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Luke � ►��;�.�a t_I..d . � F L L7 U !,; �lJ�� NOTICE OF CLAIM FORM to the City of Saint Pa�l;`'� 'A��sota Minne.�so?a�t��t��e 466.05 states that"...every person...whn claims damages frnm any municipaliry...shall cause tn be presented to the ga�refpir�¢qdy?qf��e municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and ! r r< <_ �1 � E! � circumstances thereof,and the amount of cnmpensation or nther relief demanded." Pl � �-�i.s Porm in its entirety by clearly typing or printing your answer to each question. If more space is neede�,a�dditional sheets. Please note that you w�11 not be contacted by telephone to clarify answers,so prnvide as much information as necessary to explain your claim,and the amount of compensatian being requested. You will receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the nature of your ctaim. This form must be signed,and both pages completed. If something does not apply,write`N!A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL, MN 55102 First Name ' \�� r� Middle Initial J� Last Name ,—"`�L� Company or Business Name � Are You an Insurance Company? Yes/ io If Yes,Claim Number? Street Address o��¢ � �� y� � �� 1 �c��1-F-. �O.'"'�-��- W ��-� � � City��t.'"� State M� 7�ip Code t� �� E Daytime Phone( ? 3 d��I�Cell Phone( �d ��,Evening Telephone �{ (0�14�- c� � �'3 Date of ccidenV 'uInj or Date Discovered C'� I �'L'� a o \\ Time `0�,30 �� Please state,in detail,what occuned(happened),and why you are submitting a claim. Piease in icate why�r�'ha��v you feel the City of S 'nt Paul or its empl yees aze�volyed and/or responsible far your damages.��-�i=,-- V�t r��C- ��o�. v� �'� - '1'�- .��.� o.� `l C 0.�� " v,c } � -�-C.-� A � r�e.e,'h �1 ��.�. U.?c1"� ��„.� c U c ' � O �-1 �-� � .5 •'� �' � �. � ..."� `," \ ti.c'� � � -� L�r-w'�Q V �v�v��- ' ti � � U ' ti� �✓ > . \ v,:cti\� c�] ��. w ��L�� ^�' `�'�'�cr�,'�— r� L'..� C � � UJ C�� -2'� 0.� K��_ ti-�� \ � „�= V.1�5 �`" `''-��' � �� \ �� /-�'.-. ti-��,-,,-4.-, Please check the box(es)that most closely represent the reason for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ❑My vehicle was damaged by a pothole or condition of tfie street CI My vehicle was damaged by a plow ❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property �;Orher type of property damage-please specif��Y��y.>��-� O �.� v.Y� ��,�•�-. ��.\ �L � Other type of injury-please specify c�.,�� b,�c�l�-�_ << l�.-,;.P�,��,--�� -�.ti-�,� �- 2 er1'�-�,, In order to process your claim vou need to include conies of all anaticable documents; For the claims types listed below,please be sure to include the docu�nts indicated or it will delay the handling of your claim. Dacuments WILL NOT be returned and became the property of the City. You are encouraged to keep a capy for yourself befare submitting your claim form O Property damage claims to a vehicle:two esrimates for the repairs to your vehicle if the damage exceeds $500.00;or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims: two repair estimates if the damage exceeds$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items �.Injury claims: medical bills,receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2-Please complete and return both pages of Claim Form Failure to complete and return both pages wiil result in delay in the handling of your claim. All Ctaims-ulease comolete this section Were there wimesses to the incident? Yes No Unknown (circie) Provide their names,addresses and telephone numbers: � �O��Q�" `-�� >�-- `'`'«� ��-�`'" c� ,.�c, c� n'� 5�' � -� > � \r��_ �,``� �,,;c� .p 1� . -z, .�:-t� ��\�� c�N�l ti,� , �.�1 L . ��,` C��--�? - c_�Z �t �- , �c� -Y--�=�. �Vere�police or law enforcement called? Yes No. �Unknown (circle) If es,what department or agency? Case#or re R# �. � `•-��'> �'�.��c.�\< �,,�-�F,r. -�. �_�,��J=��.� �f 1 � ` � c'�.