile dahr alas request payrrrerlt of government benefits clIMe tO niyaelf or Ic the party who ecoepte asalgomenl

12 PATIENTS OR AUTHORIZED PERSONS SIGNATURE authorIze the release of airy medical Or ether totamiadmi necessary

SIGNATURE ON FILE 07/25/11 SIGNED DATE

14 DATE OF CURRENT

ILLNESSaPIret

evrrerianr OR 115 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS

INJURY

11 PREGNAIStZP1fNJURYI GIVEF1RSTDATE MM1 DO YV

17 NAME OF REFERRING PROVIDER OR OTHERSOURCE lit

JOHN HOBAN

19 RESERVED FOR LOCAL USE

lB DATES PATIENT UNABLE TO WORK IN CUFRENT OCCUPATION

MM4 DD MM1 DO VY

FROM TO

iS NOSPITALIZATION DATES RELATED TO CURRENT SERVICES

MM oo MM DD if

FROM TO

20 OUTSIDE LAB CHARGES

21 DIAGNOSIS OR NATURE OF1Ll.NESSR1NJUflY Relate hems 123 or to Item 24E by LIne

L. 8470 __

42 MEDICAID RESUBMISSION

CODE ORIOINALREF.NO

23 PRIGR AUTHORiZATION NUMBER

24A DATES OFSERVICE PROCEDURES SERViCES ORSUPPUES IH

Etoin To IPUCEOI Expilet UnusLIet CIrcrImacea IDIAGNOSIS 1E1aiJT ID RENDERING

KOit DO Yr MM DD Yr SB1YICE EMS CPTIHOPCS NODIF1ER POINTER CHARGES L1Ra DUAL PROVIDER ID

1502hl 050211 11 ----a 197035

GO1 6000 RuTLEDGE

J______l --ii IL

2P50211 050211 11

j97140

GO 60.400 RBDGE 11 I.I Mi

GOT 75-.OO RUTLEDGE

3502h1

050211 11 97110

4fSrO2rlliOSiO2illt

ill GO1 Ii

65.tOO RUTLEDGE

.1.1 tutf

97010 GO 6000

51D5

i04111I05IO4I11I 111 NPq en

3-

.RUJ1.EDGE 605 i04llIO5O411I 111 97014 GO Ii ss.ool NPI1

25 FEDERAL TAX ID NUMBER SON ElM 25 PATIENTS ACCOUNT NO 127 AccEh ASSIGNMENT 25 TOTAL CHARGE 2t AMOUNT PAID 30 BALANCE DUE

IParcrtsese.bst

80-0503391 DIJ BONTE000 1068 PUVES 37500Is 375400

SI BIGMATURE OP PHYSICiAN OR SUPPLIER 32 SERVICE FACILITY LOCATION INFORMATtON 23 BIWNO PROVIDER INFO

INCLUDING OEGREES OR CREDENIIAI.S 81oao.04c14

Icefllfythettheeletamenteonthe reverse NEW ERA PT SERVICES NEW ERA PT SERVICES

apply to tote hO and are made pail thereof

11/11 10 4007 COURT ST SUITE 02 4007 COURT ST SUItE 02

RUTLEDGE

SIGNED DATE

--

FLINT MI 48532 FLINT MI 48532

336469139 1336469 139 JII ttrnr NUCO nSInICtIOI1 Manual available at www.nucc.org

WCMS.l500cS

rrriuvt UMIS utaiowti WIIM UMSlBUU 05105

KM RPPTOO 65350

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 24 of 28 Pg ID 336
HEALTH INSURANCE CLAIM FORM

2PROVED BY NATIONAL UNIFORM CLAIM OOMMRTEE 0555

TTP

STATE FARM INSURANCE

90 BOX 661023

DALLAS TX 75266

PICA flT

Is

MEDICARE MEDICAID TRICARE CHAMPVA OROUP TWA OiliER

CHAMPUS HEALTH PLAN DLX LUNG

fl LI ssNJ

Is INSUREDS ID NUMBE.Z For Program ii lImo

122035 F93

INSUREDS NAME Lest Name fret Wane Middle

INSUREDS ADDRESS Na Street

II INSUREDS POLICY GROUP OR FECA NUMBER

113

INSUREDS DATE OtRTh SEX

paton

MjJ FJ EMPIOYERS NAME OR SCHOOL NAME

PATIENTS NAME Lest Name First Name Mile InitIal PARENTS BIRTH DATE SEX

PATIENTS ADDRESS No. Street PATIENT RELATIONSHIP TO INSURED

L5pouseDct1C otoC

Is PATIENT STATUS

stngtefl MaMad otnerE

StudentLJ

QUasH IRSUFasSJS NAME Lest Name Errol Name MillIe ciba to IS PATIENTS CONDItiON RELATED TO

