Remit payment t SE Lancaster Health 333 North Arch St Lancaster, PA 17603-2928 (717) 299-6371 Stanley J Caterbone 1250 Fremont St Lancaster, PA 17603 ‘Stanley J Caterbone(079-425)Anna Maria Altomonte PA-C/8089377 1210372015 SP-PMT-Self Pay-GenMed Payment from Caterbone, Stanley J Balance: Patient Receipt Thursday, December 03, 2015 CC ET L____sooo | __ss.oal $0.00 $15.00 $0.00 $16.00 Your next appointment is on Thursday, January 21, 2016 9:40AM wih Douglas E Leaman MD at SouthEast Lancaster Health Services at Brighside. ‘Thank you for your payment. Total Balance Ins. Balance Pat Pop of si] ‘SouthEast Lancaster Health Services, Inc. * 515 B Hershey Ave * Lancaster, PA 17603-5762 * (717) 299-6371once a a Sale 2 sa Entry Method: hip Total: $ 15.00 ab WBS Tw Go oor Code. RSS atch: 2370‘SELHS Brightside December 3, 2015 515B Hershey Ave Lancaster, PA 17603, Page 1 (717) 299-6371 Fax: (717) 735-0518 Patient Information For : Stanley J Caterbone Date of Visit: 12/03/2015 Reason for Visit: new, back/grown pain, chronic 169 Ibs. 81 bpm 20 per min. 97% Blood Pressure: 130/84 mmHg Complete Problem List was reviewed during this visit. Complete Medication List was reviewed during this visit. Current Allergy List: + No Known Allergies Complete Allergy List was reviewed during ths visit. Scheduled Appointments: (01/21/2016, 9:40 AM, Any 40 - New Pt Over 18, SELHS (Medical - Brightside), Leaman MD, Douglas E Please visit our online Patient Connection! www.selhs. org ‘Once signed up, you may begin requesting appointments and preseripti see any of our staff members for any questions or assistance. Saturday hours now available! From 8 am. (0 12 p.m, simply walk in or call us at 717-299- 6371 for a sick visit or your child’s immunizations, school/sport physical, or well-child check. We're here for yoSouthEast Lancaster Health Service, Inc. wame_s Stat S]. Ghreceliaune oate of ith 07S /E SB L + No. —Erieg A. Cessna sissy. veN If you answered yes please tell us your disability. Meare. Disae cerry PEAS. Mind correoe Are you a vete Yes, Signature, Date Nombre Fecha de nacimiento, Yo, tiene una incapacidad. S|_No__ Si usted respondié si por favor diganos su incapacidad. Es usted un veterano? S|__No___ Signature, DateAcknowledgement of receipt or understanding of Health Information Privacy hereby acknowledge that | received a copy of HIPAA, if| requested it, or understand the policy from SouthEast Lancaster Health Service. Date. j2[3/a01 £ Signature ofPatient or legal guardian 1 Check box if refuse to sign the acknowledgement. Reason Date, Signature of SELHS staff Recibo o entendimiento de la privacidad de la informacién de salud Por la presente reconoce que recibi una copia de HIPAA, si solicita, o entender la politica del servicio de salud de Lancaster sureste. Date, Firma del tutor legal o paciente L marque ta casilla si se niegan a firmar el reconocimiento. Reason Date, Firma de personal SELHSee ud Wii Sviees Patient Name. : Chart # D Provider Name wast pate (2/3/2015 SOUTHEAST LANCASTER HEALTH SEVICES PATIENT FINANCIAL RESPONSIBILTY FORM Financial Responsibilities Payment is due at time of service. For your convenience we accept cash, check and most major credit cards at our office. Please be aware that if you are on oir Sliding Fee Discount Program or are a Self-Pay Patient the amount charges to you at the time of your visit is an ESTIMATE of charges for your visit that day. You may receive a bill from us after you visit for the balance of your charges. PATIENT INITIALS Insurance Billing SSELHS participates with mast forms of insurance. As a courtesy we will bill your insurance company if you provide ALL necessary information however the ultimate responsibility for payment of our services rests with you~ the patient. You are responsible for any co-payments, coinsurance, deductibles, and service not covered by your Insurance company. It is your responsibility to present all current insurance cards at the time of each vist. ‘Non-Payment on Account SELHS utilizes an outside Recovery Agency to assist us with the recovery of payment for our services. Should your account become 60 days