Document dYyRwakQVjmyY0eqZZzeLYQaG

UW Medicine PATIENT FINANCIAL SERVICES CERTIFICATION Billing Records Custodian for UW Medicine RE: NOLL,DONALD ERWIN Date of birth: 10/28/1948 I, CHANG, CHIA, declare that I am employed by UW Medicine Patient Financial Services department which has designated me as one of the authorized Custodian of Records. The billing records are requested by: STRATOS LEGAL RECORD SERVICES Requested facility: 0 UW Medical Center - d Harborview Medical Center Requested date of service: from 04/09/13 thru 06/14/13 fXl I have produced the accompanying records. ! I The accompanying records were produced and/or made under my direction and control. Number of page(s): 19 page(s) and that these billing records: were made, kept and maintained by UW Medicine in the regular course of business at or near the time of the act, condition, or event recorded therein. * are authentic business records of UW Medicine Patient Financial Services. I I No billing record exists. Reason(s): No billing record found for date of service(s) requested. Unable to identify patient. No patient account/record exists in our facility. Record is no longer available due to UW Medicine Records Retention Schedule. Pursuant to RCW 9A.72.085 & RCW 70.02.070,1 certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct to the best of my knowledge. Dated this 11th day of July, 2013 at Seattle, Washin^t^11 C, Chang Printed Name PFS Specialist 2 Title (206) 598-4502 Telephone Number Patient Financial Services Compliance & Release of Information Harborvievj Medical Canter ] University of Washington Medical Center UW Box 359435 - Seattle,.WA 98195| Phone 206.598.4502 j Fax 205.598.0842 R-UOW2-BILLS-0001 i DONALD ERWIN NOLL PO BOX 2703 Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN "~ Admitted: 04/26/13 Discharged: 04/26/13 Line 1 2 3 4 Date of CPT Service______ Code 4/26/2013 36415 4/26/2013 80048 4/26/2013 85027 4/26/2013 93005 Revenue Description_____________ ;________________Code HC VENIPUNCTURE, ROUTINE 0300 HC BASIC METABOLIC PANEL 0301, HC CBC 0305 HC ECG ROUTINE ECG W/LEAST 12 0730 Otv 1 1 1 1 Total Amount $32.00 $72.00 $57.00 $224.00 Total Amount: $385.00 i R-UOW2-BILLS-0002 DONALD ERWIN NOLL PO BOX 2703 Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN Admitted: 04/30/13 . Discharged: 05/07/13 Line 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 ' 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Date of CPT Revenue Service Code Description Code 4/30/2013 02000001HC LEVEL-1 ICU 0200 4/30/2013 0250 0003ATROPINE 1MG/10ML INJ (EMERG) 0250 4/30/2013 025 0 00 03BUPIVACAINE *PF* 0.25% INJ 30M 0250 4/30/2013 0250 0 0 03BUPIVACAINE *PF* 0.75% (FOR EP 0250 4/30/2013 02500003CALCIUM GLUCONATE 0.465MEQ/ML 0250 4/30/2013 02500003DEXAMETHASONE 10MG/ML INJ 0250 4/30/2013 02500003DEXTROSE 5% IN WATER 100ML 0250 . 