EMPLOYMENT Currant or Prorlous

JYES

ACCIDENT pI

fJNOjJ OTHER ACCIDENT

QYES EcNo

OTHER INSUREDS POUCY OR GROUP NUMBER

OTHER INSUREDS DATE OF BIRTH

MM00j if

IMD fl INSURANCE PLAN NAME ORPlIORAM NAME

STATE FARM INSURANCE Ill

tI IS THERE ANOTHER HEALTH BENEFiT PLAId

Li YES NO Is yes return ID end complete Item a-tI

15 INSUREDS OR AUThORIZED PERSONS SiGNAtURE euthorrze

peyrnent of medcel benefits to the underalgred physician or euppller lot

JL

servIces deacrlbed below

SIGNATURE ON FILE SIGNED

15 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DO if MM DO if

FROM TO

MM DO if MM DO if

18 HOSPITALIZAT1ON DATES RELATED TO CURRENT SERVICES

FROM TO

20 OUTSIOS LAB CHARGES

EMPLOYERS NAME OR SCHOOL NAME

INSURANCE PLAN NAME OR PROGRAM NAME iUURESERVEO FOR LOCAL USE

READ BACK OF FORM BEFORE COMPLETIN SIGNING ThIS FORM

12 PATIENTS OR AUTHORIZED PERSONS SIGNATURE authorIze the release of wry medIcal or other Wormatlcei necesaary

thcen lila clan also request pametrt of government Ireneitte elthw to myself to the party who eccepto asalgnmarri

SIGNATURE ON FILE 10/31/11 SIGNED DATE______________________

14 DATE OP OURRENT ILLNESS Arat ayrrrpccrn OR 115 IF PATIENT HAS HAD SAME OR SIMILAR IUNESS Mt DO if INJURYAccklerrOOR GIVEFIRSTDATE MM DO if

08 19j11 PREGNANCYLMPINJURY

NAMEOcREFERRINGROVIDERORb1ERSOUACE i7e

TERRY REZNICK D.O

19 RESERVED FOR LOCAL USE

21 DIAGNOSIS OR NATURE OF IU.NESS OR INJURY Retele Items 123 or to Item 245 by Line 22

DYES

MEDICAID RES

CODE

USMISSION

ORIGINAL REF NO

23 PRIOR AUTHORIZATION NUMBER

24 DATES OP SERVICE PROCEDURES SERVICES OR SUPPLiES

Front To Iyu EIaWt Uauaual

DIAGNOSIS DaYS Itretr ID RENDERING

MM DO if MM DO if SERBEE EMG CPTIHCPCS POINTER CHARGES ufls It OUAL.1PROVIDER ID

08 29 i1Io 29 14 11 97001 GPr 300OO SOffl

08 29 05 lii OQ 29 lJj

97010 GPr 60L9 _I_

08 29 11 08 29 11 97032 GPT 6000 NI

i_

08 29 lii lJj 14 97035 1GP ji 6000

0901 00

llj 0902414 14 j9701O0P

SONL__

HP

09 024 llj 09 024 14 ii j97o32 GP

FEDERAL TM 10 NUMBER SSN EM 20 PATIENTS ACCOUNT ND ACCEPT ASSIGNMENT neaad4

80-0503391 JOHWI000 13431YES LINO

31 SIGNATURE OF PHYSICIAN OR NUPPUER 32 SERViCE FACILiTY LOCATION INFORMATION

INCLUDING DEGREES OR CREDENTIAI.S

Del theatetemenraontherevense NEW ERA PT SERVICES apply to 5th Mend ore credo pail thereof