past due, the account will be turned over to the Agency. Should your account become 150 days past due you will be dismissed from our practice. Payment plans can be set up with SELHS Billing Department to avoid Alsmissal from the practice. ppointment No-show Appointments must be cancelled 24 hours in advance. If a patient fails to call or simply does not show for an ‘ppointment itis considered a no-show. there ae total of three (2) no-show appointments wihip year 3 patient may be dismissed from SELHS practice. PATIENT INITIALS Consent to treatment | hereby give my consent for myself and/or my child to receive medical/dental health care at SELHS. PATIENTS INITIALS {have read the above Patient Financial Responsibilities. | fully understand that | am responsible for payment of services rendered today at SELHS if lam uninsured or rey insurance company fails to pay for those services. owe 2 [3/201 Signature of Patient or Legal Guardian Relationship to Patient ‘Signature of SELHS Staff. DateDsus Patient Rights and Responsibilities SELES is committed to providing quality health care. Its our pledge to provide this cae with respect and dignity. In keeping with this pledge and commitment, we preset the following Patient Rights and Responsibilities: ‘A personal clinician who will see you on an on-going, regular basis ‘Know your healthcare clinician's name and title and how to reach them Competent, considerate and respectful healthcare, regardless of race, creed, age, sex or sexual orientation. A complete, easly understandable explanation of your condition, treatment and chances for recovery. ‘The personal review of your own medical records by appaintment and in accordance with applicable State and Federal guidelines. Confidential management of communication and records pertaining to your medical care. Information about the medical consequences of exercising your right to refuse treatment. The information necessary to make an informed decision about any treatment or procedure, except as limited in an emergency situation, Be fee from mental, physical md sexual abuse. ‘An individualized treatment and plan of care to manage ll of your medical concerns : Decline to have students involved in your cae. ‘An explanation of your medical bill regardless of your insurance, and the opportnity to personally examine your bill. ‘The expectation that SELBS will take reasonable steps to overcome cultural or other communication barriers, including language, ‘hearing or vision impairment, that may exist between you and the staff. + The opportunity to file « complaint should a dispute arise regarding car, treatment or service, orto selec a diferent clinician. ‘You are responsible for: ‘© Following the center's rules about patient conduct, which include following: > Behaving at all times, in a polite, courteous, considerate, and respectful manner to all SELHS employees and patients, 25 well as respecting the privacy and dignity of other patients. Respecting the rights and property of SELB and its employees and other persons in the health center, including refraining ftom use of foul language, the use ofa raised or loud tone of voice, or yelling, and/or harmful, abusive, ‘threatening or rude conduct towards other patients and/or SELHS stat. ‘There is no smoking in any areas of SELHS. ‘You will not carry any type of weapons ot explosives into SELHS. Refrain from eating, or drinking in our exam rooms. Refrain from the inappropriate use of cell phones in exam rooms. Supervising your children while at SELES. ‘© Giving your clinician correct and complete health history information, e.g. allergies, past and present illnesses, medications and hospitalizations. ‘© Providing staff with correct and complete name, addtess, telephone and emergency contact information each time you see your ‘linician so we can reach you inthe event of a schedule change or o give medical instructions. ‘Providing staff with current and complete insurance information, including any secondary insurance, each time you see your eesee ‘+ Signing a “Release of Information” form when asked so your clinician can get medical records