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MAY 2 4 1978 .- BOOK 35 PAGE 27 <br />l., .:.o. -n a... u.. '.. .. ..... ,. .. .. .n,;: 'S. .. 5 ..... ... AT...µ. .. .. ... <br />1B.�hFu-••s•'WI•n14 .4s/+#'w•4ri -awti ?=na•enRAm-••y Ct+`a91F w5s'••w t�.w+VrCW .fr W ✓....tYs..� 9l �5v. WLi4Jh.µ`i+\� ♦ W' '%dn <br />-�.>7 <br />f <br />1 <br />_ '1.. •y! •R N-iv'f; `� .>. h.M <br />uS r;lArt.uc.Y <br />T.♦ <br />-' <br />NAME <br />I. <br />_ --"-'-' ""-"--"'—'�-�-- -- --•- <br />AI.ITHORIZATION TO RELEASE INFORMATION <br />INDIVIDUAL INSURANCE: <br />SEBASTIAN RIVER MEDICAL CENTER INC. <br />' <br />BOX 838, U. S. HIGHWAY No. 1 <br />AIIT/IORI: ATION TO PAY INSURANCE BENEFITS: (t <br />POLICY NO. ' <br />SEBASTIAN. FLORIDA 32958 <br />• <br />r <br />1 <br />- <br />PHONE: 30S/589-3186 .. <br />•4• <br />CHARLES HUUQiTON <br />Xv <br />F.O. BOX 1 1 6 <br />DATE ADMITTED TIME <br />.. <br />WINTER BEACH, FLA. 32971 <br />DATE SIGNED___ <br />- <br />• <br />DATE DISCHARGED TIME <br />UY.>�. <br />L <br />. <br />'I: <br />PATIENT,�ADMISSION <br />NUMBER <br />STATCMENTOF SERVICES RENDERED <br />FROMi <br />CODE01-7 <br />PRIVATEGua <br />@ $ DAYS: <br />Ot ' <br />'- <br />SEMIPRIVATE 40 $ DAYS: <br />I A01 <br />CORONARY 0$ DAYS: <br />7 01 <br />356-00 <br />• <br />POST SURGICAL @$ 1 50, no DAYS: <br />2 O1 <br />300.00 <br />L C. U. @ $ DAYS: <br />01 <br />BLOOD PINTS <br />PINTS <br />NOT <br />CHARGE <br />-F <br />FURNISHED <br />REPLACED <br />REPLACED <br />PER PINT <br />1 <br />3 <br />LABORATORY <br />06 <br />760.50 <br />PATHOLOGY <br />OT <br />_ <br />PHARMACY AND DRUGS <br />10 <br />13.65 <br />•. <br />DRESSING, CAST AND SUPPLIES <br />13 <br />408.25 <br />E. K. 0. <br />16 <br />135.00 <br />JJJ <br />PHYSICAL THERAPY <br />ty <br />,. <br />PHYSICIAN SERVICES <br />40 <br />16.00 <br />1 <br />OPLRATING, RECOVERY OR DELIVERY ROOM03 <br />0q <br />•O <br />ANESTHESIA <br />85 <br />45.00 <br />X-RAY <br />08 <br />• <br />189-050 <br />INHALATION THERAPY <br />15 <br />• <br />EMERGENCY SERVICE <br />23 <br />ADMISSION PAK <br />40 <br />• <br />OTHER CHARGES EEG • 00 psy • <br />• 40 <br />' <br />ST PS <br />.00 <br />40 <br />TOTAL CHARGES TO DATE bu •• <br />. <br />.�, • <br />TOTAL PAYMENTS/ADJUSTMENTS <br />09 <br />BALANCE3,824.61 <br />;. <br />GROUP POLICY NUMBER <br />DOCTOR <br />(1) FINAL DIAGNOSIS (INC. SURGICAL PROCEDURE) <br />• <br />GROUP POLICY HOLDER <br />k <br />r <br />• <br />F <br />�1 <br />MAY 2 4 1978 .- BOOK 35 PAGE 27 <br />%•=' <br />a.......-� <br />OTHER GROUP INS. CO. <br />YES NO <br />-' <br />NAME <br />I. <br />_ --"-'-' ""-"--"'—'�-�-- -- --•- <br />AI.ITHORIZATION TO RELEASE INFORMATION <br />INDIVIDUAL INSURANCE: <br />EIGNL'O <br />AIIT/IORI: ATION TO PAY INSURANCE BENEFITS: (t <br />POLICY NO. ' <br />'•^'w: �`un...Itr r.. rnt wruvt Nwutu wuvrlrwtl. �V---•���—�Y�� <br />INSURANCE CLERK <br />Xv <br />..._ _.__ <br />.. <br />_... �....... _.-._...-._ _......_...__ ..-._�._-_�.____.._.. <br />DATE SIGNED___ <br />- <br />UY.>�. <br />.L.3oe,siLs:s._.b.k.....-.t....-w.usu:.5�:...:fo-'rc:�Wt,aJuj`�a .h,......w.i.:A....t. �. ... .. ,_... .._.. ...,......a. <br />... ..-. -rt t.....r .. 1. '.i�n�L'�•'��:�.:r�f'tnS.''.+ <br />'I: <br />MAY 2 4 1978 .- BOOK 35 PAGE 27 <br />