09/19/11 G4007 COURTST SUITE 02

SONI FLINT MI 48532

DATE t..133646913_9 Jb

6009 28 TOTAL CHARGE 29 AMOUNT PAID 139 BALANCE DUE

600.00I$ 600100

33 BIWNG PROVIDER INFO PH

81Q230-0444

NEW ERA PT SERVICES

4007W COtJRTST SUITE 02

FLINT MI 48532

NUGG InStnjClIOn Moflual avaliaDie at www.nuoc.org

WCMS-ISOOCS

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KMRPPTOO5OT83

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 25 of 28 Pg ID 337
II

NUCC Instruction Manual available at www.nucc.org

WCMSlSOOOS

STATE FARM INSURANCE

PC BOX 661023

DALLAS TX 75266

HEALTH INSURANCE CLAIM FORM

2PRDVED BY NATIONAL UNIFORM CLAIM COMMITTEE DaBS

PICA PICA flf

MEDICARE MEDICAID THICARE CHAMPVA GROUP FEd OThER Is INSUREDS P.O NUMBER For Progrmiits Item

CI4AMPUS HEALTH PLAN BUC LUNG

etD9.coaaswfl fltspcnsorassN JMmseruiflIssNw1tu

PATIENrS NAME last Name Fuel Name MhSe InNS PATIENTS BIRTH DATE SEX

flfll if IM PATIENT RElATIONSHIP TO INSURED

INSUREDS NAME Last Name First Name MIddle nEat

PATIENtS ADDRESS Na Sheet INSUREDS ADDRESS Na Street

Sen spousefl dlttfl Other

PATIENT STATUS

cte or9

EnPleYd fl FtTIine PaThse fl Sludeul Studenl L.J

OThER INSUREDS NAME last Noma First Name Middle lANaI 10 IS PATIENTS CONDITION RELATED TO

EMPLOYMENT distant or PrevIous

DYES AUTO ACCIDENT PLACE Sfl

YES DNO iIL OTHER ACCIDENT

LIVES ND

Ii INSUREDS POLICY GROUP OR FECA NUMBER

Ui

INSUREDS DATE OF BIRTH SEX

WA1001 YY JLNAME OThER INSUREDS POLJCY OR GROUP NUMBER

Br OTHER INSUREDS DATE OF BIRTH SEX

MM DO if

FD EMPLOYERS NAME OR SCHOOL NAME INSURANCE PLAN NAME OR PRDGRAMNAME ISTATE FARM INSURANCE

INSURANCE PlAN NAME OR PROGRAM NAME lOd RESERVED FOR LOCAL USE IS ThERE ANOThER HEALTH BENEFIT PLAN

YES UyatrewmloandcoflrlsleftemSe-d

13 INSUREDë OR AUTHORIZED PERSONS SIGNATURE authorize

services descrthed below

peynreet of medical berrellls to the undersIgned physloan or supplier for

SIGNATURE ON FILE SIGNED

REAflXEK OF FORM BEFORE COMPL Pd IONINO THIS FORM

ceea thIn dalni also request payment ci govemment beneEla esher ID myaet or to the party who accepts assignment

12 PATIENTS OR AUTHORIZED PERSONS SIGNATURE enNorlze the release of any medIcal or oUter InloImation necesawy

SIGNATURE ON FILE 10/31/11 SIGNED DATE______________________

14 DATE OF CURRENT .i ILLNESS Ran anmorom OR 115 IF PATIENT HAS NM SAME OR SIMILAR IU.NESS

DD YY /tIINIURYAcusIeriflCR GIVE RRSTOATE MM DD

08 19 ii NPREGNANCYLNPINJURYI

17 NAME OF REFERRING PROVIDER OR OTHER SOURCE vs.1

TERRY REZNICK im.f4PTi2 9527445

19 RESERVED FOR LOCAL USE

16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATiON

DO if 001 if

FROM TO

MMI DO if I00I ia HOSPITALIZATION DATES RELATED TO CURRENTSERVICEE

FROM TO

20 OUTSIDE LAS CHARGES

DYES_juo 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY ReIaIe tlema 12.3 or to Item 24E by Lire fl MEDICAID RESUBMISSION