�-1��'�C_.Cl \��f_ ��'-`<- , —�-- `��. here did the accident or injury take place. Provic� street ad ss,cross stragi�intersect�on,name of ark or facility,� closest landmark,etc. Please as detailed sible. ecessary,a ch a diagram ��_��ti��= -� ti��—�_�� t� � ��E .ti��\�_ � \�,-� -,o-,1 � �C,� �.-,-•-��--�� w �`Nr.._��-c � ��Q^'_ �1CL�� Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve 's cl�im to your satisfacrion. y..Y��. �y�cti'�- �VJ��v'�,-� �.� �� c:n,ti�ti� U,,-� � ,-r�� CC1J �V� `�" -r. � � _c��.� � � -�r-r _> j�-� <J u�c�� .. �-� �� f.,'�c�.-1 -�,`�G�C� �_ �,x� v c�\'�� -� Vehi l — 1 1 this t�on � � ❑check box if 's sectio dce n t 1 Your Vehicle: Year Make Mode License Plate Number St Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model ,_,____ __,__ License Plate Number State Color Driver of Vehicle(Ci mployee's Name) Area Damaged I Cl ims— lease com tete this don ❑check box if this section dces n t a 1 ' How were vou iniured?_`��-�-+ � .�`�- ' c_ ��--. c ;� ��^�� c� ! , at part(s)qf your body were injured? ��,-•a ti.�.�_�- ,,� �►.Y�. -� `�--�-� ��k�� c�t�•� �� ' Y_ U� �� , Have you sought medical treatment? ,�� No Planning to Seek T a�rnent(circle) When did you receive treatment? �v-�'�`�� -� ` �l� -� ��-� � Y� �l I��1�-- pro�n de date(s)) Name of Medical Provider(s): r �v� �1�,�• + , �� a Y-. �.`�`� Y-�-.� � Addressw�s��^' ��o�G ,w. �o�� -u--�.� _ � A 1� ele hone } • ly� � �--,—tit,-,--�. � '1 ��^�� Did you miss work as a resul of your i�,l Yes N When did you miss wark? � ��- z `i �� f��'�-� —1� 3��1 �-� y y� (provide date(s)) Name of your Employer: Cwv Z�`�� v. -�-Yti�;v��, ' Address"1 b�� ` "�1 1� Telephone ��O'�i '�" 3�'`1 — b �o � `n-�� 5 S �� - 313'k eck here if you are attaching more pages to this claim form. Number of addiNonal pages By signing this form,you are stating that all inforrnation you have provided is true and correct to the best of your knowledge. Unsigned forms will not be prncessed. Submitting a fatse claim can result in prosecution. Date form was completed �-.S -�d�� L �.v� .� \ �`�lz� ��'"�, Print the Name of the Person who Completed this Form: w i� �»`��- w �� \\�� Signature of Person Maldng the Claim: ��f� G!�� Revised Februsry 20ll �b�� {��__ �� Li'O 5 S-bro� � �.1r,��\�n�1.-� ��`1�'�� ► � .��o _ SS�-- �7e�� '�'�. �\� wt��'`''�"-� �� \° � `1 � 3_ ��1--�- �- 3� � � � � c� a 3 •o v a 3 � � � � � 01 3 3 3 0 � a �+ 0 3 0 � ' ^ � �p n � ro � � — m m Q v�, : � p� O O C 7' O OO � ei N m N Q O � O 7 O � N C r 3 c� c� 3 � � 3 � °' � °' °' rxo C p < < � � � °O s 3 � � � (�D n °. °, 0 3 X ±+ 3. x 3 X $ � � � m m ° m m o m o w n \ c' ^ � O ,.�. � � 0/ o o; oi 3 � � — — � p m d � \ d � 3 3 7 . N c a n a O O o O O N m -+. m m 0 �c O o H C N N C � C C d N N N ` 7 � 3 7 � F � � D � � � � D D � N n d 'p T 0 O 0 � p � � O y 3 � � in O °3 N n� -p n � _ � O m Q, i 3 °-° � �c �. o m < � �o r.`i n�i � m � F `oi °' � � � < ' = f o 0 o r"o � � � �• � �.. D � iA t/* O N F+ � f+ C V tC Vp A ln ' O v� O A f+ N �0�0 $ W $ � D 0 f '� N � I-+ F. O_ � l0 W � U� A N l0 N F+ O Oo O Oo S o s 3 D o S n �„ < < „ N < v�i O d p. 7 fD N V�i ry vi O. p. Q m O. m C R'� n Qe � 2 f n� O. -� v 'O � � n 3 O _. � O � � � N fD C n S v a � n �' � < 3 o � o v � mv n � m c � �y � � ' v '° �o m � o £ m � � � o�, °' c', � � O � y N "[ � �? c 3 '+ � in � v� d 7 O � 3 � C 3 � N d 1 � � O m n v g m d � < c o, O 3 C � � o�i t/w °/ tn tn �- n A Q w in W �n � O� _ f+ O F-' O L` h o � $ � $ _ � � a � d v � 3 n n ro m � � �'' tn �'' vT tn an tn � °o � o°o °i � r �.