4/30/2013 025 0000 3DEXTROS E 5% IN WATER 50ML 0250 4/30/2013 02500003DEXTROSE 50% 50ML INJ 0250 4/30/2013 0 25 0 0003EPHEDRINE 25MG/5ML INJ (OR SYR 0250 4/30/2013 025000Q3FENTANYL 250MCG/5ML INJ (VIAL) 0250 4/30/2013 02500003FUROSEMIDE 100MG/10ML INJ 0250 4/30/2013 02500003HEPARIN 5,OOOUNITS/ML INJ 0250 4/30/2013 02500003HETASTARCH 6%/0.9% NACL 500ML- 0250 4/30/2013 02500003HYDROMORPHONE 2MG/ML INJ 0250 4/30/2013 02 500003LIDOCAINE *PF* 1% INJ 30ML 0250 4/30/2013 025 00003LIDOCAINE 2% INJ 10ML (OR SYRI 0250 4/30/2013 02500003MIDAZOLAM 2MG/2ML INJ 0250 4/30/2013 02500003PROPOFOL 1% 20ML 0250 4/30/2013 02500003SODIUM BICARB 8.4% INJ 50ML (E 0250 4/30/2013 02500003SODIUM CHLORIDE *PF* 0.9% QS T 0250 4/30/2013 0 25 0 0 0.0 3.SODIUM CHLORIDE 0.9% 500ML 0250 4/30/2013 0250Q003SODIUM POLYSTYRENE SULF 15G/60 0250 4/30/2013 02500003STERILE WATER FOR INJECTION *P 0250 4/30/2013 0250000 3VECURONIUM 10MG INJ 0250 4/30/2013 02500003XCHG-CEFAZOLIN 2G/D5W 100ML 0250 4/30/2013 0250 0 003XCHG-PHENYLEPHRINE 0.5MG/5ML N 0250 4/30/2013 02500003XCHG-PHENYLEPHRINE 50MG/NS 250 0250 4/30/2013 0250000 3XCHG-PROPOFOL 1% 100ML 0250 4/30/2013 A9270 SELENIUM 200MCG TAB 0250 4/30/2013 P9045 ALBUMIN 5% 250ML INJ 0250 4/30/2013 J0690 CEFAZOLIN 500MG INJ 0250 4/30/2013 90000030ENDO GIA 3 0MM ARTICULATING MED 0272 4/30/2013 90000030ENDO GIA 30MM ARTICULATING VAS 0272 4/30/2013 9000003OENDO GIA 45MM ARTICULATING EX 0272 4/30/2013 9000003OENDO GIA 45MM ARTICULATING ME 0272 4/30/2013 90000030ENDO GIA' 45MM ARTICULATING VA 0272 4/30/2013 9000003OENDO GIA ULTRA STANDARD LENGTH 0272 4/30/2013 82330 HC CALCIUM, IONIZED, WB 0300 4/30/2013 85384- HC FIBRINOGEN ACTIVITY 0300 4/30/2013 85014 HC HEMATOCRIT 0300 4/30/2013 85018 HC HEMOGLOBIN D3 0 0 4/30/2013 85049 HC PLATELET 0300 4/30/2013 85610 HC PROTHROMBIN 0300 4/30/2013 84295 HC SODIUM, WB 0300 Oty 1 1 1 42 20 1 2 1 1 1 2 1 1 1 1 1 1 1 2 2 250 1 2 2 2 1 1 1 3 0 4 8 1 1 1 4 1 1 6 1 1 6 1 2 6 Total ' Amount $4,846.00 $64.41 $58.49 $61.01 $57.81 $58.38 $115.86 $57.86 $58.49 ' $59.52 $63.04 $57.76 $58.11 $69.43 $62.82 $58.84 $57.64 $61.39 $59.82 $66.39 $59.71 $57.90 $31.09 $58.22 $61.84 $108.22 $57.05 $113.44 $135.13 $0.00 $365.40 $116.44 $310.00. $310.00 . $387.00 $1,420.00 $355.00 $236.00 $510.00 $28.00 $62,00 $186.00 $48.00 $32.00 $276.00 R-UOW2-BILLS-0003 r.: I UW Medical Center Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN ' '' Page 2 of 5 Admitted: 04/30/13 Discharged: 05/07/13 Line 46 47 48 49 50 51 52 53 54 ' 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 31 92 93 94 95 96 Date of CPT Revenue Service Code DescriDtion Code 4/30/2013 80048 HC BASIC METABOLIC PANEL 0301 4/30/2013 82803 HC BLOOD GAS (PH, C02, 02) 0301 4/30/2013 82330 HC CALCIUM (IONIZED), PLASMA 0301 4/30/2013 82947 HC GLUCOSE, WB 0301 4/30/2013 83605 HC LACTATE, DIRECT 0301 4/30/2013 83735 HC MAGNESIUM, SERUM 0301 4/30/2013 84100 HC PHOSPHATE, SERUM 0301 4/30/2013 84132 HC POTASSIUM, WB 0301 4/30/2013 86923 HC CROSSMATCH, ELECTRONIC 0302 4/30/2013 86900 HC ABO TYPING . 