CODE ORIGINAL REF NO

23 PRIOR AUTHORIZATION NUMBER

L._.__

Pratt To Ituc on ErrpIaIrI Unusual Glrcwnatancsel DIAGNOSIS lOiTEr ID RENDERING

24.A OATESGFSERVICE O.PROCEDURESSERVICESORSUPPLIES 114

WA DO if MM DO if ISEIMSEI EMG CPTfrICPCS J4ODEfR POINTER CHARGES stars OUAL PROVIDER 10.1

RtJTlEDGE 09 01 111 09 01 11 97003 OOs

j12 300

0901 ill 09 01 lii ill j97010 GO 12 60t00

O90iiljO9 01 121 111970141G0 .1 j12 504

09i01i2iEL29 0111 jGO 112 65toq

BIJrLL NPII

CE

NPII

SUTLEXa

NPI

NPI

O9O211f 09 02 131 97010 100 J12 so.oq 11

09J 02 11 o2L 021 11 14 97014 GO 112 55t0 25 FEDERAL TAX 1.0 NUMBER SSN EIN 2$ PATIENTS ACCOUNT NO 127 ACCEPT ASSIGNMENT tdstnuasebsdrl

80-0503391 Dlii Jouwi000 1344jjYES

31 SIGNATURE OF PHYSICIAN OR SUPPLIER 32 SERVICE FACILITY LOCATION INFORMATION

INCLUDING DEGREES OR CREDENTIALS

Ocrstyaraltieetatementeonthemvere NEW ERA PTSERVICES aypty to Ode bit and era made pail thereof

11/11/10 4007 COURT ST SUITE 02

RUThEDGE ELIbIIJAJA8.532

SIGNED DATE j236489139

28 TOTAL CHARGE fl AMUUNT PAID

J30

BALANCE DUE

5950O 595100

33 BILLING PROVIDéT INFO PItS 8123O0444

NEW ERA PTSERVICES

4007 COURT St SUITE 02

FLINT MI 48532

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2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 26 of 28 Pg ID 338
P4UCQ Instruction Manual avallab4s at www.nucc.org

WCMSISOOCS

1500

HEALTh INSURANCE CLAIM FORM

PPReTVED BY NATIONAL UNIFORM CLAIM COMMITTEE OSOS

TflPCA

STATE FARM INSURANCE

P0 BOX 661023

DALLAS TX 75266

PICA

MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OilIER

CHAMPUS HEALTH PLAN GLIC WNG JMedicne

is INSUREDS 1.0 NUMBER For Prograrnin Item

220 35F9 30

PATIENTS NAME Last Name Fkst Name MlSa ketIsI PATIENTS DIRTH DATE SEX INSUREDS NAME Lsel Name First Name MidcSs hIlleD

I______________________

PATIENTS ADORESS Nt Street PATIENT RELATIONSHIP TO INSURED lDE ostarflINSUREDS ADDRESS Nà Set

PATIENT STATUS

singiefl stmfl

FuJTImo Part-TÈne

Esriployed SEalant Studeal

OTNEFI INSUNEDS NAME Last Name FIrst Name MIddle 52251 Ia IS PATIENTS CONOmON REL.ATED TO

EMPLOYMENT Cretan or Prenloers

EYES

AUTO ACCIDENT PLACE 5MM

DNowu OTHER ACCIDENT

ii INSUREDS POLICY GROUP OR FECA NUMBER

INSUREDS DATE OI BIRTH SEX

puLS.rvl.w

OTHER INSUREDS POLICY OR GROUP NUMBER

OTHER INSUREDS DATE OF BIRTH SEX

ME fl

EMPLOYERS NAME 01% SCHOOL NAME

EMPLOYERS NAME OR SCNCXX NAME INSURANCE PLAN NAME OR PROGRAM NAME

STATE FARM INSURANCE

INSURANCE PLAN NAME OR PROGRAM NAME itio RSEAVED FOR LOCAL USE IS THERE ANOTHER HEALTH BENEFIT PLAN

NO IF yes return 10 and complete Item m.d

READ BACK OP FORM BEFORE COMPLETIN. SIGNING THIS FORM

IL PAREFJFS OR AUTHORIZED PERSONS SIGNATURE authorize lbs release of any rnerdeal or other Ènonnatlon necessary

rocess thIs olsEn also request payslent ci govemmenl berteills eIther to myself or to the party abc armapls asslgrsnern

