Case Number: 91D 00047
File Date: 03-27-1991
ST OF KS EX REL SRS
Address:
*CASE CLOSED 2-7-94*
DOB:
Attorney:
BAILEY, MARY
Address:
ST GEORGE KS 66535
DOB:
Attorney:
| Receipt Number | Receipt Date | Payor Name | Total Amount |
|---|---|---|---|
| 92 | 04/06/1992 | BAILEY, MARY/MEM HOSP | 0.00 |
| 418 | 05/04/1992 | BAILEY,M/MEMORIAL HOSP | 0.00 |
| 812 | 06/03/1992 | BAILEY,M/MEMORIAL HOSP | 108.00 |
| 1103 | 06/30/1992 | BAILEY/MEMORIAL HOSP | 108.00 |
| 1379 | 07/21/1992 | BAILEY/STATE TAX SETOFF | 0.00 |
| 1447 | 07/28/1992 | BAILEY,M/FEDERAL SETOFF | 0.00 |
| 1517 | 08/03/1992 | BAILEY/MEMORIAL HOSPITAL | 108.00 |
| 2111 | 09/22/1992 | BAILEY/MEMORIAL HOSPITAL | 108.00 |
| 2208 | 09/30/1992 | BAILEY/MEMORIAL HOSPITAL | 108.00 |
| 2491 | 10/30/1992 | BAILEY/MEMORIAL HOSPITAL | 108.00 |
| 2594 | 12/07/1992 | BAILEY, MARY/MEM HOSPITAL | 108.00 |
| 2606 | 01/11/1993 | BAILEY, MARY/MEMORIAL HSP | 108.00 |
| 2641 | 02/08/1993 | BAILEY/MEMORIAL HOSPITAL | 108.00 |
| 2639 | 03/05/1993 | BAILEY/MEMORIAL HOSPITAL | 108.00 |
| 2807 | 04/01/1993 | BAILEY/MEMORIAL HOSPITAL | 108.00 |
| 3203 | 05/05/1993 | BAILEY/MEMORIAL HOSPITAL | 108.00 |
| 3462 | 05/28/1993 | BAILEY/MEMORIAL HOSPITAL | 108.00 |
| 3671 | 06/11/1993 | BAILEY, MARY | 0.00 |
| 3800 | 06/24/1993 | BAILEY/MEMORIAL HOSP | 108.00 |
| 4642 | 08/24/1993 | BAILEY/MEMORIAL HOSPITAL | 108.00 |
| 4884 | 09/09/1993 | BAILEY,M/MEMORIAL HOSP | 108.00 |
| 5273 | 10/07/1993 | BAILEY,M/MEMORIAL HOSP | 108.00 |
| 5594 | 11/02/1993 | BAILEY,MARY/MEMORIAL HOSP | 108.00 |
| 5889 | 11/29/1993 | BAILEY,M/MEMORIAL HOSP | 108.00 |
| 6295 | 12/27/1993 | BAILEY,M/MEMORIAL HOSP | 108.00 |
| 6834 | 02/02/1994 | BAILEY,M/MEMORIAL HOSP | 108.00 |
| 7413 | 03/14/1994 | BAILEY,M/MEMORIAL HOSP | 108.00 |
| 7496 | 03/18/1994 | ADJUSTMENT | -108.00 |
| Description | Transation Date | Amount Paid | Payor |
|---|---|---|---|
| C/S #033000 | 04/06/1992 | 108.00 | BAILEY, MARY/MEM HOSP |
| C/S #033408 | 05/04/1992 | 108.00 | BAILEY,M/MEMORIAL HOSP |
| C/S #033757 | 06/03/1992 | 108.00 | BAILEY,M/MEMORIAL HOSP |
| C/S #034084 | 06/30/1992 | 108.00 | BAILEY/MEMORIAL HOSP |
| C/S STATE (6-30-92) | 07/21/1992 | 76.71 | BAILEY/STATE TAX SETOFF |
| CS FEDERAL (6-19-92) | 07/28/1992 | 735.36 | BAILEY,M/FEDERAL SETOFF |
| C/S #034463 | 08/03/1992 | 108.00 | BAILEY/MEMORIAL HOSPITAL |
| C/S #035094 | 09/22/1992 | 108.00 | BAILEY/MEMORIAL HOSPITAL |
| C/S #035124 | 09/30/1992 | 108.00 | BAILEY/MEMORIAL HOSPITAL |
| C/S #035534 | 10/30/1992 | 108.00 | BAILEY/MEMORIAL HOSPITAL |
| C/S #035955 | 12/07/1992 | 108.00 | BAILEY, MARY/MEM HOSPITAL |
| C/S #036327 | 01/11/1993 | 108.00 | BAILEY, MARY/MEMORIAL HSP |
| C/S #036714 | 02/08/1993 | 108.00 | BAILEY/MEMORIAL HOSPITAL |
| C/S #037019 | 03/05/1993 | 108.00 | BAILEY/MEMORIAL HOSPITAL |
| C/S #037355 | 04/01/1993 | 108.00 | BAILEY/MEMORIAL HOSPITAL |
| C/S #037763 | 05/05/1993 | 108.00 | BAILEY/MEMORIAL HOSPITAL |
| C/S #038150 | 05/28/1993 | 108.00 | BAILEY/MEMORIAL HOSPITAL |
| NEG FED ADJ TO 3-17 | 06/11/1993 | -198.96 | BAILEY, MARY |
| ADJUST SRS | 06/11/1993 | 0.00 | BAILEY, MARY |
| C/S #038465 | 06/24/1993 | 108.00 | BAILEY/MEMORIAL HOSP |
| C/S #038916 | 08/24/1993 | 108.00 | BAILEY/MEMORIAL HOSPITAL |
| C/S #039205 | 09/09/1993 | 108.00 | BAILEY,M/MEMORIAL HOSP |
| C/S #039533 | 10/07/1993 | 108.00 | BAILEY,M/MEMORIAL HOSP |
| C/S #039928 | 11/02/1993 | 108.00 | BAILEY,MARY/MEMORIAL HOSP |
| C/S #040283 | 11/29/1993 | 108.00 | BAILEY,M/MEMORIAL HOSP |
| C/S #040423 | 12/27/1993 | 108.00 | BAILEY,M/MEMORIAL HOSP |
| C/S #041084 | 02/02/1994 | 108.00 | BAILEY,M/MEMORIAL HOSP |
| C/S #041522 | 03/14/1994 | 108.00 | BAILEY,M/MEMORIAL HOSP |
| REFUND#7413;SRS CLOS | 03/18/1994 | -108.00 | BAILEY, MARY |
| ADJUST SRS | 03/18/1994 | 0.00 | BAILEY, MARY |