0302 4/30/2013 86850 HC INDIRECT ANTI-GLOB 0302 . 4/30/2013 86901 HC PSBC, RH(D) 0302 4/30/2013 85027 HC CBC 0305 4/30/2013 85730 HC PTT 0305 4/30/2013 88305 RT. PLEURAL TISSUE 0312 4/30/2013 74000 HC RADEX ABD 1 ANTEROPOST VIEW 0320 4/30/2013 71010 HC RADEX CH 1 VIEW FRNT 0324 4/30/2013 03600404HC OPER RM LVL 2, 6.0 HR 0360 4/30/2013 03700217HC ANESTHESIA, GENERAL 6.0 T 0370 4/30/2013 P9016 HC P9016 RED BLOOD CELLS LEUK 0390 4/30/2013 36430 HC TRANSFUSION BLD/BLD COMPONE 0391 - 4/30/2013 94002 HC VENTILATION ASSIST & MGMT I 0410 4/30/2013 07100090HC RECOVERY ROOM 1.0 HRS-LVL 0710 5/1/2013 02000001HC LEVEL-1 ICU 0200 . 5/1/2013 02500003DEXTROSE 5% IN WATER 100ML 0250 5/1/2013 025 00 0 03DEXTROSE 50% 50ML INJ 0250 5/1/2013 02500003FENTANYL 10 0MCG/2ML INJ (VIAL) 0250 5/1/2013 02500003FUROSEMIDE 40MG/4ML INJ 0250 5/1/2013 02500003HEPARIN 5,000UNITS/ML INJ 0250 5/1/2013 02500003HYDROMORPHONE PCA 1MG/ML INJ 2 0250 5/1/2013 02500003SODIUM BICARB 8.4% INJ 50ML (E 0250 5/1/2013 02500003SODIUM CHLORIDE 0.9% 500ML 0250 5/1/2013 02500003SODIUM POLYSTYRENE SULF 15G/60 0250 5/1/2013 02500003XCHG-SODIUM CHLORIDE 0.9% 250M 0250 5/1/2013 ACETAMINOPHEN 32SMC TAB 0250 5/1/2013 DOCUSATE 100MG CAP 0250 5/1/2013 A9270 SENNA 8.6MG TAB 0250 5/1/2013 JO 690 CEFAZOLIN 500MG INJ 0250 5/1/2013 J24.05 ONDANSETRON IMG INJ 0250 5/1/2013 90732 PNEUMOCOCCAL VACCINE 0250 5/1/2013 82330 HC CALCIUM, IONIZED, WB 0300 5/1/2013 82570 HC CREATININE, URINE 0300 5/1/2013 83605 HC LACTATE, DIRECT 0300 5/1/2013 83930 HC OSMOLALITY, BLOOD 0300 5/1/2013 83935 HC OSMOLALITY, URINE 0300 5/1/2013 84133 HC POTASSIUM, URINE 0300 5/1/2013 85610 HC PROTHROMBIN 0300 5/1/2013 84300 HC SODIUM, URINE 0300 5/1/2013 80048 HC BASIC METABOLIC PANEL 0301 5/1/2013 82803 HC BLOOD GAS (PH, C02, 02) 0301 5/1/2013 82436 HC CHLORIDE, URINE 0301 Qty_ 1 6 1 6 5 1 1 7 6 1 1 1 1 1 1 1 1 1 1 3 1 1 1 1 1 2 1 1 2 1 1 2 3 1 6 2 2 4 12 1 1 1 1 1 1 2 2 2 4 5 2 Total Amount $72.00 $936.00 $85.00 $228.00 $905,00 $63.00 $34.00 $322.00 $684.00 $48.00 $61.00 $47.00 $57.00 $28.00 $233.00 $238.00 $236.00 $18,582.00 $3,809.00 $1,386.00 $439.00 $748.00 $768.00 $4,846.00 $57.93 $116.98 $61.69 $57.63 $116.22 $64.30 $61.69 $115.80 $46.65 $57.85 $0.90 . $1.06 $1.07 $58.22 $115.17 $155.25 $85.00 $52.00 $181.00 $66.00 $70.00 $88.00 $32.00 $94.00 $288.00 $780.00 $86.00 R-UOW2-BILLS-0004 ii UW Medical Center Statement Date; 07/11/2013 Patient Name: NOLL,DONALD ERWIN Page 3 of 5 Admitted; 04/30/13 Discharged: 05/07/13 Line 