13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE authorize

payment ol medical banal lie Ia the tsrderslgned physician or suppilar for

servIces described below

SIGNED

SIGNATURE ON FILE DATE

10/31/11

14 DATE OF CURRENT ILLNESS FIrst aoetea DR 115 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS

MM DO YY INJURYIAccIrMoIIOR GIVE FTRSTDATE WA DO Yr

08 19 11 PREONAUCYLMPINJUR1

SIGNED

SIGNATURE ON FILE

16 PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

MM CO YY MM CD

FROM TO

11 NAME OF REFERRING PROVIDER OR OTHER SOURCE im

TERRY REZNICE D.O FITh.INPII 1295874451

16 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DO VY WA GD YY

FROM TO

it RESERVED FOR LOCAL USE 20 OUTSIDE LAB CHARGES

21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items 123 or to Earn 24 by Line

3.L_._.____

4.L............

24 DATES OF SERVICE PROCEDURES SERVICES OR SUPPUES

From To PLACE cr4 EspleIn Urersiatl

DIAGNOSIS

sea DO MM DO Yr SEITCEI EMG CPT/NCPCS MODIFIER POINTER

DYES__ 22 MEDICAID RESUBMISSION

CODE ORIGINAL REF NO

23 PRIOR AUTHORIZATION NUMBER

easE 9007

CHARGES ria

ID

OUAL

RENDERING

PROVIDER ID

09 01 ill 001 13 13 97035 GP 60.0

09 02 lii 02 97010 GP 600Q

09 02 .QM 1i1 02 11

13

97032 CP

60.09

09 02 lij 09 13 11 97035 6009

0908 11109 13 13 1970101 GP 60.9

9J_91.211 09 08 11 13 GP 60.0Q

-r

25 FEDERALTAX ID NUMBER BEN SIN

80-0503391

28 PATIENTS ACCOUNT ND 27 AEPTSNI4EJ

JOHWI000 1343 YES

26 TOTAL CHARGE 29 AMOUNT PAID 30 BALANCE DUE

__10J008 360100

31 SIGNATURE OF PI4YSICIAHCR SUPPliER 32 SERVICE FACILITY LOCATION INFORMATION 33 BILLING PROViDER INFO PH

INCLUDING DEGREES OR CREDENTIALS 81v230-0444

ptthIs ElI end era medeapart thereof

NEW ERA PT SERVICES NEW ERA PT SERVICES

09/19/11 4007W COURTST SUITE G2 04007W COURTST SUITE 02

SONI JEUNLMIA$532___________________ FLINT MI 48532

SIGNED DATE em3s1b

srrntivcu 0MB O938tjtjtj 1tJflPrl3 IJMSIDULJ UUIUO

KM RPPT0050785

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 27 of 28 Pg ID 339
HEALTH INSURANCE CLAIM FORM

