On April 23, 2024 a
Exhibit,Appendix
was filed
involving a dispute between
Daryl Davis,
and
for Special Proceedings - Other (Infant Compromise Hearing)
in the District Court of Sullivan County.
Preview
FILED: SULLIVAN COUNTY CLERK 04/23/2024 09:37 AM INDEX NO. E2024-663
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 04/23/2024
FPM Information
Interested Party: N Dahp Total Medical Bills $1107.71 Total Copay $0.00
Paid to Date: Amount:
Claim Number: Total Lost Wages Paid $0.00 Total Copay $0.00
to Date: Remaining:
Date of Loss: 8/12/2021 Total Replacement $0.00 Total Basic Personal $1107.71
Benefits Paid to Date: Injury Protection
Paid to Date:
Total Paid to Date: $1107.71 Total $0.00 Total Additional $0.00
Death/Funeral/Survivor Personal Injury
Benefits Paid to Date: Protection Paid to
Date:
Total $0.00 Total Applicable $0.00 Total Medical $0.00
Reimbursement/Refunds Deductible Amount: Payments Paid to
Date:
Net Total Paid to Date: $1107.71 Total Amount $0.00 Total Deemer Paid $0.00
Deductible Applied: to Date:
Medical Bill Details
Date Bill Status Date(s) of Provider Charged Paid Paid/ Payee Check No. Deductible Co-Pay Offsets Subsequent
Received Service nif ibuIt Amount DeniedDate Applied Applied Applied Payment
10/19/2021 Denied 8/15/2021 GARNET $49.21 2021-10-28 $0.00 $0.00 $0.00
HEALTH
MEDICAL
CENTER
CATSKILL
01/20f2023 Paid 1/10/2023 MIDDLETOW $1550.88 $905.39 2023-02-21 Middletown 240372703 $0.00 $0.00 $0.00
N MEDICAL Medical P C
PC
02/06/2023 Denied 12/6/2022 MIDDLETOW $268.81 2023-02-20 $0.00 $0.00 $0.00
N MEDICAL
PC
02/10/2023 Paid 10/26/202 MIDDLETOW $252.90 $202.32 2023-08-16 Middletown 243199861 $0.00 $0.00 $0.00
2 N MEDICAL Medical P C
PC
FILED: SULLIVAN COUNTY CLERK 04/23/2024 09:37 AM INDEX NO. E2024-663
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 04/23/2024
05/24/2023 Denied 10/26/202 MIDDLETOW $252.90 2023 06-14 $0.00 $0.00 $0.00
2 N MEDICAL
PC
Document Filed Date
April 23, 2024
Case Filing Date
April 23, 2024
Category
Special Proceedings - Other (Infant Compromise Hearing)
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Preview
FILED: SULLIVAN COUNTY CLERK 04/23/2024 09:37 AM INDEX NO. E2024-663 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 04/23/2024 FPM Information Interested Party: N Dahp Total Medical Bills $1107.71 Total Copay $0.00 Paid to Date: Amount: Claim Number: Total Lost Wages Paid $0.00 Total Copay $0.00 to Date: Remaining: Date of Loss: 8/12/2021 Total Replacement $0.00 Total Basic Personal $1107.71 Benefits Paid to Date: Injury Protection Paid to Date: Total Paid to Date: $1107.71 Total $0.00 Total Additional $0.00 Death/Funeral/Survivor Personal Injury Benefits Paid to Date: Protection Paid to Date: Total $0.00 Total Applicable $0.00 Total Medical $0.00 Reimbursement/Refunds Deductible Amount: Payments Paid to Date: Net Total Paid to Date: $1107.71 Total Amount $0.00 Total Deemer Paid $0.00 Deductible Applied: to Date: Medical Bill Details Date Bill Status Date(s) of Provider Charged Paid Paid/ Payee Check No. Deductible Co-Pay Offsets Subsequent Received Service nif ibuIt Amount DeniedDate Applied Applied Applied Payment 10/19/2021 Denied 8/15/2021 GARNET $49.21 2021-10-28 $0.00 $0.00 $0.00 HEALTH MEDICAL CENTER CATSKILL 01/20f2023 Paid 1/10/2023 MIDDLETOW $1550.88 $905.39 2023-02-21 Middletown 240372703 $0.00 $0.00 $0.00 N MEDICAL Medical P C PC 02/06/2023 Denied 12/6/2022 MIDDLETOW $268.81 2023-02-20 $0.00 $0.00 $0.00 N MEDICAL PC 02/10/2023 Paid 10/26/202 MIDDLETOW $252.90 $202.32 2023-08-16 Middletown 243199861 $0.00 $0.00 $0.00 2 N MEDICAL Medical P C PC FILED: SULLIVAN COUNTY CLERK 04/23/2024 09:37 AM INDEX NO. E2024-663 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 04/23/2024 05/24/2023 Denied 10/26/202 MIDDLETOW $252.90 2023 06-14 $0.00 $0.00 $0.00 2 N MEDICAL PC