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 13 0 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 Date of Service 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/1/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/2/2013 5/3/2013 5/3/2013 5/3/2013 CPT Revenue Code Description Code 83605 HC LACTATE, DIRECT 0301 83735 HC MAGNESIUM, SERUM 0301 84100 HC PHOSPHATE, SERUM 0301 84132 HC POTASSIUM, SERUM 0301 84132 HC POTASSIUM, WB 0301 84540 HC UREA FRACTIONAL EXCRET 0301 86923 HC CROSSMATCH, ELECTRONIC 0302 85027 HC CBC 0305 85014 HC HEMATOCRIT 0305 85049 HC PLATELET 0305 85730 HC PTT 0305 81001 HC UA AUTO W/ MICRO 0307 71010 HC RADEX CH 1 VIEW FRNT 0324 P9016 HC P9016 RED BLOOD CELLS LEUK 0390 36430 HC TRANSFUSION BLD/BLD COMPONE 0391 94003 HC VENTILATION ASSIST & MGMT I 0410 97530 HC THERAPEUT ACTVITY DIRECT PT 0420 97001 HC PHYSICAL THER EVAL 0424 97535 HC SELF-CARE/HOME MGMT TRAININ 0430 97003 HC OCCUPATIONAL THER EVAL 0434 02000001HC LEVEL-1 ICU 0200 02500003BUPIVACAINE *PF* 0.75% (FOR EP 0250 02 50 00 0 3DEXTR0SE 5% IN WATER 5 0ML 0250 02500003HEPARIN 5,000UNITS/ML INJ 0250 02500003HYDROMORPHONE PCA 1MG/ML INJ 2 0250 02500003MAGNESIUM SULFATE 8.12MEQ/2ML 0250 02500003METOCLOPRAMIDE 10MG/2ML INJ 0250 02500003SODIUM CHLORIDE *PF* 0.9% QS T 0250 02500003SODIUM CHLORIDE 0.9% 1000ML 0250 02500003SODIUM CHLORIDE 0.9% 500ML 0250 02500003SODIUM POLYSTYRENE SULF 15G/60 0250 02500003XCHG-SODIUM CHLORIDE 0.9% 250M 0250 ACETAMINOPHEN- 325MG TAB 0250 DOCUSATE 100MG CAP 0250 FOLIC ACID IMG TAB 0250 A9270 SELENIUM 200MCG TAB 0250 A927 0 SENNA 8.6MG TAB 0250 J2405 ONDANSETRON IMG INJ 0250 85610 HC PROTHROMBIN 0300 80048 HC BASIC METABOLIC PANEL 0301 83735 HC MAGNESIUM, SERUM 0301 84100 HC PHOSPHATE, SERUM 0301 84132 HC POTASSIUM, SERUM 0301 85027 HC CBC 0305 71010 HC RADEX CH 1 VIEW FRNT 0324 97530 HC THERAPEUT ACTVITY DIRECT PT 0420 97110 HC THER PX 1+ AREAS EA 15 MIN 0420 97535 HC SELF-CARE/HOME MGMT TRAININ 04 3 0 01200002HC LEVEL-2 ROOM & BOARD (SEMI- 0120 02500003HEPARIN 5,OOOUNITS/ML INJ 0250 ACETAMINOPHEN 325MG TAB 0250 Oty 1 1 1 1 1 1 2 2 2 1 1 1 1 2 1 1 2 1 2 1 1 84 1 3 1 2 1 500 1' 5 3 1 8 2 1 1 2 16 1 2 1 1 3 1 1 2 1 2 1 3 8 Total Amount $181.00 $63.00 . $34.00 $53.00 $46.00 $26.00 $228.00 $114.00 $124.00 $48.00 $28.00 $55.00 $236.00 $924.00 $439.00 $748.00 $246.00 $293.00 $228.00 $295.00 $4,846.00 $122.02 $57.86 $174.33 $64.30 $58.26 $57.55 $119.42 $58.01 $118.50 $46.65 $57.85 $1.20 $1.06 $1.09 $1.05 $1,07 $115.56 $16.00 $144.00 $63.00 $34.00 $159.00 $57.00 $236.00 $246.00 $112.00 $228.00 $1,989,00 $174.33 $1.20 R-UOW2-BILLS-0005 TJW Medical Center Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN Page 4 of 5 Admitted:: 04/30/13 Discharged:: 05/07/13 Line 148 149 150 151 152 153 154 155 156 15-7 .158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 