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i Patient . JftU Srtfe Date of E IflAf/w Medical Records &/ct~ BilHng-APi?lPATFT/ CERTIFICATION vr .^asajfe^ y /attached. 24Z care prcnddeji-j. certifythat ;Ee SINGLE SIDED PAGES: (tad/orDOTTED? STDHD PAGES: are fane and canectcopies ofiPCDxds memtafnrvT ty aLcrra wiEt respectin the idenilned parrot. Said attached records were made and. imvt betm mjuafained. in.fee ccrdmary co arse offrnstness. R-SJMC-BILLS-0001 ! a CATHOLIC HEALTH T INITIATIVES St Joseph Medical Center FRANCISCAN HKAl.TH SYSTEM mrnummMmrnm NOLL,DONALD ERWIN LX MmtaHFjHNWKit . a. WCHAIa.: 01/16/13 mastercard VASA DISCOVER SILL DATE 02/05/13 STMT TYPE D1 BILLER 42 AMEX CARD NO. EXP. DATE SIGNATURE _________________________________ GUARANTOR: DONALD ERWIN NOLL PO BOX 2703 BELFAIR WA 98528 ST JOSEPH MEDICAL CENTER PO BOX 31001-1456 Pasadena CA 91110-1456 PLEASE&jgASETHIS PORTION WITH_TOLLR_PATMaVTAND WIBTE.YOL^R ACCOUNT NUMBER ^NYeUR CHECK PAGE NO. 001 R-SJMC-BILLS-0002 STATEMENT OF ACCOUNT D St. Joseph Medical Center TKANQ5CAN HFAITH SYSTEM NOLL,DONALD ERWIN 1300409917 01/04/13 U MASTEH CAHO CARD NO. ______ SIGNATURE _____ BILL DATE IP 01/17/13 01/09/13 STMT TYPE D1 DISCOVER AMEX BILLER 63 ---------- EXP. DATE________ GUARANTOR: DONALD ERWIN NOLL PO BOX 2703 BELFAIR WA 98528 ST JOSEPH MEDICAL CENTER PO BOX 31001-1456 Pasadena CA 91110-1456 W 01 /04/13 01/05/13 01/06/13 OT107/13 01 /OB/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/06/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/08/13 01/07/13 01/07/13 01/07/13 01/07/13 01/05/13 120 120 120 120 120 250 250 250 250 250 250 250 250 250 250 250 270 270 270 270 270 270 270 270 270 27B 278 278 278 300 PLEASEWOO$E THIS POPmpN WTH_YpliR PAYMgTBND WWTE YOURACCOUrTT NUMBER QNYOUR CHECK_ . *M**,tW`*1&* 2030 2030 2030 2030 2030 ROOM 07D4 P ROOM 07D4 P ROOM 07D4 P HCOM 07D4 P ROOM 0704 P TOTAL ROOM-BOARD/2BED wffim Uws*-:?.im";s-sisiiss!siissjsss oxvKviwwc- Fr^*ra,CE i 2,330.00 i 2,330.00 1 2,330.00 1 2,330.00 1 2.330.00 3209 4147 4568 5794 5794 6794 6851 7359 7514 8054 8107 ROCURONIUM 60MG/6ML INJ SEVOFLURANE 20ML PROPOFOL 200MG/20ML INJ TALC POWDER SPRAY 30 GM TALC POWDER SPRAY 30 GM INTUBATION ANESTHETIC OCTYLSEAL TOP SKIN ADHESIVE LIDOCAINE PF 2% INJ 5ML VASOPRESSIN 20U INJ NEOSTIGMINE TO MG/10ML BUPIVACAINE 0.6% -P EPI INJ 3 TOTAL PHARMACY 1 294.BO 1 278.30 i 190.85 2 517.85 -1 517.85 1 103.70 1 150.00 1 79.85 1 207.00 1 251.95 1 247.05 3705 1286 1540 177 2590 3674 3705 7802 1366 SOL D6 NACL 0.45PCT 1000ML 8 DRAIN CHEST DRY SUCTION ATRI GENERAL SUTURE |0 TO 5-0 SUT PACK ENDOSCOPIC TRIAD HANDPIECE