from other clinicians involved in your care. ‘+ Telling your clinician about all prescription medication(s) altemative, ie. herbal or other, therapies, or over-the-counter medications you take. If possible, bring the bottles to your appointment. ‘+ Telling your clinician about any changes in your condition or reactions to medications or treatment. ‘© Asking Your clinician questions when you do not understand your iliness, treatment plan or medication instructions. Following your clinician's advice. If you refuse treatment or refuse'to follow instructions given by your health care clinician, nsible for any medical consequences. ‘Ifyou must cancel yout appointment, please call the health center atleast 24 hours in advance. visitor other bills upoa receipt. 772014PNC Online Banking Vamenta) (iazersecgneou Page 1 of 2 fraety sano ‘ena Snare 2 Ea ober a Ser ego ah rane ena ater gfecfode, Pa ge Summary Gar nacteunec) saccoare heh QVirtuatwaltet nie he at og eet Wate uc tart (tp /pcvrtuahatt cm eer) ‘Quick view @ ‘Account Detail | Account activity ‘Spending zone | Savings Engine Preferences (eco ain| ‘Sains atone) December 2015 ‘rae Your Spending View Al» - no ual atee: $0 ) gans means naowns gowns nesns nins nouns nesns eseition ‘rage unewAs mora $9 “ANCASTER CH WEBSINGLE C#90000591090S PL ELECTRIC Foote gen UMCAoTER De Poors Gas UNCASTER DA Deposits Spend balance ss238 sues ee 0076 oso sm sino https://www.onlinebanking pne.com/vw/v2/LaunchV WApp?vwid=a50feOdbd6edee6094d..._ 12/3/2015PNC Online Banking Page 2 of 2 {ayes DEBT cago puncrase ooo CIT OF 20.00 sean View Al Aco testeOpa iso isDservetra.teottspges0~nyAcoumsArouteORESBrWSD-caree) C> | Moble + Text Barkng (itrotontshsaisD-sereaouteopsmsepapehs0 nablebokingorweueOeNserensD~curen) > | Acestlty https://www.onlinebanking, pnc.com/vw/v2/LaunchVW App? vwId=aS 0fe0dbd6edee6094d..._ 12/3/2015PNC Online Banking Page 1 of 6 (ermrecrconcsie) sree treme ena EER ease iy pccounts rater unde ye ais ciate Sevce My oters oe rt trees teat) Ss tid he Wa os stato eu Wat ui Se peta ga) quick view © fccount Beta | account activity | Spending Zone | Savings Engine | Preferences Commnanen ] November 2015 {can Flow and Traneaction Mstory (Cees aembursement )CSearn ) (Export) Crt) ‘ack Your Sending ew Al» Gm ) Geetiooee ———) Crens 5 sie nares 7086 wipe Dace 49589 Aceves 1990 ome onion Veh bea ope innes ma spans rospuRcase rosin oases Lowes enn2 so sauce unas -scL es mA TER oe ur S008 AOHWEDSNGLETRUTORUCPAIPAL STARR 800, pam hinons AC WER-SNGLEOMMISHEDOR PAPAL ISTIER 85 nan sinans rosa sani mac orice son nm sinans peer oo aos noone Luts my 500 pao hioans par cnonmowse nen is cecee 00 exe nipans ser ago nous poor: namorr 00 ene nioons— osmoase ose esee soo vs one hoons ser ogo nse papas: waar 1200 oma hipens—posnueaseoseyne ose omice sw seas Linens paar op rouse xeon Fos 1090 sn pons gr cp nacuase pane: sere ma ease hipens sar oomincuse pane voces 1500 sen sinons ogi ep rncuse econ wamort sce wo 1yB07'S EIT cARo PURCHASE 0009982 WEIS MARKETS sa sen 50 ‘unens oe arp nena econ THE SALTON ma sso ‘anens Dear cro mReNSe ero HABUOTE sisc0 ss2535 https://www.onlinebanking pne.com/vw/v2/LaunchVW App?vwld=a50feOdbd6edee6094d... 12/3/2015PNC Online Banking Linons oar co acide oosnn wes MeneTs vnens OME Taner Row Dp0OGEDD ior 177s AOI WEB SNL TUNESSTONEPANPAL IN AER MTS SipenCENTER OST UNETE OR ‘Siem @iuhenoracra Sees Genceonacoa hia7is pe cronmcase mma: roo. rms omar cao ncn necro masiort inns og ep nese neoo3e2 Tne lirns ogni emo runcnae cognate ors tiarns ogni amo rurcnse none 81 west brnns gaa oo pmowsp omnes ze so ss pa oo pmease poser rue Sani Pace oe rans sci wensine ovneonsnioos conCAST niasns — sesr ogo nnouse poms: wes MRIS hasns pam ono nponase panos: s52- OF lunar sev chot oeeorec WeLsFaRcO TIN DEP Iiwis sos uncnase ost inns eases Aco inwis om mp rurciase xeononea AOA tunais og ean unease nora cw eATERNG Sera av tancaen on 1inans oer camo puncwse sora TURKEY HL Lunas og amo runewAsen00932 COUMBIA DINER hutps://www.onlinebanking. pne.com/vw/v2/LaunchVW App?vwld=a50fedbd6edees094d. 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