Date of CPT Revenue Service Code Description Code 5/3/2013 DOCUSATE 100MG CAP 0250 5/3/2013 FOLIC ACID IMG TAB 0250 5/3/2013 A9270 SELENIUM 200MCG TAB 0250 5/3/2013 A9270 SENNA 8.6MG TAB 0250 5/3/2013 A9270 VITAMIN PRENATAL, FOLATE IMG T 0250 5/3/2013 85610 HC PROTHROMBIN 0300 5/3/2013 80048 HC BASIC METABOLIC PANEL 0301 5/3/2013 84132 HC POTASSIUM, SERUM 0301 5/3/2013 85027 HC CBC 0305 5/3/2013 71010 HC RADEX CH 1 VIEW FRNT 0324 5/3/2013 97530 HC THERAPEUT ACTVITY DIRECT PT 0420 5/3/2013 97001 HC PHYSICAL THER EVAL 0424 5/3/2013 97535 HC SELF-CARE/HOME MGMT TRAININ' 0430 5/4/2013 01200002HC LEVEL-2 ROOM & BOARD (SEMI- 0120 5/4/2013 02500003BUPIVACAINE *PF* 0.75% (FOR EP 0250 5/4/2013 02500003HEPARIN 5,000UNITS/ML INJ 0250 5/4/2013 02500003SODIUM CHLORIDE *PF* 0.9% QS T 0250 5/4/2013 02500003SODIUM CHLORIDE 0.9% 500ML 0 25 0 5/4/2013 ACETAMINOPHEN 325MG TAB 0250 5/4/2013 DOCUSATE 100MG CAP 0250 5/4/2013 FOLIC ACID IMG TAB 0250 5/4/2013 MENTHOL LOZENGE #20 0250 5/4/2013 A9270 POTASSIUM CHLORIDE ER 20MEQ TA 0250 5/4/2013 A9270 SELENIUM 200MCG TAB 0250 5/4/2013 A9270 SENNA 8.6MG TAB 0250 5/4/2013 A9270 VITAMIN PRENATAL, FOLATE IMG T 0250 5/4/2013 85610 HC PROTHROMBIN 0300 5/4/2013 36415 HC VENIPUNCTURE, ROUTINE 0300 5/4/2013 80048 HC BASIC METABOLIC PANEL 0301 5/4/2013 84132 HC POTASSIUM, SERUM 0301 5/4/2013 85027 HC CBC 0305 5/4/2013 71010 HC RADEX CH 1 VIEW FRNT 0324 5/4/2013 97530 HC THERAPEUT ACTVITY DIRECT PT 0420 5/4/2013 97110 HC THER PX 1+ AREAS EA 15 MIN 0420 5/5/2013 01200002HC LEVEL-2 ROOM & BOARD (SEMI- 0120 5/5/2013 02500003DEXTROSE 5% IN WATER 250ML 0250 5/5/2013 0250 00 03HEPARIN 5,000UNITS/ML INJ 0250 5/5/2013 02500003METOCLOPRAMIDE 10MG/2ML INJ 0250 5/5/2013 02500003POTASSIUM CHLORIDE 2MEQ/ML INJ 0250 5/5/2013 02500003XCHG-SODIUM CHLORIDE 0.9% 250M 0250 5/5/2013 ACETAMINOPHEN 325MG TAB 0250 5/5/2013 DOCUSATE 100MG CAP 0250 5/5/2013 FOLIC ACID IMG TAB 0250 5/5/2013 A927 0 POTASSIUM CHLORIDE 2 0MEQ PACKE' 0250 5/5/2013 A9270 SELENIUM 200MCG TAB 0250 5/5/2013 A9270 SENNA 8.6MG TAB 0250 5/5/2013 A9270 VITAMIN PRENATAL, FOLATE IMG T 0250 5/5/2013 85610 HC PROTHROMBIN 0300 5/5/2013 36415 HC VENIPUNCTURE, ROUTINE 0300 5/5/2013 80048 HC BASIC METABOLIC PANEL 0301 5/5/2013 85027 HC CBC 0305 Otv 2 1 1 2 1 1 1 1 1 1 2 1 2 1 42 3 250 1 8 4 1 1 1 1 2 1 1 2 1 1 1 2 1 1 1 1 3 1 20 1 8 4 1 2 1 2 1 1 1 1 1 Total Amount $1.06 $1.09 $1.05 $1.07 $1.06 $16.00 $72.00 $53.00 $57.00 $236.00 $246.00 $293.00 $228.00 $1,989.00 $61.01 $174.33 $59.71 $57.90 $1.20 $2.12 $1.09 $48.43 $1.34 $1.05 $1.07 $1.06 $16.00 $64.00 $72.00 $53.00 $57.00 . $472,00 ' $123.00 $112,00 $1,989.00 $57.86 .