aRoVED BY NATiONAL UNIFORM ClAIM coMMrrrEE cares

PICA

STATE FARM INSURANCE

P0 BOX 661023

DALLAS TX 75266

PICA fl7

CHAMPUS HEALTH Pt/N BLIC LUNG

MEDICARE MEDICAID TRICARE CNAMPVA GROUP FECA OTHER INSUREDS LO NUMBER For Progrein In limo

DMb0sDs5brn fliswo 22035 F93

PATIStWS NAME flat Rn Nfl t55 MiSI PAENTS BII DATE INSUREDS NAME LAst Nama Name

MtoiI

PATIENTS ADDRESS Na Street PATiENT RELATTONSHIPTO INSURED

senJ Spouse cblld Otherfl

INSUREDS ADDRESS Na Steel

PATIENT STATUS

Sifl Marrlodfl other

Put-Time Peot-Tfrne fl EThIOS Studenl Stodent

OTHER INSUREDS NAME Last Name PhIl Name Middle ItItlal

10 IS PATIENTS CONDITION RELATED T0

EMPLOYMENT Current or Previous

AUTO ACCIDENT PLACE State

IYES LM.IJ

OThER ACCIDENT

11 INSUREDS POLICY GROUP OR FECA NUMBER

uJ

OTHER INSUREDS POLICY DR GROUP NUMBER INSURED DATE OP BIRTH SEX

OTHER

EM

INSUREDS DATE OF

DO YY

BIRTH SALE

MJ rp EMPLOYERS NAME OR SCHOOL NAME INSURANCE PLAN NAMEtR PROGRAM NAME

STATE FARM INSURANCE 1st

INSURANCE PLAN NAME DR PROGRAM NAME 105 RESERVED FOR LOCAL USE IS THERE ANOTHER HEALTH BENEFIT PlAN

YES NO if return to and complete ItemS ad

13 INSUREDS OR AUTHORIZED PERSONS SIGNATURE authorIze

services denoted bates

payment of melboal banallta 10 the undersigned phyaldan or eiwpller br

SIGNED_SIGNATURE ON FILE

READ BACK OF FORM BEFORE COMPLETiNG SIGNING THIS FORM

to process thIs dfln also request paymami of goverrenant benallls eIther 10 myself or to the party etmo aocepta assrganant

below

12 PATIENTS OR AUTHORIZED PERSONS SIGNATURE authorIze the release of any medico or other ailarmatiorm neoemary

SIGNED

SIGNATURE ON FILE DAlE

10131/11

14 DATE OF CURRENT LLNESS FEet astaplom OR 115 IF PATIENT HAS NAG SAME OR SIMILAR IU.NESS

EM AINJURYMSdeIIIOR GIVEF1RSTDATE MM

08 19 J.i

IT NAME OF REFERRING PROVIDER OR OTHER SOURCE

TERRY REZNICK D.O ktNPrk29587445

16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

OD YY MM DD

PROM TO

15 HOSPITAUZA11ON DATES RELAtED TO CURRENT SERVICES

MM DI MM1 DC FROM TO

19 RESERVEO FOR LOCAL USE 20 OUTSIDE LAB CHARGES

21 CLASS oR NATURE OF IU.NESS OR INJURY IRstate Items t23 or to barn 245 by LIne

LJ L__

4L____

24 DATESOFSERVICS PROEOURES SERVICES ORSUPPLIES

From To JItAC0FI Pusfl Unusual Clroumuthlcas IDIAGNOSIS

MM DO YY MM CO ISERNCE EMS CPT/HCPCS MODIFIER POINTER

9YES 25 MEDICAID RESUBMISSION

CODE ORIGINAL REF NO

23 PRIOR AUTHOR2AI1SSI NUMBER

IN

ante rroor

on tony CHARGES umaTa Pan

ID

DUAL

RENDERING

PROVIDER ID

09 02 13109 02 IL 13 97035 GOr 12 60c00 VIP3

09 02 131 02 11 97124 GOt 12 60c00 -- ------ INFI

09 08_lij_0908_13_13 97010 GOL j_12 60.09__1 NPI

-a

I..fl1-Eg

09 08 11j09 oa 11 11 97014 GO 12 5509 PT

09 08_134_09_0_13_13 97035 GO 112 60.09__1

a---

NPI

09 08 1j 090 13 97124 GO 12 6000 --

NPI

25 FEDERAL TM ID NUfeER SSN EIN 25 PA11ENTS ACCOUNT NO 2T ACCEPT ASSIGNMENT 2$ TOTAL CHARGE 29 AMOUNT PAID 130 BALANCE CUE

IFaantSoens.aeelmdr

31

80-0503391

SIGNATURE OF FHYSICLAII ON SUPPUER

DE rSERVI5E

JOHWI000 Pctun LOCATION INFORMATION1344ff YES

OVIRqNFbS PH.D

3551 00

INCLUDING DESREES OR CR1ENTIAI.S 81 230-0444

OestdvthaeoOwrevese NEW ERA PT SERVICES NEW ERA PT SERVICES apply Is this bit and are made pert thereof

1111/10 G4007W COURTST SUITE G2 4007W COURTST SUITE G2

RUTLEDGE JELINLML4B532__________________ FLINT MI 48532

SIGNED DATE tJ236482i.39 93Jb --

NLJCC InSIzUClIOn MSI1UBJ available BE www.nUCo.org

WOMS-ISCOCS

RVVHUVtL 0MB 0938-0999 FORM CMS- WIAJ UtI/UD

KMRPPTOOSOB85

2:14-cv-11700-PDB-MJH Doc # 1-29 Filed 04/29/14 Pg 28 of 28 Pg ID 340