�.. O O O O O O O Robert luke-Add"rtional information Family Dentist Dr. Fu Wong 7200 Hemlock Lane N,Suite 105 Maple Grove, MN 55359 763-424-4415 Oral Surgeon Abdollah Rahimi, DDS 15600 36`h Avenue North, Suite 100 Plymouth, MN 55446 763-559-7688 Employer Group Dental Plan Metropolitan Life Insurance Company P O Box 981282 EI Paso,TX 79998 800-942-0854 Employer Group Medical Plan Connecticut General Life Insurance Bourbonnais Claim Office P. O. Box 182223 Chattanooga,TN 37422-7223 Group 3203328 i I D U 324458101 800-268-3901 Employer-Cardinal Health 9000109'h Avenue North Champlin, MN 55316-3138 763-323-9666 We had originally assumed between our medical and dental plan all would be covered.We are finding out of pocket expense caused by the trip on the sidewalk and therefore the submitted claim. Our medical plan only provides for treatment to sound and natural teeth.The side front tooth was sound and the expenses were paid at 1�`.6 so we are making no claim on this tooth. The front tooth had a crown and is nat eonsidered sound so the medical plan will pay no benefits.We called our insurance company and this is what they told us.We copied the infarmation from our employee benefit booklet(attachedj as well. � � Robert Luke "� U l��'� Date Z-� - ��:� � � � � �� ; !, � t�,= ��: ;,,� r � - � ��, � � �� _ - �� > � � : :�� ; �� , � . ' � �'�,�� .. � . .: � �"�ii�' . ��°� � � � � �. � \� �,`�-�-� I�l� � _ \� ti� �� .�-�- �-�. ��;�. w;•:�� ea t an rou ene ts . su m ma � a n escrs � � on . � � � Ca rd i na I H ea Ith cardinalheaith.com . Treatment of teeth/periodontium unless such expenses are incurred for: i Charges made for a continuous course of dental treatment started within six months of an injury to sound,natural teeth; — Charges made by a hospital for room and board or necessary services and supplies; or — Charges made by a hospital outpatient department in connection with surgery. . Alternative medicine treatments including,but not limited to: — Primal therapy; _ .�.. `� : What is considered — Rolfin F "experimental"or g' � "investegational"? : A drug,clevice,procedure or — Psychodratna; ; treatment is experimental or � investigational if — Megavitamin therapy; � There is insuffcient ; outcome data availahte '�; ;. — Biogenetic therapy; or from contro(led ciinicai ' trisls published in the —Vision perception training. peer-reviewed tiierature to suhstaniiate its safet�and � effectiveness for the disease y • For charges for unnecessary care,treatment or surgery. , Qr,,,j„ry invatved; h � � • Charges for or in connectivn with services or supplies that are • Approval has not�een � granted for marketing b�+ experimental or investigational. the FbA;or ` � A recognized natianal f ' • Care fumished mainly to provide a surrounding free from exposure � " medical or dental society that can worsen the person's disease or injury. � or regulatory agency has � determined in writing . Charges associated with missed medical appointments. � that it is experimental, �a invest[gationaZ or fQr ' � research purposes. � • Charges to complete or file claim forms. �. • Notwithstanding the criteria pernutting coverage of certain cosmetic surgery as set forth in the SPD on page lOb,certain cosmetic surgery procedures are never covered, including Panniculectomy,Abdominoplasty and Skin Tag Removal. Cranial Sacral Therapy is also not covered. � � ^d • SexuaUerectile dysfunction—Diagnosis only. Any services or supplies for the treatment of male or female sexual dysfunction such as,but not limited to,treatment of erectile dysfunction � (including penile implants),anorgasmia and premature ejaculation. • Prolotherapy—Excluded from coverage even if inedically necessary. 108 � �II �IMIIIIilill Illlllllll�f � MetLife Expianation of Dentai Benefits GROUP Jf 84999 CARDINAL HEALTH DENTAL BENEFITS PLAN CLAIM YEAR: 2011 02 This is not a bill. It is an expianation of how MetLite computed the payment for you� recent dental services. EMPLOYEE'S NAME ID NUMBER SERVICES RENDERED BY ROBERT LUKE XXXXXXXXXXX DR. FU WONG PATIENT'S NAME/RELATIONSHIP DATE PROCESSED FILE REFERENCE ROBERT SELF DECEMBER 28, 2011 1122735053 9 DCN: 111227432869 DATE SERVICE TOOTH#t PROCEDURE FEE POP FEE COVERED PLAN DESCRIPTION�SERVtCE/ PERWRMED /AREA CODE CHARGED (If AppticaWe) EI�ENSE BENEFR CAMMENTS 09/23/11 