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,.. .. ,. .. � .. a a.....a. ��..: u. ,t a .-.. a..a ,„: .. <br />... ,..1. .,�.,,.. �•..,.�...:..... .:,.. '"...e..-uua. �:. �• ..,,C .e..,., .Aiw•..+.-•w tiu 'Rw F�r�J. SAF' L..ku .,1 <br />• TYPEFI7ILL BILLING DATE BILLING PERIOD e� 7JACKSON °�EI+tlOR1 <br />OAL HOSPITAL <br />CQ <br />AA = •UPublic hospital Lwenxd by lite Stale of Florida <br />' / 031;.'.3 a`�I • rUOLIC6H6ALTN,NULToro^DCCOUNTV • FLORIDA PHONE 305 325-6463 <br />N I{II N.W. I&TH AVCNU . MI AMI. FLORIO^ 771]4 a <br />(l�dt4l. !)�/hi 01107 ' <br />PATIENT NAME PATIENT NUAfBE ROOM NUMBER DOCTOR r ADMITTED DISCHARGED P91E <br />t) 6734-02 A 0 C GILLW-41 01/07/78 03/16/78 � <br />J i-E(.II�IT(.Sti, .ICiiTC � 1:35211_ dF,O 7 . <br />BIL.L. TO <br />__INSURANCE COMPANY GROUP NUMBER POLICY NUMBER <br />JOHN 11GI10f;511 <br />Inidan River County Welfare Dep&tme t . <br />I� 514 SC; 27 CT #7 <br />= 2535 - 14th Avenue <br />~ Vero Beach, Fla. 3296 ATTN: Ms. anice Lindsey • VF'p"'iN 9&RAN ""AA E FOR '149110r�9'149110N ION IS HOSPITALS ESTIMATE <br />O --. <br />OATS^ DESCRIPTION TOTAL IST. INSURANCE TND. INSURANCE • 3RD. INSURANCE DUE FROM <br />CHARGE COVERAGE COVERAGE COVERAGE GUARANTOR* <br />. LV <br />I-1 <br />SUMf4 RY OF CFMRGES. <br />K£.0 SEI11-1'. 9 DAYS all 72.77/DAY . 1,555.00 1,555.0(1 <br />Ix K&C .IAE';0 38 DAYS x131.94/0AY 5101 r1.00 9,400.00 <br />U) R.&<�':.{:fii�F 21 13AYS . a?400-00/`2AY 8,400.00 81400.00 <br />ONI: i T iNv F. F E.C.(?VF =:Y (?t ."� -2 1, 13o.')0 11 130.00 <br />441.00 <br />w ANF�OH-:SIA SUP"I'LIES 04 441.00 <br />9# E357.5C <br />2:FW- LAI•^F°.ATrt;� { 116 9#857.5041830.50 - <br />vO INJt i,TARL [ ,FfJGS L IV SOLUTIONS 10 41P,30.50 11122.00 <br />A X -VAN - UTAGNOSTIC OE) 11'17_2.00 8#656.32 <br />q <br />DRUG1C 8,656.32 <br />Q = CFf'SSIhJ1:.S AN10 SUPPLIL'S 13 111.783.00 1117£t8.00 <br />E- ( CYYt;E� 15 77,3.00 77&.00 <br />v <br />tz ELEL�.l i. All 1)117 GR AMS (EKG) 16' 301).00 300.00 <br />• = O T/ KL hC.NIE: DFUCS 90 54. 11 54.17 <br />z PPYSICAL TtIERAPY 1C� 21552.00 2*552.QO E <br />O ¢ TF,1F Sh{151Ot1 SFT -UP AND SEfiViCi: 20 2110.00 2'40.00 <br />N <br />D' k3,CLE: IBLCCU AND PACKFC CELLS 21 390.00 390.00 <br />3300 <br />w ¢ Et*ERGS v1.Y I.i; M VISIT 23. 33.00 . <br />Ix <br />w kl>i31C15(1T()Nks 27 27.00 277.0000 <br />60.00 <br />v ¢ R .00 DERIVATIVES 31 60000 <br />J >> 57.229.47 571228x49 • <br />LU 1.. ,...... <br />W I,GT 1 : n <br />R 1".SlJr,'1Ct' Co1 PU POSES <br />_ Per diem rate 68 days @$242.00=$16,456.00 ' <br />LU <br />IX <br />Diagnosis: 40% total body surface area -flame burn. Surgery: 1 25 78 - S lit thickness kin <br />Surgery: 1 11 78 - Debridement left .& right arms graft w ole body. <br />1 Surgery: l 18 78 - Debridement burn wounds See attached letter of.auth rization�� <br />•I _ .�.__.12_i$-�G 57,2Z".k? J 571228.49 <br />TOTAL <br />DATE INDICATCD FOR CHARGES REPRESENTS ALL BILLS ARE DUE AND PAYABLE ON DISCHARGE. ' <br />DATE OF POST NG. NOT NECESSARILY DATE *INSURANCE PORTION OF THIS STATEMENT IS HOSPITAL'S 7.228.49 <br />SERVICE RENDERED. ESTIMATE, AND NOT TO BE CONSIDERED FINAL. PAY THIS ESTIMATED AMOUNT <br />ALL UNPAID BALANCES ARE DUE FROM GUARANTOR. IRS *59 = 6600.673 <br />* .IINPr <br />C <br />�E <br />