$174.33 $57.55 $57.73 $57.85 $1.20 . $2.12 $1.09 $6.89 $1.05 $1.07 $1.06 $16.00 $32.00 $72.00 . $57.00 R-UOW2-BILLS-0006 UW Medical Center Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN ' Page 5 of 5 Admitted: 04/30/13 Discharged: 05/07/13 Line 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 ' Date of CPT Revenue Service Code Descrintion Code 5/5/2013 71010 HC RADEX CH 1 VIEW FRNT 0324 5/5/2013 71020 HC RADEX CH 2 VIEWS FRNT&LAT 0324 5/6/2013 01200002HC LEVEL-2 ROOM & BOARD {SEMI 0120 5/6/2013 02500003BUPIVACAINE *PF* 0.75% (FOR EP 0250 5/6/2013 02500003HEPARIN 5,000UNITS/ML INJ 0250 5/6/2013 0250 0 00 3METOCLOPRAMIDE 10MG/2ML INJ 0250 5/6/2013 02500003SODIUM CHLORIDE *PF* 0.9% QS T 0250 5/6/2013 ACETAMINOPHEN 325MG TAB 0250 5/6/2013 DOCUSATE 100MG CAP 0250 5/6/2013 FOLIC ACID IMG TAB 0250 5/6/2013 A9270 OXYCODONE 5MG TAB 0250 5/6/2013 A9270 SELENIUM 200MCG TAB 0250 5/6/2013 A927 0 SENNA 8.6MG TAB 0250 5/6/2013 A9270 VITAMIN PRENATAL, FOLATE IMG T 0250 5/6/2013 J24 05 ONDANSETRON IMG INJ 0250 5/6/2013 85610 HC PROTHROMBIN 0300 5/6/2013 36415 HC VENIPUNCTURE, ROUTINE 0300 5/6/2013 80048 HC BASIC METABOLIC PANEL 0301 5/6/2013 85027 HC CBC 0305 5/6/2013 71010 HC RADEX CH 1 VIEW FRNT 0324 5/6/2013 71020 HC RADEX CH 2 VIEWS FRNT&LAT 0324 5/7/2013 02500003HEPARIN 5,000UNITS/ML INJ 0250 5/7/2013 ACETAMINOPHEN 325MG TAB 0250 5/7/2013 DOCUSATE 100MG CAP 0250 5/7/2013 FOLIC ACID IMG TAB 0250 5/7/2013 A9270 SELENIUM 200MCG TAB 0250 5/7/2013 A9270 SENNA 8.6MG TAB 0250 5/7/2013 A92 7 0 VITAMIN PRENATAL, FOLATE IMG T 0250 5/7/2013 DOCUSATE 100MG CAP 0253 5/7/2013 OXYCODONE HCL 5MG TAB 02 53 5/7/2013 SENNA 8.6MG TAB 0253 5/7/2013 85610 HC PROTHROMBIN 0300 5/7/2013 36415 HC VENIPUNCTURE, ROUTINE 03 0 0 5/7/2013 80048 HC BASIC METABOLIC PANEL 0301 5/7/2013 85027 HC CBC 0305 5/7/2013- 71010 HC RADEX CH 1 VIEW FRNT 0324 5/7/2013 97530 HC THERAPEUT ACTVITY DIRECT PT 0420 5/7/2013 97535 HC SELF-CARE/HOME MGMT TRAININ 0430 Qty 1 1 1 42 3 1 250 8 4 1 5 1 2 1 8 1 1 .1 1 1 1 1 2 2 1 1 2 1 120 100 60 1 1 1 1 1 3 2 Total Amount $236.00 $293.00 $1,989.00 $61.01 $174.33 $57.55 $59.71 $1.20 $2.12 $1.09 $48.48 $1.05 $1.07 $1.06 $114.78 $16.00 $32.00 $72.00 $57.00 $236-. 00 $293.00 $58.11 $0.30 $1.06 $1.09 $1.05 $1.07 $1- 06 $8.40 $13.40 $5.55 $16.00 $32.00 $72.00 $57.00 $236.00 $369.00 $228.00 Total Amount: $74,922.21 R-UOW2-BILLS-0007 DONALD ERWIN NOLL PO BOX 2703 Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN Admitted 05/13/13 Discharged 05/13/13 Line 1 2 3 4 Date of CPT Service______Code 5/13/2013 36415 5/13/2013 80048 5/13/2013 71020 5/13/2013 99213 Revenue Description_____________________________ Code______Otv HC VENIPUNCTURE, ROUTINE 0300 1 HC BASIC METABOLIC PANEL 0301 1 HC RADEX CH 2 VIEWS FRNT&LAT 0324 1 HC FOB L3 ESTABLISHED OUTPT VI 0510 1 Total Amount $32.00 $72.00 $293.00 $187.00 Total Amount: $584.00 R-UOW2-BILLS-0008 DONALD ERWIN NOLL PO BOX 2703 Page 1 UW Medical Center