D5820 700.00 339.00 INTERIM DENTURE - UPPER NOT A COVERED EXPENSE. TOTALS 700.00 339.00 .00 ■ METLIFE DENTAL CLAIM FORMS ARE AVAILABLE THROUGH THE FOLLOWTNG SOURCES: 1) 1-800-942-0854, 2) www.metlife.com/dental YOUR GROUP PARTICIPATES IN METLIFE'S PREFERRED DEIdTIST PROGRAM (PDP). AS A PARTICIPATING PDP PROVIDER, YOUR DENTIST HAS AfiREED Tfl AECEPT A MAXIMUM AiL4MtABtf-EthhRQE FfSR-ElEL'Yf�`£RVI�-E. THIS "PDP FEE" IS TYPICALLY LESS THAN THE NORMAL "FEE CHARGEO" BY THE DENTIST AND YOU SHOULD BE BILLED ONLY THE DIFFERENCE BETWEEN THE "PDP FEE° FOR ACTUAL SERVICES PROVIDED AND YOUR °PLAN BENEFIT". "PDP FEE$" MAY EXTEND TO NONCOVERED SERVICE$ WHERE PERMITTED BY STATE LAW. PLEASE VERIFY WITH YOUR PRUVIDER THE FEE CHARGED FOR SERVICES THAT ARE NOT COVERED UNDER YOUR PLAN. METLIFE PDP DENTISTS DIRECTORIES ARE AVAILABLE THROUGH THE FOLLOWIN6 SOURCES: i) 1-800-942-0854, 2) www.metlife.com/dental FIND INFORMATION ON YOUR AVAILABLE DENTAL BfNEFITS, CLAIMS DETAILS, AND MORE ONLINE AT www.metlife.com/mybenefits � � � � . _ ___ i GDENEOSQ8 If benefits are denied in whole or part,see"Notice to Emptoyse" on reverse side_ Please save this statement for your tax recorrfs. _ K5836A.SCR(OZ/09) Metropalitan Life Insurance Company �.Q� HDX 9R1�R2 EL E9SII IX Z24.28 ssas� ROBERT LUKf` 26115 SYLVAN LAKE PKWY ROGERS MN 55374 � MetLife� summary Statement of �'�l��I��I� ��'NII��'�I�� . Dental Benefits This Summary Statement of Dental Benefits may coMain information on multiple patients. It is being fumished for the iMemai administrative use of your dentai office qnly and PAGE . should not be given out to patfents or other 7nsurance carriers. � O PROVIDER'S NAME: �, FU WQNG Fu � �os Pa 72� HEMLOpC LN N MAPLE GROVE A�V 55369 PROVIDER�s i.o.a�:�(XXXXXXX METLIFE DAre oF srA�MEnrr: DEC 2S, 2O 11 P.O. BOX 8H 12SZ ( OOUFS EL PASO TX 79898 �'�S� E3QY(�f# R� �� <PEtF+h�:: Ci�f3� : ;E��9Yf�Q fRR�Ic L� f,Y'bkR�$k $�lppliS�W� EISR�t$E ` 8E�.FfT I5E'SG{31P7{C�id��i�S+IE''� >- ..._:.:- „ ' .. , __ . .::: �; - _._ �" CGxu�,. - - .,.. ... ...._. _ . ; , :...:. > ,:._ .:: , .:._- ,.- _; : ;.. . ' .; .:: :: GROUP NLlMBER: 0084889 GRpUP NAME: CARDINAL HEAITH DfNTAI BENEFITS PLAN EMPLDYEE'S NAME EMPLOYEE'S I.D. RiiT�fN.I'S NAME / RELATIONSHIP FILE REFERENCE N0. � LUKE.ROBER XXXXX85Q1 ROBERT '� SELF 1122735053 9 _..,�_ . �.._--.-.-- ----._.,.- D�1: 11122T432869 --------------------------------------------------------- ---_..�_---- �----- ===- ------------- 09/23/11 D5820 700.00 339.00 INTERIM DENTURE - UPPER-� , NOT A CpVERED EXPENSE �,.' `�._ �..�:.>-^°" TOTAlS 700.00 338.00 `"""-^°`°�"�"."-� ---------------------- '�—__�. ----------------------------------------------------------------------- ----------- UP TOTAL: .pp ****FOR FASTER, MORE EFFICIENT CLAIM PROCESSING, VISIT 1�lI�Y1,METDENTAL.COM-SUBMIT GIAIMS TO ANY PAYQR AND GET REAL-TIME ACCESS TO PATIENT E065, BENEFITS, CLAIMS STATUS AND MORE! OR DIAL 877-MET-DDSB (638-3379) TO SUBMIT METLIFE CLAIMS RIG'FiT OVER YOUR TELEPhqNE AT NO COST OR TO RE4UEST AN IMqEDIATE FAX OF PATIEMT BENEFIT COYERAGE AND CLAIM STATUS! "COVERED EXPENSE" IS THE AMOUNT AILOWl48LE UNDER THE DENTAL BENEFIT PLAN. . i � I _. -- SEE-REV€RSE SI9E -- , K5601 H.SCRE{09/D5) pqGE TOTAL: .00 SUB-TOTAL: .00 Pl�se save this stateme�K for your tax records METROPOLITAN LIFE INS.CO. p"n_ Bt1X 281_2.82 ; El P�4a IX 7999R asaz2 � DR. FU WONG FtJ 4JONG DDS PA 7200 HEMLOCK lN N MAPLE GROVE MN 55369 Fu Wong,D.D.S. 7200 Hemlock Lane North Suite 1Q5 Mapie Grove,MN 55369 CurreM Accourrt A in : Robert Luk2 Current 30 Day �0.00 26115 Sylvan Lake Parkway fi0 Day 50.00 Rogers, MN 55374 so oay �o.00 Contract �0.00 Balance Due Estimated Ins �0.00 Phone: (763)424-4415 Balance Due Now ACCOUNT HlSTORY _ _ FOR 3185: Robert Luke From Sep 23,2011 To Sep 23.2011 Date Name Provider Type Descri�tion Debit Credit Baiance »»»>Sum of ail account activity prior to Sep 23,2011 9/23/2011 Robert Luke Service 05820 INTERIM UPD-FLIPPER 5350.00 9/23/2011 Robert Luke 9l23/2011 Robert luke 9/23l2011 RobeR Luke Acct Pmt Credit Card Payment: Number R5160B 5350.00 »»»»>Sum of all account actfvity after Sep 23,2011 � i I I Cu•ren!penfal 7ertninoloqy(CDTt�Amencan pental AssociaGOn(Apq). qlt nghts:eser�. Page 1 of 1 � � � � ��ALA.tpr :-. . . _. . .. . . ... � � � : � : .. p@�" ,�k�� . ;''� � r°�`� . . . � _ `y �^ ,t z � � r ! � r 1 � � r' { � � 1 a � � . � > . . . . . . .. I '.