BLADED TB ENDO BRONCH-CATH R/L 39F SOL D5 NACL 0.45PCT 1000ML B TRNSDCR IV VAMP 72IN KIT SYR SNGL W/T CONN STELLA TOTAL MED-SUR SUPPLIES 1 12.00 1 211.56 3 20.50 1 182.40 1 259.89 1 272.27 1 12.00 1 103.32 1 37.42 2399 2812 6416 857 TRCR BLDLS XCL W/OPTIVW 75-1 CATH DRAIN HYDRAGLIDE XL 20HEMOSTAT ORIGINAL 2X14IN ABS CATH TRY STLK U/M 16-18FR (B TOTAL SUPPLY/IMPLANTS 1 237.05 1 115.87 1 263.17 1 72,40 3269 85026 CBC/DIFF 1 81.90 2.330.00 2.330.00 2, 330.00 2.330.00 2.330.00 11,650.00 294.60 278.30 190.85 1,035,70 517.85CR 103.70 160.00 79.85 207.00 251.95 247.05 2.321.15 12.00 211.56 61 . 50 182.40 269.89 272.27 12.00 103.32 37.42 ,152.36 237.05 116.87 293.17 72.40 688.49 B1.90 NOTE: THIS BALANCE DDES NOT INCLUDE PROFESSIONAL CHARGES FOR PHYSICIANS SUCH AS EMERGENCY PHYSICIANS, ANESTHESIOLOGISTS, RADIOLOGISTS, PATHOLOGISTS AND CARDIOLOGISTS. YOU WILL RECEIVE A SEPARATE BILL DIRECTLY FROM THE PHYSICIAN FOR THOSE SERVICES. PAGE NO. 001 STATEMENT OF ACCOUNT R-SJMC-BILLS-0003 xCATHOUC HEALTH T INITIATIVES St, Joseph Medical Center FRANCISCAN HEA1TH SYSTEM NOLL,DONALD ERWIN 1300409917 01/04/13 G MASTER CARO ip 01/09/13 D VISA Q DISCOVER BILL DATE 01/17/13 STMT TYPE D1 BILLER 63 G AMEX GUARANTOR; DONALD ERWIN NOLL PO BOX 2703 BELFAIR WA 98528 CARD NO, _EXP. DATE _______________________________________ SIGNATURE __ ----- ST JOSEPH MEDICAL CENTER PO BOX 31001-1456 Pasadena CA 91110-1456 mmmmm#-*:' ******* 01/06/13 01/05/13 01/06/13 01/06/13 01/06/13 01/06/13 01/06/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/OB/13 01/08/13 01/08/13 01/08/13 01/08/13 01/08/13 01/08/13 01/08/13 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 01/07/13 01/08/13 01/09/13 01/09/13 320 320 320 320 01/08/13 341 01/08/13 343 01/08/13 350 iUUEBKLOSiTHSPOjgpJiWWTEVpUFLAC^ypiTNUMBaQNjrgUj CHJCK. ' flBSCRlPTlON 4092 4740 3269 3360 4095 8015 8015 3120 3269 4095 4695 4700 BOI5 3269 4095 4720 4810 9015 BOI 5 8015 B470 80053 CGMPREHENSIVEMETABOLIC B3735 MAGNESIUMSERUM 85026 CBC/DIFF 85010 PROTHROMBINTIME 80048 TPNPANEL10 36415 VENIPUNCTURE 36416 VENIPUNCTURE 81003 URINALYSISW/OUTMICROSC 85025 CBC/DIFF 90048 TPNPANEL10 83540 IRONSERUM 83560 TOTALIRONBINDINGCAFACI 36415 VENIPUNCTURE 85025 CBC/DIFF 80048 TPNPANEL10 83616 LACTATEOEHYDROGENASE 84132 POTASSIUM 36416 VENIPUNCTURE 36415 VENIPUNCTURE 36415 VENIPUNCTURE 82378 CARCINOEMBRYONICANTIGE TOTAL LABORATORY i IT(M PRICE 1 99.25 1 83.45 1 81 .90 1 90.24 1 92.10 1 56.00 1 56.00 1 34.65 1 81 .90 1 92.10 1 61.80 1 83.60 1 56.00 1 SI .90 1 92.10 1 34.40 1 54.70 1 66.00 1 56.00 1 66.00 1 181.05 7101 7101 7101 7102 71010 XR CHEST SINGLE VIEW 71010 XR CHEST