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r. P. A.
	DATE: 06/OSl92	J A	I L Y C N F C	K ~t E u I 5 T E R N Y	G R	O	U	P						PAGE: 4
				fnIJAY JUNE 5, 1992										
				R~GISTEK '+UMBEp 205										
:NECK	CHICK													CHECK
{UMBcR	DATE ILA IM NO	SOC SEC	40 EMPLOYEE	CL AIHANT	PAY	TD								AMOUNT
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;U: TPk^00[4 GRUUP: Tpk-OU24	KERN	COUNTY											
	CHECK tiftOUP: 024	KERB	COUNTY											
1749	06/05/92			MANUAL OTHER	YOID									.UO
1750	06/05/92 LINE UP			~	## Y	0	I	D	C	H	E	C	K ##	,00
1751	06/05/92 LINE UP				## V	0	I	0	C	H	E	C	K ##	.00
1751	06/05/42			MANUAL OTHER	VOID									.00
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1754	ue/05/92 LINE UP				## V	O	t	U	C	H	E	C	K S	.oo
1755	Oa/OS/92			VOUCHER PAYMENT	S[D	PETERSON	MEM	HOSPITAL	i,70 L 57
														5,701.57
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T.P.A.
!ATE bti/12/92 PROVIDER UQUCHER LISTIN& PAGE ?
~PU003}
"Ok PROVIDER: 79-1733761 MILL COUNTRY RADIOLOGY
FOR GROUP: iP8-0024 ifERR COUttTY
SEQUENCE N0: 1
PATIENT CIAIN INCURRED COVERED TOTAL
CLAIMANT DEP. N0. N0. FROM TO CNARGF PAID
POLY, E 125960 9000572706 04!21!92 Q4/30192 35.00 35.00
GROUP tOTAI: 35.00 35.00
PROVIDER iQiAl: 35.04 35.00
T.P.A.
:ATE ObJ12192 PROVIDER VOUCHER tISTIk6 PAGE 1
iPU003}
'0~ PRGUIDFfi: 74-2446814 ALLEN HD, WILLIAM M
FOR SRilUP: TFX-0424 HERR CDUHTY
SEQUENCE N0. 2
PATIEFIT CLRIIt INCURRED COVERED IOTRL
CLAIgAhT DEP. N0. 1lO. FRtMI i0 CHARGE PAID
IIARSC1iAtt I. 1414 92000b4607 04/13/92 09/13/92 290.47 290.47
6Rt1UP TOTAL: 290.47 290.47
PROVIDER TOTAt: 290.47 290.47
M _ .~
I.P.A.
LATE 46112192 PROVIDER UOUCMER LISTING PAGE 1
4PV003?
'OR PROVIDERS 74-194i405A ST IUKES LUTHERAN NOSP
FOR CROUP: TPR-0024 NERR COUNTY
SE4UFiiCE N0: 3
PATIENT CLAIM INCURRED COVERED TOTAL
CLAIMANT DEP. N0. NO. FROtf To CNARSE PAID
gALift9 E 2594232 92000b310~ 04/06/92 0410b/92 3b02.b9 1944.67
iDiOUP TOTAL: 3b0?.69 1944.61
PROVIDER TOTAL: 3b02.b9 1944.b7