�. . . . .Y ?�s= \�' : IMPL/�t�tT FEE ESTIMATE Name: ' Date: Referring Doctor. ' Treating Doctor.�` Rahimi : Karban . ; :, � _._. ,_ : Insurance Company: -` ' PHASE t SURGERY m t n •on PHASE !1 SURGERY ' 1Uncover�ng.Abutmenf Attachmer�t and tem�ra,{y crownt Procedure Procedute Tooih# Code Procedure Fee Tooth# Code' Procedure Fee D6010 im lant `; D6057 Custom Abutment D7953 Bone Graft sin le Site 100% Temporary,Abutment : ', Db 190 Sur ica!Guide Db 199 if a licab!' : i ; D9220 Generai Anesthesia � Additional General D9221 Ar►esthesia � y.=,. ( D9610 Thera utic In'ection . D7999 Sur ical Tra D7999 Sur icaf Tra D999R MnCare Tax f I D9999 MnCare Tax �`�� , ,: ; . Estimated Total Cost Due Phase t.................•---.......................---..........................._... 5 ; , . .. s .., ., , S°k(No insurance,cash/check payment,day of service)....................:.••••-.............. .._...:.... � •, 10%Seniar Discount{No insurance,cash/chedc payment,day of servicej............................:. S Estimated 7otal Cost Due Phase 1 ...................................................••-••••................_... S Estimated Tota! Cost Due Ahase It ............................................................�...---------•-• $ 5%(No insurance,cash/chedc payment,day of service�.............•--•-•---•......-------•-------•-•---•-- S 10%Senior Discount(No insurance,cast�Jcheck payment,day of service) .............................. S Estimated Total Cost Due Phase !t ............................................................................. S F[NAL ESTIMATED TOTAL FOR PHASE 1 S� It: .................:........................................... S **P►ease note you wili incur additionai charges with your dentist for the final restoration** i have read the above and understand that t am responsfbie for ali office charges. If a payment is made by my insurance, I understand any final balances owing witf be due within ]5 days. S+gnature of Responsible Parry Date � - ri�iiri�riMi'iit�iii�ii si�ir�iN — MetLife Estimate of Dental Benefits GROUP I! 84999 CARDINAL HEALTH OENTAL BENEFITS PLAN Expires 12 Months from Dffie PrOCess� EMPLOYEE'S NAME ID NUMBER SERVICES REI�ERED BY ROBERT LUKE XXXXXXXXXXX DR. FU WONG PATIENT'S NAME/RELATIONSHIp DATE PROCESSED FlLE REFERENCE ROBERT SELF NOVEMBER S, 2011 1102435426 9 DCN: 111024$24470 DATE SERVICE TOOTH� PROCEDURE FEE POP FEE COVERED PLAN DESCRIPTiON�SERVICE! PERFORMEO fAREA CADE CHARGED if Appiicable EXPENSE BENEFIT COMMENTS 09 D6056 70Q.00 485.00 485.00 50% 242.50 PREFAB IMPLANT ABUTMENT 09 D6058 1200.00 931.00 931.00 5096 465.50 IMPLANT CROWN - PORCELAIN TAX 38.00 38.00 38.00 100�0 38.Q0 TAX OR SURCHARGE � METLIFE DENTAL CLAIM FORMS ARE AYAILABLE THROUGH THE FOLLOWING SOURCES: 1) 1-800-942-0854, 2) www.metlife.com/dentat YOUR GROUR AARTICIPAfiES TN METLiFE'S PREFERRED DENTIST PROGRAM (PDP). AS a PARTICIPATING PDP PROVIDER, YOUR DENTIST HAS AGREED TO dCCEPT A MAXIMUM ALLOWABLE CHAR6E FOR EACH SERVICE. THIS "PDP FEE" IS TYPI�ALLY LESS TttAAt-fiftE NQRMAt "FEf CtikRGED" BY F+lE DEMTI�T AND VAFJ SHOULO BE BILLEO ONLY THE DIFFERENCE BETWEEN THE "PDP FEE" FOR ACTUAL SERVICES PROVIDED AND YOUR "PLAN BENEFIT". "PDP FEES" MAY EXTEND TO NONCOVEREO SERVICES WHERE PERMITTED BY STATE LAW. PIEASE VERIFY WITH YOUR PR�VIDER THE FEE CHARGED FOR SERVICES THAT ARE NOT COVERED UNDER YOUR PLAN. METLIFE POP DENTISTS DIRECTORIES ARE AUAILABLE THROUGH THE