SINGLE VIEW 71010 XR CHEST SINGLE VIEW 71020 XR CHEST-2 VIEW TOTAL DX X-RAY 1 369.60 1 369.BO 1 369.60 1 510.00 3003 78306 NM BONE SCAN - WHOLE B TOTAL nuc med/dx 3289 NM ISOTOPE TC MDP UP TO 30 M TOTAL NUC MED/DX RADIOPHARM 2264 74177 CT ABDOMEN AND PELVIS TOTAL CT SCAN 1 2,691.09 1 118.81 1 6,869.72 99.25 93 .45 81.90 90.24 92.10 56.00 56.00 34.55 81 .90 92.10 61 .80 83.60 56.00 81 .90 92.10 34.40 54.70 66.00 66-00 56.00 1S1.05 1,662.94 369.60 369.60 369.60 610.00 1 .618.60 2.691.08 2.591.08 118.81 118.81 6.868.72 6.858.72 ROTE: THIS BALANCE DOES NOT INCLUDE PROFESSIONAL CHARGES FOR PHYSICIANS SUCH AS EMERGENCY PHYSICIANS, i ANESTHESIOLOGISTS. RADIOLOGISTS, PATHOLOGISTS AND CARDIOLOGISTS. YOU WILL RECEIVE A SEPARATE BILL DIRECTLY -------F-R-O-M.-T-H-E--P-H-Y-S-IC-I-A-N-F-O-R--T-H-O-S-E--S-E-R-V-I-C-ES. L PAGE NO. 002 STATEMENT Of ACCOUNT R-SJMC-BILLS-0004 D r initiatives St. Joseph Medical Center FRANCISCAN HEAITH SYSTFAl NOLL,DONALD ERWIN 1300409917 01/04/13 MASTER CARD CARD NO. SIGNATURE MIL DATE IP 01/17/13 01/09/13 G VISA discover STMT TYRE D1 AMEX BILLER 63 EXP. DATE GUARANTOR: DONALD ERWIN NOLL P0 BOX 2703 BELFAIR WA 98528 ST JOSEPH MEDICAL CENTER PO BOX 31001-1456 Pasadena CA 91110-1456 PLEASEENCLOSETHl TORTJON WTHjraJRPAY!<e!IA!ID.WPSTE ^TOUR ACOOUNT NUMBER QNjrgUB CHECK iwm?6 U6B2 (tv ITEM NO OMOWmMt 01/07/13 01/07/13 01/07/13 360 360 360 1605 1606 5672 SURGERY INTERMED 1ST 15MIN SURGERY INTERMED EA ADDL 15M ARTERIAL LINE PLACEMENT TOTAL OR SERVICES iiii is; i 4 1 tYtft H3ICS 2,568.04 2,668.04 406.67 01/07/13 01/07/13 370 5000 ANES GEN EA ADDL 15 MIN 370 7000 ANESGEN 1ST 16 MIN TOTAL ANESTHESIA 4 322.86 1 703.03 oi/oa/13 611 B 70663 JOI MFtl BRAIN WO W TOTAL MRI-BRAIN 1 6,474.00 01/04/13 01/04/13 01/04/13 01/04/13 01/06/13 01/05/13 01/05/13 01/05/13 01/05/13 01/05/13 01/05/13 01/06/13 01/06/13 01/06/13 01/06/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 01/07/13 Qt/07/13 01/07/13 01/07/13 01/07/13 01/06/13 636 636 636 636 636 636 636 636 636 636 636 636 636 636 636 636 B36 636 636 636 636 636 636 636 636 636 5199 5586 6B5E 6665 5199 5199 5199 5586 6655 6655 6655 5586 6555 6656 6665 49B2 5098 55B6 6655 6665 7562 7899 7903 8220 9498 5257 MORPHINE SULFATE 2MG/ML INJ LEVOFLOXACIN 76OMG/1S0ML INJ PIPERACILLIN-TAZO 3.375 G IV PIPERAC1LLIN-TA20 3.376 G IV MORPHINE SULFATE 2MG/ML INJ MORPHINE SULFATE 2MG/ML INJ MORPHINE SULFATE 2MG/ML INJ LEVOFLOXACIN 750MGM50ML INJ PIPERACILL1N-TAZO 3.375 G IV PIPERACILL1N-TAZO 3.375 G IV PIPERACILLIN-TAZO 3.375 G IV LEVOFLOXACIN 760MG/150ML INJ PIPERACILLIN-TAZO 3.375 G IV PIPERACILLIN-TAZO 3.375 G IV PIPERACILLIN-TAZO 