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<br /> FAIRVIEW SOUTHDALE HOSPIT 2 i 3 PATIENT CONTROL NO. 4 type <br /> of bill <br /> PO BOX 147 I 068186773S 131 <br /> MINNEAPOLIS MN 55440-0147 5 FED. TAX NO. t 6 STATEMENT I COVERS PERIODI 7 COV D. \, N-C D. \9 C-[ {J. I 10 l-ft a. \ 11 <br /> FROM THROUGH <br /> (612)672-2762 410991680 1092800 1092800 I I I I I <br /> 12 PATIENT NAME 1~13 PATIENT ADDRESS <br /> STRONG PHYLLIS A 7500 EDINBOROUGH WAY EDINA MN 55435-5609 <br /> 14 BIRTHDA TE -115 SEX I 16 M~I ADr[~;I~N 119 TYPE!20 SR 21 a HR 22 I I 24 I CONDITION COeES I I JD 131 <br /> 17 CATE STAT 23 MEDICAL RECORD NO. I 25 26 27 28 25 <br /> 05201941 IF I W 1092800 118 I 11 20 01 I 0007183588 I I I I I <br /> 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE 36 OCCURRENCE SPAN 37 <br /> CODE DATE CODE DATE CODe DATE CODE DATE CODE f:ROM THROUGH A I <br /> i <br /> 05 092800 B I <br /> C <br /> 'PHYLLIS A STRONG " VALUE CODES 40 VALUE CODES .' VALUE CODES <br /> CODE AMOUNT CODE AMOUNT CODE AMOUNT <br /> 7500 EDINBOROUGH WAY 3105 , <br /> EDINA MN 55435-5609 b <br /> C <br /> d <br /> 42 REV CD 43 DESCRIPTION 44 HCPCS/RATES 45 SERV DATE 46 SERV UNITS 47 TOTAL CHARGES 48 NON-CQVERED CHARGES 49 <br /> 1 253 DRUGS/TAKEHOME 1 12 78 12 78 <br /> , 320 DX X-RAY 71020 1 152 64 <br /> ] 450 EMERG ROOM 99283 1 220 00 <br /> ; 001 TOTAL CHARGES 385 42 12 78 , <br /> ; <br /> , ; <br /> 3 , <br /> ; , <br /> ) , <br /> 1 1 <br /> 1 1 <br /> 3 \ <br /> , <br /> i 1 <br /> 1 <br /> 1 <br />\ 1 <br />I , <br />I , <br />, , <br />, 2 <br />i , <br /> 50 PAYER 51 PROVIDER NO. 52REl 53 AS 54 PRIOR PAYMENTS 55 EST AMOUNT DUE 56 <br /> INFO 'EN <br /> *LIABILITY WITH ME F Y Y <br /> MEDICARE C 240078 Y Y <br /> HEALTH PARTNERS F 17 Y y <br /> 57 DUE FROM P A TrENT .... <br /> 58 INSURED'S NAME 59PRE 60 CERT-SSN-HIC-ID NO 61 GROUP NAME 62 INSURANCE GROUP NO <br /> STRONG, PHYLLIS A 15 475428767 <br /> STRONG, PHYLLIS A 01 475428767A <br /> STRONG. PHYLLIS A 01 31731653 7008 <br /> 63 TREATMENT AUTHORIZATION CODES 64 65 EMPLOYER NAME 66 EMPLOYER LOCATION <br /> ,sc <br /> 5 05201941 <br /> 5 05201941 <br /> 5 05201941 <br /> 67 PRIN DIAG CD , I I I I OTHER DI~G CODES I 75 ADM DIAG CD 177 E" CODE [78 <br /> 6a CODE 69 CODE 70 CODE 71 CODE 72 CODE 73 CODE 74 CODE 7S CODE <br /> 80701 17140 13694 I I 1 9591 IE 88 5 I <br /> 79 PC '0 cm!:RINCIPAL 1 PROS:~YRE 81 con?THERIPROCE~~~E _M<OTHER IPROCE~A~E 82 ATTEND PHYS ID <br /> 9 I I E58770 STEINMAN RANDALL I <br /> COD,OTHER IPROCE~~~E CDD,OTHER I PROCE~~,R,E coo, OTHER IPROCEDS~~E 83 OTHER PHYS ID <br /> I I <br /> 84 REMARK S OTHER PHYS ID <br /> 85 PROVIDER REPRESENTATIVE 86 DATE <br /> X CBO TEMPORARY 08/29/01 <br /> <br />U8-92 HCFA-1450 <br /> <br />nr.R I nRIr.INAI <br /> <br />I CERTIFY THE CERTIFIcAtiONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF <br />