FOLLOWIN6 50URCE5: i) 1-800-942-0854, 2) www.metlife.com/dental ACTUAL BENEFIT DETERMINATIONS ARE MADE WHEN SERVICES ARE RENDERED AND ARE SUBJECT TO THE FOLLOWING AS APPLICABLE ON THE DATE OF SERVICE: PATIENT ELIGIBILITY; PIQN & FREQUENCY LIMITATIONS; MAXIMUMS AND DEDUCTIBLES; AND OTHER COVERAGES. TO DATE. $300.80 HAS BEEN PAID TOWARDS THE MAX-IMUM OF $2,000.00. FINO INFORMATION ON YOUR AVAItABLE DENTAL BENEFITS, CLAIMS DETAILS, AND MORE ONLINE AT www.metlife.com/mybenetits A COPY OF THIS FORM WAS SENT TO DR. FU WONG GDENE0B08 If benefits are denied in whole or part,see"No6ce to Emptoyee'on rever�side. K5938A.SCR(02AD9) Meiropolitan Life Insurance Company PyO.� ROX 251.2�.2 f_L P9SII IX Z9948 _ ssoas ` ROBERT LUKf 26115 SYLVAM LAKE PKWY ROGERS MN 5_`�374 �4,ytini.avo o'� , t �� ? E - _ � . . � . . . � i . � . � � � a � �� `j' .7 J r _�' ' . �, ��, t , , Name: " t�` ,;,. .t�=-Y=-�-. Date: �� ,'r; , - � � ` . ;. r Referring Doctor. - � - `' � ` `��:�•- Treating Doctor. Rahimi .t �_�� insurance Company: _ �! �t ,4' " f�_. A B C D E F�� G H I J ; �s��!`� :, 1 2 3 4 5 6 7 8 -9" 10 11 12 13 14 15 16 . ''�� ,�i�' �,.�`° 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 ��'� �'" ,,.-` Right T S R Q P O N M L K Left � `�. EXTRACTIONS OTHER PROCEDURES T'ooth# Procedure Code Fee Pmcedure Code Procedure --Fee ',�. `% _'� � ` D0140 = -Lonsultation ' D0330 Panorex ,f :;- ' -_ :�, D0220 Peria ical � , D7960 Frenectom ` ` � � "� � D7280 Sur ical Ex osure . .- ."/� � fi�- � _ �i [�,� _'. D7953 Bone GraR sin le 100% D4266 Membrane D9220 Generai Anesthesia D9221 Adtl General Anesthesia D9230 Niirous Oxide D7999 Sur ical Tra ��` � D9999 MnCare Tax i � •r ` D9610 Thera eutic In'ection TOTAL FEE ESTIMA'TE........................ $_�`i�f- � We are happy to file insurance claims for you, but piease understand that insurance companies rarely reimburse the full amount, usually paying between 50 percent and 80 percent of the cost.This o�ce quotes current fees that are within the usual and customary range of oral and maxillofacial surgery offices in our area, while many companies pay from a set fee schedule that may be outdated. This estimate is valid for 90 days and may increase for services prszuided after tt�at ume. �:_ - _. We ask that a partial payment, usua�ly approximately your estimated entage of the fe�;�made at the time of surgery. In cases of divorced parenu, the parent bnnging the child will be deem��respo sible for pa e�.ti �� `� � � �� ' ` . . ��:, -i-, ,�J- .�b r? A MINIMUM PAYMENT OF $ tl�3�'_r� '� I �` '' IS EXPE �A THE ME F URGERY. �J-IIS REPRESEMT YOUR ESTIMATED CO-PAYMEN7: . , ,� I r FULL PAYMENT OF $ IS DUE AT THE TIM��OF SURGERY. RECENE A S% DISCOUNT IF PAYING BY CHECK OR CASH (5%disc�rtflican only be ap�Ii�if patierrt has no insurance coverage)TNE PAYMENT DUE $ t have read the above and understand that t am responsible for all office charges. 1 also understand that once payment has been received from my insurance company, the balance will be due within 1 S days. Signature of Responsible Party Date NI I �IlilllN IIII�II I N 11111 MetLife� Expianation of Dental Benefits GROUP If 84999 CAROINAL HEALTH DENTAL BENEFITS PLAN CLAIM YEAR: 2011 02 , This is not a bili. It is an explanation of how MetLife computed the payment for you� recent dental services. i EMPIOYEE'S NAME ID NUMBER SfRVICES RENDERED BY !, R06ERT LUKE XXXXXXXXXXX �R. ABDOLLAH RAHIMI PATIEiYT'S NAMEJRELATIONSHIP DATE PROCESSED FILE REFERENCE , ROBERT SELF NOVEMBER 18, 2011 1111406T89 9 ' i DATE SERYfCE TOOTH� PROCEDURE FEE PDP FEE COVERED PLAN DESCRIPTION OF SERVICE/ � PERFORMED /AREA CODE CHARGEO (If ApplicaWe) EXPENSE BENEF(T COMMEMTS I 09f09/11 D0140 51.00 51.00 LIMITED ORAL EVALUATION II DUPLICATE BILL: PREVIOUSLY ' PROCESSED ON 09/21/11. � 1 TOTALS 51.00 51.00 .Od METLIFE DENTAL CLAIM FORMS ARE AYAILABLE THROUGH THE FOLLOWING SOURCES: 1) 1-80Q-942-0854, 2) www.mettife.com/dentat