3.375 G IV HYDROMORPHONE PCA IMG/ML 30M HYDROMOHPHONE IMG/ML INJ LEVOFLOXACIN 750MG/150ML INJ PIPERACILLIN-TAZO 3.376 G IV PIPERACIUJN-TAZO 3.375 G IV CEFAZOLIN 1GM INJ FENTANYL 100MCG/2ML INJ FENTANYL 250 MCG/5ML INJ DEXAMETHASONE 4MG INJ MIDAZOLAM 2MG/2ML INJ HEPARIN 5000 UNITS/ML INJ SC 1 47.96 1 384.00 1 204.70 1 204.70 1 47.96 1 47.95 1 47.96 1 384.00 1 204.70 1 204.70 1 204.70 1 384.00 1 204.70 1 204.70 1 204.70 1 323.55 1 39.95 1 384.00 1 204.70 1 204.70 2 181.00 1 79.35 1 81.40 2 66.00 1 139.30 1 8.15 2,568.04 10,272.16 406.67 13,246.87 1,291.44 703.B3 1,995.27 6,474.00 6,474.00 47.95 384.00 204,70 204.70 47.95 47.95 47.95 384.00 204.70 204.70 204.70 384.00 204.70 204.70 204.70 323.55 39.95 384.00 204.70 204.70 362,00 79,35 81 .40 112.00 139.30 8.15 NOTE: THIS BALANCE DDES NOT INCLUDE PROFESSIONAL CHARGES FOR PHYSICIANS SUCH AS EMERGENCY PHYSICIANS, ANESTHESIOLOGISTS, RADIOLOGISTS, PATHOLOGISTS AND CARDIOLOGISTS, YOU WILL RECEIVE A SEPARATE BILL DIRECTLY [.FROM THE PHYSICIAN FOR THOSE SERVICES. ____________________________________________________________________ _________________________________________________________ - - :::. PAGE NO. 003 STATEMENT OF ACCOUNT R-SJMC-BILLS-0005 D " INI7JATJVES Sl Joseph Medical Center FRANCISCAN HEALTH SYSTEM NOLL,DONALD ERWIN 1300409917 01/04/13 0 MASTER CARD CARD NO, ______ SIGNATURE _____ BILL DATE IP 01/17/13 01/09/13 STMT TYPE D1 G DISCOVER AMEX BILLER 63 ______ EXP, DATE________ GUARANTOR: DONALD ERWIN NOLL PO BOX 2703 BELFAIR WA 9852B ST JOSEPH MEDICAL CENTER PO BOX 31001-1456 Pasadena CA 91110-1456 01/08/13 01/08/13 01/08/13 01/08/13 01/08/13 01/08/13 01/08/13 01/08/13 01/09/13 01/09/13 01/04/13 01/05/13 01/06/13 01/06/13 01/06/13 01/06/13 01/06/13 01/07/13 01/07/13 01/07/13 01/08/13 01/08/13 01/08/13 01/08/13 01/08/13 01/06/13 01/08/13 01/08/13 01/08/13 01/09/13 01/09/13 01/09/13 01/09/13 01/99/13 01/09/13 01/09/13 636 636 636 636 636 836 636 836 636 836 637 637 637 637 637 637 637 637 637 637 637 637 637 637 637 637 637 637 637 637 637 637 637 637 637 637 PLEMUgjCLDSETHIS PORTION M&L.yfiUP_PAYMBLWB_WISTlYOOHACMUNT WUMBEfl L>ryufj HK:I KfiS>WSA'*- fl 5686 6656 6656 6655 B079 B409 B414 8677 5267 5257 LEVOFLOXACIN 750MG/160ML INJ PIPERACILLIN-TAZO 3.376 G IV PIPERACILLIN-TAZO 3.375 G IV PIPERACILLIN-TAZO 3.375 G IV PROMETHAZINE 25MG INJ MR MULTIHANCE PER ML |5ML] CT NON IONIC 300 PER ML-150M ONDANSETRON 4MG/2ML INJ HEPARIN 5000 UNITS/ML INJ SC HEPARIN 6000 UNITS/ML INJ SC TOTAL DRUGS/OETAIL CODE 1 384.00 1 204.70 1 204.70 1 204.70 1 92.90 15 17.04 150 3.90 1 187.75 1 8.15 1 8.18 382 382 382 6078 382 382 607B 382 393 65 2 