BELFAIR, WA 98528 ' Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN Admitted 05/17/13 Discharged 05/17/13 Line 1 Date of OPT Service Code 5/17/2013 99212 ' Revenue Description_____________________________ Code HC FOB L2 ESTABLISHED OUTPT VI 0510 1 Total Amount $145.00 Total Amount: $145.00 R-UOW2-BILLS-0009 DONALD ERWIN NOLL PO BOX 2703 Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN Admitted: 05/21/13 Discharged: 05/21/13 Line 1 2 3 4 Date of Service 5/21/2013 5/21/2013 5/21/2013 5/21/2013 CPT Code 77290 77334 77332 77014 Revenue Description Code HC THER RAD SIMULAJ-AIDED FLD 0333 HC TX DEV DESIGN&CONSTJ CPLX 0333 HC TX DEV DESIGN&CONSTJ SMPL S 0333 HC CT GUIDANCE RADIATION THERA 0350 Otv 1 1 2 1 Total Amount $2,081.00 $2,046.00 $1,474.00 $747.00 Total Amount: $6,348.00 R-UOW2-BILLS-0010 DONALD ERWIN NOLL PO BOX 2703 Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN Admitted: 06/04/13 Discharged 06/04/13 Line 1 2 Date of CPT Service_____ Code 6/4/2013 77301 6/4/2013 77338 Revenue Total Description______________________________ Code_____Qty_______ Amount HC NTSTY MODUL RADTHX PLN DOSE 0333 1 $6,235.00 HC SD DESIGN MLC DEVICE FOR IM 0333 1 $3,396.00 Total Amount: $9,631.00 i R-UOW2-BILLS-0011 DONALD ERWIN NOLL PO BOX 2703 Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN Admitted: 06/05/13 Discharged: 06/05/13 Line 1 2 Date of Service 6/5/2013 6/5/2013 CPT Code 77300 77280 Revenue Description Code HC BASIC RADJ DOSIM CAL 0333 HC THER. RAD SIMULAJ-AIDED FLD 03 3 3 Pty 1 1 Total Amount $547.00 $1,108.00 Total Amount: $1,655.00 i R-UOW2-BILLS-0012 DONALD ERWIN NOLL PO BOX 2703 Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN ' Admitted 06/06/13 Discharged: 06/06/13 Line 1 2 Date of CPT Service_____ Code 6/6/2013 77418 6/6/2013 77014 Revenue Description______________________________ Code HC NTSTY MODUL DLVR l/MLT FLDS 0333 HC CT GUIDANCE RADIATION THERA 0350 Oty 1 1 Total Amount $2,159.00 $747.00 Total Amount: $2,906.00 R-UOW2-BILLS-0013 DONALD ERWIN NOLL PO BOX 2703 Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: noi.t. nnuai.n ERWIN Admitted: 06/07/13 Discharged: 06/07/13. Line 1 2 Date of CPT Service_____ Code 6/7/2013 77418 6/7/2013 77014 Revenue Description_________________ ____ ______ Code HC NTSTY MODUL DLVR l/MLT FLDS 0333 HC CT GUIDANCE RADIATION THERA 0350 Otv 1 1 Total Amount $2,159,00 $747.00 Total Amount: $2,906.00 R-UOW2-BILLS-0014 DONALD ERWIN NOLL PO BOX 2703 . Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN '~ Admitted 06/10/13 Discharged: 06/10/13 Line 1 2 Date of CPT Service______Code 6/10/2013 77418 6/10/2013 77014 Revenue Description____________________________ Code______Oty HC NTSTY MODUL DLVR l/MLT FLDS 0333 1 HC CT GUIDANCE RADIATION THERA 0350 1 Total Amount $2,159.00 $747.00 Total Amount: $2,906.00 R-UOW2-BILLS-0015 DONALD ERWIN NOLL PO BOX 2703 Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN Admitted 06/11/13 Discharged 06/11/13 Line 1 2 Date of CPT Service_____ Code 6/11/2013 77418 6/11/2013 77014 Revenue Total Description______________________________ Code_____Otv_______ Amount HC NTSTY MODUL DLVR l/MLT FLDS 0333 1 $2,159.00 HC CT GUIDANCE RADIATION THERA 0350 1 $747,00 Total Amount: $2,906.00 R-UOW2-BILLS-0016 DONALD ERWIN NOLL PO BOX 2703 ' Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN ' Admitted 06/12/13 Discharged 06/12/13 Line 1 2 Date of CPT Service_____ Code 6/12/2013 77418 6/12/2013 77014 Revenue Description______________________________ Code HC NTSTY MODUL DLVR l/MLT FLDS 0333 HC CT GUIDANCE RADIATION THERA 0350 Otv 1 1 Total Amount $2,159.00 $747.00 Total Amount: $2,906.00 R-UOW2-BILLS-0017 DONALD ERWIN NOLL PO BOX 2703 Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN . Admitted: 06/13/13 Discharged: 06/13/13 Line 1 2 Date of CPT ' Service_____ Code 6/13/2013 77418 6/13/2013 77014 Revenue Description______________________________ Code_____Otv HC NTSTY MODUL DLVR l/MLT FLDS 0333 1 HC CT GUIDANCE RADIATION THERA 0350 1 Total Amount $2,159.00 $747.00 Total Amount: $2,906.00 ii R-UOW2-BILLS-0018 DONALD ERWIN NOLL PO BOX 2703 Page 1 UW Medical Center BELFAIR, WA 98528 Statement Date: 07/11/2013 Patient Name: NOLL,DONALD ERWIN Admitted 06/14/13 Discharged 06/14/13 Line 1 2 Date of CPT Service_____ Code 6/14/2013 77418 6/14/2013 77014 Revenue Description______________________________ Code_____ Oty HC NTSTY MODUL DLVR l/MLT FLDS 0333 1 HC CT GUIDANCE RADIATION THERA 0350 1 Total Amount $2,159.00 $747.00 Total Amount: $2,906.00 R-UOW2-BILLS-0019 UW Medicine UW Medical Center Harborview Medical Center Medical Record No. U3407349 Prepared by: Chia Chang Direct Line: Settlement Contact: Bruce Pyper: ibDVDer@uw.edu Release of Information Phone: 206.S98.45Q2 Fax: 206.598,0842 Patient Name: NOLL,DONALD ERWIN Facility Name: University of WA Medical Center Date Prepared: 07/11/13 Page(s):1 Signature: 57- Date of Service From To Account/ Bill No. 04/26/13 04/30/13 05/13/13 05/17/13 05/21/13 06/04/13 06/05/13 06/06/13 06/07/13 06/10/13 06/11/13 06/12/13 06/13/13 06/14/13 04/26/13 05/07/13 05/13/13 05/17/13 05/21/13 06/04/13 06/05/13 06/06/13 06/07/13 06/10/13 06/11/13 06/12/13 06/13/13 06/14/13 11477422 11451535 11501884 11510025 11513878 11535887 11537151 11539424 11541318 11543492 11545540 11547781 11549711 11551706 _. arges $385.00 $74,922.21 $584.00 $145.00 $6,348.00 $9,631.00 . $1,655.00 $2,906.00 $2,906.00 $2,906.00 $2,906,00 $2,906.00 $2,906.00 $2,906.00 Summary: Total $114,012.21 Total Charges $114,012.21 Total Balance Due As of $114,012:21 7/4/2013 R-UOW2-BILLS-0020 Page 1 Comments