CALIFORNIA BLUE SHIELD EXPLANATION OF BENEFITS-MEDICARE
HEALTH   INSURANCE   CLAIM   NO.
575249435A
DATE   OF PL*"   ;       PROCEDURE
SERVICE        :   SERVICE" NUMBER
P. O.  BOX 7968, SAN FRANCISCO. CALIFORNIA 94 11^
HY<j*
DESCRIPTION       OF      SERVICES
CONTROL   NUMBER
49607648
TOTAL
CHARGES
CHARGES NOT
ALLOWED
DATE
04   11   68
ALLOWED
CHARGES
02 28 fea NH  <*0l»
THIS STATE«C.N
PROGRAM, AM A
hlU fcE RECEI
MtOICAL   C*kE
'   IS  FOh   bL;i4EFlTS  U?"wlK   THE   rtfcDICARL
LJDITlO^sL   PAY.HLWT   KOK   Mfc'UI-CAL .tiENtHT
VEO   AT   <i   LiTEK   DATt*
ti»C0
I5.«00
PLACE OF SERVICE
CODES
0 - DOCTOR S OFFICE
IH - INPATIENT
HOSPITAL
H - PATIENT'S HOME
OH - OUTPATIENT
HOSPITAL
1L - INDEPENDENT
LABORATORY
NH-NURSING
HOME
OL-OTHER
LOCATION
ECF - EXTENDED.
CARE FACILITY
DEDUCTIBLE RECORD
AMOUNT OF THE $50.00
DEDUCTIBLE YOU HAVE MET
St HYLfc
933 MALTMAN AVfc
LOS ANGELES CALIF
YEAR
iK* eOU
TOTALS
1>>_0U
LESS DEDUCTIBLE PAYABLE  BY  BENEFICIARY
LESS 20%  PAYABLE  BY  BENEFICIARY
TOTAL ALLOWED CHARGES  PAYABLE  BY  BENEFICIARY
MEDICAL   INSURANCE  PAYS  PROVIDER  OF  SERVICES
15.00
113,00
_.3_do
&L2.0Q
THIS   IS   NOT   A   BILL
yaartb
PLEASE RETAIN THIS FOR YOUR RECORDS. IF YOU VISIT YOUR
SOCIAL SECURITY OFFICE TO INQUIRE ABOUT YOUR CLAIM. BE
SURE  TO TAKE THIS  FORM  WITH   YOU.
California blue shield FOR HEALTH INSURANCE - SOCIAL SECURITY ACT
P.O.  BOX  7968.  SAN  FRANCISCO.  CALIFORNIA  94119
HEALTH   INSURANCE   CLAIM   NO.
5?52*tf43SA
CHECK NUMBER
MO.
0*
DAY
U
YR
6a
•<r  ON  THIS  DATE   AMOUNT SHOWN   ->■
WAS  PAI%ON*ypjJ|R^_3EHALF TO
ASSIGNEE NaMeD BELOW
DOLLARS          CENTS
PhCX   SHi.PKO
■MEUGfeR   KAPLAN   AND
KCPPELMAN  Mi. _
4120   to   PICO   jLV'j
LCS  ANGtLES  CAHf
90019
f_®TT R3__(ffi(OTM[I