Free Status Report - District Court of Arizona - Arizona

UNITED STATES DISTRICT COURT
DISTRICT OF ARIZONA
CASE NO. CIV 03-1987 PHX JAT
MARY CSANYI
v.
REGIS CORPORATION ct al.
ATTACHMENT TO DEFENDANT SUPER CUT’S
SEPARATE STATUS REPORT
Case 2:03-cv-01987-JAT Document 131 -2 Filed 06/O2/2008 Page 1 of 2

. _ - _` ‘ _ - _ §*"-ottsdale Psychiatric Service _. _ »-·’ l
_ ,_ 1 · _ · · -- 7432 East Camelback Roed ’ - -
A Q . ` . Scottsdale, AZ8525,‘l·35D9 _ _ ‘
· Page; I · [4BO)423—O7'l 3 l _ · mm mm
. - ° - 5- . I
I _‘P¤tient: MARY CSANYI _ Instructions: .
A- · · . _ 8627 ELNORII1-H,AND DR. ` Complete the patient infomation portion ofyour insurance
- ‘ ` _ 0 _ - " SCOTTSDALE, AZ 85251 seam rmi, Auschihk san, signed ami a¤¢ea,s¤d an other
_ - Z — * , . · bills pertaining to the claim. lf you have a deductible policy,
" .-_ a r .‘c‘-had in CSAMMH0 _ ‘ hold your claim forms until you have met your deductible.
H C*" iii 9905 . Mail directly to your insurance carrier. — -
Data Description Procedure Modify Dx 1 Dx 2 Dx 3 Dx i Units Charge
gv 9!24·’2003 Psychiatric Evaluation 90001 296.23 I - 250.00
. ‘9}24J2003 _ Check Payment _ · PCK · l 425.00
· f l W20!2003 deductible . DBD ' l 0.00 .
. - _ l(lr°20f2003 Insurance Adjustment ADJINS I -I2J0.00
_ l0Q’2lf2003 _ Psychotherapy. · 90805 · 296.23 ` · _l ' 120.00
-_ I' ` I0}'1{l{2003 Check Payment PCK i l . -65.00
` " · -. I- Provider Iufomiaiion . Tom charges: - _$ 300.00 U
.. ' - Providerblame: LAWRENCE M. MARTIN T¤l·¤l P¤¥m¤¤l·‘!! ·$ umn
·` ' License: I8040 Total Adjustments: -·$ l2>0.00
‘ ·. _ ¤=>¤¤?¤=¤¢*¤* PN _ _ ‘ _ Ten; use This were . ss moo
._ ` - n ` SSN or Emi 3 I Total Account Balance: $ 70,00
_ ·. Agign and Release: I hereby authorise payment of medical benefits to this physichu for the services described
` ~_ = ` _ above. iclso authorize the release of any int'orrmtion necessmyto process this claim. .
Z, ` - _` ‘ Patient Signature: _, ' Dam? _ l V _ `· `.
· · ‘ V · Case 2:O3—cv-O1987—JAT Document 131 -2 Filed 06/O2/2008 ‘ Page 2: of 2 .

Case 2:03-cv-01987-JAT

Document 131-2

Filed 06/02/2008

Page 1 of 2

Case 2:03-cv-01987-JAT

Document 131-2

Filed 06/02/2008

Page 2 of 2