3649 3649 382 382 393 5272 6078 85 2 2 382 393 5272 6078 65 FAMOTIDINE 20MG FAMOTIDINE 20MG FAMOTIDINE 20MG LACTOBACILLUS GG CAP FAMOTIDINE 20MG FAMOTIDINE 20MG LACTOHACILLUS GG CAP FAMOTIDINE 20MG FERROUS SULFATE 300MG TAB ASCORBIC ACID 500MG ACETAMINOPHEN 325MG TAB DOCUSATE SODIUM 100MG DOCUSATE SODIUM 100MG FAMOTIDINE 20MG FAMOTIDINE 20MG FERROUS SULFATE 300MG TAB TRAMADOL 50MG TAB LACTOBACILLUS GG CAP ASCORBIC ACID 500MG ACETAMINOPHEN 325MGTAB ACETAMINOPHEN 326MG TAB FAMOTIDINE 20MG FERROUS SULFATE 300MG TAB TRAMADOL 60MG TAB LACTOBACILLUS GG CAP ASCORBIC ACID 500MG 1 12.00 1 12,00 1 12.00 1 5-15 1 12.00 1 12.00 1 5.15 1 12.00 1 4.16 1 4.10 2 0.80 1 4,15 1 4.15 1 12.00 1 12.00 1 4.15 2 8.20 1 5.15 1 4.10 2 0.80 2 0.80 1 12.00 1 4.15 2 8.20 1 5.15 1 4,10 384.00 204.70 204.70 204.70 92.90 255.60 585.00 187.75 8.15 8.15 7,056.15 12.00 12.00 12.00 6.15 12.00 12.00 6.15 12.00 4.15 4.10 1.60 4.15 4.15 12.00 12.00 4. IS 16.40 6.15 4.10 1.60 1 .60 12.00 4.15 16.40 5.15 4.10 NOTE; THIS BALANCE DOES NOT INCLUDE PROFESSIONAL CHARGES FOR PHYSICIANS SUCH AS EMERGENCY PHYSICIANS, ANESTHESIOLOGISTS, RADIOLOGISTS, PATHOLOGISTS AND CAROIOLOGISTS. YOU WILL RECEIVE A SEPARATE BILL DIHECTLY FROM THE PHYSICIAN FOR THOSE SRVICES. PAGE NO. 004 STATEMENT OF ACCOUNT R-SJMC-BILLS-0006 .... r INITIATIVES St. Joseph Medical Center FRANCISCAN HEALTH SYSTEM 1300409917 GUARANTOR: DONALD ERWIN NOLL PO BOX 2703 BELFAIR WA 9852B !I 01/04/13 MASTER CARD CARD NO. _______ SIGNATURE _____ BILL DATE IP 01/1 7/13 01/09/13 VISA D DISCOVER STMT TYPE 1 O AMEX BILLER 63 ________________________ EXP. DATE________ ST JOSEPH MEDICAL CENTER PO BOX 31001-1456 Pasadena CA 91110-1456 mm 01/07/13 01/07/13 01/06/13 01/04/13 01/06/13 710 710 730 040 940 _PLAEENCLOSE.THIS PORTION ynjH.YpURJ'.^BST.AND.WTE TpURACCpiflITDUMBER ONYpUR CHGCj(_ tet% TOTAL SELF ADMINISTERED DRUGS 1 9919 RECOVERY PHASE I EA ADDL 16 RECOVERY PHASE 1 1ST 30 MIN TOTAL RECOVERY ROOM 514.38 1,028.76 1922 93005 ECG 12 LEAD STD - R TOTAL EKG/ECG 279.00 3112 3641 96376 INJECT/IV PUSH PER DRU 96376 INJ/IV PUSH ADDITIONAL TOTAL OTHER RXSVC 219.43 130.00 TOTAL BILLED CHARGES TO DATE ,' TOTAt CHARGES 199.25 3,086.28 1,028.76 4,115.04 279.00 279.00 219.43 260.00 479.43 02,507.36 NOTE THIS BALANCE DOES NOT INCLUDE PROFESSIONAL CHARGES FOR PHYSICIANS SUCH AS EMERGENCY PHYSICIANS, ANESTHESIOLOGISTS, RADIOLOGISTS, PATHOLOGISTS AND CARDIOLOGISTS. YOU WILL RECEIVE A SEPARATE BILL OIRECTLY I -------- -FROM THE PHYSICIAN FOR THOSE SERVICES. -------------- -- . -- ___________________________ _________ >>-: PAGE NO. 005 STATEMENT OF ACCOUNT R-SJMC-BILLS-0007 ......... D