YOUR 6ROUP PARTICIPATES IN METLIFE`5 PREFERRED DENTIST PROGRAM (PDP). AS A PARTICIPATING PDP PROVIDER, YOUR OENTIST HAS ACaREED TO ACCEPT A MAXIMUM ALLOWABLE CHARGE FOR EACH SERVICE. TMIS "PDP FEE" IS TYPICALLY LESS THAN THE NORMAL "FEE CHARGED" BY THE DENTIST AND YOU SHOULD BE BILIED ONLY THE DIFFERENCE BETWEEN THE "PDP FEE" FOR ACTUAL SERVICES PROVIDED AND YOUR "PLQN BENEFIT°. "PDP FEES" MAY EXTEND TO NONCQVERED SERVICES WHERE PERMITTED BY STATE LAW. PLEASE VERIFY YVITH YOUR PROVIDER THE FEE CHARGED FOR SERVICES THAT ARE NOT COVERED UNDER YOUR PIAN. METLIFE PDP DENTISTS DIRECTORIES ARE AVAILABLE THROUGH THE FOLLOWING SOURCE5: 1) 1-800-942-0854, 2) www.metlife.com/dental FIND INFORMATION ON YOUR AVAII.ABLE DENTAL BENEFITS, CLAIMS DETAILS, � AND MORE ONUNE AT www.mettife.com/mybenefits , . I ; � i I ; GDENEOBOS If benefits ere denied in wFale or part,see'Notice�o Entployee'on reverse side. Please save this statement tor your tax r�ecoricis. _ __ K5833R.SCR(02/09) Metropolitan Life Insurance Company P�Ila flO.X 38]_28.2 El. PA�Q LX ?4948 ss�oe ROBERT LUKE' 26115 SYLVAN LAKE PKWY ROGERS MN 55374 - � �I�i NINI�INII� IIIIIIIII I�II� M�'L�'�A Explanation of Dentat Benefits GROUP N 84999 CARDINAL HEALTH DENTAL BENEFITS PLAN CLAIM YEAR• 20i1 02 This is not a bill. It is an explanation of how MetLife computed the payment for your recent dental services. EMPLQYEE'S NAME ID NUMBER SERVICES RENDERED BY ROBERT LUKE XXXXXXXXXXX QR. MATTHEW KARBAN PATIENT'5 NAME/RELATIONSNIP DATE PROCESSED FIlE REFERENCE ROBERT SELF NOVEMBER 18; 2011 1'111206789 9 DATE SERVICE TOOTH i� PROCEWRE FEE PDP FEE C0IIERED PLAN DESCRIPTION OF SERVICEJ PERFORMED /AREA CODE CHARGED (If Applk:able) EXPENSE BEWEFlT COMMENTS CONTINUED FROM PAGE 1 -FOR PROSTHETIC SERVICES & IMPLANTS RECENT DATED PRE-OP X-RAY COPIES OF THE ENTIRE ARCH(S) AND DATE OF EXTRACTION(5). -FOR CODE D3331 PRE AND POST OPERATIVE X-RAY COPIES. 1 -FOR CODE D6080 A DETAII.ED CIINICAL NARRATIVE. -FOR CODES D4270, D4271, D4273, D4275, & D4276 A NARRATIVE INDICATING IOCATION, NATURE. & EXTENT OF THE MUCOGINGIVAL PROBLEM. -FOR ALL OTHER SERVICES SUBMIT DATE[7 CURRENT OIAGNOSTIC X-RAY COPIES. -FOR ALL OTHER PERIODONTAL SERVICES SUBMIT DATED APPROPRIATE CHARTING. NOTE M -BJ: THIS PLAM DOES NOT PROVIDE BENEFITS FOR THE SUBMITTED ADJUNCTIVE PROCEDURE. FIND INFORMATION ON YOUR AVAILABLE DENTAL BENEFITS, CLAIMS DETAIIS, AND MORE ONLINE AT www.metlife.com/mybenefits � I� PA6E 2 � GDENE0B08 If benefrts are deniecf in wtwte or pari,see"iVotice to Employee"on reverse side. Please save this statement for your tax records. _ _ K5838A:SCR(02/09j Metropolitan Life Insurance Company p-n- HOX 481282 EL PASII IX Z9948 ss�os - ROBERT LUKE 26115 SYLVAN LAKE PKWY ROGERS MN 55374 . � ul�ll I�IIIi� lIIINf�NN 11lI� • MetLife Explanation of Dentat Benefits 6ROUP !1 84999 CARDINAL HEALTH DENTAL BENEFITS PLAN CLAIM YEAR: 2011 02 This is not a bill. It is an explanation of how MetLife computed the payment for your recent dental services. EMPLOYEE`S NAME ID NUMBER SERVICES RENDERED BY ROBERT LUKE XXXXXXXXXXX DR. MATTHEW KARBAN PATIENT'S NAME/RELATIONSHIP DATE PROGESSED FILE REFERENCE ROBERT SELF DECEMBER 16, 2011 1120524317 8 DATE SERVICE TOOTH 31` PROCEDURE FEE PDP FEE COVERED PLAN DESCRIPTION OF SERVICE/ PERFORMED lAREA CODE CHARGED Qf Applicable) EXPENSE BENEFR CONIMEWTS 09/22/11 09 D7210 346_00 185.00 185.00 8076 148-00 EXTRACT ERUPTED TOOTH - SURGICAL 09/22/11 09 D4266 300.00 300.00 300.00 809L 240.00 GTR - RESORBABLE BARRIER 09/22/11 09 D7953 250.00 250.00 250.00 50% 125.00 BONE GRAFT � pg/22/11 D9230 107.00 49.00 ANAL6ESIA, ANXIOLYSIS, NITROUS NOT A COVERED EXPENSE. 09/22/11 D7999 23.00 .00 UNSPECIFIED ORAL SURG. PRUCEDURE NOT A COVERED EXPENSE. SEE NOTE J Q9/22/11 TAX 18.38 18.38 18.38 100� 18.38 TAX OR SURCHARGE TOTALS 1044.38 802.38 753.38 531 .38 METLIFE DENTAI CLAIM FORMS ARE .AVAILABLE THROUGH THE FOLLOWING SOURCES: 1) 1-800-942-0854, 2) www.metlife.comjdental YOUR GROUP PARTICIPATES IN METLIFE'S PREFERRED DENTIST PROGRAM (PDP). AS A PARTICIPATING PDP PROVIDER, YOUR DENTIST HAS AGREED TO ACCEPT A MAXIMUM ALLOWABLE CHAR6E FOR EACH SERVICE. THIS "PDP FEE" IS TYPICALLY LESS THAN THE NORMAL "FEE CHARGED• BY THE DENTIST AND YOU SHOULD BE BILLED ONLY THE DIFFERENCE BETWEEN THE "PDP FEE" FOR ACTUAL SERVICES PROVIDED AND YOUR "PLAN BENEFIT". 'PDP FEES" MAY EXTEMD TO NONCOVERED SERVICES WHERE PERMITTED BY STATE LAW. PLEASE VERIFY WITH YOUR PROVIDER THE FEE CHARGED FOR SERVICES THAT ARE NUT COVERED Ut�ER YOUR PLAN. METLIFE POP DENTISTS DIRECTORIES ARE AVAILABLE THROUGh THE FOLLOWING SOURCES: 1) 1-800-942-0854, 2) www.metlife.com/dental $531.38 WILL BE PAID TO MINNESOTA MAX & ORAL CONSULTANTS ON 12/22/11 PATIENT'S FINANCIAL RESPONSIBILITY PAYABLE TO THE DENTIST IS 5271.00 THIS CLAIM HAS BEEN ADJUSTED DUE TO ADDITIONAL INFORMATION THAT WAS RECEIVED i TO DATE, $832.18 HAS BEEN PAID TOWARDS THE MAXIMUM OF $2,000.00. �I NOTE J -E6: THE INFORMATION SUBMITTED HAS BEEN REVIEWED BY OUR DENTAL CONSULTANTS I AND NO BENEFITS CAN BE ALLOWED FOR THIS SERVICE(5). � PAGE --1 _ . � GDENE0�8 � If benefrts are denied in whoie or part,see'Noticc�to Employee' on rev�side. , Plesse save tMs statemeM for your tax rec�rds. ' K5836A.SGR f07J05) Metropolitan Life Insurance Company P-�- SIIX 9812R1 EL P�S11 IX 7999R s�zos ROBERT LUKE 26115 SYLVA�� LAKE PKWY ROGERS MN 5`i374 . � �i�i��"is�Mii� iiii�i�r r,r�«r MetLife� Explanation of Dentai Benefits GROUP X 84999 CARDINAL HEALTH DENTAL BENEFITS PLAN CLAIM YEAR• 2011 02 This is not a bili. It is an explanation of how MetL'efe computed the payment for your recent dental services. EMPLOYEE'S NAME ID Pri1MBER SERVICES RENDERED BY ROBERT LUKE XXXXXXXXXXX` DR. MATTHEW KARBAN NATfENT'S NAMEIRECATiONSHIP DATE PROCESSED fILE REFERENCE ROBERT SELF DECEMBER 16, 2011 i120524317 8 DATE SERVICE TOOTH/ PROCEDURE PEE PDR FEE COYERED PIAN DESCRIPTION QF SERVICEI PERFORMED lAREA CODE GiARGED (If Applicable) OCPENSE BENEF(T COMMENTS CONTINUED FROM PAGE 1 FIND INFORMATION ON YOUR AVAILABLE DENTAL BENEFITS. CLAIMS DETAILS, AND MORE ONLINE AT www.mettife.com/mybenefits i � �I PAC,E 2 __ GDENEOB08 If benefits are denied in whole or part,see"Notice to Employee°or►reverse side. Please save thls Statemetrt for your tax rec�rds. _ . _ _ K.ri898A.SGR(Oti09j _ Metropolitan life Insurance Company P_n_ HO.X 281282 EL PASII Ix �8 97209 ROBERT LUKE 26115 SYLVAN LAKE PKWY ROGERS MN 55374 � STATEMENT Mn Maxitlofaciai and Oral Cons Page 1 15600 36th Ave N Statement Date 01/18/2012 Suite 100 Plymauth, MN 55446-3372 Patient ID 36982 Robert Luke Due Now$ 0.00 26115 Sylvan Lake Pkwy Rogers, MN 55374 Amount Enciosed$ ____ _ Detach Stub��Betum wi�►Payment Keep this portion for your records Date Patient Patierrt ID Description Amount ', Starting Balance 0.00 '� 09/09/11 Robert Luke 36982 Lim Orai EvahProb Focus 51.00 09/22/11 Robe�t Luke 36982 Surgical Ext #9 346.00 09/22/11 Robe�t Luke 36982 Bone Graft-Ridge preserva #9 250.00 09I22/11 Robert Luke 36982 Membrane-Resorbable Bartier #9 300.00 09i22/11 Robert Luke 36982 Surgical Tray Setup 23.00 09/22/11 Robert Luke 36982 Mn Care Tax 18.38 09/22/11 Robert Luke 36982 Patient Payment/CG�sa -249.00 09/22/11 Robert Luke 36982 Pafient Payment/CG/MasterCard -378_48 09/22/11 Robert Luke 36982 Malgesia N20-02 107.00 12/28/11 Robert Luke 36982 Insurance PaymentlMETLIF/CK -531.38 12/28/11 Robert Luke 36982 Insurance Write Off/METLIF -242.00 12/28/11 Robert Luke 36982 insurance Denied/METLIF 0.00 01/18/12 Robert Luke 36982 Patient Refund/QB 305.48 I ( ( 1 Ending Balance � 0.00 � Current 31-60 61�0 91-120 121+ Unapplied Total Due Now$ 0.00 o.00 o.00 o.00 o.00 o.00 o.00 o.00 Mn Mauiliofacial and Orai Co� For billing inquiries call: 763-659-7688 Insurance Last Billed on Nov 08,2011 IF YOUR INSURANCE HAS BEEN BILLED DISREGARD THIS STATEMENI: