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Home My WebLink About20013457.tiff RESOLUTION RE: CANCELLATION OF OUTSTANDING ACCOUNTS RECEIVABLE FOR THE WELD COUNTY PARAMEDIC SERVICES WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, a list of ambulance accounts has been submitted to the Accounting Department of Weld County, Colorado, and WHEREAS, said accounts have been deemed uncollectible in accordance with guidelines adopted by the City of Greeley and County of Weld, a copy of said list being attached hereto and incorporated herein by reference, and WHEREAS, the Accounting Department has recommended the cancellation of said list of uncollectible debts due and owing the Weld County Paramedic Services in the amount of $1,016,734.46. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the aforementioned list of uncollectible accounts in the amount of $1,016,734.46. be, and hereby is, approved for cancellation. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 19th day of December, A.D., 2001. Ella BOARD OF COUNTY COMMISSIONERS WELD C_O NTY, COLORADO 21 t '+ ////�� // // M. J. Celle, Chaipman rk to the Board.,;(ji \ 414 / Glenn Vaad, Pro- e BY: i eputy Clerk to the Board V William H. Jerke APPROVED AS T M: EXCUSED DATE OF SIGNING (AYE) vi E. Lon County Att rney obert D. Masden Date of signature: j9/P�&9- 2001-3457 AM0001 MEMORANDUM a TO: Claud Hanes, Accounting DATE: December 14, 2000 FROM: Kathy Baxley, Ambulance Service III I SUBJECT: Accounts Written Off in 2001 C. COLORADO Attached are the lists of accounts written off in 2001 . Listed below are the amounts each month for a total of $1 , 016 , 734 . 45 . All journal entries have been made except for the one for December, which will be after the end of the month. Let me know if you have any questions . January $117, 275 . 64 February $97, 047 . 34 March $275 . 00 April $89, 951 . 25 May $141 , 862 . 59 August $124 , 960 . 79 September $156, 667 . 08 October $99, 522 . 06 November $99 , 096 . 99 December $90 , 075 . 71 Total $1 , 016, 734 . 46 2001-3457 I Date:01/11/2001 Weld County Ambulance Page: 1 Time:10:48:16 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 01/10/2001 Thru 01/10/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 01/10/2001 650.00 4 83C 000100178A 01/08/2000 GONZALES, LESLIE 01/10/2001 545.00 4 83C 000100198A 01/09/2000 GONZALES, LESLIE 01/10/2001 590.00 4 83C 000100238A 01/11/2000 GONZALES, LESLIE 01/10/2001 600.00 4 83C 000100246A 01/11/2000 GONZALES, LESLIE 01/10/2001 420.64 4 83C 000100322A 01/14/2000 HEARON, DORIS 01/10/2001 400.00 4 83C 000100399A 01/17/2000 JANNUSCH, ARTHUR 01/10/2001 - 656.14 4 83C 000100617A 01/26/2000 ESCOBEDO, VICENTA 01/10/2001 575.00 4 83C 000100624A 01/26/2000 VELEZ, ALEIDA 01/10/2001 145.00 4 83C 000200964A 02/09/2000 CURRIER, SHEILA 01/10/2001 28.56 4 83C 000201107A 02/14/2000 BROCK, BETTIE LOU 01/10/2001 85.90 4 83C 000201186A 02/18/2000 CUMMINGS, JOLENE R 01/10/2001 726.14 4 83C 000301505A 03/03/2000 SHUFELT, ARBUTUS 01/10/2001 420.00 4 83C 000301509A 03/03/2000 SHUFELT, ARBUTUS 01/10/2001 409.43 4 81 000301697A 03/09/2000 WRIGHT, BERT 01/10/2001 100.00 4 83C 000301720A 03/09/2000 ROOT, SHANDREA 01/10/2001 70.93 4 83C 000301748A 03/11/2000 STULTZ, CAROL 01/10/2001 215.00 4 83C 000302185A 03/28/2000 RUBIO, RUDOLFO R 01/10/2001 298.00 4 83C 000302217A 03/29/2000 ANDREWS, COLLEEN 01/10/2001 25.00 4 83C 000402431A 04/05/2000 HEIDLER, AMY 01/10/2001 715.00 4 83C 000402645A 04/13/2000 PETERSEN, CHARLES 01/10/2001 290.00 4 83C 000402944A 04/24/2000 BOONE, LAUREN 01/10/2001 830.00 4 83C 000402972A 04/24/2000 STREIFEL, SKYLAR 01/10/2001 215.00 4 83C 000402977A 04/25/2000 STREIFEL, SKYLAR 01/10/2001 195.46 4 83C 000402991A 04/25/2000 HALL, JOSHUA 01/10/2001 725.00 4 83C 000403031A 04/26/2000 MURAFSKI BETTY J 01/10/2001 411.94 4 83C 000503395A 05/10/2000 BARBER, PRICILLA 01/10/2001 545.00 4 83C 000503407B 05/11/2000 TROUT, MARGARET 01/10/2001 173 .00 4 83C 000503623A 05/19/2000 SMITH, JAIME 01/10/2001 290.00 4 83C 000503850A 05/27/2000 GREEN, DEBORAH 01/10/2001 855.00 4 83C 000603999A 06/02/2000 VILI,ARREAL, ARNOLDO 01/10/2001 545.00 4 83C 000604022A 06/02/2000 MOORCROFT, JOSEPH 01/10/2001 565.00 4 83C 000604026A 06/03/2000 NELSON, RONALD 01/10/2001 880.00 4 83C 000604038A 06/03/2000 GREEN, JAMES HARLAN 01/10/2001 80 .00 4 83C 000604040A 06/03/2000 HERNANDEZ, ADRIANA 01/10/2001 25.00 4 83C 000604056A 06/03/2000 MEDINA, NAVORIA 01/10/2001 328.60 4 83C 000604100A 06/04/2000 GARCIA, JOE 01/10/2001 80.00 4 83C 000604118A 06/05/2000 LILLIARD, DEE 01/10/2001 80.00 4 83 000604141B 06/06/2000 HART, JOHN 01/10/2001 80.00 4 83C 000604153A 06/07/2000 MOREHOUSE, MICHELLE 01/10/2001 765.00 4 83C 000604154A 06/07/2000 MARTINEZ, OSCAR 01/10/2001 695.00 4 83C 000604183A 06/08/2000 MARES, DAVID DEAN 01/10/2001 71.59 4 83C 000604188A 06/08/2000 PEVLER, DALE 01/10/2001 730.00 4 83C 000604190A 06/08/2000 ALCALA, DONNA 01/10/2001 265.00 4 83C 000604192A 06/08/2000 BROWN, ZOE 01/10/2001 690.00 4 83C 000604204A 06/08/2000 BLACKSTON, CAROL 01/10/2001 605.00 4 83C 000604212A 06/09/2000 MARQUEZ, CARLOS J 01/10/2001 290.00 4 83C 000604217A 06/09/2000 MARQUEZ, CARLOS J 01/10/2001 780.00 4 83C 000604235A 06/10/2000 ORTIZ, IRMA 01/10/2001 960.00 4 83C 000604250A 06/10/2000 ZAVALA-GUERRA, PEDRO Date:01/11/2001 Weld County Ambulance Page: 2 Time:10:48:17 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 01/10/2001 Thru 01/10/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 01/10/2001 545.00 4 83C 000604253A 06/10/2000 MEZA-CANALES, VICTOR 01/10/2001 650.00 4 83C 000604325A 06/13/2000 STEPHENS, CHARITY 01/10/2001 40 .00 4 83C 000604336A 06/13/2000 MCNULTY, NICOLE 01/10/2001 290 .00 4 83C 000604348A 06/13/2000 MCNULTY, NICOLE 01/10/2001 290 .00 4 83C 000604374A 06/14/2000 PACHECO, GILBERT 01/10/2001 290 .00 4 83C 000604383A 06/14/2000 GREEN, DEBORAH 01/10/2001 290.00 4 83C 000604396A 06/15/2000 DELGADO, MANUEL 01/10/2001 815.00 4 83C 000604407A 06/15/2000 MORADO, MARTIN J 01/10/2001 841.14 4 83C 000604425A 06/16/2000 SCHONEMAN, ALBERT RO 01/10/2001 161.00 4 83C 000604435A 06/17/2000 KINDT, PAT 01/10/2001 710.00 4 83C 000604447A 06/17/2000 BENAVIDEZ, EDDIE 01/10/2001 290.00 4 83C 000604454A 06/17/2000 BENAVIDEZ, EDDIE 01/10/2001 925.00 4 83C 000604465A 06/18/2000 LOPEZ, ROBERT 01/10/2001 675.00 4 83C 000604467A 06/18/2000 ARRIOLA, ELBA 01/10/2001 80.00 4 83C 000604495A 06/18/2000 PADILLA, LUCILLE 01/10/2001 710.00 4 83C 000604516A 06/19/2000 MILLER, JEFF 01/10/2001 705.00 4 83C 000604538A 06/20/2000 FALMOE, DAVID 01/10/2001 80.00 4 83C 000604548A 06/20/2000 LUEHRING, KIM 01/10/2001 69.50 4 83C 000604610A 06/22/2000 MEISNER, GARY 01/10/2001 38.16 4 83C 000604676A 06/24/2000 JENNINGS, ANTONIE 01/10/2001 730.00 4 83C 000604703A 06/25/2000 WEIDENKELLER, SANDRA 01/10/2001 590.00 4 83C 000604714A 06/26/2000 LANCKRIET, GREGORY 01/10/2001 38.16 4 83C 000604724A 06/26/2000 JENNINGS, ANTONIE 01/10/2001 755.00 4 83C 000604765A 06/27/2000 ZAMORA, JOHN 01/10/2001 656.14 4 83C 000604791A 06/28/2000 GREEN, DEBORAH 01/10/2001 40 .00 4 83C 000604794A 06/29/2000 GREEN, DEBORAH 01/10/2001 290 .00 4 83C 000604824A 06/30/2000 NUNN, ANNA M 01/10/2001 80 .00 4 83C 000604830A 06/30/2000 MALDONADO, EDUVINA 01/10/2001 785.00 4 83C 000704869B 07/01/2000 TEJEDA, JORGE 01/10/2001 80.00 4 83C 000704878A 07/01/2000 WALTERS, TABITHA 01/10/2001 710.00 4 83C 000704884A 07/01/2000 BURTON, MARY BETH 01/10/2001 656.14 4 83C 000704893A 07/02/2000 ROSIN, FREIDA 01/10/2001 775.00 4 83C 000704907A 07/02/2000 SCHNEIDER, BIFF A 01/10/2001 80.00 4 83C 000704913B 07/02/2000 MONSON, IRENA 01/10/2001 800.00 4 83C 000704916A 07/02/2000 SISNEROS, EVA 01/10/2001 605.00 4 83C 000704919A 07/02/2000 REGALADO, STEVEN 01/10/2001 650.00 4 83C 000704925A 07/02/2000 GARCIA, EVARISTO 01/10/2001 290.00 4 83C 000704927A 07/03/2000 RAEHAL, ADA 01/10/2001 470.00 4 83C 000704931A 07/03/2000 MILLER, BARBARA 01/10/2001 650.00 4 83C 000704942A 07/03/2000 GODFREY, CORY 01/10/2001 775.00 4 83C 000704946A 07/03/2000 TAPPIN, DIRON M 01/10/2001 290.00 4 83C 000704951A 07/03/2000 GODFREY, CORY 01/10/2001 545.00 4 83C 000704958A 07/04/2000 STOLTZ, ROSELLA 01/10/2001 620.00 4 83C 000704965A 07/04/2000 YODER, ZACHARY 01/10/2001 25.00 4 83C 000704967A 07/04/2000 MATA, MARIA 01/10/2001 695.00 4 83C 000704976A 07/04/2000 TAYON, MARY 01/10/2001 80 .00 4 83C 000705003A 07/05/2000 AVILA, ERICA 01/10/2001 80 .00 4 83C 000705004A 07/05/2000 WOOD, ALICIA 01/10/2001 290 .00 4 83C 000705013A 07/05/2000 PARKER, ROBERT i Date:01/11/2001 Weld County Ambulance Page: 3 Time:10:48:17 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 01/10/2001 Thru 01/10/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 01/10/2001 885.00 4 83C 000705018A 07/05/2000 BEVINS, BARBARA 01/10/2001 169.00 4 83C 000705024A 07/06/2000 ROGLEN, MICHELLE 01/10/2001 545.00 4 83C 000705039A 07/06/2000 DIETERLE, RICHARD J 01/10/2001 50.00 4 83C 000705044A 07/06/2000 CASIAS, DAVID 01/10/2001 240.00 4 83C 000705048A 07/06/2000 HEIMANN, SHANDA 01/10/2001 720.00 4 83C 000705059A 07/07/2000 TURNER, JOEL 01/10/2001 660.00 4 83C 000705061A 07/07/2000 GODFREY, CORY 01/10/2001 590.00 4 83C 000705064A 07/07/2O00 TRACY, ANN 01/10/2001 590.00 4 83C 000705071A 07/07/2000 STRAUB, EDNABELLE 01/10/2001 50.00 4 83C 000705072A 07/07/2000 DEIGHTON, MARY 01/10/2001 855.00 4 83C 000705088A 07/07/2000 GLENN, OVID LEE 01/10/2001 625.00 4 83C 000705099A 07/08/2000 BAASE, BRIAN 01/10/2001 696.14 4 83C 000705107A 07/08/2000 BAKER, DOREEN R 01/10/2001 695.00 4 83C 000705109A 07/08/2000 LANCKRIET, GREGORY 01/10/2001 680.00 4 83C 000705117A 07/08/2000 HAGAN, STEPHANIE 01/10/2001 780 .00 4 83C 000705124A 07/08/2000 RODGERS, SAMANTHA 01/10/2001 650.00 4 83C 000705126A 07/09/2000 HERANDEZ, JOSE 01/10/2001 565.00 4 83C 000705131A 07/09/2000 MINTZ, HOLLY 01/10/2001 80.00 4 83C 000705134A 07/09/2000 AJ.ANIZ, LUCAS 01/10/2001 437.01 4 83C 000705146A 07/09/2000 SWOVELAND, LINDA 01/10/2001 137.36 4 83C 000705150A 07/09/2000 SWOVELAND, LINDA 01/10/2001 650.00 4 83C 000705154A 07/09/2000 DOMINGUEZ, KIM M 01/10/2001 785.00 4 83C 000705176B 07/10/2000 KLINE, RUTH 01/10/2001 615.00 4 83C 000705191A 07/11/2000 MCALPIN, RANDALL 01/10/2001 885.00 4 83C 000705196A 07/11/2000 GODLEWSKI, WENDY 01/10/2001 2.90.00 4 83C 000705222A 07/11/2000 RAEHAL, AMANDA 01/10/2001 80.00 4 83C 000705224A 07/11/2000 MIRELES, MARIBEL 01/10/2001 885 .00 4 83C 000705226A 07/11/2000 BRYAN, JENNEANE K 01/10/2001 740 .00 4 83C 000705232A 07/11/2000 BURTON, SHANTEL 01/10/2001 836.14 4 83C 000705235A 07/12/2000 TELLER, ANNA C 01/10/2001 695.00 4 83C 000705238A 07/12/2000 YODER, ZACHARY 01/10/2001 Patient 290.00 4 83C 000705243A 07/12/2000 ROGERS, KAREN 01/10/2001 80.00 4 83C 000705267A 07/12/2000 RAEHAL, ADA 01/10/2001 610.00 4 83C 000705284A 07/13/2000 MAXWELL, RUSTI 01/10/2001 650.00 4 83C 000705317A 07/14/2000 HOWARD, CHRISTINA 01/10/2001 209.00 4 83C 000705322A 07/14/2000 OVERTON, ELIZABETH B 01/10/2001 590.00 4 83C 000705360A 07/15/2000 MAES, CASEY D 01/10/2001 555 .00 4 83C 000705363A 07/15/2000 LANCKRIET, GREGORY 01/10/2001 665.00 4 83C 000705376A 07/15/2000 BURTON, SHANTEL 01/10/2001 190 .00 4 83C 000705392A 07/16/2000 WORLEY, RON 01/10/2001 590 .00 4 83C 000705396A 07/16/2000 GARCIA, FRANCES 01/10/2001 650.00 4 83C 000705401A 07/17/2000 BURTON, SHANTEL 01/10/2001 755.00 4 83C 000705403A 07/17/2000 CONTRERAS, MARIO 01/10/2001 290.00 4 83C 000705424A 07/17/2000 TRUESDELL, ROXIANNE 01/10/2001 675.00 4 83C 000705427A 07/18/2000 HERZOG, JOSHUA J 01/10/2001 695.00 4 83C 000705453A 07/19/2000 CLIFTON, SHELLY 01/10/2001 725.00 4 83C 000705456A 07/19/2000 GATES, LASHAUNTA 01/10/2001 665.00 4 83C 000705469A 07/19/2000 BURTON, SHANTEL 01/10/2001 720.00 4 83C 000705481A 07/20/2000 RUSSELL, WILLIAM A Date:01/11/2001 Weld County Ambulance Page: 4 Time:10:48:18 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 01/10/2001 Thru 01/10/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 01/10/2001 695.00 4 83C 000705484A 07/20/2000 VILLALOBOS, CHRIS 01/10/2001 695.00 4 83C 000705493A 07/21/2000 JENSEN, MATTHEW J 01/10/2001 605.00 4 83C 000705495A 07/21/2000 GOODRO, SAMI J 01/10/2001 666 .14 4 83C 000705499A 07/21/2000 GONZALES, GRACE MARY 01/10/2001 590.00 4 83C 000705501A 07/21/2000 JEFFERSON, GEORGE A 01/10/2001 263 .00 4 83C 000705502A 07/21/2000 PAYLOR, MARIA 01/10/2001 935.00 4 83C 000705551A 07/22/2000 LUNA, GLORIA 01/10/2001 545.00 4 83C 000705554A 07/22/2000 ROMERO, ROLAND 01/10/2001 545.00 4 83C 000705557A 07/22/2000 MCLANE, ADA 01/10/2001 650.00 4 83C 000705574A 07/23/2000 FISHER, MARGIE A 01/10/2001 80.00 4 83C 000705601A 07/24/2000 RODRIGUEZ, ISREAL 01/10/2001 545.00 4 83C 000705606A 07/24/2000 BARRIENTOS, LETICIA 01/10/2001 290.00 4 83C 000705611A 07/24/2000 BARRIENTOS, LETICIA 01/10/2001 80.00 4 83C 000705647A 07/26/2000 HOLLERAN JR, DEREK 01/10/2001 605.00 4 83C 000705663A 07/27/2000 LANCKRIET, GREGORY 01/10/2001 290.00 4 83C 000705665A 07/27/2000 PURCELL, WENDY 01/10/2001 695.00 4 83C 000705680A 07/27/2000 RICHARDSON, CARL T 01/10/2001 80.00 4 83C 000705682A 07/27/2000 JACKSON, GARY 01/10/2001 40.00 4 83C 000705705A 07/28/2000 PBR BULL RIDING, 01/10/2001 671.14 4 83C 000705707A 07/28/2000 GREEN, DEBORAH 01/10/2001 650.00 4 83C 000705710A 07/29/2000 NOLLETT, SHAWNA L 01/10/2001 565.00 4 83C 000705714A 07/29/2000 SALINAS, PAULA 01/10/2001 80.00 4 83C 000705715A 07/29/2000 BRIGGS, STEVE 01/10/2001 . 40.00 4 83C 000705728A 07/29/2000 PBR BULL RIDING, 01/10/2001 2050.00 4 83C 000705730A 07/29/2000 GREEN, DEBORAH 01/10/2001 80.00 4 83C 000705738B 07/30/2000 IBARRA, JOEL 01/10/2001 80.00 4 83C 000705748A 07/30/2000 SLATER, NATHANIEL 01/10/2001 489.83 4 83C 000705755A 07/30/2000 TAYLOR, LARRY 01/10/2001 775.00 4 83C 000705757A 07/30/2000 PESINA, .LICILA M 01/10/2001 80.00 4 83C 000705782A 07/31/2000 GARCIA, DARLENE 01/10/2001 80.00 4 83C 000705782B 07/31/2000 LUJAN, KRISTA 01/10/2001 605.00 4 83C 000805851A 08/03/2000 COLE, MATTHEW L 01/10/2001 545.00 4 83C 000805855A 08/03/2000 BYASSEE, MICHAEL 01/10/2001 290.00 4 83C 000805861A 08/03/2000 COLE, MATTHEW L 01/10/2001 650.00 4 83C 000805862A 08/03/2000 SMITH, GEOFFREY 01/10/2001 650.00 4 83C 000805870A 08/03/2000 BARRIENTOS, LETICIA 01/10/2001 650.00 4 83C 000805873A 08/03/2000 CAMERON, VERONICA 01/10/2001 740.00 4 83C 000805903A 08/04/2000 WATSON, SHANE 01/10/2001 290.00 4 83C 000805944A 08/06/2000 MARQUEZ, JEANNIE M 01/10/2001 671.14 4 83C 000805965A 08/06/2000 MILLER, JEFF 01/10/2001 695.00 4 83C 000805975A 08/07/2000 DAVIS, SANDRA 01/10/2001 134.45 4 83C 000806037A 08/08/2000 BOOTHBY, SHIRLEY 01/10/2001 660.00 4 83C 000806097A 08/11/2000 BETCHEL, JAMES 01/10/2001 545.00 4 83C 000806130A 08/12/2000 BYASSEE, MICHAEL 01/10/2001 695.00 4 83C 000806131A 08/12/2000 DITCH, ELOISA 01/10/2001 80.00 4 83C 000806171A 08/13/2000 CERVANTES, ROBERTO 01/10/2001 765.00 4 83C 000806179A 08/14/2000 CANTU, PEDRO 01/10/2001 710.00 4 83C 000806219A 08/15/2000 REGAJ.AnO, JOSE A 01/10/2001 650.00 4 83C 000806247A 08/16/2000 BENJAMIN, JENNIFER Date:01/11/2001 Weld County Ambulance Page: 5 Time:10:48:18 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 01/10/2001 Thru 01/10/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 01/10/2001 359.55 4 83C 000806256A 08/16/2000 SHEARER, VIOLET 01/10/2001 290.00 4 83C 000806395A 08/21/2000 ADAME SALAZAR, STEPH 01/10/2001 80 .00 4 83C 000806399A 08/21/2000 EURESTI, BENJAMIN 01/10/2001 336.20 4 83C 000806404A 08/22/2000 BOWERMAN, JACK D 01/10/2001 725.00 4 83C 000806419A 08/22/2000 SANDOVAL, LAWRENCE 01/10/2001 560 .00 4 83C 000806455A 08/23/2000 CUBAS, CHRISTINA 01/10/2001 125.00 4 83C 000806455C 08/23/2000 CRUZ-ESTRADA, SOPHIA 01/10/2001 545.00 4 83C 000806465A 08/24/2000 FITZNER, DANNY 01/10/2001 290.00 4 83C 000806470A 08/24/2000 FITZNER, DANNY 01/10/2001 695.00 4 83C 000806473A 08/24/2000 BARRIONVEVO, LONI 01/10/2001 915.00 4 83C 000806476A 08/24/2000 BARRIONVEVO, LONI 01/10/2001 - 695.00 4 83C 000806478A 08/24/2000 WATSON, SHANE 01/10/2001 695.00 4 83C 000806504A 08/25/2000 RIOS, GEORGE 01/10/2001 565.00 4 83C 000806510A 08/26/2000 BUCHANAN, CINDY 01/10/2001 615.00 4 83C 000806520A 08/26/2000 DAVIS, JOSHUA 01/10/2001 695.00 4 83C 000806569A 08/28/2000 ALVAREZ-MARTINEZ, JU 01/10/2001 290.00 4 83C 000806578A 08/28/2000 BENAVIDEZ, EDDIE 01/10/2001 695.00 4 83C 000806639A 08/30/2000 RODRIGUEZ, ANA 01/10/2001 169.00 4 83C 000806640A 08/30/2000 BREST, MARK A 01/10/2001 705.00 4 83C 000806653A 08/30/2000 CLARK, DARLENE 01/10/2001 720.00 4 83C 000906912A 09/08/2000 COLORADO COUNTRY CLA 01/10/2001 1080.00 4 83C 000906941A 09/09/2000 COLORADO COUNTRY CLA 01/10/2001 705.00 4 83C 000906952A 09/09/2000 MCPHILLIPS, MICHAEL 01/10/2001 545.00 4 83C 000906955A 09/09/2000 WEIDENKELLER, SANDRA 01/10/2001 545.00 4 83C 000907146A 09/16/2000 WEIDENKELLER, SANDRA 01/10/2001 710.00 4 83C 000907192A 09/18/2000 REGALADO, JOSE A 01/10/2001 715.00 4 83C 000907274A 09/20/2000 MILLER, JEFF 01/10/2001 290.00 4 83C 000907279A 09/21/2000 MILLER, JEFF 01/10/2001 270 .00 4 83C 000907285A 09/21/2000 SALEMINK, BRETT 01/10/2001 725.00 4 83C 000907387A 09/24/2000 ROBERTS, WILLIAM L 01/10/2001 635.00 4 83C 001007624A 10/02/2000 BARRIONVEVO, LONI 01/10/2001 960.00 4 83C 001007631A 10/02/2000 BARRIONVEVO, LONI 01/10/2001 635.00 4 83C 001008132A 10/21/2000 MILLER, JEFF 01/10/2001 290.00 4 83C 001008173A 10/22/2000 MILLER, JEFF 01/10/2001 650.00 4 83C 001108818A 11/14/2000 TIMBE, JAMES 01/10/2001 545.00 4 83C 001209207A 12/01/2000 TORREZ, SOTERO 01/10/2001 660.00 4 83C 001209224A 12/02/2000 RED EARTH, KENNETH 01/10/2001 605.00 4 83C 001209459A 12/10/2000 RODRIGUEZ, ARMANDO 01/10/2001 47.66 4 83C 941207271A 12/21/1994 MARQUEZ, FILIVERTO 01/10/2001 395.00 4 83C 980704627A 07/16/1998 RASMUSSEN, SHELBY LE 01/10/2001 610.00 4 83C 990201601A 02/28/1999 MARQUEZ, MARY J 01/10/2001 650.74 4 83C 990503367A 05/07/1999 MARQUEZ, MARY J 01/10/2001 460.00 4 83C 991007555A 10/12/1999 MANN, SUSAN 01/10/2001 600.00 4 83C 991209064A 12/08/1999 SHAFFER, RODGER Date:01/11/2001 Weld County Ambulance Page: 6 Time:10:48:19 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 01/10/2001 Thru 01/10/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Total of 240 WriteOff Entries Totaling 117765.07 Dollars Average WriteOff: 490.69 Dollars Average Time:207 Days Date:01/11/2001 Weld County Ambulance Page: 7 Time:10:48:19 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 01/10/2001 Thru 01/10/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 238 117275.64 492 .75 206.13 81 MEDICARE WRITEOFF 1 409.43 409.43 307.00 83 WRITEOFF 1 80.00 80.00 218.00 • Date:02/16/2001 Weld County Ambulance Page: 1 Time:08:26:52 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 02/15/2001 Thru 02/15/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 02/15/2001 271.28 4 83C 000100482A 01/21/2000 CONDREAY, MARY 02/15/2001 67.72 4 83C 000100494A 01/21/2000 CONDREAY, MARY 02/15/2001 52.50 4 83C 000100741A 01/30/2000 DUNNELL, SUZANNE H 02/15/2001 685.00 4 83C 000301797A 03/13/2000 FLORES, BERNICE 02/15/2001 510.00 4 83C 000302245A 03/30/2000 DROVDAL, SCOTT 02/15/2001 425.60 4 83C 000302297A 03/31/2000 VAN ACKER, GREGORY 02/15/2001 780.00 4 83C 000402472A 04/07/2000 AGENBROAD, GARY 02/15/2001 960.00 4 83C 000402522A 04/08/2000 DIAZ JR, FRANCISCO 02/15/2001 565.00 4 83C 000503651A 05/21/2000 PALEN, NICOLETTA A 02/15/2001 290.00 4 83C 000503930A 05/30/2000 WARD, SANDRA L 02/15/2001 625.00 4 83C 000503931A 05/30/2000 ROMERO, REGINA 02/15/2001 38.16 4 83C 000604117A 06/05/2000 BERKHOLDER, JOHN C 02/15/2001 40.00 4 83C 000604201A 06/08/2000 MCCORMICK, GENE 02/15/2001 435.00 4 83C 000604255A 06/10/2000 CHRISTMAN, AMANDA 02/15/2001 560.00 4 83C 000604316A 06/12/2000 SUMMER, TINA 02/15/2001 16.00 4 83C 000604500A 06/19/2000 BALDERRAMA, GUADALUP 02/15/2001 355.00 4 83C 000604547A 06/20/2000 BAXTER, BRITTANEY 02/15/2001 695.00 4 83C 000604761A 06/27/2000 RIVERO, ESPERANZA 02/15/2001 50.00 4 82 000604804A 06/29/2000 DEVORA, ANTHONY 02/15/2001 80.00 4 83C 000704883A 07/01/2000 OCHOA, JAIME 02/15/2001 785.00 4 83C 000704912A 07/02/2000 CERDA, ELENA ROSA 02/15/2001 425.00 4 83C 000704948A 07/03/2000 BARNES, JAMES A 02/15/2001 605.00 4 83C 000704964A 07/04/2000 SMOCK, VIRGINIA A 02/15/2001 387.72 4 83C 000705249A 07/12/2000 BADIAL, JENNY 02/15/2001 625.00 4 83C 000705302A 07/14/2000 NAJERA, CARMEN OLIVI 02/15/2001 425.00 4 83C 000705319A 07/14/2000 BARNES, JAMES A 02/15/2001 650.00 4 83C 000705369A 07/15/2000 SILVA, JOSE D 02/15/2001 290.00 4 83C 000705375A 07/15/2000 SILVA, JOSE D 02/15/2001 370.83 4 83C 000705439A 07/18/2000 WOODWARD, VIOLET 02/15/2001 695.00 4 83C 000705443A 07/18/2000 MAYORGA, MARIA G 02/15/2001 425.00 4 83C 000705482A 07/20/2000 BARNES, JAMES A 02/15/2001 455.00 4 83C 000705597B 07/24/2000 NEAL, CHARISE 02/15/2001 545.00 4 83C 000705635A 07/25/2000 SERRANO-GONZALEZ, HU 02/15/2001 80.00 4 83C 000705637A 07/26/2000 MARTINEZ, CHRISTINE 02/15/2001 50.00 4 83C 000705739A 07/30/2000 OCHOA, JOY 02/15/2001 665.00 4 83C 000805871A 08/03/2000 PAULS, DIANA L 02/15/2001 780.00 4 83C 000805919A 08/05/2000 PADILLA, JASON 02/15/2001 720.00 4 83C 000805926A 08/05/2000 SEGURA, MARY 02/15/2001 696.14 4 83C 000805937A 08/05/2000 SMOCK, VIRGINIA A 02/15/2001 780.00 4 83C 000805945A 08/06/2000 LUNA, DAVID 02/15/2001 475.00 4 83C 000805958A 08/06/2000 VITTETOE, JOSHUA R 02/15/2001 650 .00 4 83C 000805967A 08/06/2000 VIZCAINO, PAULINO 02/15/2001 290 .00 4 83C 000805989A 08/07/2000 LOBATO, JEFF T 02/15/2001 805.00 4 83C 000806027A 08/08/2000 SANTOS, OSIEL 02/15/2001 605.00 4 83C 000806038A 08/08/2000 MARTINEZ, JESSIE 02/15/2001 825.00 4 83C 000806051A 08/09/2000 SMALL, ERICA J 02/15/2001 720.00 4 83C 000806051B 08/09/2000 SMALL, DESMOND 02/15/2001 80.00 4 83C 000806072A 08/10/2000 LONGAXER, BRENDAN 02/15/2001 80.00 4 83C 000806088A 08/10/2000 PHILLIPS, ANDREW Date:02/16/2001 Weld County Ambulance Page: 2 Time:08:26:52 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 02/15/2001 Thru 02/15/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 02/15/2001 625.00 4 83C 000806099A 08/11/2000 YATES, RYAN 02/15/2001 605.00 4 83C 000806100A 08/11/2000 PARKER, BRITTNEY R 02/15/2001 290.00 4 83C 000806104A 08/11/2000 PARKER, BRITTNEY R 02/15/2001 650.00 4 83C 000806111A 08/11/2000 SUMMERS, ERICA 02/15/2001 650.00 4 83C 000806156A 08/13/2000 STEWART, RONALD 02/15/2001 830.00 4 83C 000806158A 08/13/2000 MORENO, CLAUDIA 02/15/2001 750.00 4 83C 000806166A 08/13/2000 MARTINEZ, ENRIQUE 02/15/2001 660.00 4 83C 000806179B 08/14/2000 PANTOJA, VICENTE 02/15/2001 25.00 4 82 000806196A 08/14/2000 PISHNA, WANDA 02/15/2001 325.00 4 83C 000806200A 08/14/2000 THOMPSON, BYRON 02/15/2001 25.00 4 83C 000806214A 08/15/2000 CONTRERAS, SERGIO 02/15/2001 80.00 4 83C 000806224A 08/15/2000 THOMPSON, JEFF 02/15/2001 845.00 4 83C 000806255A 08/16/2000 ATTIX, MARY 02/15/2001 800.00 4 83C 000806258A 08/20/2000 LARKIN, CHRISTOPHER 02/15/2001 23 .75 4 83C 000806286A 08/18/2000 CONTRERAS, SERGIO 02/15/2001 137.36 4 83C 000806309A 08/18/2000 BENSON, SALLY 02/15/2001 921.14 4 83C 000806331A 08/19/2000 PREWITT, WILLIAM 02/15/2001 695.00 4 83C 000806343A 08/19/2000 SHAEFFER, STAN 02/15/2001 545.00 4 83C 000806346A 08/19/2000 TREVIZO, DEYANIRA 02/15/2001 590 .00 4 83C 000806348A 08/19/2000 SEELEY, LARRY 02/15/2001 775.00 4 83C 000806353A 08/20/2000 RODRIGUEZ, CLARICE 02/15/2001 860 .00 4 83C 000806364A 08/20/2000 SLAGER, DONALD 02/15/2001 80 .00 4 83C 000806369A 08/20/2000 WHITE, TRACY 02/15/2001 545.00 4 83C 000806415A 08/22/2000 VIGIL, PHILLIP V 02/15/2001 675.00 4 83C 000806477A 08/24/2000 MENDOZA, JORGE 02/15/2001 545.00 4 83C 000806484B 08/25/2000 LOPEZ, MARY 02/15/2001 40 .00 4 83C 000806517A 08/26/2000 BENAVADEZ, AMY 02/15/2001 545.00 4 83C 000806526A 08/26/2000 WORTH, MARY 02/15/2001 80 .00 4 83C 000806549A 08/27/2000 MOLINA, MAXIMINA OLG 02/15/2001 695.00 4 83C 000806570A 08/28/2000 SMITH, KAREN M 02/15/2001 745.00 4 83C 000806580A 08/28/2000 ZEIGAFUSE, DEBRA 02/15/2001 25.00 4 83C 000806598A 08/29/2000 BEJARANO, MARYLOU 02/15/2001 710 .00 4 83C 000806602A 08/29/2000 ROGERS, LUELLA 02/15/2001 600 .00 4 83C 000806613A 08/29/2000 WATSON, ROBERT 02/15/2001 695.00 4 83C 000806619A 08/29/2000 TRUJILLO, MELODY R 02/15/2001 290 .00 4 83C 000806620A 08/29/2000 EDDY, SHANNON M 02/15/2001 290 .00 4 83C 000806621A 08/30/2000 TRUJILLO, MELODY R 02/15/2001 715.00 4 83C 000806622A 08/30/2000 LITTLENEST, BERNARD 02/15/2001 855.00 4 83C 000806636A 08/30/2000 SANTEE, TAMMY S 02/15/2001 820.00 4 83C 000806665A 08/31/2000 SPEAKER, HERBERT 02/15/2001 590.00 4 83C 000906691A 09/01/2000 CHAROWHAS, PETER J 02/15/2001 650 .00 4 83C 000906727A 09/02/2000 MENDEZ, ANDRES 02/15/2001 745.00 4 83C 000906746A 09/02/2000 DUFFY, GARY 02/15/2001 735.00 4 83C 000906761A 09/03/2000 FINLAYSON, JENIFER 02/15/2001 801.14 4 83C 000906775A 09/04/2000 CROTTEAU, CLARA 02/15/2001 80 .00 4 83C 000906796A 09/05/2000 MARTIN, PATRICK D 02/15/2001 545.00 4 83C 000906811A 09/05/2000 ESPARZA, JOSIE 02/15/2001 660 .00 4 83C 000906814A 09/05/2000 ARGUELLO, FRANCES 02/15/2001 545.00 4 83C 000906816A 09/05/2000 MONTOYA, LISA Date:02/16/2001 Weld County Ambulance Page: 3 Time:08:26:53 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 02/15/2001 Thru 02/15/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 02/15/2001 545.00 4 83C 000906823A 09/05/2000 BODELL, TARA 02/15/2001 80.00 4 83C 000906826A 09/06/2000 ORTIZ, JOSE 02/15/2001 545.00 4 83C 000906827A 09/06/2000 ESPINOZA, LINDA 02/15/2001 770.00 4 83C 000906843A 09/06/2000 ORTEGA, PATRICIA 02/15/2001 710.00 4 83C 000906846A 09/06/2000 LECHUGA, ANA 02/15/2001 80.00 4 83C 000906866A 09/07/2000 OCHOA, MIA 02/15/2001 80.00 4 83C 000906919B 09/08/2000 ODOM, CHERRIE 02/15/2001 545.00 4 83C 000906927A 09/08/2000 OCHOA, LUCIO JAMES 02/15/2001 726.14 4 83C 000906936A 09/08/2000 CROTTEAU, CLARA 02/15/2001 770.00 4 83C 000906937A 09/08/2000 BRAMBLETT, MEGAN 02/15/2001 885.00 4 83C 000906956A 09/09/2000 PHILLIPS, TRAVIS 02/15/2001 925.00 4 83C 000906991A 09/10/2000 BATH, MARY D ' 02/15/2001 660.00 4 83C 000906993A 09/10/2000 LOINES, SCOTT 02/15/2001 290 .00 4 83C 000906995A 09/10/2000 EDDY, SHANNON M 02/15/2001 650 .00 4 83C 000907062A 09/13/2000 WOODS, CLARENCE 02/15/2001 80.00 4 83C 000907102A 09/14/2000 LOZANO, RACHAEL 02/15/2001 760 .00 4 83C 000907113A 09/14/2000 CURTIS, SCOTT 02/15/2001 600 .00 4 83C 000907135A 09/15/2000 PEREZ, MARIA 02/15/2001 660 .00 4 83C 000907194A 09/18/2000 ELKINS, MICHAEL 02/15/2001 650 .00 4 83C 000907204A 09/18/2000 LEWIS, VANESSA 02/15/2001 710.00 4 83C 000907215A 09/18/2000 BEVARMANN, YVONNE 02/15/2001 75 .50 4 83C 000907248A 09/20/2000 MENDOZA, RAMON 02/15/2001 290.00 4 83C 000907249A 09/20/2000 BURT, BRIAN J 02/15/2001 786.14 4 83C 000907262A 09/20/2000 CROTTEAU, CLARA 02/15/2001 545.00 4 83C 000907280A 09/21/2000 SCOTT, BLAKE 02/15/2001 705.00 4 83C 000907282A 09/21/2000 FOOSE, LARRY 02/15/2001 565.00 4 83C 000907283A 09/21/2000 BARCELONA, SHERRY 02/15/2001 710.00 4 83C 000907307A 09/21/2000 LOPEZ-MUNIZ, ISREAL 02/15/2001 290.00 4 83C 000907309A 09/22/2000 LOPEZ-MUNIZ, ISREAL 02/15/2001 605.00 4 83C 000907336A 09/22/2000 MALDONADO, ANTONIO R 02/15/2001 80 .00 4 83C 000907363A 09/24/2000 CAT,TTWELL, ERIC 02/15/2001 80.00 4 83C 000907471A 09/27/2000 PREWITT, WILLIAM 02/15/2001 656.14 4 83C 000907475A 09/28/2000 BROOKS, LEO GENE 02/15/2001 148.00 4 83C 000907486A 09/28/2000 MICHAEL, TASHENE 02/15/2001 80.00 4 83C 000907556A 09/30/2000 MASON, JR, PHILLIP 02/15/2001 730.00 4 83C 000907903A 09/29/2000 DANIEL, RICHARD 02/15/2001 70.93 4 83C 001007658A 10/04/2000 KLAMM, BENJAMIN 02/15/2001 50.00 4 82 001108552A 11/06/2000 DEVORA, ANTHONY 02/15/2001 370.00 4 83W 001108987A 11/22/2000 GEORGE, GREG D 02/15/2001 315.00 4 83C 990100472A 01/18/1999 FENDEL, KEVIN L 02/15/2001 85.00 4 83C 990301907A 03/12/1999 PETZANTZIN, CELESTIN 02/15/2001 390.00 4 83C 990604229A 06/11/1999 VALENTINE, BECKY 02/15/2001 210.00 4 83C 990705445A 07/25/1999 PETZANTZIN, CELESTIN Total of 141 WriteOff Entries Totaling 68052 .19 Dollars Average WriteOff: 482.64 Dollars Average Time:204 Days Date:02/16/2001 Weld County Ambulance Page: 4 Time:08:26:54 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 02/15/2001 Thru 02/15/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 137 67557.19 493.12 205.07 82 MEDICAID WRITEOFF 3 125.00 41.67 172 .33 83W WRITEOFF WORK COMP 1 370.00 370.00 85.00 Date:02/20/2001 Weld County Ambulance Page: 1 Time:10:01:46 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 02/16/2001 Thru 02/16/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 02/16/2001 137.00 4 83C 000200934A 02/07/2000 BOWLES, PATRICIA 02/16/2001 1166.14 4 83C 000301945A 03/18/2000 PEDERSEN, WILLIAM 02/16/2001 656.14 4 83C 000503908A 05/30/2000 HETHERINGTON, MILTON 02/16/2001 465.00. 4 83C 000704921A 07/02/2000 GONZALES, FRANCISCO 02/16/2001 715 .00 4 83C 000705091A 07/07/2000 WILLIAMS, GUINEVERE 02/16/2001 670 .00 4 83C 000705153A 07/09/2000 GROSSMAN, CHERYL 02/16/2001 705.00 4 83C 000705186A 07/10/2000 THOMPSON, MICHAEL 02/16/2001 598.01 4 83C 000705462A 07/19/2000 OCONNOR, JAMES R 02/16/2001 60.00 4 83C 000705472A 07/19/2000 MIJARES, GABRIELA 02/16/2001 650.00 4 83C 000705513B 07/21/2000 BARRON, DONNA 02/16/2001 50 .00 4 83C 000705533A 07/22/2000 PENAFLOR, PHILIP 02/16/2001 290.00 4 83C 000705712A 07/29/2000 GREEN, JOHN R 02/16/2001 80 .00 4 83C 000805846A 08/02/2000 GOMEZ, HONORIO 02/16/2001 650.00 4 83C 000805928A 08/05/2000 TALMADGE, RAYMOND J 02/16/2001 174.86 4 83C 000806025A 08/08/2000 HAZLITT, JOHN 02/16/2001 770 .00 4 83C 000806077A 08/10/2000 HENRY, DAVID 02/16/2001 80 .00 4 83C 000806186A 08/14/2000 SMITH, IRENE 02/16/2001 290.00 4 83C 000806209A 08/15/2000 WEBB, SARA 02/16/2001 605 .00 4 83C 000806221A 08/15/2000 HERBERT, SHELDON 02/16/2001 735.00 4 83C 000806234A 08/15/2000 HOPKINS, PAT 02/16/2001 545.00 4 83C 000806262A 08/16/2000 HILL, JOHN C 02/16/2001 790 .00 4 83C 000806305A O8/18/2000 GARCIA, JOSE 02/16/2001 765.00 4 83C 000806324A 08/18/2000 HARKLESS, ADAM 02/16/2001 615.00 4 83C 000806351A 08/20/2000 VALDEZ, CHARLES 02/16/2001 715.00 4 83C 000806370A 08/20/2000 JOHNSON, DENNIS 02/16/2001 80.00 4 83C 000806398A 08/21/2000 GENTRY, JAMEE 02/16/2001 605.00 4 83C 000806434A 08/23/2000 WELLS, DENISE 02/16/2001 830.00 4 83C 000806455B 08/23/2000 HERNANDEZ, JOSE 02/16/2001 785.00 4 83C 000806455D 08/23/2000 HERNANDEZ, WILFREDO 02/16/2001 290.00 4 83C 000806497A 08/25/2000 GARDINER, TRAVIS J 02/16/2001 810.00 4 83C 000806538A 08/27/2000 PACHECO, DONNA 02/16/2001 80.00 4 83C 000806587A 08/28/2000 HERNANDEZ, AMALIA 02/16/2001 80.00 4 83C 000906984A 09/10/2000 PEREZ, ALFONZO 02/16/2001 650.00 4 83C 001007584A 10/01/2000 MONTERO, MANUEL 02/16/2001 590.00 4 83C 001007717A 10/06/2000 HAYES, KIMBERLY 02/16/2001 80.00 4 83C 001007750A 10/07/2000 MARTINEZ, EDUARDO 02/16/2001 80.00 4 83C 001007768A 10/08/2000 NORREGO, SABINO 02/16/2001 845.00 4 83C 001008111A 10/20/2000 RAY, JAMES 02/16/2001 540.00 4 83C 001008126A 10/21/2000 ORTEGA, LUIS 02/16/2001 290 .00 4 83C 001008144A 10/21/2000 RAY, JAMES 02/16/2001 545.00 4 83C 001008235A 10/25/2000 QUIROZ, JUAN 02/16/2001 545.00 4 83C 001008337A 10/29/2000 ALVARADO, MAJIN M 02/16/2001 545.00 4 83C 001008337B 10/29/2000 BOCANEGRA, ABRAHAM 02/16/2001 80 .00 4 83C 001008344A 10/29/2000 FIREBAUGH, JEFF I 02/16/2001 80 .00 4 83C 001008350A 10/29/2000 WINDEDAHL, JULIE 02/16/2001 80 .00 4 83C 001108448A 11/02/2000 PLEIGO, VICTOR MANUE 02/16/2001 745.00 4 83C 001108516B 11/04/2000 QUINTERO, MANDIE I 02/16/2001 545.00 4 83C 001108703A 11/10/2000 MORGAN, CAROL 02/16/2001 715.00 4 83C 001108897A 11/18/2000 HERNANDEZ, MARIO Date:02/20/2001 Weld County Ambulance Page: 2 Time:10:01:47 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 02/16/2001 Thru 02/16/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 02/16/2001 955.00 4 83C 001108993A 11/22/2000 NIELSON, SHANNON 02/16/2001 545.00 4 83C 001109000A 11/22/2000 J.ANGREN, MIKE 02/16/2001 650.00 4 83C 001109166A 11/30/2000 PAREDES, ANTONIO 02/16/2001 80.00 4 83C 001209322A 12/05/2000 MUNOZ-FLORES, ANTONI 02/16/2001 755.00 4 83C 001209329A 12/05/2000 MCMAHON, JOHN 02/16/2001 605.00 4 83C 001209457B 12/09/2000 RANGEL, TEOFILO B 02/16/2001 635.00 4 83C 001209680A 12/17/2000 BRUNNER, LISA A 02/16/2001 650.00 4 83C 001209822A 12/23/2000 CHALI, ERIC 02/16/2001 1107.00 4 83C 010100143A 01/06/2001 GARIBAY, ELOY 02/16/2001 144.00 4 REV 010100538A 01/20/2001 VEROVAC, RUTH 02/16/2001 16.00 4 83C - 991007604A 10/14/1999 INGERSOLL, ROCHELLE Total of 60 WriteOff Entries Totaling 29634.15 Dollars Average WriteOff: 493 .90 Dollars Average Time:162 Days • Date:02/20/2001 Weld County Ambulance Page: 3 Time:10 :01:47 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 02/16/2001 Thru 02/16/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 59 29490.15 499.83 164.07 REV REVERSE CHARGED IN ERROR 1 144 .00 144.00 27.00 Date:03/07/2001 Weld County Ambulance Page: 1 Time:16:59:22 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 03/07/2001 Thru 03/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 03/07/2001 275.00 4 83C 000805944A 08/06/2000 MARQUEZ, JEANNIE M 03/07/2001 371.43 4 81 001007756A 10/07/2000 GEORGE, BARBARA 03/07/2001 301.50 4 81 001007777A 10/08/2000 GEORGE, BARBARA 03/07/2001 99.20 4 81 001007779A 10/08/2000 GEORGE, BARBARA 03/07/2001 510.77 4 82 001108817A 11/14/2000 MARTINEZ, ERNESTINA 03/07/2001 607.19 4 82 001108914A 11/18/2000 RENDON, PERFETA 03/07/2001 513 .20 4 82 001209826A 12/23/2000 CARRASCO, RUBEN 03/07/2001 462 .22 4 81 010100397A 01/15/2001 ROBERTS, BEN C 03/07/2001 493 .17 4 81 010100803A 01/28/2001 BUCHTEL, ALTA 03/07/2001 411.05 4 81 010100852A 01/30/2001 VILLANUEVA, CATLETAN 03/07/2001 595.72 4 81 010200918A 02/02/2001 DUNN, PATRICIA 03/07/2001 491.24 4 81 010200933A 02/02/2001 MARQUEZ, MARY J 03/07/2001 544.52 4 81 010200949A 02/03/2001 KUHN, GLADYS 03/07/2001 544.52 4 81 010200960A 02/03/2001 WOOTEN, NAOMI A 03/07/2001 BUFF CAP 65.00 4 81 010200963A 02/03/2001 GILLILAND, LEONA 03/07/2001 662.79 4 81 010200964A 02/03/2001 APPLE, DARLINE 03/07/2001 545.31 4 81 010200966A 02/03/2001 STROH, MOLLIE 03/07/2001 549.15 4 81 010200976A 02/04/2001 ARMENDARIZ, JESUS 03/07/2001 427.65 4 81 010200993A 02/04/2001 MIRICK, J. D. 03/07/2001 411.05 4 81 010200996A 02/04/2001 BROSSMAN, FRANCES 03/07/2001 423 .20 4 82 990705003A 07/07/1999 MARTINEZ, JENNIFER Total of 21 WriteOff Entries Totaling 9304.88 Dollars Average WriteOff: 443 .09 Dollars Average Time:96 Days Date:03/07/2001 Weld County Ambulance Page: 2 Time:16:59:24 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 03/07/2001 Thru 03/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 1 275.00 275.00 213.00 81 MEDICARE WRITEOFF 16 6975.52 435.97 55.94 82 MEDICAID WRITEOFF 4 2054.36 513.59 226.25 Date:04/05/2001 Weld County Ambulance Page: 1 Time:11:19:27 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 04/04/2001 Thru 04/04/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 04/04/2001 400.00 4 83C 000201344A 02/24/2000 COLLENTINE, CHARLIE 04/04/2001 660.00 4 83C 000301981A 03/20/2000 GALLEGOS, CARLOS 04/04/2001 650.00 4 83C 000503253A 05/06/2000 RODRIGUEZ, PAUL 04/04/2001 590.00 4 83C 000503514B 05/15/2000 GRANADOS, MELINDA 04/04/2001 505.00 4 83C 000503878A 05/29/2000 GARCIA, OBED 04/04/2001 328.60 4 83C 000603979A 06/01/2000 SMALL, CINDY 04/04/2001 695.00 4 83C 000604382A 06/14/2000 PIEDALUE, MARIE 04/04/2001 480.00 4 83C 000604619A 06/22/2000 SANCHEZ, ANGELA 04/04/2001 815.00 4 83C 000604719A 06/26/2000 PARRIS, RICHARD 04/04/2001 25.00 4 83C 000604793A 06/29/2000 FLOREZ, ALANA 04/04/2001 193.50 4 83C 000704999A 07/04/2000 REED-ADDY, DIANA 04/04/2001 80.00 4 83C 000705115A 07/08/2000 MATHEWS, JUNE 04/04/2001 130.00 4 83C 000705731A 07/29/2000 HIGGINS, CHRISTINE 04/04/2001 710.00 4 83C 000805803A 08/01/2000 RIVAS, OLGA 04/04/2001 545.00 4 83C 000805865A 08/03/2000 GARZA, NANCY 04/04/2001 660.00 4 83C 000805985A 08/07/2000 SWOVELAND, LINDA 04/04/2001 780.00 4 83C 000806014A 08/08/2000 STEARSMAN, DONALD 04/04/2001 372 .43 4 83C 000806113A 08/11/2000 OCONNOR, JAMES R 04/04/2001 137.36 4 83C 000806115A 08/11/2000 OCONNOR, JAMES R 04/04/2001 1216.14 4 83C 000806197A 08/14/2000 BUTLER, L WILLIAM 04/04/2001 656.14 4 83C 000806216A 08/15/2000 KOONCE, ELDON 04/04/2001 545.00 4 83C 000806241A 08/16/2000 WILLIS, JASON 04/04/2001 605.00 4 83C 000806280A 08/17/2000 RICKETTS, CARRIE L 04/04/2001 290.00 4 83C 000806296A 08/18/2000 RICKETTS, CARRIE L 04/04/2001 650.00 4 83C 000806315A 08/18/2000 LAGUARDIA, MARCUS 04/04/2001 25.00 4 83C 000806317A 08/18/2000 MALLORY, MATT R 04/04/2001 25.00 4 83C 000806326A 08/19/2000 WATSON, BOB 04/04/2001 815.00 4 83C 000806425A 08/22/2000 TORRES, SILVERIO 04/04/2001 202.20 4 83C 000806568A 08/28/2000 SCHRIMPF, STEVEN A 04/04/2001 290.00 4 83C 000806583A 08/28/2000 MOCK, ALYSSA 04/04/2001 560.00 4 83C 000806589A 08/29/2000 OWENS, RANDY 04/04/2001 545.00 4 83C 000806611A 08/29/2000 KOONCE, ELDON 04/04/2001 72 .50 4 83C 000806680A 08/31/2000 ALPERT, JENNA 04/04/2001 670.00 4 83C 000906683A 09/01/2000 SALAZAR, JOANN 04/04/2001 600.00 4 83C 000906699A 09/01/2000 ALPERT, JENNA 04/04/2001 290.00 4 83C 000906701A 09/01/2000 KENNEDY, CHRIS 04/04/2001 372.43 4 83C 000906768A 09/03/2000 OCONNOR, JAMES R 04/04/2001 80.00 4 83C 000906798A 09/05/2000 SCHMIDT, DONNA 04/04/2001 25.00 4 82 000906802A 09/05/2000 THOMAS, KATLYN R 04/04/2001 590.00 4 83C 000906804A 09/05/2000 GARCIA, MARIA 04/04/2001 66.72 4 83C 000906813A 09/05/2000 ERICKSON, CARL 04/04/2001 80.00 4 83C 000906826B 09/06/2000 VIGIL-BIREER, ERNEST 04/04/2001 545.00 4 83C 000906845A 09/06/2000 PANZLAU, OLIVER S 04/04/2001 725.00 4 83C 000906874A 09/07/2000 VERMACE, CHARLES E 04/04/2001 650.00 4 83C 000906877A 09/07/2000 CLEMENT, M J 04/04/2001 80.00 4 83C 000906886A 09/07/2000 WILSON, WALTER A JR 04/04/2001 795.00 4 83C 000906891B 09/07/2000 PORTER, SCOTT 04/04/2001 605.00 4 83C 000906894A 09/07/2000 GUEVARRA, EMILSE 04/04/2001 825.00 4 83C 000906905A 09/08/2000 STEVENS, MARY Date:04/05/2001 Weld County Ambulance - Page: 2 Time:11:19:28 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 04/04/2001 Thru 04/04/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 04/04/2001 80.00 4 83C 000906907A 09/08/2000 ANDIS, MICHAEL 04/04/2001 161.00 4 83C 000906948A 09/09/2000 HEER, DEBORAH 04/04/2001 715.00 4 83C 000906990A 09/10/2000 CONTRERAS, JOSEPHINE 04/04/2001 60.50 4 83C 000907020A 09/11/2000 RICKETTS, CARRIE L 04/04/2001 290.00 4 83C 000907022A 09/11/2000 RICKETTS, CARRIE L 04/04/2001 554.40 4 83C 000907042A 09/12/2000 SANCHEZ, REBEKAH J 04/04/2001 720.00 4 83C 000907044A 09/12/2000 REITZ, CHRISTOPHER 04/04/2001 80.00 4 83C 000907070A 09/13/2000 JARAMILLO, BRITTANY 04/04/2001 545.00 4 83C 000907074A 09/13/2000 PARRA, SUELI 04/04/2001 665.00 4 83C 000907101A 09/14/2000 WINTER, KEVIN J 04/04/2001 50.00 4 83C 000907104A 09/14/2000 MCWILLIAMS, JOHNNY 04/04/2001 795.00 4 83C 000907130A 09/15/2000 HARTMAN, DAVID 04/04/2001 25.00 4 83C 000907132A 09/15/2000 WATSON, BOB 04/04/2001 795.00 4 83C 000907134A 09/15/2000 WATKINS, CHRISTINE 04/04/2001 80.00 4 83C 000907163A 09/16/2000 GUERRA, GARY 04/04/2001 825.00 4 83C 000907166A 09/17/2000 VELO-BRAVO, TEODOSIO 04/04/2001 580 .00 4 83C 000907176A 09/17/2000 HAFFNER, JERRY 04/04/2001 80.00 4 83C 000907177B 09/17/2000 GUTIERREZ, RUBY 04/04/2001 685.00 4 83C 000907178A 09/17/2000 REIMERS, MARK 04/04/2001 660.00 4 83C 000907209A 09/18/2000 SOUTHWICK, RACHEL L 04/04/2001 290.00 4 83C 000907213A 09/18/2000 SOUTHWICK, RACHEL L 04/04/2001 695.00 4 83C 000907238A 09/19/2000 RAMIREZ, LILIANA 04/04/2001 . 191.00 4 83C 000907265A 09/20/2000 MARTIN, HARVEY M 04/04/2001 525.00 4 83C 000907289A 09/21/2000 SALINAS, YVETTE 04/04/2001 82 .50 4 83C 000907291A 09/21/2000 GORE, LAWRENCE H 04/04/2001 470.00 4 83C 000907316A 09/22/2000 KING, DONALD 04/04/2001 514.83 4 83C 000907325A 09/22/2000 PEDERSEN, WILLIAM 04/04/2001 1080.00 4 83C 000907357A 09/23/2000 RIVAS, EMMANUEL 04/04/2001 80.00 4 83C 000907374A 09/24/2000 RIVERA, JAMIE 04/04/2001 545.00 4 83C 000907398A 09/25/2000 ZELINGER, RICHARD SC 04/04/2001 80.00 4 83C 000907399A 09/25/2000 WILSON, CLIFFORD W 04/04/2001 605.00 4 83C 000907438A 09/26/2000 PANZLAV, OLIVER S 04/04/2001 430.00 4 83C 000907441A 09/26/2000 WINDEN, TOM 04/04/2001 560.00 4 83C 000907446A 09/27/2000 EGGLESTON, NATHAN 04/04/2001 605.00 4 83C 000907462A 09/27/2000 GODWIN, PEARL 04/04/2001 650.00 4 83C 000907464A 09/27/2000 MARTIN, KRISTOPHER 04/04/2001 290.00 4 83C 000907469A 09/27/2000 GODWIN, PEARL 04/04/2001 650.00 4 83C 000907484A 09/28/2000 RODRIGUEZ, JESUS 04/04/2001 560.00 4 83C 000907496A 09/28/2000 SMITH, JAMES R 04/04/2001 80.00 4 83C 000907518A 09/29/2000 GAWRYL, MARISSA 04/04/2001 353.00 4 83C 000907521A 09/29/2000 SMALL, CINDY 04/04/2001 130.00 4 83C 000907526A 09/29/2000 HUGHES, DANIEL H 04/04/2001 660.00 4 83C 000907538A 09/29/2000 SANTORO, ADRIANNE 04/04/2001 545.00 4 83C 000907567A 09/30/2000 WAGNER, MANDI 04/04/2001 555.00 4 83C 001007575A 10/01/2000 HILL, NOEL B 04/04/2001 590.00 4 83C 001007595A 10/01/2000 NAVA, JENNIFER 04/04/2001 650.00 4 83C 001007595C 10/01/2000 NAVA, SANDRA 04/04/2001 590.00 4 83C 001007595D 10/01/2000 NAVA, ALDO 04/04/2001 80.00 4 83C 001007615A 10/02/2000 PADILLA, MAX Date:04/05/2001 Weld County Ambulance Page: 3 Time:11:19:28 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 04/04/2001 Thru 04/04/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 04/04/2001 80.00 4 83C 001007629A 10/02/2000 POPOVICH, MICHAEL 04/04/2001 605.00 4 83C 001007630A 10/02/2000 BAREA, ADRIANA 04/04/2001 265.00 4 83C 001007634A 10/02/2000 RICHARD, ANDREW A 04/04/2001 725.00 4 83C 001007643A 10/03/2000 HOLSCLAW, IDYLL M 04/04/2001 650.00 4 83C 001007647A 10/03/2000 HARDING, MELISSA M 04/04/2001 710.00 4 83C 001007648A 10/03/2000 MARTINEZ, JUAN ALVAR 04/04/2001 710.00 4 83C 001007674A 10/04/2000 SUTTON, GARY D 04/04/2001 755.00 4 83C 001007690A 10/05/2000 RICO, MARINA 04/04/2001 80.00 4 83C 001007716A 10/06/2000 ALVARADO, TAMARA 04/04/2001 670.00 4 83C 001007728A 10/06/2000 ONEILL, JENNIFER D 04/04/2001 455.00 4 83C 001007748A 10/07/2000 ABELS, KRISTAPHER 04/04/2001 705.00 4 83C 001007773A 10/08/2000 MADRID, MAYRA 04/04/2001 650.00 4 83C 001007775A 10/08/2000 JONES, DORIS 04/04/2001 80.00 4 83C 001007787A 10/08/2000 SEAN, ADAM 04/04/2001 290.00 4 83C 001007788A 10/08/2000 ROMERO, JOSE 04/04/2001 290.00 4 83C 001007790A 10/08/2000 KENITZER, LANCE 04/04/2001 545.00 4 83C 001007849A 10/11/2000 GARCIA, BERNADETTE 04/04/2001 290.00 4 83C 001007850A 10/11/2000 ROBERTS, LYNNSEY M 04/04/2001 695.00 4 83C 001007851A 10/11/2000 RIVERA, ARNULFO 04/04/2001 615.00 4 83C 001007859A 10/11/2000 BURGESS, CARLA M 04/04/2001 710.00 4 83C 001007876A 10/11/2000 HEBERLING, ASHLEY 04/04/2001 660.00 4 83C 001007884A 10/12/2000 KURY, PAT 04/04/2001 835.00 4 83C 001007895A 10/12/2000 WATERS, MITCHELL 04/04/2001 332.00 4 83C 001007902A 10/13/2000 BORLAND, CURT A 04/04/2001 705.00 4 83C 001007922A 10/13/2000 CLIFTON, SHELLY 04/04/2001 80.00 4 83C 001007925A 10/14/2000 ESPINOSA, ALEJANDRO 04/04/2001 80.00 4 83C 001007925B 10/14/2000 RUBIO, FELIPE 04/04/2001 80.00 4 83C 001007929A 10/14/2000 MARTINEZ, SIGFREDO P 04/04/2001 710.00 4 83C 001007930A 10/14/2000 HASLEY, GARY L 04/04/2001 80.00 4 83C 001007942A 10/14/2000 RUDE, LISA 04/04/2001 80.00 4 83C 001007942B 10/14/2000 PINO, JUAN 04/04/2001 660.00 4 83C 001007966A 10/15/2000 SMITHEY, COLTON C 04/04/2001 605.00 4 83C 001007982A 10/15/2000 HORNE, ANTHONY 04/04/2001 545.00 4 83C 001007995A 10/16/2000 STERN, MADELINE G 04/04/2001 660.00 4 83C 001007999A 10/16/2000 KIRKER, KELLY 04/04/2001 580.00 4 83C 001008006A 10/16/2000 MARR, JESSICA 04/04/2001 675.00 4 83C 001008007A 10/16/2000 BIGLER, AARON 04/04/2001 710.00 4 83C 001008009A 10/16/2000 NIRA-JONES, NANCY L 04/04/2001 290.00 4 83C 001008033A 10/17/2000 BOSELEY, RICHARD 04/04/2001 80.00 4 83C 001008058A 10/18/2000 AGUILAR, VICTOR 04/04/2001 650.00 4 83C 001008063A 10/18/2000 OSBORNE, DANTE 04/04/2001 80.00 4 83C 001008067A 10/19/2000 SORENSEN, LANNY 04/04/2001 840.00 4 83C 001008074A 10/19/2000 TALAVERA, ANA 04/04/2001 770.00 4 83C 001008086A 10/19/2000 BRAMBLETT, BRUCE W 04/04/2001 290.00 4 83C 001008091A 10/19/2000 DEMAY, ADAM 04/04/2001 290.00 4 83C 001008094A 10/19/2000 CORTES, ANA 04/04/2001 545.00 4 83C 001008095B 10/19/2000 COLUNGA, ANTHONY 04/04/2001 785.00 4 83C 001008102A 10/20/2000 VILLARREAL, ARNOLDO 04/04/2001 80.00 4 83C 001008108A 10/20/2000 RAEHAL, CRYSTAL Date:04/05/2001 Weld County Ambulance Page: 4 Time:11:19:29 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 04/04/2001 Thru 04/04/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 04/04/2001 650.00 4 83C 001008116A 10/20/2000 BUCHANAN, CINDY 04/04/2001 80.00 4 83C 001008118A 10/20/2000 STATON, KIM 04/04/2001 95.00 4 83C 001008119A 10/20/2000 SAUCEDO, JULIAN 04/04/2001 80.00 4 83C 001008143A 10/21/2000 GULLON, ANDRES 04/04/2001 750.00 4 83C 001008147A 10/21/2000 GARCIA RICO, JUAN 04/04/2001 290.00 4 83C 001008148A 10/21/2000 BJORDAHL, GREGORY 04/04/2001 840.00 4 83C 001008155A 10/21/2000 TORRES, PAULINA 04/04/2001 795.00 4 83C 001008155B 10/21/2000 PEREZ, EDUARDO 04/04/2001 80.00 4 83C 001008158A 10/22/2000 BASS, LOWELL BRENT 04/04/2001 1075.00 4 83C 001008159A 10/22/2000 SENA, DALE A 04/04/2001 755.00 4 83C 001008160A 10/22/2000 BERTRAM, ELI 04/04/2001 290.00 4 83C 001008174A 10/22/2000 VOLD, BRIAN 04/04/2001 720.00 4 83C 001008189A 10/23/2000 WORLEY, RON 04/04/2001 740.00 4 83C 001008194A 10/23/2000 TOLSON, AMANDA 04/04/2001 600.00 4 83C 001008196A 10/23/2000 BLACK, CANDICE Y 04/04/2001 545.00 4 83C 001008220A 10/24/2000 RODRIGUEZ, JESSIE 04/04/2001 545.00 4 83C 001008241A 10/25/2000 VELA, MICHAEL 04/04/2001 815.00 4 83C 001008243A 10/25/2000 TUNSTEAD, SCOTT 04/04/2001 290.00 4 83C 001008245A 10/25/2000 BLOOM, DANIEL 04/04/2001 710.00 4 83C 001008249A 10/25/2000 LLERENAS, GUSTAVO 04/04/2001 50.00 4 83C 001008277A 10/27/2000 DELGADILLO, SUSAN 04/04/2001 695.00 4 83C 001008286A 10/27/2000 OLIVER, LORRI 04/04/2001 590.00 4 83C 001008287A 10/27/2000 FRITZKE, RICHARD 04/04/2001 705.00 4 83C 001008295A 10/27/2000 REICH, JASON 04/04/2001 1225.00 4 83C 001008296A 10/27/2000 MORALES, DANIELA A 04/04/2001 695.00 4 83C 001008299A 10/28/2000 OLIVER, LORRI 04/04/2001 545.00 4 83C 001008315A 10/28/2000 SEGURA, BERTHA 04/04/2001 545.00 4 83C 001008317A 10/28/2000 VIERYA, LORRAINE 04/04/2001 600.00 4 83C 001008324A 10/28/2000 SMARTT, EMILY 04/04/2001 710.00 4 83C 001008332A 10/28/2000 CAMPOS LUNA, SAMUEL 04/04/2001 790.00 4 83C 001008333A 10/28/2000 ATENCIO, LOUIS 04/04/2001 670.00 4 83C 001008339A 10/29/2000 KELLOGG, IRENE 04/04/2001 625.00 4 83C 001008341A 10/29/2000 BARELA, YSIDRO 04/04/2001 290.00 4 83C 001008349A 10/29/2000 REICH, JASON 04/04/2001 80.00 4 83C 001008371A 10/30/2000 VANDERWARF, CLEOPATR 04/04/2001 290.00 4 83C 001008404A 10/31/2000 SWANSON, RENEE 04/04/2001 650.00 4 83C 001008408A 10/31/2000 SANDOVAL, EUSEBIO 04/04/2001 290.00 4 83C 001008412A 10/31/2000 NIRA, CHRISTINA G 04/04/2001 80 .00 4 83C 001108514A 11/04/2000 PADILLA, MAX 04/04/2001 100.00 4 82 010200901A 02/01/2001 TREVINO, GERONIMO 04/04/2001 12 .00 4 REV 010201249A 02/13/2001 TOLLEFSON, MICHAEL N 04/04/2001 769.00 4 83C 010302073A 03/16/2001 CHALI, ERIC 04/04/2001 240.00 4 83C 990100323A 01/13/1999 MCDONALD, JEANNE I 04/04/2001 25.00 4 83C 990906798A 09/12/1999 BERTELSEN, BRIDGET 04/04/2001 355.00 4 83C 991007294A 10/03/1999 DIETERLE, MARVIN 04/04/2001 530.00 4 83C 991007998A 10/30/1999 RODRIGUEZ, REYNALDO Date:04/05/2001 Weld County Ambulance Page: 5 Time:11:19:29 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 04/04/2001 Thru 04/04/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Total of 193 WriteOff Entries Totaling 90088.25 Dollars Average WriteOff: 466.78 Dollars Average Time:201 Days Date:04/05/2001 Weld County Ambulance Page: 6 Time:11:19:29 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 04/04/2001 Thru 04/04/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 190 89951.25 473.43 202.96 82 MEDICAID WRITEOFF 2 125.00 62.50 136.50 REV REVERSE CHARGED IN ERROR 1 12.00 12 .00 50.00 Date:05/18/2001 Weld County Ambulance Page: 1 Time:10 :32:38 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 05/17/2001 Thru 05/17/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 05/17/2001 510 .00 4 83C 000100326A 01/14/2000 HOWELL, TIMOTHY URIA 05/17/2001 255 .72 4 83C 000604104A 06/05/2000 CLAY, RANDY 05/17/2001 595.00 4 83C 000704976A 07/04/2000 TAYON, MARY 05/17/2001 740.00 4 83C 000705735A 07/29/2000 BURKE, CHRIS 05/17/2001 860.00 4 83C 000705744A 07/30/2000 DUNN, JEFFREY 05/17/2001 650 .00 4 83C 000805848A 08/02/2000 HAMILTON, SAVANAH 05/17/2001 870 .00 4 83C 000806009A 08/08/2000 EASLEY, RONALD E 05/17/2001 290.00 4 83C 000906931A 09/08/2000 HAMILTON, SAVANAH 05/17/2001 725 .00 4 83C 000907128A 09/15/2000 LINDSEY, JANE A 05/17/2001 275.43 4 83C 000907402A 09/25/2000 ARCHULETA, SONIA 05/17/2001 650.00 4 83C 001007846A 10/11/2000 BENAVIDES, REBECCA 05/17/2001 385.00 4 83C 001007972A 10/15/2000 BIEBER, CHRIS W 05/17/2001 89.76 4 83C 001008271A 10/26/2000 DEINES, EDWIN 05/17/2001 80.00 4 83C 001008300A 10/28/2000 BUHRMANN, YVONNE 05/17/2001 545.00 4 83C 001008328A 10/28/2000 BENNETT, ALVIN L 05/17/2001 705.00 4 83C 001008367A 10/30/2000 BENNETT, ALVIN L 05/17/2001 80.00 4 83C 001008403A 10/31/2000 ARAGON, ALEXANDRIA 05/17/2001 80.00 4 83C 001108417A 11/01/2000 DOMINGUEZ, HORTENCIA 05/17/2001 590.00 4 83C 001108427A 11/01/2000 BENNETT, ALVIN L 05/17/2001 705.00 4 63C 001108441A 11/01/2000 BLAIR, ROBERT 05/17/2001 545.00 4 83C 001108445A 11/02/2000 GONZALES, ROCIO 05/17/2001 555.00 4 83C 001108449A 11/02/2000 BENNETT, ALVIN L 05/17/2001 290.00 4 83C 001108453A 11/02/2000 BENNETT, ALVIN L 05/17/2001 1116.14 4 83C 001108515A 11/04/2000 HEALD, JIMMY R 05/17/2001 710.00 4 83C 001108538A 11/05/2000 GARZA, RODRIGO 05/17/2001 680 .00 4 83C 001108544A 11/06/2000 BUSTILLOS, ENRIQUE 05/17/2001 695.00 4 83C 001108575A 11/06/2000 BARRIENTEZ, MICHELLE 05/17/2001 725 .00 4 83C 001108607A 11/07/2000 ARMSTRONG, JASPER 05/17/2001 545.00 4 83C 001108635A 11/09/2000 RANGEL, CHRISTA A 05/17/2001 545 .00 4 83C 001108710A 11/11/2000 HUSS, JOE 05/17/2001 655.00 4 83C 001108787B 11/13/2000 CASTORENA, DIANE 05/17/2001 290 .00 4 83C 001108810A 11/14/2000 BROWN, ZOE 05/17/2001 1050.00 4 83C 001108821A 11/15/2000 BARKER, RALPH C 05/17/2001 650 .00 4 83C 001108887A 11/17/2000 MILES, JULIE 05/17/2001 760.00 4 83C 001108919A 11/18/2000 GALINDO, ELOISA 05/17/2001 50 .00 4 83C 001108933A 11/19/2000 DYMOND, DEBBIE G 05/17/2001 590 .00 4 83C 001108949A 11/20/2000 BENNETT, ALVIN L 05/17/2001 650.00 4 83C 001108976A 11/21/2000 BARHAM, TROY J 05/17/2001 740.00 4 83C 001108978A 11/21/2000 BENAVIDES, REBECCA 05/17/2001 25.00 4 83C 001108997A 11/22/2000 DULIN, RICHARD P 05/17/2001 80.00 4 83C 001109011A 11/23/2000 BOONE, MARTY 05/17/2001 695.00 4 83C 001109016A 11/23/2000 BENNETT, ALVIN L 05/17/2001 545.00 4 83C 001109036A 11/24/2000 ESPINOSA, ADAM 05/17/2001 290 .00 4 83C 001109039A 11/24/2000 ESPINOSA, ADAM 05/17/2001 605.00 4 83C 001109044A 11/25/2000 ACKERSON, DAVID J 05/17/2001 940.00 4 83C 001109070A 11/26/2000 ESCOBEDO, PABLO 05/17/2001 681.14 4 83C 001109082A 11/26/2000 REED, CHARLES 05/17/2001 590.00 4 83C 001109141A 11/29/2000 ANDERSON, DOROTHY 05/17/2001 730.00 4 83C 001109153A 11/29/2000 CANO, HILLARIE Date:05/18/2001 Weld County Ambulance Page: 2 Time:10 :32 :39 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 05/17/2001 Thru 05/17/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 05/17/2001 635 .00 4 83C 001109175A 11/30/2000 CLARK, JEREMY F 05/17/2001 870.00 4 83C 001109641A 11/09/2000 DELGADO, VANESSA J 05/17/2001 80 .00 4 83C 001209240A 12/02/2000 GARCIA, OBDULIA 05/17/2001 650.00 4 83C 001209241A 12/03/2000 DIAZ, FRANK 05/17/2001 1065.00 4 83C 001209249B 12/03/2000 BURRIS, JASON 05/17/2001 650.00 4 83C 001209250A 12/03/2000 FOXWORTHY, ANGELA 05/17/2001 635.00 4 83C 001209290A 12/04/2000 CASAS, BRUNO G 05/17/2001 715.00 4 83C 001209318A 12/05/2000 BEASLEY, JESSE 05/17/2001 80.00 4 83C 001209396A 12/07/2000 KEE, KERI ANN 05/17/2001 695.00 4 83C 001209417A 12/08/2000 BELL, JOHN 05/17/2001 80.00 4 83C 001209441A 12/09/2000 CAMARENA, MARIA 05/17/2001 715.00 4 83C 001209453A 12/09/2000 GRIEGO, ERNEST J 05/17/2001 650.00 4 83C 001209481A 12/10/2000 HERNANDEZ, SAMUEL 05/17/2001 915.00 4 83C 001209496A 12/11/2000 ADCOCK, KIMBERLY 05/17/2001 775.00 4 83C 001209513A 12/11/2000 BALDERAS, BRITNEY N 05/17/2001 605.00 4 83C 001209583A 12/14/2000 ANDERSON, SHARI 05/17/2001 650 .00 4 83C 001209585A 12/14/2000 DELEON, ELVIRA 05/17/2001 605 .00 4 83C 001209597A 12/14/2000 BOYCE, LILLIE 05/17/2001 590 .00 4 83C 001209684A 12/17/2000 FARR, CHAD 05/17/2001 695 .00 4 83C 001209685A 12/18/2000 CHISHOLM, JOSEPH S 05/17/2001 855 .00 4 83C 001209737A 12/19/2000 CAREY, DON 05/17/2001 670 .00 4 83C 001209763A 12/20/2000 ALEJANDRO, J J 05/17/2001 780 .00 4 83C 001209768A 12/20/2000 KINISTON, BRIAN 05/17/2001 500 .00 4 83C 001209802A 12/22/2000 FULTON, DEBRA 05/17/2001 650 .00 4 83C 001209812A 12/22/2000 GAMEZ, FERNANDO 05/17/2001 605 .00 4 83C 001209861A 12/25/2000 BIRLEW, SHARON KAY 05/17/2001 855.00 4 83C 001209873A 12/25/2000 HENDERSON, RODNEY VA 05/17/2001 80.00 4 83C 001209923A 12/27/2000 GONZALEZ, DEANGELO 05/17/2001 650.00 4 83C 001209928A 12/27/2000 ANDRES, JUAN 05/17/2001 765.00 4 83C 001209930B 12/28/2000 BYASSEE, MICHAEL 05/17/2001 665.00 4 83C 001209945A 12/28/2000 GARCIA, CARMEN 05/17/2001 565.00 4 83C 001209964A 12/29/2000 BULLOCK, CYNTHIA J 05/17/2001 705.00 4 83C 001210005A 12/31/2000 GUDEHUS, GLENDA C 05/17/2001 690.00 4 83C 001210007A 12/31/2000 BRUNTZ, RYAN 05/17/2001 913 .00 4 83C 010100582A 01/22/2001 HINOJOSA, ESPERANZA 05/17/2001 100.00 4 83C 010100882A 01/31/2001 DUNN, KERRY 05/17/2001 654.00 4 83C 010200889A 02/01/2001 HENRY, CHRISTIAN 05/17/2001 769.00 4 83C 010200913A 02/01/2001 HENRY, CHRISTIAN 05/17/2001 399.00 4 83C 010201102A 02/08/2001 GARCIA, NOE 05/17/2001 1165.00 4 83C 010201378A 02/18/2001 FERGUSON, BRANTON L 05/17/2001 100.00 4 83C 010201419A 02/19/2001 GLANZ, PAUL 05/17/2001 100.00 4 83C 010301737A 03/04/2001 FARROW, DAVID 05/17/2001 769.00 4 83C 010302157A 03/19/2001 HENRY, CHRISTIAN 05/17/2001 399.00 4 83C - 010302160A 03/19/2001 HENRY, CHRISTIAN 05/17/2001 100 .00 4 83C 010302300A 03/24/2001 CHAFIN, TALITHA 05/17/2001 817.00 4 83C 010302352A 03/26/2001 DARLING, MELISSA Date:05/18/2001 Weld County Ambulance Page: 3 Time:10:32 :41 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 05/17/2001 Thru 05/17/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Total of 95 WriteOff Entries Totaling 54378.19 Dollars Average WriteOff: 572 .40 Dollars Average Time:174 Days Date:05/18/2001 Weld County Ambulance Page: 4 Time:10:32 :41 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 05/17/2001 Thru 05/17/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 95 54378.19 572 .40 174 .28 Date:05/21/2001 Weld County Ambulance Page: 1 Time:10:06:10 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 05/18/2001 Thru 05/18/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 05/18/2001 630 .00 4 83C 000100453A 01/20/2000 FRANCIS, TROY 05/18/2001 450.00 4 83C 000200858A 02/05/2000 SMALL, SHIRLEY ROSE 05/18/2001 139.87 4 82 000200888D 02/05/2000 GALVAN, FEDERICO 05/18/2001 25.00 4 82 000201232A 02/19/2000 FLYNN, BRIAN 05/18/2001 70 .93 4 82 000201267A 02/21/2000 SIMPSON, AUDREY 05/18/2001 396.66 4 81 000301959A 03/19/2000 GRAHAM, BARBARA W 05/18/2001 25.00 4 82 000402860A 04/21/2000 WILLIAMS, FRANK 05/18/2001 25.00 4 83C 000604179A 06/07/2000 PUTNAM, IVOL 05/18/2001 82 .10 4 82 000604510A 06/19/2000 VALERIO, JULIA 05/18/2001 77.00 4 83C 000604785A 06/28/2000 BOYD, BLANCA 05/18/2001 80.00 4 83C 000704869D 07/01/2000 TAMAYO, ANTONIO RAMO 05/18/2001 645.00 4 83C 000705057A 07/07/2000 CRESPIN, ANITA 05/18/2001 139.00 4 83C 000705200A 07/11/2000 SHAVER, VIOLET 05/18/2001 120.00 4 83C 000705504A 07/21/2000 SORENSEN, BRODERICK 05/18/2001 145.00 4 83C 000705794B 07/31/2000 TORREZ-JIMENEZ, EMAN 05/18/2001 755.00 4 83C 000805952A 08/06/2000 BOSTICK, JAMES 05/18/2001 71.16 4 82 000806035A 08/08/2000 GILSTRAP, LENA 05/18/2001 27.62 4 83C 000806144A 08/12/2000 LESLIE, WADE 05/18/2001 25.00 4 82 000806320A 08/18/2000 CASTOR, PATRICIA 05/18/2001 235.50 4 83C 000906849A 09/06/2000 MARTINEZ, SAGE LEIGH 05/18/2001 150 .00 4 83C 000906971A 09/10/2000 TAFT, ALLISON 05/18/2001 650 .00 4 83C 000907025A 09/12/2000 REYES, ROLANDO 05/18/2001 290.00 4 83C 000907083A 09/14/2000 SIMER, CHARITY D 05/18/2001 146.00 4 83C 001007587A 10/01/2000 ZIPPERER, DANIELLE 05/18/2001 425.00 4 83C 001007721A 10/06/2000 WHITE, TRACY 05/18/2001 25.00 4 83C 001008022A 10/17/2000 OSCKEL, CATHERINE J 05/18/2001 229.00 4 83C 001008157A 10/22/2000 STENSETH, TAMMIE M 05/18/2001 80.00 4 83C 001008233A 10/24/2000 TAYLOR, GARY 05/18/2001 650.00 4 83C 001008283A 10/27/2000 WELCH, KENNETH 05/18/2001 284.00 4 83C 001008292A 10/27/2000 BURKEY, TAMMY 05/18/2001 80.00 4 83C 001008308A 10/28/2000 WHITE, TRACY 05/18/2001 50.00 4 83C 001008390A 10/31/2000 STAHLA, LISA 05/18/2001 656.14 4 83C 001008395A 10/31/2000 MARTINEZ, PRECILIANO 05/18/2001 650.00 4 83C 001108418A 11/01/2000 MARTINEZ, CHRIS 05/18/2001 605.00 4 83C 001108440A 11/01/2000 LUGO, JOSE 05/18/2001 590.00 4 83C 001108460A 11/02/2000 MORALES, TANIA 05/18/2001 695.00 4 83C 001108476A 11/02/2000 SANCHEZ, AMANDA E 05/18/2001 585.00 4 83C 001108478A 11/02/2000 DAVIS, HEATHER 05/18/2001 680.00 4 83C 001108499A 11/03/2000 RAMIREZ, MARIA 05/18/2001 655.00 4 83C 001108499B 11/03/2000 OLMOS, NINFA 05/18/2001 29.00 4 83C 001108508A 11/04/2000 SANCHEZ, AMANDA E 05/18/2001 790.00 4 83C 001108516A 11/04/2000 MEFFORD, RAYMOND S 05/18/2001 650.00 4 83C 001108524A 11/05/2000 PEREZ, ARMANDO 05/18/2001 875.00 4 83C 001108532B 11/05/2000 PACKARD, MATO 05/18/2001 605.00 4 83C 001108597A 11/07/2000 MARTINEZ, BRIGIDA 05/18/2001 - 130.00 4 83C 001108643A 11/09/2000 SORENSEN, BRODERICK 05/18/2001 840.00 4 83C 001108647A 11/09/2000 MOYA, JUDY 05/18/2001 705.00 4 83C 001108652A 11/10/2000 PORTER, JOHN 05/18/2001 660.00 4 83C 001108668A 11/10/2000 MASON, MICHAEL Date:05/21/2001 Weld County Ambulance Page: 2 Time:10:06:11 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 05/18/2001 Thru 05/18/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 05/18/2001 227 .00 4 83C 001108684A 11/10/2000 OSBORNE, NICOLAUS 05/18/2001 950 .00 4 83C 001108702A 11/10/2000 WORREL, JACK 05/18/2001 623 .28 4 83C 001108754C 11/12/2000 LEE, QUINNA C 05/18/2001 671.14 4 83C 001108764A 11/12/2000 MANDEZ, ROSE 05/18/2001 665 .00 4 83C 001108767A 11/13/2000 TRIMBLE, SUSAN 05/18/2001 590.00 4 83C 001108773B 11/13/2000 SEPEDA, JAYLON 05/18/2001 610.00 4 83C 001108787A 11/13/2000 VIGIL, EVANGELINA 05/18/2001 825.00 4 83C 001108798A 11/14/2000 OCHOA, JERRY 05/18/2001 720.00 4 83C 001108808A 11/14/2000 CROUSE, JOHN J 05/18/2001 545.00 4 83C 001108809A 11/14/2000 STREIFEL, LEONARD 05/18/2001 825.00 4 83C 001108814A 11/14/2000 NEZ PERCE, DENNIS 05/18/2001 545.00 4 83C 001108817B 11/14/2000 PARKER, MICHELLE L 05/18/2001 650 .00 4 83C 001108827A 11/15/2000 MAURICIO, MARIA 05/18/2001 735.00 4 83C 001108853A 11/16/2000 NICHOLS, JOLEEN J 05/18/2001 535.00 4 83C 001108874A 11/17/2000 MENDOZA-NEVAREZ, FEL 05/18/2001 280 .00 4 83C 001108880A 11/17/2000 MENDOZA-NEVAREZ, FEL 05/18/2001 80.00 4 83C 001108905A 11/18/2000 SIXTOS, LUZERO 05/18/2001 80 .00 4 83C 001108905C 11/18/2000 MORALES, CARLOS 05/18/2001 545.00 4 83C 001108912A 11/18/2000 DECAMP, TROY 05/18/2001 290.00 4 83C 001108931A 11/19/2000 CROUSE, JOHN J 05/18/2001 650.00 4 83C 001108938A 11/19/2000 RICE, TODD 05/18/2001 705.00 4 83C 001108985A 11/22/2000 LOYA, RAMON 05/18/2001 665.00 4 83C 001109004A 11/22/2000 GUTHRIE, TRACI 05/18/2001 515.00 4 83C 001109015A 11/23/2000 GIEDRAS, SANDRA 05/18/2001 342.00 4 83C 001109018A 11/23/2000 RAMIREZ, MARICELA 05/18/2001 290.00 4 83C 001109029A 11/24/2000 MAURER, RICH 05/18/2001 885.00 4 83C 001109063A 11/25/2000 ROJAS-PEREZ, JUAN 05/18/2001 565.00 4 83C 001109072A 11/26/2000 PEREA, SERGIO 05/18/2001 80 .00 4 83C 001109076A 11/26/2000 MORENO, BOBBY 05/18/2001 695.00 4 83C 001109118A 11/28/2000 REYES, DALE 05/18/2001 290 .00 4 83C 001109129A 11/28/2000 CRANMER, RICK 05/18/2001 600.00 4 83C 001109147A 11/29/2000 MCCLAIN, ANGEL 05/18/2001 605.00 4 83C 001109154A 11/30/2000 BRACKEN, ERICKA 05/18/2001 290.00 4 83C 001109156A 11/30/2000 BRACKEN, ERICKA 05/18/2001 258.00 4 83C 001109157A 11/30/2000 MCGEE, LINDSEY 05/18/2001 650.00 4 83C 001109158A 11/30/2000 COZAD, BRENDA 05/18/2001 695.00 4 83C 001209228A 12/02/2000 MONTOYA, ELOY 05/18/2001 545.00 4 83C 001209244A 12/03/2000 LOZANO, ROBBIE 05/18/2001 455.00 4 83C 001209249A 12/03/2000 MCTAGGART, TIM 05/18/2001 440.00 4 83C 0012092538 12/03/2000 HEGWOOD, JERRY 05/18/2001 80.00 4 83C 001209260A 12/03/2000 BOSTICK, JAMES 05/18/2001 80.00 4 83C 001209301C 12/05/2000 MORENO, ADRIENNA 05/18/2001 139.00 4 83C 001209313A 12/05/2000 LANGE, CRYSTAL L 05/18/2001 650.00 4 83C 001209346A 12/06/2000 ELDER, BOBBY 05/18/2001 40.00 4 83C 001209353A 12/06/2000 ELDER, BOBBY 05/18/2001 150.00 4 83C 001209362A 12/06/2000 MARTINEZ, CARLOS 05/18/2001 40 .00 4 B3C 001209367A 12/06/2000 MARTINEZ, CARLOS 05/18/2001 290.00 4 83C - 001209512A 12/11/2000 MOSER, GALE 05/18/2001 650.00 4 83C 001209514A 12/11/2000 SANCHEZ, AMADOR • Date:05/21/2001 Weld County Ambulance Page: 3 Time:10:06:11 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 05/18/2001 Thru 05/18/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 05/18/2001 80.00 4 83C 001209524A 12/11/2000 MOORE, CLIFFORD 05/18/2001 87.00 4 83C 001209527A 12/11/2000 OSBORNE, NICOLAUS 05/18/2001 80 .00 4 83C 001209546A 12/12/2000 O'ROURKE, STACEY 05/18/2001 80.00 4 83C 001209564A 12/13/2000 MASON, MICHAEL 05/18/2001 25.00 4 83C 001209579A 12/13/2000 LEITER, TERRY W 05/18/2001 - 25.00 4 83C 001209601A 12/14/2000 LEITER, TERRY W 05/18/2001 935.00 4 83C 001209647A 12/16/2000 TORRES, SILVERIO 05/18/2001 290.28 4 81 001209651A 12/16/2000 STAPP, MARJORIE L 05/18/2001 353 .93 4 81 001209661A 12/17/2000 STAPP, MARJORIE L 05/18/2001 290.00 4 83C 001209764A 12/20/2000 MEYER, JEFFERY 05/18/2001 605.00 4 83C 001209766A 12/20/2000 MCLANE, ADA 05/18/2001 - 79.57 4 83C 001209837A 12/24/2000 PREWITT, WILLIAM 05/18/2001 290.00 4 83C 001209898A 12/26/2000 QUEZADA, ANA 05/18/2001 750.00 4 83C 001209903A 12/26/2000 MARTINDALE, DIANNA 05/18/2001 825.00 4 83C 001209925A 12/27/2000 LORRY, JOHN A 05/18/2001 795.00 4 83C 001209943A 12/28/2000 RYAN, MICHAEL 05/18/2001 710.00 4 83C 001209951A 12/29/2000 MARTINEZ, ANTONIO 05/18/2001 80.00 4 83C 001209974A 12/29/2000 PURVIS, DAVID 05/18/2001 25.00 4 83C 001209975A 12/29/2000 MOODY, MICHAEL L 05/18/2001 930.00 4 83C 001209996A 12/30/2000 MENDOZA, MARYBEL M 05/18/2001 590.00 4 83C 001210003A 12/30/2000 MARTINEZ, ANTONIO 05/18/2001 650.00 4 83C 001210033A 12/31/2000 MARTINEZ, ANTONIO 05/18/2001 726.00 4 83C 010100005A 01/01/2001 MARINELERENA, OLGA 05/18/2001 654.00 4 83C 010100035A 01/01/2001 MARTINEZ, ANTONIO 05/18/2001 1074.00 4 83C 010100294A 01/12/2001 MCLANE, MICHAEL 05/18/2001 1237.00 4 83C 010100457A 01/16/2001 MURRAY, TIMOTHY 05/18/2001 100.00 4 83C 010100778B 01/28/2001 ONTIVEROS, FILIBERTO 05/18/2001 100.00 4 83C 010100778D 01/28/2001 MALDONADO, ERNESTO 05/18/2001 100.00 4 83C 010100778E 01/28/2001 LOPEZ, ROBERTO 05/18/2001 687.00 4 83C 010201035A 02/05/2001 LOPEZ, MELISSA 05/18/2001 43.92 4 81 010201341A 02/16/2001 HOUSEWERT, BETTY 05/18/2001 654.00 4 83C 010201384A 02/18/2001 LORENZ, JAMES 05/18/2001 399.00 4 83C 010201390A 02/18/2001 LORENZ, JAMES 05/18/2001 819.00 4 83C 010301689A 03/02/2001 NAVARRO, ANDRES 05/18/2001 399.00 4 83C 010301706A 03/02/2001 MASON, STEVEN 05/18/2001 666.00 4 83C 010301778A 03/05/2001 LORENZ, JAMES 05/18/2001 493 .48 4 81 010302112A 03/17/2001 BECKER, IRENE 05/18/2001 831.00 4 83C 010302183B 03/20/2001 ORTIZ, DAVID 05/18/2001 705.65 4 82 010402721A 04/08/2001 VISCAINO SANCHEZ, IR 05/18/2001 620.95 4 81 010402731A 04/08/2001 HERNANDEZ, NELLIE 05/18/2001 445.39 4 81 010402986A 04/17/2001 PORTER, LOUELLA 05/18/2001 699.10 4 82 010402997A 04/17/2001 COLE, SONIA MARIE 05/18/2001 247.27 4 82 010403014A 04/17/2001 VALDEZ, KAYLENE 05/18/20O1 410.26 4 81 010403024A 04/18/2001 FOELSKE, DONNA J 05/18/2001 769.31 4 82 010403032A 04/18/2001 RIOS, IVAN J 05/18/2001 45.25 4 83C 990201140A 02/11/1999 MURPHY, JOE 05/18/2001 135.00 4 83C 990906488A 09/01/1999 SALINAS, BERNADETTE 05/18/2001 545.00 4 83C 991208930A 12/03/1999 SALAZAR, JILLIAN Date:05/21/2001 Weld County Ambulance Page: 4 Time:10 :06:12 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 05/18/2001 Thru 05/18/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Total of 146 WriteOff Entries Totaling 63136.76 Dollars Average WriteOff: 432 .44 Dollars Average Time:196 Days I Date:05/21/2001 Weld County Ambulance Page: 5 Time:10:06:12 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 05/18/2001 Thru 05/18/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 127 57221.50 450.56 195.62 82 MEDICAID WRITEOFF 11 2860.39 260.04 253.36 81 MEDICARE WRITEOFF 8 3054.87 381.86 123.00 Date:05/22/2001 Weld County Ambulance Page: 2 Time:08:53 :38 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 05/21/2001 Thru 05/21/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 05/21/2001 650.00 4 83C 001209436A 12/09/2000 VARGAS, MOSES 05/21/2001 630.00 4 83C 001209443A 12/09/2000 ROMAN, JOSE 05/21/2001 705.00 4 83C 001209455A 12/09/2000 STICHTER, TERRY J 05/21/2001 331.40 4 83C 001209456A 12/09/2000 URBACH, JEFFREY L 05/21/2001 605.00 4 83C 001209457A 12/09/2000 RANGEL, EDUARDO LOPE 05/21/2001 545.00 4 83C 001209463A 12/10/2000 RODRIGUEZ, ALFREDO 05/21/2001 81.00 4 83C 001209467A 12/10/2000 BARTHOLOMEW, JOAN L 05/21/2001 565.00 4 83C 001209566A 12/13/2000 HERNANDEZ, SERGIO 05/21/2001 585.00 4 83C 001209572A 12/13/2000 STOCKOVER, ROBERT 05/21/2001 290.00 4 83C 001209577A 12/13/2000 SNELL, WILLARD 05/21/2001 780.00 4 83C 001209638A 12/16/2000 SIDEBOTTOM, K C 05/21/2001 705.00 4 83C 001209676A 12/17/2000 VALDEZ, MARYCELA 05/21/2001 705.00 4 83C 001209679A 12/17/2000 MORGAN, MICHAEL J 05/21/2001 545.00 4 83C 001209692B 12/18/2000 SIFUENTES, NANCY 05/21/2001 650.00 4 83C 001209693A 12/18/2000 BARRIENTOS, LETICIA 05/21/2001 590.00 4 83C 001209702A 12/18/2000 SUAREZ-ANAYA, BEATRI 05/21/2001 290.00 4 83C 001209703A 12/18/2000 BARRIENTOS, LETICIA 05/21/2001 290.00 4 83C 001209724A 12/19/2000 VALDEZ, MARYCELA 05/21/2001 665.00 4 83C 001209863A 12/25/2000 RODGERS, BRENDA M 05/21/2001 67.05 4 83C 001209881A 12/25/2000 CASEDY, MICHAEL A 05/21/2001 710.00 4 83C 001209910A 12/26/2000 VIGIL, JESUS J 05/21/2001 290.00 4 83C 001209926A 12/27/2000 SAVAGE-WHITE, TAMARA 05/21/2001 590.00 4 83C 001209972A 12/29/2000 BYASSEE, MICHAEL 05/21/2001 610.00 4 83C 001210024A 12/31/2000 TAYLOR, JAMES ANDREW 05/21/2001 590.00 4 83C 001210039A 12/31/2000 ORNELAS, JACK 05/21/2001 769.00 4 83C 010100004A 01/01/2001 WILLIAMS, JODY 05/21/2001 95.90 4 82 010200982A 02/04/2001 BROYLES, HAROLD L 05/21/2001 79.48 4 82 010201144A 02/09/2001 BROYLES, HAROLD L 05/21/2001 43 .92 4 81 010402542A 04/02/2001 FOOS, HAROLD 05/21/2001 704.00 4 83C 010402548A 04/02/2001 GASPAR, FRANCISCO Total of 79 WriteOff Entries Totaling 31323.18 Dollars Average WriteOff: 396.50 Dollars Average Time:185 Days Date:05/22/2001 Weld County Ambulance Page: 3 Time:08:53:39 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 05/21/2001 Thru 05/21/2001. Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 62 30262 .90 488.11 184.73 82 MEDICAID WRITEOFF 16 1016.36 63 .52 197.00 81 MEDICARE WRITEOFF 1 43 .92 43 .92 49.00 • Date:08/08/2001 Weld County Ambulance Page: 1 Time:11:10:23 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 08/07/2001 Thru 08/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 08/07/2001 75.20 4 83C 000201458A 02/29/2000 MEEKER, DENISE 08/07/2001 0.65 4 83 000301772A 03/12/2000 RIOS, MARGARITA 08/07/2001 785.00 4 83C 000402712A 04/15/2000 HERNANDEZ, CAROLINA 08/07/2001 16.50 4 83C 000503386A 05/10/2000 SERNA, MARK 08/07/2001 19.00 4 83C 000503392A 05/10/2000 SERNA, MARK 08/07/2001 1181.14 4 83C 000604392A 06/15/2000 YOCAM, DAVID 08/07/2001 725.00 4 83C 000604681A 06/24/2000 SOTO, MINDY 08/07/2001 25.00 4 83C 000604795A 06/29/2000 MAURY, JENNIFER 08/07/2001 425.00 4 83C 000806394A 08/21/2000 SOWDERS, BETH 08/07/2001 695.00 4 83C 000806491A 08/25/2000 MEDINA, RUDOLPH C 08/07/2001 25.00 4 83C 000806672A 08/31/2000 JANIEC, IAN 08/07/2001 25.00 4 83 000907050A 09/12/2000 ACHZIGER, NELDA 08/07/2001 817.50 4 83C 000907114A 09/14/2000 MASTERS, NANCY 08/07/2001 252 .50 4 83C 000907117A 09/15/2000 MASTERS, NANCY 08/07/2001 25.00 4 83 000907288A 09/21/2000 ACHZIGER, NELDA 08/07/2001 590 .00 4 83C 000907519A 09/29/2000 OLIVAS, ZACH 08/07/2001 615.00 4 83C 001007712A 10/06/2000 JONES, WOODY E 08/07/2001 65.00 4 83C 001007738B 10/07/2000 TILTON, JUSTIN 08/07/2001 796.14 4 83C 001007867A 10/11/2000 HERNANDEZ, CAROLINA 08/07/2001 153.00 4 83C 001008152A 10/21/2000 TORRES-GUERRA, ARTUR 08/07/2001 870.00 4 83C 001008169A 10/22/2000 ALLEE, ROBERT C 08/07/2001 545.00 4 83C 001008247A 10/25/2000 WELLS, BRANDI N 08/07/2001 690.00 4 83C 001008345A 10/29/2000 MENDEZ, JOSE 08/07/2001 590.00 4 83C 001008393A 10/31/2000 RUTZ, CHARLES 08/07/2001 215.00 4 83C 001108473A 11/02/2000 HAMILTON, KIRBY G 08/07/2001 25.00 4 83C 001108518A 11/04/2000 MCQUALITY, KATHY 08/07/2001 815.00 4 83C 001108532A 11/05/2000 EMERY, WILLIAM 08/07/2001 25.00 4 83C 001108587A 11/07/2000 MORENO, DALE 08/07/2001 695.00 4 83C 001108625A 11/09/2000 CASH, CARL M 08/07/2001 . 339.52 4 83C 001108639A 11/09/2000 TAYLOR, PAM 08/07/2001 230.00 4 83C 001108670A 11/10/2000 JOHNSON, TRACY 08/07/2001 650.00 4 83C 001108720A 11/11/2000 SOLIS, MARTIN J 08/07/2001 590.00 4 83C 001108736A 11/11/2000 CASH, CARL M 08/07/2001 585.00 4 83C 001108819A 11/14/2000 COON, RAMONA 08/07/2001 660.00 4 83C 001108834A 11/15/2000 SMITH, BETH 08/07/2001 85.00 4 83C 001108981A 11/22/2000 FOSTER, MIKE 08/07/2001 590.00 4 83C 001109067A 11/25/2000 CROSBY, KATRINA L 08/07/2001 150.00 4 83C 001109067C 11/25/2000 CARILLO, ALEXANDER 08/07/2001 150.00 4 83C 001109067D 11/25/2000 CARILLO, ADRIANA 08/07/2001 540.00 4 83C 001109068A 11/26/2000 WILKIE, TODD 08/07/2001 25.00 4 83C 001109100A 11/27/2000 SALAZAR, NICHOLAS G 08/07/2001 650.00 4 83C 001109104A 11/27/2000 MARTINEZ, ELIZABETH 08/07/2001 25.00 4 83C 001109106A 11/27/2000 SALAZAR, NICHOLAS G 08/07/2001 130.00 4 83C 001109155A 11/30/2000 CORRAL, JOSE P 08/07/2001 401.52 4 83C 001209245A 12/03/2000 HILLESLAND, AGNES L 08/07/2001 1055.00 4 83C 001209271A 12/03/2000 SEARS, DAVID 08/07/2001 705.00 4 83C 001209301A 12/05/2000 MORENO, JESUSA 08/07/2001 645.00 4 83C 001209301B 12/05/2000 MORENO, FRANCISCO 08/07/2001 71.65 4 83C 001209311A 12/05/2000 SINISI, PASQUALE Date:08/08/2001 Weld County Ambulance Page: 2 Time:11:10:23 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 08/07/2001 Thru 08/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 08/07/2001 895.00 4 83C 001209336A 12/05/2000 CORDOVA, SEVERO 08/07/2001 676.14 4 83C 001209356A 12/06/2000 HERNANDEZ, CAROLINA 08/07/2001 545.00 4 83C 001209556A 12/13/2000 O'SHEE, NANCY 08/07/2001 645.00 4 83C 001209835A 12/23/2000 REEVES, MILEY J 08/07/2001 671.14 4 83C 001209937A 12/28/2000 SHOCKLEY, JOHN G 08/07/2001 720.00 4 83C 001209989A 12/30/2000 FINLAYSON, ALEXIS MA 08/07/2001 25.00 4 83C 001210027A 12/31/2000 WATSON, BOB 08/07/2001 24.00 4 83C 001210037A 12/31/2000 WATSON, BOB 08/07/2001 100.00 4 83C 010010064A 01/02/2001 TOVAR, OLIVIA 08/07/2001 956.00 4 83C 010100016A 01/01/2001 RODRIGUEZ, SALLY 08/07/2001 741.00 4 83C 010100016B 01/01/2001 RODRIGUEZ, IRENE 08/07/2001 839.00 4 83C 010100039A 01/02/2001 MCCURDY, WILLIAM H 08/07/2001 1107.00 4 83C 010100050A 01/02/2001 YOUNG, VICTORIA 08/07/2001 173.80 4 83C 010100058A 01/02/2001 WALKER, JOSEPH 08/07/2001 824.00 4 83C 010100110A 01/05/2001 ACOSTA, CINDY 08/07/2001 654.00 4 83C 010100131A 01/05/2001 CARD, HARRY N 08/07/2001 81.90 4 83C 010100132A 01/05/2001 TARIN, ROSA 08/07/2001 399.00 4 83C 010100135A 01/05/2001 CARD, HARRY N 08/07/2001 1323.00 4 83C 010100144A 01/06/2001 FETTIG, ROLAND 08/07/2001 654.00 4 83C 010100159A 01/06/2001 WALKER, JULIE S 08/07/2001 170.80 4 83C 010100166A 01/07/2001 VALLEJO, OSCAR E 08/07/2001 399.00 4 83C 010100167A 01/07/2001 WALKER, JULIE S 08/07/2001 719.00 4 83C 010100179A 01/07/2001 HILL, JOHN C 08/07/2001 399.00 4 83C 010100181A 01/07/2001 NARANJO, JENNIFER 08/07/2001 654.00 4 83C 010100184A 01/07/2001 THOMAS, BRYAN 08/07/2001 100.00 4 83C 010100193A 01/08/2001 TRUMBLEE, KEN 08/07/2001 819.00 4 83C 010100203A 01/08/2001 CRAIN, VIRGINIA I 08/07/2001 399.00 4 83C 010100207A 01/08/2001 RAMIREZ, DAVID 08/07/2001 704.00 4 83C 010100209A 01/08/2001 DUARTE, JACOB LORIN 08/07/2001 100.00 4 83C 010100216A 01/08/2001 GALLEGOS, BRANDON 08/07/2001 100.00 4 83C 0101002168 01/08/2001 RODRIGUEZ, JOHN 08/07/2001 704.00 4 83C 010100224A 01/09/2001 ERICKSON, RENA B 08/07/2001 100.00 4 83C 010100228A 01/09/2001 PAGAN, GEORGE 08/07/2001 841.00 4 83C 010100229A 01/09/2001 MARKLEY, JESSICA 08/07/2001 719.00 4 83C 010100232A 01/09/2001 DAHLMAN, ERIC 08/07/2001 100.00 4 83C 010100235A 01/09/2001 STAMPER, TRACY 08/07/2001 399.00 4 83C 010100236A 01/09/2001 CARRILLO, RUTH 08/07/2001 996.00 4 83C 010100260A 01/11/2001 SILVA-RAMOS, JOSE DA 08/07/2001 654.00 4 83C 010100284A 01/11/2001 BACA, DONOVAN D 08/07/2001 100.00 4 83C 010100288A 01/11/2001 MILLER, ALAN 08/07/2001 100.00 4 83C 010100326A 01/13/2001 LUCERO, EVA 08/07/2001 975.00 4 83C 010100336A 01/13/2001 ROMERO, ROBERTO 08/07/2001 843.00 4 83C 010100371A 01/15/2001 MOSCHETTI, ALETHA L 08/07/2001 399.00 4 83C 010100372A 01/15/2001 MOSCHETTI, ALETHA L 08/07/2001 666.00 4 83C 010100387A 01/15/2001 ILTZASCH, TERRY 08/07/2001 100.00 4 83C 010100398A 01/15/2001 WHITE, TASHA 08/07/2001 678.00 4 83C 010100411A 01/16/2001 STEINMETZ, TRISHA L 08/07/2001 923.00 4 83C 010100415A 01/16/2001 VA7.AnEZ, SANTOS D 08/07/2001 100.00 4 83C 010100437A 01/16/2001 ONTIVEROS, MARIO , Date:08/08/2001 Weld County Ambulance Page: 3 Time:11:10:24 - • Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 08/07/2001 Thru 08/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 08/07/2001 100.00 4 83C 010100437B 01/16/2001 MENDEZ, CESAR 08/07/2001 730.08 4 83C 010100498A 01/18/2001 SHOCKLEY, JOHN G 08/07/2001 654.00 4 83C 010100503A 01/18/2001 CRANMER, RICK 08/07/2001 399.00 4 83C 010100506A 01/18/2001 CRANMER, RICK 08/07/2001 810.00 4 83C 010100509A 01/18/2001 AVILA, SERAFIN 08/07/2001 769.00 4 83C 010100515A 01/19/2001 VASQUEZ, ELENA 08/07/2001 100.00 4 83C 010100523A 01/19/2001 GONZALES, DENISE 08/07/2001 1491.00 4 83C 010100525A 01/19/2001 DUENAS, ESTER 08/07/2001 654.00 4 83C 010100531A 01/20/2001 MAES, JUAN F 08/07/2001 1120.00 4 83C 010100555A 01/20/2001 SANTEE, TAMMY S 08/07/2001 399.00 4 83C 010100605A 01/22/2001 TULLY, MARK L 08/07/2001 654.00 4 83C 010100608A 01/22/2001 SIMMONS, VERA 08/07/2001 719.00 4 83C 010100612A 01/23/2001 HERNANDEZ, EVA M 08/07/2001 399.00 4 83C 010100632A 01/23/2001 MCALPIN, BRYCE 08/07/2001 769.00 4 83C 010100636A 01/23/2001 VARGAS, MOSES 08/07/2001 739.00 4 83C 010100655A 01/24/2001 GALLEGOS, DON 08/07/2001 915.00 4 83C 010100661A 01/24/2001 RATHGEBER, JACK 08/07/2001 666.00 4 83C 010100667A 01/24/2001 MARTINEZ, LEO 08/07/2001 654.00 4 83C 010100692A 01/25/2001 IGNACIO MIRELES 08/07/2001 430.20 4 83C 010100693A 01/25/2001 SILVA, ARMANDO 08/07/2001 819.00 4 83C 010100694A 01/25/2001 GREENWOOD, SEAN C 08/07/2001 810.00 4 83C 010100697A 01/26/2001 BERNAL, CARMEN 08/07/2001 704.00 4 83C 010100701A 01/26/2001 MARTINEZ, ADONIS 08/07/2001 831.00 4 83C 010100702A 01/26/2001 SAPP, JEFFREY 08/07/2001 100.00 4 83C 010100719A 01/26/2001 GARCIA, JUAN 08/07/2001 704.00 4 83C 010100723A 01/27/2001 BENAVIDEZ, GENEVA 08/07/2001 1109.00 4 83C 010100728A 01/27/2001 THOMAS, BRYAN 08/07/2001 100.00 4 83C 010100778A 01/28/2001 BETANEUR, MIGUEL 08/07/2001 100.00 4 83C 010100778C 01/28/2001 FELIS, PONCIANO 08/07/2001 840.08 4 83C 010100807A 01/28/2001 DHOOGE, BEATRICE E 08/07/2001 839.00 4 83C 010100811A 01/29/2001 VAUGHN, EARL 08/07/2001 853.00 4 83C 010100817A 01/29/2001 DILKA, LANNY 08/07/2001 - 819.00 4 83C 010100825A 01/29/2001 SOTO, LYDIA 08/07/2001 769.00 4 83C 010100839A 01/30/2001 WEIDENKELLER, SANDRA 08/07/2001 865.00 4 83C 010100867A 01/31/2001 DILKA, LANNY 08/07/2001 1105.00 4 83C 010100881A 01/31/2001 JEFFRES, SCOTT 08/07/2001 100.00 4 83C 010102049A 03/15/2001 DICKSON, MELISSA 08/07/2001 654.00 4 83C 010200891A 02/01/2001 GREEN, DEBORAH 08/07/2001 100.00 4 83C 010200905D 02/01/2001 RODENBURG, KRISTINA 08/07/2001 819.00 4 83C 010200914A 02/01/2001 SALAZAR, PAULA 08/07/2001 399.00 4 83C 010200917A 02/02/2001 SALAZAR, PAULA 08/07/2001 399.00 4 83C 010200929A 02/02/2001 HERNANDEZ, EVA M 08/07/2001 715.00 4 83C 010200958A 02/03/2001 WHITE, TRACY 08/07/2001 359.00 4 83C 010200959A 02/03/2001 DILKA, LANNY 08/07/2001 654.00 4 83C 010201021A 02/05/2001 DILKA, LANNY 08/07/2001 399.00 4 83C 010201027A 02/05/2001 DILKA, LANNY 08/07/2001 715.00 4 83C 010201074A 02/07/2001 GATLEGOS, DON 08/07/2001 883.00 4 83C 010201081A 02/07/2001 GAJ,AN, MICHELLE 08/07/2001 624.00 4 83C 010201117A 02/08/2001 DILKA, LANNY Date:08/08/2001 Weld County Ambulance Page: 4 Time:11:10:24 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 08/07/2001 Thru 08/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 08/07/2001 715.00 4 83C 010201131A 02/09/2001 GALLEGOS, DON 08/07/2001 654.00 4 83C 010201142A 02/09/2001 ROMERO, DEBBIE 08/07/2001 754.00 4 83C 010201178A 02/11/2001 VIGIL, ADRIAN 08/07/2001 769.00 4 83C 010201202A 02/11/2001 RIOZ, RICHARD 08/07/2001 839.00 4 83C 010201291A 02/14/2001 TROTCHIE, JACK 08/07/2001 654.00 4 83C 010201364A 02/17/2001 STADLEMAN, LISA 08/07/2001 399.00 4 83C 010201367A 02/17/2001 STADLEMAN, LISA 08/07/2001 100.00 4 83C 010201416A 02/19/2001 BRISENO, STEPHANIE 08/07/2001 471.69 4 81 010201468A 02/21/2001 SIEH, TED 08/07/2001 819.00 4 83C 010201469A 02/21/20-01 SEYMOUR, MARK 08/07/2001 654.00 4 83C 010201575A 02/25/2001 ONEIL, JON 08/07/2001 100.00 4 83C 010201602A 02/26/2001 WILLIAMS, JASON 08/07/2001 524.90 4 83C 010301695A 03/02/2001 BURTON, HAL 08/07/2001 704.00 4 83C 010301720A 03/03/2001 CALL, MARY 08/07/2001 769.00 4 83C 010301728A 03/03/2001 MONTOYA, GILBERT 08/07/2001 1003 .00 4 83C 010301747A 03/04/2001 GARCIA, AMADOR 08/07/2001 719.00 4 83C 010301780A 03/05/2001 JENSON, ROBERT 08/07/2001 678.00 4 83C 010301804A 03/06/2001 EDWARDS, DAVID A 08/07/2001 678.00 4 83C 010301812A 03/07/2001 BARRAZA, LISA M 08/07/2001 831.00 4 83C 010301825A 03/07/2001 MCPHILLIPS, MICHAEL 08/07/2001 831.00 4 83C 010301847A 03/08/2001 MORENO, JESUSA 08/07/2001 831.00 4 83C 010301921A 03/10/2001 BARRAZA, LISA M 08/07/2001 793 .00 4 83C 010301993A 03/13/2001 FITZGERALD, GLENN 08/07/2001 831.00 4 83C 010302027A 03/14/2001 VALDIVIA, RUDINA 08/07/2001 769.00 4 83C 010302028A 03/14/2001 SANCHEZ, NORMA 08/07/2001 1107.00 4 83C 010302124A 03/17/2001 ALCANTAR, GILBERTO 08/07/2001 100.00 4 83C 010302128A 03/17/2001 CLEAVER, VANESSA 08/07/2001 831.00 4 83C 010302183A 03/20/2001 DURAN, PEDRO M 08/07/2001 819.00 4 83C 010302252A 03/22/2001 CRENSHAW, DAMION 08/07/2001 769.00 4 83C 010302289A 03/24/2001 BAKER, LOREN J 08/07/2001 879.00 4 83C 010302291A 03/24/2001 BANUELOS-GONZALEZ, S 08/07/2001 399.00 4 83C 010302296A 03/24/2001 DELROSARIO, RENARD 08/07/2001 781.00 4 83C 010302359A 03/27/2001 FITZGERALD, GLENN 08/07/2001 859.00 4 83C 010302401A 03/28/2001 RODMAN, LOREN 08/07/2001 654.00 4 83C 010302430A 03/30/2001 MARTINEZ, LEE R 08/07/2001 731.00 4 83C 010402526A 04/01/2001 LOPEZ, JIMMIE 08/07/2001 1243.00 4 83C 010402587A 04/04/2001 MARTINEZ, RUDY N 08/07/2001 704.00 4 83C 010402622B 04/05/2001 GONZALES, LUCY S 08/07/2001 775.08 4 83C 010402634A 04/06/2001 EDWARDS, DAVID A 08/07/2001 399.00 4 83C 010402694A 04/07/2001 EDWARDS, DAVID A 08/07/2001 399.00 4 83C 010402697A 04/07/2001 RODNEY, STEPHANIE 08/07/2001 831.00 4 83C 010402765A 04/09/2001 CASTILLO, NORA 08/07/2001 819.00 4 83C 010402865A 04/12/2001 GONZALES, LARRY 08/07/2001 908.00 4 83C 010402913B 04/14/2001 GUTIERREZ, JOSE L 08/07/2001 859.00 4 83C 010402952A 04/15/2001 JUAREZ, CESAR 08/07/2001 831.00 4 83C 010402962A 04/16/2001 BARNARD, RICHARD E 08/07/2001 853 .00 4 83C 010402968A 04/16/2001 WAHLER, DAWN 08/07/2001 951.00 4 83C 010402980A 04/16/2001 FLINT, SHERI ANN 08/07/2001 1009.00 4 83C 010402981A 04/16/2001 MCLAIN, SANDI Date:08/08/2001 Weld County Ambulance - Page: 5 Time:11:10:25 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 08/07/2001 Thru 08/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 08/07/2001 654.00 4 83C 010403079A 04/19/2001 LOPEZ, JAMES 08/07/2001 834.00 4 83C 010403092A 04/20/2001 DIAZ, HECTOR 08/07/2001 825.00 4 83C 010403149B 04/21/2001 VASQUEZ, CRESENTO 08/07/2001 704.00 4 83C 010503586A 05/05/2001 JONES, TYRELL J 08/07/2001 896.00 4 83C 010503659A 05/08/2001 BRUNNER, ANNA 08/07/2001 839.00 4 83C 010503702A 05/10/2001 BROWN, TOMMY 08/07/2001 731.00 4 83C 010503755A 05/12/2001 CASSADY, JASON D 08/07/2001 690.00 4 83C 010503992A 05/20/2001 BERWAL, WILLIAM 08/07/2001 835.00 4 83C 010504031A 05/22/2001 BOWMAN, RON 08/07/2001 704.00 4 83C 010504161A 05/27/2001 PARKER, GLENN 08/07/2001 819.00 4 83C 010604325A 06/02/2001 COOPER, TERRY 08/07/2001 80.00 4 81 010604532A 06/11/2001 ARMENDARIZ, JESUS 08/07/2001 20.00 4 81 010604639A 06/15/2001 DILLARD, VERA FERN 08/07/2001 20.00 4 81 010604640A 06/15/2001 PURINTUN, KATHY 08/07/2001 40.00 4 81 010604656A 06/15/2001 PITTMAN, TERRI N 08/07/2001 863 .00 4 83C 010604691A 06/16/2001 LOPEZ, JIMMIE 08/07/2001 769.00 4 83C 010604710A 06/17/2001 CARMONO, JULIAN M 08/07/2001 40.00 4 81 010604736A 06/18/2001 CISNEROS, TONY 08/07/2001 20.00 4 81 010604755A 06/19/2001 SILVERFOX, IDA R 08/07/2001 7/20 EOB 80.00 4 81 010604782A 06/20/2001 ROSALES, PATRICIA 08/07/2001 20.00 4 81 010604831A 06/22/2001 LALONDE, GERALD 08/07/2001 388.78 4 81 010604886A 06/23/2001 MARTINEZ, MARIA 08/07/2001 203 .04 4 81 010604890A 06/23/2001 MARTINEZ, MARIA 08/07/2001 80.00 4 81 010605030A 06/28/2001 APPLE, DARLINE 08/07/2001 60.00 4 81 010605064A 06/29/2001 EWERTZ, SHIRLEY 08/07/2001 40.00 4 81 010605067A 06/29/2001 PADRON, JOYCE 08/07/2001 726.00 4 83C 010605092A 06/30/2001 CHAVEZ, ABEL 08/07/2001 20.00 4 81 010705147A 07/02/2001 ROHN, BONNIE 08/07/2001 40.00 4 81 010705155A 07/02/2001 BUNN, NATHAN 08/07/2001 726.00 4 83C 010705199A 07/03/2001 BATALLA, JESUS 08/07/2001 40.00 4 81 010705221A 07/04/2001 ROBINSON, LEAH 08/07/2001 530.00 4 REV 010705653A 07/19/2001 DRISKELL, CRAIG 08/07/2001 805.00 4 83C 020300961A 02/03/2001 YOUNGER, PATRICK 08/07/2001 230.00 4 83C 991108579A 11/20/1999 MCQUALITY, KATHY Total of 230 WriteOff Entries Totaling 127204.95 Dollars Average WriteOff: 553.06 Dollars Average Time:195 Days I Date:08/08/2001 Weld County Ambulance Page: 6 Time:11:10:25 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 08/07/2001 Thru 08/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 209 124960.79 597.90 204.27 83 WRITEOFF 3 50.65 16.88 387.33 81 MEDICARE WRITEOFF 17 1663 .51 97.85 52.35 REV REVERSE CHARGED IN ERROR 1 530.00 530.00 19.00 Date:09/10/2001 Weld County Ambulance Page: 1 Time:11:27: 04 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 09/07/2001 Thru 09/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 09/07/2001 127.20 4 83C 000302076A 03/24/2000 DICAMILLO, JEFFREY H 09/07/2001 166.50 4 83C 000402604A 04/12/2000 CARLSON, PENNY T 09/07/2001 195.14 4 83C 000503246A 05/05/2000 CHERRY, ODILIA G 09/07/2001 71.00 4 83C 000705544A 07/22/2000 ANDERSON, ANDREW 09/07/2001 25.00 4 83C 000906793A 09/04/2000 CRESPIN, IZAYAH M 09/07/2001 76. 00 4 83C 000907397A 09/25/2000 CARLSON, PENNY T 09/07/2001 25.00 4 83C 001008198A 10/23/2000 CRAWFORD, KAREN S 09/07/2001 40.00 4 83C 001108517A 11/04/2000 ALCORN, ERIC L 09/07/2001 70.00 4 83C 001109052A 11/25/2000 MIJARES, JEFFREY 09/07/2001 150.00 4 83C 001109067B 11/25/2000 CARILLO, GABRIELLA K 09/07/2001 38.16 4 83C 001209418A 12/08/2000 FLETCHER, EMILY B 09/07/2001 590.00 4 83C 001209540A 12/12/2000 DUFFIELD, SHERRI 09/07/2001 290.00 4 83C 001209574A 12/13/2000 BERNAL, NAOMI 09/07/2001 671.14 4 83C 001209580A 12/13/2000 REHFELD, GARY 09/07/2001 386.14 4 83C 001209627A 12/16/2000 MATTHEWS, PAUL R 09/07/2001 656.14 4 83C 001209636A 12/16/2000 BLEA, STELLA 09/07/2001 59.86 4 83C 001209651A 12/16/2000 STAPP, MARJORIE L 09/07/2001 290.00 4 83C 001209658A 12/16/2000 STAPP, MARJORIE L 09/07/2001 38.16 4 83C 001209661A 12/17/2000 STAPP, MARJORIE L 09/07/2001 290.00 4 83C 001209664A 12/17/2000 STAPP, MARJORIE L 09/07/2001 755.00 4 83C 001209767A 12/20/2000 BELT, CHRISTINE 09/07/2001 25.00 4 83C 001209775A 12/21/2000 HASTINGS, DANIELLE M 09/07/2001 650 .00 4 83C 001209795A 12/22/2000 HOFFNER, GLEN A 09/07/2001 25.00 4 83C 001209815A 12/23/2000 RAMOS, JOHN FREDRICK 09/07/2001 84.10 4 83C 010100141A 01/06/2001 SHOOP, REBECCA A 09/07/2001 795.08 4 83C 010100194A 01/08/2001 HOFFNER, GLEN A 09/07/2001 819.00 4 83C 010100234A 01/09/2001 VANCLEAVE, LUCINDA 09/07/2001 349.00 4 83C 010100290A 01/11/2001 HERNANDEZ, ROBERT C 09/07/2001 39.19 4 83C 010100314A 01/12/2001 ARMSTRONG, GARY V 09/07/2001 72.80 4 83C 010100363A 01/14/2001 TAPIA, STEVE 09/07/2001 166.20 4 83C 010100390A 01/15/2001 DE PIERRE, JOHANNA 09/07/2001 166.20 4 83C 010100400A 01/15/2001 SWEIGARD, RICHARD 09/07/2001 100.00 4 83C 010100413A 01/16/2001 WILLARD, TIFFANY 09/07/2001 199.00 4 83C 010100554A 01/20/2001 GOODRICH, JEAN 09/07/2001 819.00 4 83C 010100557A 01/21/2001 GILBERT, SHARON 09/07/2001 50. 00 4 83C 010100573A 01/21/2001 NORMAND, SHAWN 09/07/2001 774.00 4 83C 010100591A 01/22/2001 SOUTHARDS, SHAWN 09/07/2001 769.00 4 83C 010100617A 01/23/2001 ALANIZ, ROBERT M 09/07/2001 961.00 4 83C 010100627A 01/23/2001 HOWARD, JOSH 09/07/2001 290.80 4 83C 010100670A 01/25/2001 FOSTER, MICHAEL 09/07/2001 865.08 4 83C 010100700A 01/26/2001 SHARICK, JOHN 09/07/2001 25.00 4 83C 010100712A 01/26/2001 WALKER, JACKSON 09/07/2001 202.00 4 83C 010100763A 01/27/2001 VILLARREAL, JIM 09/07/2001 174.60 4 83C 010100769A 01/27/2001 BISHOP, PHILLIP 09/07/2001 841.00 4 83C 010200895A 02/01/2001 MELENDEZ, MANUELA 09/07/2001 743.00 4 83C 010200904A 02/01/2001 ESPINOZA, LINDA 09/07/2001 654.00 4 83C 010200911A 02/01/2001 ALANIZ, ROBERT M 09/07/2001 399.00 4 83C 010200924A 02/02/2001 ALANIZ, ROBERT M 09/07/2001 25.00 4 83C 010200928A 02/02/2001 PANTOJA, JOSEFINA Date:09/10/2001 Weld County Ambulance Page: 2 Time:11:27:04 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 09/07/2001 Thru 09/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 09/07/2001 25.00 4 83C 010200940A 02/02/2001 PANTOJA, JOSEFINA 09/07/2001 1220.00 4 83C 010200943A 02/02/2001 PATTERSON, PETER 09/07/2001 859.00 4 83C 010200969A 02/03/2001 ALANIZ, ROBERT M 09/07/2001 399.00 4 83C 010200973A 02/04/2001 AT,ANIZ, ROBERT M 09/07/2001 201.44 4 83C 010200974A 02/04/2001 DIAZ, DANIEL 09/07/2001 819.00 4 83C 010200977A 02/04/2001 MATA, ALFREDO 09/07/2001 769.00 4 83C 010200990A 02/04/2001 WILLIAMS, STEVEN B 09/07/2001 81.90 4 83C 010200999A 02/04/2001 FERGUSON, DARREN W 09/07/2001 654.00 4 83C 010201000A 02/04/2001 DURAN, CONSUELO 09/07/2001 1011.00 4 83C 010201033A 02/05/2001 MILLER, ERIN 09/07/2001 719.00 4 83C 010201049A 02/06/2001 SPENCE, MARK 09/07/2001 841.00 4 83C 010201059A 02/06/2001 PEREZ, REYNA 09/07/2001 399.00 4 83C 010201061A 02/06/2001 SPENCE, MARK 09/07/2001 931.00 4 83C 010201070A 02/07/2001 RANEY, ALETHEA 09/07/2001 818.00 4 83C 010201081B 02/07/2001 MUNOZ-BANELOS, MANUE 09/07/2001 100.00 4 83C 010201092A 02/07/2001 PRIETO, LUZ EMMA 09/07/2001 819.00 4 83C 010201097A 02/08/2001 MATA, ALFREDO 09/07/2001 399.00 4 83C 010201100A 02/08/2001 MATA, ALFREDO 09/07/2001 715.00 4 83C 010201109A 02/08/2001 BARNES, JAMES A 09/07/2001 987.00 4 83C 010201113A 02/08/2001 TAYLOR, NICOLE 09/07/2001 264.94 4 83C 010201121A 02/08/2001 FELKER, PETER 09/07/2001 819.00 4 83C 010201123A 02/08/2001 SANCHEZ, LONNIE 09/07/2001 100.00 4 83C 010201125A 02/08/2001 SCHWARTZ, DEBBY 09/07/2001 819.00 4 83C 010201146A 02/09/2001 HEGWOOD, JERRY 09/07/2001 666.00 4 83C 010201153A 02/10/2001 KNOUSE, TRINA 09/07/2001 100.00 4 83C 010201159A 02/10/2001 MOORE, MEGAN 09/07/2001 654.00 4 83C 010201183A 02/11/2001 HOLIMAN, DONALD 09/07/2001 843.00 4 83C 010201187A 02/11/2001 JIMENEZ, PRISCILLA 09/07/2001 853.00 4 83C 010201190A 02/11/2001 MELENDEZ, MANUELA 09/07/2001 789.00 4 83C 010201200A 02/11/2001 WARE, JERMAINE T 09/07/2001 819.00 4 83C 010201205A 02/11/2001 MORALES, JULIAN 09/07/2001 704.00 4 83C 010201205B 02/11/2001 GARCIA-PEREZ, SYLVIA 09/07/2001 738.00 4 83C 010201214A 02/12/2001 GESICK, CASEY L 09/07/2001 1047.00 4 83C 010201217A 02/12/2001 SHERWOOD, RENEE 09/07/2001 999.00 4 83C 010201225A 02/12/2001 GESICK, CASEY L 09/07/2001 781.00 4 83C 010201226A 02/12/2001 REED, DENNIS 09/07/2001 100.00 4 83C 010201229A 02/12/2001 KRAUTSCHUN, BRANDON 09/07/2001 1328.00 4 83C 010201231A 02/12/2001 STROH, RENEE 09/07/2001 839.00 4 83C 010201232A 02/12/2001 SPAIN, ROBERT 09/07/2001 399.00 4 83C 010201290A 02/14/2001 ANDERSEN, DANIEL J 09/07/2001 1215.00 4 83C 010201294A 02/14/2001 RUBI, RONNIE 09/07/2001 843 .00 4 83C 010201311A 02/15/2001 AYALA, ROBERT L 09/07/2001 877.00 4 83C 010201327A 02/16/2001 TANNER, TERRY 09/07/2001 72.80 4 83C 010201334A 02/16/2001 RUIZ, MIGUEL 09/07/2001 115.00 4 83C 010201337A 02/16/2001 REED, MARK 09/07/2001 654.00 4 83C 010201347A 02/16/2001 STAHLA, LISA 09/07/2001 925.00 4 83C 010201352A 02/17/2001 HARDING, DAVID 09/07/2001 769.00 4 83C 010201360A 02/17/2001 BOLTJES, ROLAND 09/07/2001 25.00 4 83C 010201362A 02/17/2001 REED, MARK Date:09/10/2001 Weld County Ambulance Page: 3 Time:11:27:05 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 09/07/2001 Thru 09/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 09/07/2001 100.00 4 83C 010201378B 02/18/2001 THERMAN, ROBERT 09/07/2001 819.00 4 83C 010201379A 02/18/2001 TREVINO, GUADALUPE H 09/07/2001 - 769.00 4 83C 010201383A 02/18/2001 CASTANEDA-HERNANDEZ, 09/07/2001 654.00 4 83C 010201397A 02/18/2001 BENAVIDEZ, EDDIE 09/07/2001 678.00 4 83C 010201402A 02/18/2001 ABBOTT, DARRELL D 09/07/2001 824.00 4 83C 010201425A 02/20/2001 SILVERFOX-GORE, BRAN 09/07/2001 728.00 4 83C 010201428A 02/20/2001 MARTINEZ, JOANNA 09/07/2001 399.00 4 83C 010201431A 02/20/2001 BAUMGARTNER, RONALD 09/07/2001 819.00 4 83C 010201436A 02/20/2001 ALANIZ, ROBERT M 09/07/2001 100.00 4 83C 010201437A 02/20/2001 RIOS, SONIA 09/07/2001 719.00 4 83C 010201452A 02/21/2001 JERONIMO, ELISA 09/07/2001 801.00 4 83C 010201454A 02/21/2001 ELDER, BOBBY 09/07/2001 399.00 4 83C 010201460A 02/21/2001 RAMIREZ, BRIANA 09/07/2001 871.00 4 83C 010201465A 02/21/2001 SCHAFFER, SHURRI 09/07/2001 100.00 4 83C 010201477A 02/21/2001 SULLIVAN, CHRISTOPHE 09/07/2001 836.00 4 83C 010201490A 02/22/2001 GARCIA, JOHNIE 09/07/2001 879.00 4 83C 010201498A 02/22/2001 CORBIN, DEBRA D 09/07/2001 781.00 4 83C 010201510A 02/22/2001 GALLEGOS, ZELDA 09/07/2001 654.00 4 83C 010201510B 02/22/2001 GUEVARA, YESENIA 09/07/2001 769.00 4 83C 010201512A 02/22/2001 PIEROT, GREG 09/07/2001 704.00 4 83C 010201531A 02/23/2001 SILVA, GERARDO 09/07/2001 100.00 4 83C 010201537A 02/23/2001 DOCKERY, CHRIS 09/07/2001 153.80 4 83C 010201549A 02/24/2001 BALDERRAMA, EDGAR A 09/07/2001 769.00 4 83C 010201549B 02/24/2001 SANTILLIAN, RIGO 09/07/2001 891.00 4 83C 010201556A 02/24/2001 MUNIZ, TRINIDAD 09/07/2001 399.00 4 83C 010201563A 02/24/2001 LOUD, KAYA 09/07/2001 100.00 4 83C 010201572A 02/25/2001 AVARA, JENNIFER 09/07/2001 736.00 4 83C 010201587A 02/26/2001 WHEELER, WAYNE 09/07/2001 769.00 4 83C 010201619A 02/27/2001 RAMOS, MOSES 09/07/2001 819.00 4 83C 010201620A 02/27/2001 CHERRY, CARLA L 09/07/2001 50.00 4 83C 010201635A 02/27/2001 ADAMS, GEORGE 09/07/2001 996.00 4 83C 010201644A 02/28/2001 GONZALEZ, BEATRICE 09/07/2001 719.00 4 83C 010201645A 02/28/2001 TURNER, MARIANNA 09/07/2001 745.00 4 83C 010201651A 02/28/2001 RODGERS, SCOTT 09/07/2001 654.00 4 83C 010201653A 02/28/2001 GORE, KAREN 09/07/2001 819.00 4 83C 010301666A 03/01/2001 MORENO, SANTOS 09/07/2001 975.00 4 83C - 010301691A 03/02/2001 CAMPBELL, FELIX M 09/07/2001 787.08 4 83C 010301726A 03/03/2001 HOFFNER, GLEN A 09/07/2001 781.00 4 83C 010301727A 03/03/2001 BEAMAN, TREVOR L 09/07/2001 10.00 4 83C 010301739A 03/04/2001 CLINK, STEPHEN 09/07/2001 25.00 4 83C 010301795A 03/06/2001 ARCHIBEQUE, MATT 09/07/2001 100.00 4 83C 010301814B 03/07/2001 CORDONA, BRIANNA 09/07/2001 39.19 4 83C 010301834A 03/07/2001 PAREDES, ANTONIO 09/07/2001 819.00 4 83C 010301882A 03/09/2001 DRAGOO, ALAN W 09/07/2001 824.00 4 83C 010301902A 03/09/2001 CAMPBELL, FELIX M 09/07/2001 719.00 4 83C 010301977A 03/12/2001 BERNAL, LARRY 09/07/2001 715.00 4 83C 010301998A 03/13/2001 BARNES, JAMES A 09/07/2001 399.00 4 83C 010302014A 03/13/2001 BENSON, MICHAEL L 09/07/2001 754.00 4 83C 010302111A 03/17/2001 DOMINGUEZ, GUADALUPE Date:09/10/2001 Weld County Ambulance Page: 4 Time:11:27:05 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 09/07/2001 Thru 09/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 09/07/2001 1004.00 4 83C 010302114A 03/17/2001 ORTIZ, JOSHUA 09/07/2001 50.00 4 83C 010302115A 03/17/2001 CRAVEN, MAX 09/07/2001 399.00 4 83C 010302143A 03/18/2001 ORTIZ, JOSHUA 09/07/2001 824.00 4 83C 010302159A 03/19/2001 DEMMA, MIKE 09/07/2001 100.00 4 83C 010302228A 03/22/2001 GONZALEZ, BALDAMAR 09/07/2001 851.00 4 83C 010302263A 03/23/2001 CERDA, ORALIA 09/07/2001 873 .00 4 83C 010302286A 03/24/2001 FLYNN, BRIAN 09/07/2001 769.00 4 83C 010302287A 03/24/2001 BEGAYE, ELIZABETH 09/07/2001 779.00 4 83C 010302308A 03/25/2001 ARADERDO, JOSE 09/07/2001 704.00 4 83C 010302337B 03/25/2001 HOFFNER, GLEN A 09/07/2001 654.00 4 83C 010302391A 03/28/2001 DUFFIELD, SHERRI 09/07/2001 575.77 4 83C 010302393A 03/28/2001 ANTHONY, SOPHIE 09/07/2001 439.00 4 83C 010302409A 03/29/2001 AYARS, SHEENA 09/07/2001 50.00 4 83C 010302413A 03/29/2001 DAVIS, PAUL 09/07/2001 911.00 4 83C 010302415A 03/29/2001 FERRARIS, PETE 09/07/2001 769.00 4 83C 010302481C 03/31/2001 ESPINOZA, CHARLES 09/07/2001 769.00 4 83C 010302493A 03/31/2001 COOK, FREDERICK E 09/07/2001 666.00 4 83C 010402653A 04/06/2001 ADAMS, JOSHUA DAVID 09/07/2001 769.00 4 83C 010402663A 04/07/2001 CAMPBELL, GEORGETTE 09/07/2001 100.00 4 83C 010402702A 04/08/2001 ALVAREZ, MARIA 09/07/2001 824.00 4 83C 010402712A 04/08/2001 DEMMA, MIKE 09/07/2001 399.00 4 83C 010402763A 04/09/2001 MELENDEZ, ALONDRA 09/07/2001 728.00 4 83C 010402859A 04/12/2001 BAKER, CARRIE 09/07/2001 843.00 4 83C 010402913A 04/14/2001 ANALCO, CIRILO A 09/07/2001 913.00 4 83C 010402949A 04/15/2001 ANCHONDO, MIGUEL A 09/07/2001 399.00 4 83C 010402971A 04/16/2001 DEMMA, MIKE 09/07/2001 776.00 4 83C 010403011A 04/17/2001 LEWIS, LAURIE 09/07/2001 769.00 4 83C 010403022A 04/18/2001 BAREFIELD, JAMES F 09/07/2001 56.83 4 83C 010403209A 04/23/2001 CAPP, ROBERT J 09/07/2001 100.00 4 83C 010403213A 04/23/2001 BEJARANO, EMANUAL 09/07/2001 769.00 4 83C 010403242A 04/23/2001 ESPINOZA, LINDA 09/07/2001 831.00 4 83C 010403309A 04/26/2001 GALLEGOS, JUAN 09/07/2001 25.00 4 83C 010403334A 04/27/2001 PANTOJA, JOSEFINA 09/07/2001 399.00 4 83C 010403342A 04/27/2001 ENSINA, HOPE 09/07/2001 939.00 4 83C 010403347A 04/27/2001 DEMMA, MIKE 09/07/2001 769.00 4 83C 010403353A 04/28/2001 CARRION, JOEL C 09/07/2001 1520.00 4 83C 010403401A 04/29/2001 CLARK, GREGORY B 09/07/2001 789.00 4 83C 010403423A 04/30/2001 LOPEZ, IGNACIO 09/07/2001 831.00 4 83C 010503503A 05/02/2001 FRANCIS, YVONNE 09/07/2001 833 .00 4 83C 010503986A 05/20/2001 ALANIZ, ROBERT M 09/07/2001 872 .00 4 83C 010504180B 05/28/2001 LOPEZ, ERNESTINE 09/07/2001 784.00 4 83C 010504182A 05/28/2001 LOPEZ, HERNAN 09/07/2001 715.00 4 83C 010504234A 05/30/2001 MUNOZ, RAFAEL 09/07/2001 47.85 4 83C 010604338A 06/02/2001 DICKSON, DEBRA L 09/07/2001 85.64 4 83C 010604748A 06/18/2001 DICKSON, DEBRA L 09/07/2001 577.92 4 82 010604848A 06/22/2001 ARCHIBEQUE, ADOLPH 09/07/2001 100.00 4 83C 010604982A 06/26/2001 BENSON, FRANK 09/07/2001 74.96 4 82 010705563A 07/15/2001 DROEGE, HELEN 09/07/2001 80.77 4 82 010705633A 07/18/2001 HURTADO, ISAAC Date:09/10/2001 Weld County Ambulance Page: 5 Time:11:27:06 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 09/07/2001 Thru 09/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 09/07/2001 88.72 4 82 010705681A 07/20/2001 EITEL, DANIEL 09/07/2001 39.96 4 82 010705683A 07/20/2001 ALBERTSON, ALICE 09/07/2001 63.87 4 82 010705689A 07/20/2001 HURTADO, ISAAC 09/07/2001 38.45 4 82 010705690A 07/20/2001 ALBERTSON, ALICE 09/07/2001 39.96 4 82 010705692A 07/20/2001 EITEL, DANIEL 09/07/2001 100.00 4 REV 010705725A 07/21/2001 RUYLE, MARGUERITE 09/07/2001 69.82 4 82 - 010705818A 07/24/2001 DITTMER, CHUCK 09/07/2001 56.25 4 82 010705827A 07/24/2001 GAITAN, BISCENTE J 09/07/2001 63.74 4 82 010705841A 07/25/2001 GARCIA, MIKE 09/07/2001 63.74 4 82 010705856A 07/26/2001 BOWERS, MARGARET ONE 09/07/2001 73.15 4 82 010705863A 07/26/2001 GARCIA, MIKE 09/07/2001 74.81 4 82 010705883A 07/27/2001 DEBROCK, NANCY M 09/07/2001 47.29 4 82 010705925A 07/28/2001 BARHAM, VERA 09/07/2001 38.45 4 82 010705935A 07/28/2001 BARHAM, VERA 09/07/2001 63.74 4 82 010706044A 07/31/2001 CLARK, RICHARD A 09/07/2001 17.02 4 81 010706275A 08/07/2001 KNESPEL, JERRY L 09/07/2001 417.67 4 81 010806260A 08/07/2001 HURTADO, ISAAC 09/07/2001 403.28 4 81 010806276A 08/07/2001 BENNETT, PATRICIA 09/07/2001 404.07 4 81 010806288A 08/08/2001 DILL, HENRY 09/07/2001 404.07 4 81 010806289A 08/08/2001 SUTTON, MARGLA P 09/07/2001 403.28 4 81 010806294A 08/08/2001 LEDFORD, REUBEN 09/07/2001 560.39 4 81 010806310A 08/09/2001 OVALLE, GUADALUPE 09/07/2001 513.44 4 82 980905912A 09/03/1998 BRADLEY, RICK 09/07/2001 235.00 4 83C 981006959A 10/15/1998 DYER, JAMES R Total of 220 WriteOff Entries Totaling 110275.55 Dollars Average WriteOff: 501.25 Dollars Average Time:195 Days Date:09/10/2001 Weld County Ambulance Page: 6 Time:11:27:06 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 09/07/2001 Thru 09/07/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 194 105496.73 543.80 209.46 82 MEDICAID WRITEOFF 18 2069.04 114.95 106.06 REV REVERSE CHARGED IN ERROR 1 100.00 100.00 48.00 81 MEDICARE WRITEOFF 7 2609.78 372 .83 30.29 Date:09/11/2001 Weld County Ambulance - Page: 1 Time:09:40:42 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 09/10/2001 Thru 09/10/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 09/10/2001 240.70 4 83C 000403042A 04/27/2000 MONTEZ, DOROTHY 09/10/2001 545.00 4 83C 000705011A 07/05/2000 JIMENEZ, CARMEN 09/10/2001 140.00 4 83C 000705048A 07/06/2000 HEIMANN, SHANDA 09/10/2001 140.00 4 83C 000705658A 07/26/2000 KEENE, KRISTINA 09/10/2001 786.14 4 83C 000705685A 07/27/2000 MATHEWS, JUNE 09/10/2001 101.00 4 83C 000806664A 08/31/2000 HERNANDEZ, OLIVER R 09/10/2001 525.00 4 83C 000906851A 09/06/2000 RODRIGUEZ, MAGDALENA 09/10/2001 86.00 4 83C 000906934A 09/08/2000 WALSH, ALISSA 09/10/2001 80.00 4 83C 000907563A 09/30/2000 GLADDEN, LATASHA 09/10/2001 770.00 4 83C 001008002A 10/16/2000 BARGER, JEREMY 09/10/2001 140.00 4 83C 001008407A 10/31/2000 JIMENEZ, CARMEN 09/10/2001 130.51 4 83C 001109045A 11/25/2000 PEMBERTON, MARIE 09/10/2001 415.00 4 83C 001209201A 12/01/2000 LOZANO, RUDY 09/10/2001 800.00 4 83C 001209309A 12/05/2000 JONES, MICHELLE 09/10/2001 327.22 4 83C 001209559A 12/13/2000 LUNA, ISABEL P 09/10/2001 744.00 4 83C 010100138A 01/05/2001 GONZALES, PATRICIA 09/10/2001 885.00 4 83C 010100190A 01/07/2001 GAWRYL, SUNDA 09/10/2001 716.00 4 83C 010100298A 01/12/2001 LOPEZ, STASIA J 09/10/2001 789.00 4 83C 010100403A 01/15/2001 HILLESLAND, AGNES L 09/10/2001 678.00 4 83C 010100505A 01/18/2001 HERNANDEZ, ERICA G 09/10/2001 619.00 4 83C 010100552A 01/20/2001 JIMENEZ, CARMEN 09/10/2001 925.00 4 83C 010100558A 01/21/2001 HUERTA, PETE 09/10/2001 484.40 4 83C 010100725A 01/27/2001 PARKER, CAMIE C 09/10/2001 497.00 4 83C 010200898A 02/01/2001 KISTLER, MARY 09/10/2001 995.00 4 83C 010201013A 02/05/2001 GUTEKUNST, REVA 09/10/2001 399.00 4 83C 010201065A 02/07/2001 CHUBBUCK, GLORIANNE 09/10/2001 1195.00 4 83C 010201087A 02/07/2001 ENDSLEY, PAM 09/10/2001 700.00 4 83C 010201163A 02/10/2001 VAN ACKER, GREGORY 09/10/2001 769.00 4 83C 010201180A 02/11/2001 GRIEGO, GABRIEL 09/10/2001 775.08 4 83C 010201192A 02/11/2001 RODRIGUEZ, ESTER M 09/10/2001 304.94 4 83C 010201213A 02/12/2001 GIROUARD, JANET M 09/10/2001 50.00 4 83C 010201221A 02/12/2001 HENDERLONG, ARTHUR D 09/10/2001 781.00 4 83C 010201224A 02/12/2001 KLEINHANS, ANDREW L 09/10/2001 793 .00 4 83C 010201380A 02/18/2001 SOLIZ, PAULA 09/10/2001 942.00 4 83C 010201422A 02/19/2001 LEE, KIM 09/10/2001 684.00 4 83C 010201545A 02/23/2001 HACKETT, JANET 09/10/2001 789.00 4 83C 010201546A 02/24/2001 VASQUEZ, ERMA 09/10/2001 823 .08 4 83C 010201551A 02/24/2001 STITT, MARLA J 09/10/2001 399.00 4 83C 010201552A 02/24/2001 STITT, MARLA J 09/10/2001 100.00 4 83C 010201613A 02/27/2001 JOHNSON, LYNETTE 09/10/2001 841.00 4 83C 010301662A 03/01/2001 SARDINA EDUARDO 09/10/2001 399.00 4 83C 010301677A 03/01/2001 HERNANDEZ, ERICA G 09/10/2001 696.00 4 83C 010301725B 03/03/2001 WEBER, CHRISTOPHER 09/10/2001 1304.08 4 83C 010301731A 03/03/2001 VALENCIANO, JOE 09/10/2001 100.00 4 83C 010301734A 03/04/2001 SCHRYURE, JACOB 09/10/2001 399.00 4 83C 010301741A 03/04/2001 MARQUEZ, MARIVEL 09/10/2001 775.00 4 83C 010301771A 03/05/2001 TORRES, ISELA 09/10/2001 558.60 4 83C 010301789A 03/05/2001 OWENS, NATHAN P 09/10/2001 835.00 4 83C 010301832A 03/07/2001 WINTERS, CHRISTOPHER Date:09/11/2001 Weld County Ambulance Page: 2 Time:09:40:42 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 09/10/2001 Thru 09/10/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 09/10/2001 631.00 4 83C 010301839A 03/07/2001 RODARTE, JOSHUA E 09/10/2001 819.00 4 83C 010301841A 03/07/2001 ROSENKHAN, SAADIA B 09/10/2001 39.19 4 83C 010301860A 03/08/2001 MCCOY, CONSTANCE 09/10/2001 908.00 4 83C 010301873A 03/09/2001 SOLIZ, PAULA 09/10/2001 100.00 4 83C 010301879A 03/09/2001 ULLOA, MAYRA 09/10/2001 786.00 4 83C 010301910A 03/10/2001 VANCE, JONATHON 09/10/2001 995.00 4 83C 010301923A 03/10/2001 ROMERO, BALTAZAR 09/10/2001 889.00 4 83C 010301926A 03/11/2001 GARZA, JOSIE 09/10/2001 738.00 4 83C 010301928A 03/11/2001 GOMEZ, DIANA 09/10/2001 769.00 4 83C 010301948C 03/11/2001 MIRANDA, HELEN J 09/10/2001 769.00 4 83C 010301949A 03/11/2001 MONCADA, SANDRA S 09/10/2001 100.00 4 83C 010301949B 03/11/2001 MONCADA, ROBERTO 09/10/2001 654.00 4 83C 010301975A 03/12/2001 SOLIZ, PAULA 09/10/2001 496.46 4 82 010301992A 03/13/2001 ENDRESON, BENJAMIN A 09/10/2001 100.00 4 83C 010302018A 03/14/2001 MONCADA, SANDRA S 09/10/2001 399.00 4 83C 010302020A 03/14/2001 THOMAS, MICHELLE 09/10/2001 321.80 4 83C 010302038A 03/14/2001 MAURER, DEBRA L 09/10/2001 973.00 4 83C 010302043A 03/15/2001 MONARD, MARLENE 09/10/2001 877.00 4 83C 010302045A 03/15/2001 MEZA, ENEDINE 09/10/2001 399.00 4 83C 010302069A 03/15/2001 MACHENDRIE, DANNE A 09/10/2001 227.49 4 83C 010302071A 03/15/2001 WILLIS, JR, BRUCE 09/10/2001 100.00 4 83C 010302074A 03/16/2001 MORALES, DAVID 09/10/2001 100.00 4 83C 010302152A 03/18/2001 MINNEY, ROSITA 09/10/2001 716.00 4 83C 010302162A 03/19/2001 VIGIL-LIRA, TASHA C 09/10/2001 399.00 4 83C 010302169A 03/19/2001 GULLICKSON, MICHAEL 09/10/2001 100.00 4 83C 010302187B 03/20/2001 JIMENEZ, JUAN 09/10/2001 678.00 4 83C 010302193A 03/20/2001 RONQUILLO, ROSALIO 09/10/2001 769.00 4 83C 010302204A 03/20/2001 HADLEY, LESLIE L 09/10/2001 399.00 4 83C 010302253A 03/22/2001 KREHMEYER, BETTY 09/10/2001 100.00 4 83C 010302276B 03/23/2001 MCLAUGHLIN, JOEY 09/10/2001 740.00 4 83C 010302284A 03/24/2001 WOODS, REILLEY 09/10/2001 769.00 4 83C 010302288B 03/24/2001 MONTELONGO, THOMAS 09/10/2001 399.00 4 83C 010302299A 03/24/2001 YANES, JENNY 09/10/2001 100 .00 4 83C 010302310A 03/25/2001 STEC, BRENDA 09/10/2001 769.00 4 83C 010302337A 03/25/2001 HOFFNER, LORI 09/10/2001 704.00 4 83C 010302361A 03/27/2001 MORGAN, MICHAEL J 09/10/2001 654.00 4 83C 010302365A 03/27/2001 LUCIO, GLORIA 09/10/2001 399.00 4 83C 010302367A 03/27/2001 MORGAN, MICHAEL J 09/10/2001 781.00 4 83C 010302378A 03/28/2001 HATFIELD, MARK ANDRE 09/10/2001 654.00 4 83C 010302379A 03/28/2001 MOONEY, JAMIE T 09/10/2001 399.00 4 83C 010302411A 03/29/2001 KIELER, COTTON D 09/10/2001 64.77 4 81 010302416A 03/29/2001 MOSER, MARY E 09/10/2001 704.00 4 83C 010302448A 03/30/2001 LUJAN, JR, BERNADO 09/10/2001 100.00 4 83C 010302485A 03/31/2001 LAYNE, BRITTANY 09/10/2001 769.00 4 83C 010402607B 04/04/2001 QUEZADA, JUAN 09/10/2001 45.95 4 83C 010403430A 04/30/2001 MCCOY, CONSTANCE 09/10/2001 56.16 4 82 010604413A 06/06/2001 CURRY, JULIA 09/10/2001 109.76 4 82 010706037A 07/31/2001 WAYMAN, JOHN J 09/10/2001 391.42 4 81 010806120A 08/03/2001 HENRY, LENA W Date:09/11/2001 Weld County Ambulance Page: 3 Time:09:40:43 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 09/10/2001 Thru 09/10/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 09/10/2001 440.03 4 81 010806328A 08/10/2001 STONE, VERNER E 09/10/2001 478.14 4 81 010806335A 08/10/2001 MARTINEZ, FLORINDA 09/10/2001 503 .25 4 81 010806340A 08/10/2001 SUPPES, LEROY 09/10/2001 19.50 4 81 010806351A 08/10/2001 CINEA, GENEVA MAE 09/10/2001 19.50 4 81 010806401A 08/12/2001 WILCOX, SABRA 09/10/2001 528.55 4 81 010806406A 08/12/2001 MOSS, HELEN 09/10/2001 404.07 4 81 010806450A 08/13/2001 IKENOUYE, CAROL 09/10/2001 452.30 4 81 010806474A 08/14/2001 HADDAD, JAMES J 09/10/2001 - 199.23 4 81 010806476A 08/14/2001 ORMROD, ALEX K 09/10/2001 576.11 4 81 010806507A 08/15/2001 APPLE, DARLINE 09/10/2001 411.51 4 81 010806509A 08/15/2001 CORLISS, RUTH 09/10/2001 722 .05 4 81 010806511A 08/15/2001 BURBACK, MARY 09/10/2001 76.37 4 81 010806512A 08/15/2001 FONTES, DOLORES M 09/10/2001 357.17 4 83C 990906487A 09/01/1999 GROSSMAN, CHRISTOPHE Total of 112 WriteOff Entries Totaling 57119.53 Dollars Average WriteOff: 510.00 Dollars Average Time:195 Days Date:09/11/2001 Weld County Ambulance Page: 4 Time:09:40:43 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 09/10/2001 Thru 09/10/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 94 51170.35 544.37 223 .09 82 MEDICAID WRITEOFF 3 662 .38 220.79 106.00 81 MEDICARE WRITEOFF 15 5286.80 352.45 38.07 Date:10/17/2001 Weld County Ambulance Page: 1 Time:16:56:05 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 10/17/2001 Thru 10/17/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 10/17/2001 550.00 4 83C 000402344A 04/02/2000 GAUKEL, DAVID 10/17/2001 165.00 4 83C 000402350A 04/02/2000 GAUKEL, DAVID 10/17/2001 112.65 4 83C 000402794A 04/18/2000 PEREA-NATERA, ROSA 10/17/2001 405.00 4 83C 000403115A 04/30/2000 NELSON, HEATHER LEIG 10/17/2001 403.14 4 83C 000704904A 07/02/2000 MEADOR, DWAINE 10/17/2001 25.00 4 83C 000806238A 08/16/2000 ROTH, MARIE 10/17/2001 25.00 4 83C 000806242A 08/16/2000 ROTH, MARIE 10/17/2001 630.00 4 83C 000906754A 09/03/2000 KELLY, DEAN M 10/17/2001 37.70 4 83C 000907242A 09/19/2000 MOGUS, NATE 10/17/2001 200.00 4 83C 001007841A 10/10/2000 TAUILIILI, KOLOTITA 10/17/2001 25.00 4 83C 001008066A 10/19/2000 MOORE, INA 10/17/2001 231.85 4 83C 001008354A 10/29/2000 KEIHL, ARON 10/17/2001 395.00 4 83C 001108692A 11/10/2000 JIMERSON, DARLENE 10/17/2001 183 .28 4 83C 001108744A 11/12/2000 HOPKINS, RICHARD 10/17/2001 362.43 4 83C 001108858A 11/16/2000 SWOVELAND, LINDA 10/17/2001 53 .00 4 83C 001108890A 11/17/2000 LOPEZ, ESMELEGLIDA 10/17/2001 139.00 4 83C 001209491A 12/10/2000 PALACIOS, JESUS E 10/17/2001 58.00 4 83C 001209495A 12/11/2000 PALACIOS, JESUS E 10/17/2001 150.25 4 83C 001209819A 12/23/2000 GOMEZ, AUDREY L 10/17/2001 230.80 4 83C 010100027A 01/01/2001 OTT JANDA, BARBARA L 10/17/2001 651.00 4 83C 010100130A 01/05/2001 WILEY, ZANE D 10/17/2001 407.00 4 83C 010100155A 01/06/2001 NELSON, HEATHER LEIG 10/17/2001 592.00 4 83C 010100155B 01/06/2001 HAHLER, DAWN M 10/17/2001 867.00 4 83C 010100169A 01/07/2001 JOHNSON, DENNIS 10/17/2001 775.08 4 83C 010100246A 01/10/2001 VASQUEZ, ERMA 10/17/2001 74.28 4 83C 010100259A 01/10/2001 RODELLO, LEROY 10/17/2001 793 .00 4 83C 010100295A 01/12/2001 HERNANADEZ, FRANCES 10/17/2001 754.00 4 83C 010100334A 01/13/2001 RODRIGUEZ, ANA C 10/17/2001 894.00 4 83C 010100338A 01/13/2001 KELLER, ALIYAH L 10/17/2001 399.00 4 83C 010100339A 01/13/2001 RODRIGUEZ, ANA C 10/17/2001 741.00 4 83C 010100456A 01/16/2001 SPECHT, AUDREY 10/17/2001 630.00 4 83C 010100610A 01/22/2001 WOOLDRIDGE, BRIAN 10/17/2001 56.22 4 83C 010100665A 01/24/2001 CAMPELLONE, STELLA D 10/17/2001 704.00 4 83C 010100737A 01/27/2001 HIDALGO, PATRICIA 10/17/2001 399.00 4 83C 010200894A 02/01/2001 GREEN, DEBORAH 10/17/2001 269.41 4 83C 010201011A 02/05/2001 THAYER, HELEN L 10/17/2001 819.00 4 83C 010201174A 02/10/2001 POLLMILLER, JEFF 10/17/2001 765.08 4 83C 010201186A 02/11/2001 KAY, MARGARET WILSON 10/17/2001 399.00 4 83C 010201193A 02/11/2001 KAY, MARGARET WILSON 10/17/2001 343.00 4 83C 010201215A 02/12/2001 SAMPLES, JIMMIE 10/17/2001 980.00 4 83C 010201256A 02/13/2001 ELOYD, TROY 10/17/2001 614.00 4 83C 010201370A 02/17/2001 JONES, MARION 10/17/2001 384.00 4 83C 010201373A 02/17/2001 JONES, MARION 10/17/2001 843.00 4 83C 010201394A 02/18/2001 LICERIO, DEBRA J 10/17/2001 433 .00 4 83C 010201427A 02/20/2001 REYES, FLORENCE 10/17/2001 839.00 4 83C 010201494A 02/22/2001 RAMOS, MARIA 10/17/2001 25.00 4 83C 010201544A 02/23/2001 WOOLDRIDGE, BRIAN 10/17/2001 25.00 4 83C 010301742A 03/04/2001 HOGG, JAKE 10/17/2001 200.00 4 83C 010301891A 03/09/2001 GONZALES, JAMES M Date:10/17/2001 Weld County Ambulance Page: 2 Time:16:56:06 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 10/17/2001 Thru 10/17/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 10/17/2001 100.00 4 83C 010301956A 03/11/2001 GURRINI, NATE 10/17/2001 831.00 4 83C 010302032A 03/14/2001 MITCHELL, EDWARD 10/17/2001 769.00 4 83C 010302064A 03/15/2001 MARTIN, NOAH 10/17/2001 399.00 4 83C 010302133A 03/18/2001 KIEKHAEFER, CLARA M 10/17/2001 399.00 4 83C 010302137A 03/18/2001 HERRICK, TAWONNA J 10/17/2001 72.80 4 83C 010302249A 03/22/2001 MAY, JAMES AARON 10/17/2001 39.19 4 83C 010302258A 03/22/2001 MAY, JAMES AARON 10/17/2001 769.00 4 83C 010302268A 03/23/2001 GORE, DELBERT 10/17/2001 737.70 4 83C 010302318A 03/25/2001 RIVERA, TYLER 10/17/2001 819.00 4 83C 010302407A 03/28/2001 LANCKRIET, GREGORY 10/17/2001 175.46 4 83C 010402557A 04/02/2001 HOOD, DOUGLAS M 10/17/2001 - 25.00 4 83C 010402589A 04/04/2001 JARAMILLO, DAVID A 10/17/2001 819.00 4 83C 010402604A 04/04/2001 ZAPATA-TOMES, MARIEL 10/17/2001 819.00 4 83C 010402661A 04/07/2001 MILAND JR, MILO L 10/17/2001 653.00 4 83C 010402685A 04/07/2001 CIPRIANO, ALBERTO G 10/17/2001 100.00 4 83C 010402772A 04/09/2001 GRAJEDA, TROY 10/17/2001 654.00 4 83C 010402787A 04/10/2001 GARCIA, ANGELICA 10/17/2001 824.00 4 83C 010402800A 04/10/2001 GARZA, ANDRES 10/17/2001 100.00 4 83C 010402811A 04/11/2001 HERBST, MIKE E 10/17/2001 769.00 4 83C 010402817A 04/11/2001 GOMEZ, DIANE CATHERI 10/17/2001 100.00 4 83C 010402879A 04/13/2001 HERBST, MIKE E 10/17/2001 781.00 4 83C 010402907A 04/13/2001 KHALIPEH, AMEEDAH 10/17/2001 399.00 4 83C 010402920A 04/14/2001 TRENARY, WILLIAM R 10/17/2001 50.00 4 83C 010402950A 04/15/2001 GARCIA, ELIAS 10/17/2001 949.00 4 83C 010402970A 04/16/2001 JEALOUS OF HIM, JARR 10/17/2001 399.00 4 83C 010403042A 04/18/2001 SWOVELAND, LINDA 10/17/2001 883.00 4 83C 010403046A 04/18/2001 GUERRERO, MILTON J 10/17/2001 760.00 4 83C 010403141A 04/21/2001 GONZALES, JERRIAH 10/17/2001 100.00 4 83C 010403159A 04/21/2001 HUNTSMAN, GENEVIEVE 10/17/2001 819.00 4 83C 010403203A 04/22/2001 KENITZER, LANCE 10/17/2001 891.00 4 83C 010403211A 04/23/2001 LINDSEY, JANE A 10/17/2001 100.00 4 83C 010403214A 04/23/2001 GALLEGOS, GERALD WAY 10/17/2001 985.00 4 83C 010403235A 04/23/2001 KORGAN, LAVERN A 10/17/2001 819.00 4 83C 010403240A 04/23/2001 LLAMAS, BENJAMIN M 10/17/2001 888.08 4 83C 010403245A 04/23/2001 HERBST, MIKE E 10/17/2001 423 .00 4 83C 010403250A 04/23/2001 LLAMAS, BENJAMIN M 10/17/2001 423 .00 4 83C 010403251A 04/24/2001 LLAMAS, BENJAMIN M 10/17/2001 399.00 4 83C 010403269A 04/24/2001 LLAMAS, BENJAMIN M 10/17/2001 769.00 4 83C 010403301A 04/26/2001 RAMOS, MELISSA 10/17/2001 819.00 4 83C 010403303A 04/26/2001 LIEBY, CORRY 10/17/2001 399.00 4 83C 010403310A 04/26/2001 LIEBY, CORRY 10/17/2001 801.00 4 83C 010403333A 04/27/2001 WERNER, SCOTT 10/17/2001 666.00 4 83C 010403348A 04/27/2001 HERNANDEZ, RICCARDO 10/17/2001 74.00 4 83C 010403363A 04/28/2001 GRAHAM, LISA M 10/17/2001 855.00 4 83C 010403370A 04/28/2001 GREENE, DONNA 10/17/2001 24.00 4 83C 010403394A 04/29/2001 GRAHAM, LISA M 10/17/2001 819.00 4 83C 010403422A 04/30/2001 HUGHLEY, STINSON J 10/17/2001 819.00 4 83C 010503456A 05/01/2001 BIENZ, MICHAEL W 10/17/2001 765.00 4 83C 010503464A 05/01/2001 GUSTUS, DOUGLAS W Date:10/17/2001 Weld County Ambulance Page: 3 Time:16:56:06 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 10/17/2001 Thru 10/17/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 10/17/2001 110 .00 4 83C 010503466A 05/01/2001 HERBST, MIKE E 10/17/2001 100.00 4 83C 010503538A 05/03/2001 HARMON, ROBERT 10/17/2001 791.00 4 83C 010503539A 05/04/2001 BROOKS, DANIEL 10/17/2001 781.00 4 83C 010503542A 05/04/2001 HARMON, ROBERT 10/17/2001 731.00 4 83C 010503643A 05/07/2001 GREEN, RICHARD 10/17/2001 791.00 4 83C 010503782A 05/12/2001 AVILA, ROMAN JAMES D 10/17/2001 100.00 4 83C 010503799B 05/13/2001 RUELAS, ADRIAN 10/17/2001 100.00 4 83C 010503840A 05/14/2001 JOHNSON, BRIAN 10/17/2001 654.00 4 83C 010503845A 05/14/2001 CHAVEZ, GARY F 10/17/2001 64.36 4 83C 010503985A 05/20/2001 SCHAFER, STEVEN 10/17/2001 39.19 4 83C 010504013A 05/21/2001 CLARKE, ELEANORE 10/17/2001 769.00 4 83C 010504036A 05/22/2001 ELOYD, TROY 10/17/2001 654.00 4 83C 010504052A 05/23/2001 GRIEGO, RICHARD M 10/17/2001 843.08 4 83C 010504091A 05/24/2001 HERBST, MIKE E 10/17/2001 100.00 4 83C 010504211A 05/29/2001 TRUJILLO, JOHN 10/17/2001 817.00 4 83C 010504242A 05/30/2001 HUNTER, CHAD 10/17/2001 100.00 4 83C 010504271A 05/31/2001 MEDINA, HECTOR 10/17/2001 861.02 4 83C 010604282A 06/01/2001 POWERS, FRED E 10/17/2001 55.16 4 83C 010604289A 06/01/2001 NEHRING, LINDA 10/17/2001 819.00 4 83C 010604293A 06/01/2001 TRENARY, WILLIAM R 10/17/2001 781.00 4 83C 010604327A 06/02/2001 PHILLIPS, MICHAEL 10/17/2001 839.00 4 83C 010604329A 06/02/2001 GUTIERREZ, EFRAIN 10/17/2001 - 901.00 4 83C 010604334A 06/02/2001 BAEZA, ISABEL 10/17/2001 399.00 4 83C 010604335A 06/02/2001 SAINT, ANTHONY K 10/17/2001 39.19 4 83C 010604360A 06/04/2001 LORENZ, JAMES 10/17/2001 965.00 4 83C 010604367A 06/04/2001 BRITO MONTES, GABRIE 10/17/2001 719.00 4 83C 010604396A 06/05/2001 RAMIREZ, JENNIFER 10/17/2001 822.00 4 83C 010604458A 06/08/2001 VALENZUELA, ROBERT L 10/17/2001 839.00 4 83C 010604541A 06/11/2001 MITTL, MARY JANE 10/17/2001 781.00 4 83C 010604577A 06/12/2001 SPENCER, JASON L 10/17/2001 654.00 4 83C 010604649A 06/15/2001 ELOYD, TROY 10/17/2001 831.00 4 83C 010604671A 06/16/2001 PERALES, CLAUDIA 10/17/2001 769.00 4 83C 010604725A 06/17/2001 VIZCAINO, PAULINO 10/17/2001 947.00 4 83C 010604778A 06/19/2001 BRAMBLETT, REGINA 10/17/2001 819.00 4 83C 010604779A 06/19/2001 GUAJARDO, VANESSA 10/17/2001 399.00 4 83C 010604783A 06/20/2001 GUAJARDO, VANESSA 10/17/2001 100.00 4 83C 010604789A 06/20/2001 NICHOLS, DAMON 10/17/2001 399.00 4 83C 010604804A 06/21/2001 GARCIA, NOE 10/17/2001 989.00 4 83C 010604872A 06/23/2001 KEEL, JAMES A 10/17/2001 719.00 4 83C 010604878A 06/23/2001 GUTIERREZ-CRUZ, BERN 10/17/2001 740.00 4 83C 010604879A 06/23/2001 SOTO-LOPEZ, IGNACIO 10/17/2001 819.00 4 83C 010605027A 06/28/2001 STIMPLE, JAMES 10/17/2001 719.00 4 83C 010605081A 06/30/2001 GARCIA-CORDOVA, MART 10/17/2001 719.00 4 83C 010605081B 06/30/2001 GARCIA, PACO 10/17/2001 654.00 4 83C 010605082A 06/30/2001 VENEGAS, FRANCISCO 10/17/2001 949.00 4 83C 010605094A 06/30/2001 VILT,ATOBOS, LEONARDO 10/17/2001 1177.00 4 83C 010705109A 07/01/2001 GIRON, AUGUSTINE 10/17/2001 831.00 4 83C 010705178A 07/03/2001 WAREHIME, SHANE L 10/17/2001 731.00 4 83C 010705224A 07/04/2001 ILTZASCH, TERRY Date:10/17/2001 Weld County Ambulance Page: 4 Time:16:56:07 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 10/17/2001 Thru 10/17/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 10/17/2001 989.00 4 83C 010705228A 07/04/2001 ROBLES, MATTHEW 10/17/2001 769.00 4 83C 010705257A 07/05/2001 ROMERO, BARBARA 10/17/2001 769.00 4 83C 010705264A 07/06/2001 RIVERA, ANITA M 10/17/2001 841.00 4 83C 010705329A 07/08/2001 MORALES, ANA 10/17/2001 819.00 4 83C 010705469A 07/12/2001 NAULT, PAM 10/17/2001 704.00 4 83C 010705573A 07/15/2001 ROMERO, BARBARA 10/17/2001 1057.00 4 83C 010705668A 07/20/2001 GUZMAN, MIGUEL 10/17/2001 839.00 4 83C 010705723A 07/21/2001 BAREA, JOHN 10/17/2001 100.00 4 83C 010705742A 07/22/2001 PIERCE, MAXINE 10/17/2001 1009.00 4 83C 010705761A 07/23/2001 SEGURA-ALCAT.A, DANIE 10/17/2001 819.00 4 83C 010705772A 07/23/2001 HUGHLEY, STINSON J 10/17/2001 100.00 4 83C 010705776A 07/23/2001 MARTINEZ, RAYMOND 10/17/2001 831.00 4 83C 010705788A 07/23/2001 RAWLINGS, ROBERT 10/17/2001 969.00 4 83C 010705920A 07/28/2001 RODRIGUEZ, RODRIGO G 10/17/2001 831.00 4 83C 010706030A 07/31/2001 FITZGERALD, GLENN 10/17/2001 543.28 4 83C 010806132A 08/03/2001 WAGNER, WILMER 10/17/2001 925.00 4 83C 010806169B 08/04/2001 AGUILAR, JESUS 10/17/2001 399.00 4 83C 010806201A 08/05/2001 SCHAEFFER, JASON L 10/17/2001 781.00 4 83C 010806250A 08/07/2001 AMAN, STEVE 10/17/2001 399.00 4 83C 010806296A 08/08/2001 BULLOCK, CYNTHIA J 10/17/2001 769.00 4 83C 010806497A 08/15/2001 TANGUMA, PATRICIA M 10/17/2001 819.00 4 83C 010806588A 08/18/2001 SANCHEZ, TINA P 10/17/2001 148.39 4 83C 010806598A 08/18/2001 HARRIS, DAVID 10/17/2001 819.00 4 83C 010806759A 08/24/2001 GODFREY, CORY 10/17/2001 25.18 4 81 010806839A 08/26/2001 BAXTER, ARDENE 10/17/2001 325.41 4 81 010806861A 08/27/2001 FOX, ALMA 10/17/2001 769.00 4 83C 010806862A 08/27/2001 YOUNG, GERALD 10/17/2001 654.00 4 83C 010806909A 08/29/2001 BOYCE, LILLIE 10/17/2001 399.00 4 83C 010806912A 08/29/2001 BOYCE, LILLIE 10/17/2001 1129.00 4 83C 010907027A 09/03/2001 LUDWIG, STEVEN 10/17/2001 40.00 4 81 010907160A 09/07/2001 KING, FLORENCE M 10/17/2001 114.00 4 81 010907251A 09/10/2001 CARTER, YVONNE 10/17/2001 17.74 4 81 010907256A 09/10/2001 VARRA, JACK W 10/17/2001 10.70 4 81 010907383A 09/14/2001 BAROS, JOSEPH 10/17/2001 58.50 4 81 010907392A 09/14/2001 BAAB, DONALD 10/17/2001 404.07 4 81 010907402A 09/15/2001 BLEHM, THEODORE 10/17/2001 19.50 4 81 010907418A 09/15/2001 DIVORNE, RAMONA A 10/17/2001 40.00 4 81 010907424A 09/15/2001 HINDMAN, VICKIE 10/17/2001 19.50 4 81 010907441A 09/16/2001 VAGHER, MONA 10/17/2001 50.36 4 81 010907454A 09/16/2001 FREDERIKSEN, AGNES E 10/17/2001 40 .00 4 81 010907507A 09/19/2001 JORGENSEN, MARY N 10/17/2001 40.00 4 81 010907534A 09/19/2001 JANSSEN, MADELINE 10/17/2001 00001 20.00 4 81 010907751A 09/27/2001 BRAY, MARTHA BEULAH 10/17/2001 00001 60.00 4 81 010907792A 09/28/2001 BAXTER, ARDENE 10/17/2001 60.00 4 81 010907813A 09/29/2001 CATON, JUNE 10/17/2001 20.00 4 81 010907864A 09/30/2001 ZIMMERMAN, BARBARA 10/17/2001 80.00 4 83C 971107247A 11/01/1997 KUSSMAN, MICHELLE 10/17/2001 - 488.33 4 83C 990302138A 03/22/1999 PROVENCHER, JESSIAH 10/17/2001 202.65 4 83C 990402666A 04/11/1999 HEALEY, JAMES Date:10/17/2001 Weld County Ambulance Page: 5 Time:16:56:07 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 10/17/2001 Thru 10/17/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 10/17/2001 436.72 4 83C 990705290A 07/19/1999 MARCH, CHESTER A 10/17/2001 567.64 4 83C 990805753A 08/04/1999 HEALEY, JAMES 10/17/2001 507.65 4 83C 990806420A 08/29/1999 HFATEY, JAMES Total of 199 WriteOff Entries Totaling 100887.02 Dollars Average WriteOff: 506.97 Dollars Average Time:199 Days I Date:10/17/2001 Weld County Ambulance Page: 6 Time:16:56:08 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 10/17/2001 Thru 10/17/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 181 99522.06 549.85 215.97 81 MEDICARE WRITEOFF 18 1364.96 75.83 31.72 Date:11/15/2001 Weld County Ambulance Page: 1 Time:09:59:09 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 11/14/2001 Thru 11/14/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 11/14/2001 1010.00 4 83C 001007731A 10/06/2000 HENDRIX, KATHERINE P 11/14/2001 500.00 4 83C 001108505A 11/03/2000 VERGARA-GARCIA, DAVI 11/14/2001 666.14 4 83C 001108869A 11/16/2000 HENDRIX, KATHERINE P 11/14/2001 435.00 4 83C 001109115A 11/27/2000 ALMOND, APRIL D 11/14/2001 550.00 4 83C 001109919A 11/23/2000 GOMEZ, LAURA 11/14/2001 254.54 4 83C 001209268A 12/03/2000 GREENHILL, KRYSTAL L 11/14/2001 50.00 4 83C 010100097A 01/04/2001 CHRISS, RITA M 11/14/2001 581.60 4 83C 010100129A 01/05/2001 GOMEZ, VANESSA 11/14/2001 834.00 4 83C 010100306A 01/12/2001 KERBY, ANDREW F 11/14/2001 438.22 4 83C 010100366A 01/14/2001 BOYD, HAZEL 11/14/2001 643.85 4 83C 010100521A 01/19/2001 KAY, MARGARET WILSON 11/14/2001 BANKRUPTCY 64.00 4 83 010100539A 01/20/2001 STROSNIDER, CHERYL** 11/14/2001 167.69 4 83C 010100874A 01/31/2001 SHIELDS, PRUDENCE 11/14/2001 931.00 4 83C 010200954A 02/03/2001 KERBY, ANDREW F 11/14/2001 100.00 4 83C 010201560A 02/24/2001 URESTE, CELESTINO 11/14/2001 898.00 4 83C 010201655A 02/28/2001 SPARKS, KRISTINA L 11/14/2001 198.68 4 83C 010301735A 03/04/2001 LOPEZ, THOMAS 11/14/2001 686.22 4 83C 010301744A 03/04/2001 J,AFGER, DUANE 11/14/2001 666.00 4 83C 010301766A 03/05/2001 BREWER, SHIRLEY 11/14/2001 50.00 4 83C 010301767A 03/05/2001 SCOTT, MICHAEL 11/14/2001 399.00 4 83C 010301769A 03/05/2001 BREWER, SHIRLEY 11/14/2001 89.10 4 83C 010301840A 03/07/2001 LEBLANC, RICHARD 11/14/2001 678.00 4 83C 010301848A 03/08/2001 MCKERN, SUE L 11/14/2001 669.00 4 83C 010302036A 03/14/2001 BARRON, GENEVA J 11/14/2001 153.80 4 83C 010302077A 03/16/2001 LOPEZ, VICTORIA 11/14/2001 25.00 4 83C 010302080A 03/16/2001 APPERSON, ASHLEY 11/14/2001 770.00 4 83C 010302232A 03/22/2001 GUTIERREZ, SAUL 11/14/2001 879.00 4 83C 010302240A 03/22/2001 TRIMBLE, SUSAN 11/14/2001 189.80 4 83C 010302368A 03/27/2001 MELENDEZ-MIRELES, AN 11/14/2001 654.00 4 83C 010302373A 03/27/2001 SANTORO, ADRIANNE 11/14/2001 769.00 4 83C 010302377A 03/27/2001 CORRAL-GONZALEZ, JEN 11/14/2001 841.00 4 83C 010302420A 03/29/2001 CUTTRELL, STEVEN 11/14/2001 25.00 4 83C 010402501A 04/01/2001 DAY, BRIANNE 11/14/2001 784 .00 4 83C 010402534A 04/02/2001 MENDOZA-GONZALEZ, AL 11/14/2001 726.00 4 83C 010402535A 04/02/2001 RODRIGUEZ, FELIPA 11/14/2001 654.00 4 83C 010402545A 04/02/2001 WHITETAIL, JENNIFER 11/14/2001 824.0O 4 83C 010402546A 04/02/2001 DOMORACKI, PAUL 11/14/2001 100.00 4 83C 010402559A 04/02/2001 WEIDENKELLER, SANDRA 11/14/2001 695.00 4 83C 010402602A 04/04/2001 SALVADOR, PAM E 11/14/2001 1167.00 4 83C 010402603A 04/04/2001 SALVADOR, STEVE 11/14/2001 140.80 4 83C 010402607A 04/04/2001 SALGADO, BERNADETTE 11/14/2001 1191.08 4 83C 010402613A 04/05/2001 TURECEK, JAMES 11/14/2001 260.97 4 83C 010402620A 04/05/2001 GUTIERREZ, GENARA 11/14/2001 654.00 4 83C 010402630A 04/06/2001 SCHLUTER, ANN 11/14/2001 399.00 4 83C 010402631A 04/06/2001 SCHLUTER, ANN 11/14/2001 478.85 4 83C 010402635A 04/06/2001 SCHMUNK, DOROTHY M 11/14/2001 819.00 4 83C 010402639A 04/06/2001 MORONES, WILLIAM A 11/14/2001 45.00 4 83C 010402644A 04/06/2001 SCHMUNK, DOROTHY M 11/14/2001 100.00 4 83C 010402664A 04/07/2001 QUINTANA, RICHARD Date:11/15/2001 Weld County Ambulance Page: 2 Time:09:59:09 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 11/14/2001 Thru 11/14/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 11/14/2001 1171.08 4 83C 010402684A 04/07/2001 TURECEK, JAMES 11/14/2001 793 .00 4 83C 010402685B 04/07/2001 TAPIA, MIGUEL 11/14/2001 153.80 4 83C 010402701A 04/08/2001 MELENDEZ, RAQUEL N 11/14/2001 904.00 4 83C 010402704A 04/08/2001 MARTINEZ, BENJI 11/14/2001 835.00 4 83C 010402770A 04/09/2001 LIGGETT, SANDRA 11/14/2001 704.00 4 83C 010402805A 04/10/2001 ROMERO CRUZ JR, SERG 11/14/2001 731.00 4 83C 010402809A 04/11/2001 LOPEZ, ANTHONY 11/14/2001 176.00 4 83C 010402816A 04/11/2001 SCHLUTER, MICHAEL 11/14/2001 1064.00 4 83C 010402842A 04/12/2001 MARKHAM, STEVEN CLAY 11/14/2001 769.00 4 83C 010402868A 04/12/2001 SELLERS, BRANDON 11/14/2001 654.00 4 83C 010402871A 04/12/2001 TOWNDROW, VICKI SUE 11/14/2001 992.00 4 83C 010402877A 04/13/2001 SANCHEZ, NOEMI 11/14/2001 700.00 4 83C 010402915A 04/14/2001 MONTOYA, STEPHANIE 11/14/2001 100.00 4 83C 010402930A 04/15/2001 LUJAN, JULIANA E 11/14/2001 922.00 4 83C 010402944A 04/15/2001 JOHNSON, CHRISTOPHER 11/14/2001 1028.00 4 83C 010402964A 04/16/2001 TURECEK, ROBERT 11/14/2001 190.20 4 83C 010403000A 04/17/2001 LOCKER, MICHAEL E J 11/14/2001 839.00 4 83C 010403025A 04/18/2001 SCHNEIDER, ELAINE D 11/14/2001 399.00 4 83C 010403063A 04/19/2001 SCHNEIDER, ELAINE D 11/14/2001 167.80 4 83C 010403064A 04/19/2001 LUERSON, STEPHEN M 11/14/2001 769.00 4 83C 010403106A 04/20/2001 MCCORD, HEATHER 11/14/2001 852.00 4 83C 010403155A 04/21/2001 VELA7QUEZ, EDUARDO 11/14/2001 769.00 4 83C 010403260A 04/24/2001 PATTON, FRANCES L 11/14/2001 399.00 4 83C 010403291A 04/25/2001 ADAMS, NICHOTAS 11/14/2001 527.13 4 83C 010403294A 04/25/2001 DIAZ, CANDALARIO 11/14/2001 831.00 4 83C 010403369A 04/28/2001 LOPEZ, SANDRA 11/14/2001 899.00 4 83C 010403374A 04/28/2001 SALDANO, JUAN 11/14/2001 937.00 4 83C 010403383A 04/29/2001 RODRIGUEZ, STEVEN 11/14/2001 100.00 4 83C 010403405A 04/29/2001 SANTORO, ADRIANNE 11/14/2001 399.00 4 83C 010403428A 04/30/2001 PULLIAM, AMBER R 11/14/2001 716.00 4 83C 010503498A 05/02/2001 LYONS, HEATHER 11/14/2001 261.60 4 83C 010503509A 05/03/2001 MILES, BRANDON 11/14/2001 654.00 4 83C 010503511A 05/03/2001 HERNANDEZ, RAYMUNDO 11/14/2001 793.00 4 83C 010503642A 05/07/2001 CREECH, KELLI 11/14/2001 654.00 4 83C 010503653A 05/08/2001 JIMENEZ, CAROLYN 11/14/2001 819.00 4 83C 010503661A 05/08/2001 BROWN, JEANNE R 11/14/2001 769.00 4 83C 010503665A 05/08/2001 WEIMER, MIKE 11/14/2001 819.00 4 83C 010503674A 05/09/2001 MOOTE, LARRY A 11/14/2001 817.00 4 83C 010503678A 05/09/2001 EVANS, ALICIA C 11/14/2001 654.00 4 83C 010503693A 05/10/2001 RIVERA, RICHARD J 11/14/2001 769.00 4 83C 010503700A 05/10/2001 GALLEGOS, JULIAN C 11/14/2001 1129.00 4 83C 010503720A 05/10/2001 WILSON, DAN 11/14/2001 769.00 4 83C 010503756B 05/12/2001 JIMINEZ, MAURICIO 11/14/2001 100.00 4 83C 010503821A 05/14/2001 MARKHAM, STEVEN CLAY 11/14/2001 927.08 4 83C 010503861A 05/15/2001 BRUNGARDT, JUDY 11/14/2001 901.00 4 83C 010503875A 05/16/2001 STAHN, JASON 11/14/2001 999.00 4 83C 010503877A 05/16/2001 ALEMAN, MARCELINA 11/14/2001 654.00 4 83C 010503948A 05/18/2001 HEGINBOTTOM, BRYAN 11/14/2001 1004.00 4 83C 010503990A 05/20/2001 IXMAY, CLAUDIA Date:11/15/2001 Weld County Ambulance Page: 3 Time:09:59:10 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 11/14/2001 Thru 11/14/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 11/14/2001 781.00 4 83C 010504077A 05/24/2001 GARDUNO, BRENDA L 11/14/2001 100.00 4 83C 010504097B 05/24/2001 KANZENBACH, GREG 11/14/2001 . 884.00 4 83C 010504157A 05/27/2001 GONZAES-PINEDA, JESU 11/14/2001 399.00 4 83C 010504163A 05/27/2001 WEISCOPF, JOHN C 11/14/2001 399.00 4 83C 010504244A 05/30/2001 LYONS, HEATHER 11/14/2001 855.00 4 83C 010604288A 06/01/2001 DELONG-LILES, PAIGE 11/14/2001 765.00 4 83C 010604291A 06/01/2001 BLOSS, BRIAN 11/14/2001 399.00 4 83C 010604331A 06/02/2001 BOBBITT, ELLEN L 11/14/2001 678.00 4 83C 010604351A 06/03/2001 WINSLOW, BRADLEY A 11/14/2001 819.00 4 83C 010604406A 06/06/2001 JACKSON, DON 11/14/2001 100.00 4 83C 010604436A 06/07/2001 VERA, JOSE 11/14/2001 775.08 4 83C 010604440A 06/07/2001 YINGLING, RAYMOND 11/14/2001 927.00 4 83C 010604456A 06/08/2001 BALENSEIFEN, GENE 11/14/2001 140.80 4 83C 010604486A 06/09/2001 PAYLOR, CINDA L 11/14/2001 769.00 4 83C 010604488A 06/09/2001 TAPIA, MARISSA 11/14/2001 819.00 4 83C 010604512A 06/10/2001 CONKLIN, JAMES R 11/14/2001 100.00 4 83C 010604518A 06/10/2001 ZAVALA, FELICIANO 11/14/2001 775.08 4 83C 010604540A 06/11/2001 MENDOZA, JOSEFA 11/14/2001 100.00 4 83C 010604607B 06/13/2001 TELLEZ, DENISE 11/14/2001 819.00 4 83C 010604614A 06/14/2001 GARCIA, SARAH 11/14/2001 843 .00 4 83C 010604627A 06/14/2001 URBACH, JEFFREY L 11/14/2001 384.60 4 83C 010604650A 06/15/2001 MCKIBBEN, MICHELLE 11/14/2001 769.00 4 83C 010604651B 06/15/2001 FRANCO, MARIA 11/14/2001 1052.00 4 83C 010604654B 06/15/2001 DELAROSA, OLIVIA 11/14/2001 654.00 4 83C 010604655A 06/15/2001 TORRES, CHRISTIE 11/14/2001 . 819.00 4 83C 010604659A 06/15/2001 HELUS, WILLIAM 11/14/2001 348.00 4 83C 010604673A 06/16/2001 OWENS, VALERIE K 11/14/2001 839.00 4 83C 010604710B 06/17/2001 SMITH, EDWARD C 11/14/2001 100.00 4 83C 010604715A 06/17/2001 WEAVER, KIRSTEN 11/14/2001 884 .00 4 83C 010604721A 06/17/2001 SCHMIDT, DONNA 11/14/2001 831.00 4 83C 010604723A 06/17/2001 WEAVER, PATRICK 11/14/2001 769.00 4 83C 010604743A 06/18/2001 COLLOP, KRISTIE L 11/14/2001 751.08 4 83C 010604785A 06/20/2001 HENDRIX, KATHERINE P 11/14/2001 769.00 4 83C 010604897A 06/24/2001 RIVERA, JAMES 11/14/2001 20.00 4 81 010605000A 06/27/2001 KINEMAN, HELEN 11/14/2001 795.08 4 83C 010605025A 06/28/2001 BLAKE, LESTER 11/14/2001 1077.00 4 83C 010705258A 07/05/2001 RUIZ, AYDE YUDITH 11/14/2001 1070.00 4 83C 010705314A 07/07/2001 COX, ALBERT J 11/14/2001 399.00 4 83C 010705387A 07/10/2001 ROBERTS, JASON L 11/14/2001 781.00 4 83C 010705605B 07/17/2001 MOWREY, CHET 11/14/2001 669.00 4 83C 010705615A 07/17/2001 IWERKS, TANYA M 11/14/2001 704.00 4 83C 010705931A 07/28/2001 SAENZ, FLOYD 11/14/2001 100.00 4 83C 010806106A 08/02/2001 CORDOVA, SATERO 11/14/2001 - 793.00 4 83C 010806147A 08/04/2001 RODRIGUEZ, ANA C 11/14/2001 678.00 4 83C 010806445A 08/13/2001 KRIEN, CHARLES 11/14/2001 100.00 4 83C 010806478A 08/14/2001 GRIEGO, FRED 11/14/2001 769.00 4 83C 010806489A 08/15/2001 TROTCHIE, JACK 11/14/2001 819.00 4 83C 010806655A 08/20/2001 TROTCHIE, JACK 11/14/2001 844.00 4 83C 010806660A 08/21/2001 SKINNER, RHONDA Date:11/15/2001 Weld County Ambulance Page: 4 Time:09:59:10 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 11/14/2001 Thru 11/14/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 11/14/2001 100.00 4 83C 010806680A 08/21/2001 FETTES, TIM 11/14/2001 789.00 4 83C 010906977A 09/01/2001 GALLEGOS, DON 11/14/2001 754.00 4 83C 010907155A 09/07/2001 SIGMON, MEGAN L 11/14/2001 714.00 4 83C 010907399A 09/15/2001 PILLARD, SHANE D 11/14/2001 956.00 4 83C 010907453A 09/16/2001 BARBER, JAY E 11/14/2001 0.08 4 83 010907515A 09/19/2001 HORII, ROY 11/14/2001 10.70 4 81 011008233A 10/14/2001 REIMER, NILES K 11/14/2001 391.42 4 81 011008240A 10/14/2001 BAILEY, ROSE 11/14/2001 526.36 4 81 011008245A 10/14/2001 CARROLL, PAULINE 11/14/2001 462.46 4 81 011008252A 10/14/2001 SANCHEZ, ROSE 11/14/2001 404.07 4 81 011008266A 10/15/2001 OSTER, EDNA 11/14/2001 419.74 4 81 011008267A 10/15/2001 ALDRIDGE, WILLIAM W 11/14/2001 199.23 4 81 011008274A 10/15/2001 OSTER, EDNA 11/14/2001 404.07 4 81 011008291A 10/16/2001 HETTINGER, CLARA 11/14/2001 391.42 4 81 011008306A 10/16/2001 STEMBRIDGE, MARY C 11/14/2001 54.79 4 81 011008315A 10/16/2001 MOODY, BEVERLY 11/14/2001 25.18 4 81 011008322A 10/17/2001 PETERSON, AUDREY J 11/14/2001 654.00 4 83C 011008442A 10/20/2001 LICANO, CALLETANO 11/14/2001 654.00 4 83C 011008531A 10/24/2001 CARDONA, GUSTAVO Total of 166 WriteOff Entries Totaling 97634.27 Dollars Average WriteOff: 588.16 Dollars Average Time:184 Days Date:11/15/2001 Weld County Ambulance Page: 5 Time:09:59:10 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 11/14/2001 Thru 11/14/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83C WRITEOFF TO COLLECTION AG 152 94260.75 620.14 195.44 83 WRITEOFF 2 64.08 32.04 177.00 81 MEDICARE WRITEOFF 12 3309.44 275.79 39.08 Date:11/19/2001 Weld County Ambulance Page: 1 Time:10:38:44 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 11/16/2001 Thru 11/16/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 11/16/2001 8.33 4 70CE 000100069A 01/04/2000 PINEDA, MARK 11/16/2001 147.55 4 70CE 000100219A 01/10/2000 PADILLA, MAX 11/16/2001 8.26 4 70CE 000100342A 01/15/2000 GOMEZ, MARCOS 11/16/2001 36.36 4 70CE 000100501A 01/21/2000 MEEKS, KATHY 11/16/2001 16.66 4 70CE 000100624A 01/26/2000 VELEZ, ALEIDA 11/16/2001 18.75 4 70CE 000100698A 01/29/2000 EREBIA, ANNE 11/16/2001 25.02 4 70CE 000301498A 03/02/2000 WARENBOURG, BONNIE 11/16/2001 7.37 4 70CE O00301910C 03/17/2000 REYES, MAGDA 11/16/2001 95.25 4 70CE 000302068A 03/24/2000 SISNEROS, DANIEL J 11/16/2001 42.40 4 70CE 000302076A 03/24/2000 DICAMILLO, JEFFREY H 11/16/2001 15.00 4 70CE 000402324A 04/01/2000 BURT, JAMES 11/16/2001 313.33 4 70CE 000402832A 04/20/2000 RUPP, ERIC 11/16/2001 5.00 4 70PF 000403026A 04/26/2000 HARRIS, ROBERT JOSEP 11/16/2001 37.50 4 70CE 000403033A 04/26/2000 MORRELL, GIESELE M 11/16/2001 33.33 4 70CE 000503246A 05/05/2000 CHERRY, ODILIA G 11/16/2001 18.92 4 70CE 000503254A 05/06/2000 ARCHULETA, ANTHONY 11/16/2001 33.33 4 70CE 000503288B 05/07/2000 GONZALES, DAVID ROLA 11/16/2001 50.00 4 70CE 000503412A 05/11/2000 REDDIN, JOHN D 11/16/2001 16.66 4 70CE 000503621A 05/19/2000 ZAMORA, BLANCA 11/16/2001 135.30 4 70CE 000603979A 06/01/2000 SMALL, CINDY 11/16/2001 32 .98 4 70CE 000604261A 06/11/2000 TILLMAN, KATIE 11/16/2001 5.00 4 70PF 000604348A 06/13/2000 MCNULTY, NICOLE 11/16/2001 382 .50 4 70PF 000604403A 06/15/2000 SLOAN, TRISHA J 11/16/2001 25.00 4 70CE 000704893A 07/02/2000 ROSIN, FREIDA 11/16/2001 3 .33 4 70PF 000704904A 07/02/2000 MEADOR, DWAINE 11/16/2001 181.66 4 70CE 000705011A 07/05/2000 JIMENEZ, CARMEN 11/16/2001 8.33 4 70CE 000705048A 07/06/2000 HEIMANN, SHANDA 11/16/2001 13.33 4 70PF 000705048A 07/06/2000 HEIMANN, SHANDA 11/16/2001 8.33 4 70CE 000705048A 07/06/2000 HEIMANN, SHANDA 11/16/2001 8.33 4 70CE 000705057A 07/07/2000 CRESPIN, ANITA 11/16/2001 8.33 4 70PF 000705057A 07/07/2000 CRESPIN, ANITA 11/16/2001 44.81 4 70CE 000705360A 07/15/2000 MAES, CASEY D 11/16/2001 6.66 4 70CE 000705456A 07/19/2000 GATES, JASHAUNTA 11/16/2001 16.66 4 70CE 000705739A 07/30/2000 OCHOA, JOY 11/16/2001 66.66 4 70CE 000705744A 07/30/2000 DUNN, JEFFREY 11/16/2001 15.23 4 70CE 000705755A 07/30/2000 TAYLOR, LARRY 11/16/2001 66.66 4 70CE 000805803A 08/01/2000 RIVAS, OLGA 11/16/2001 37.50 4 70CE 000805958A 08/06/2000 VITTETOE, JOSHUA R 11/16/2001 6.72 4 70CE 000806619A 08/29/2000 TRUJILLO, MELODY R 11/16/2001 49.01 4 70CE 000906814A 09/05/2000 ARGUELLO, FRANCES 11/16/2001 33 .33 4 70CE 000906849A 09/06/2000 MARTINEZ, SAGE LEIGH 11/16/2001 15.78 4 70CE 000906866A 09/07/2000 OCHOA, MIA 11/16/2001 33.33 4 70CE 000906894A 09/07/2000 GUEVARRA, EMILSE 11/16/2001 37.50 4 70CE 000907044A 09/12/2000 REITZ, CHRISTOPHER 11/16/2001 177.09 4 70CE 000907062A 09/13/2000 WOODS, CLARENCE 11/16/2001 25.00 4 70CE 000907113A 09/14/2000 CURTIS, SCOTT 11/16/2001 32.47 4 70CE 000907113A 09/14/2000 CURTIS, SCOTT 11/16/2001 33.33 4 70CE 000907166A 09/17/2000 VELO-BRAVO, TEODOSIO 11/16/2001 97.49 4 70CE 000907519A 09/29/2000 OLIVAS, ZACH Date:11/19/2001 Weld County Ambulance Page: 2 Time:10:38:47 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 11/16/2001 Thru 11/16/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 11/16/2001 102 .50 4 70CE 000907521A 09/29/2000 SMALL, CINDY 11/16/2001 215.63 4 81 001007666A 10/04/2000 GIBSON, MARIAN E 11/16/2001 33 .33 4 70CE 001007690A 10/05/2000 RICO, MARINA 11/16/2001 33 .33 4 70CE 001007999A 10/16/2000 KIRKER, KELLY 11/16/2001 13 .33 4 70PF 001008243A 10/25/2000 TUNSTFAn, SCOTT 11/16/2001 15.00 4 70CE 001008317A 10/28/2000 VIERYA, LORRAINE 11/16/2001 16.66 4 7OPF 001008341A 10/29/2000 VARELA VARELA, NORMA 11/16/2001 46.66 4 70CE 001008407A 10/31/2000 JIMENEZ, CARMEN 11/16/2001 13 .33 4 70CE 001108517A 11/04/2000 ALCORN, ERIC L 11/16/2001 17.52 4 70CE 001108670A 11/10/2000 JOHNSON, TRACY 11/16/2001 6.66 4 70PF 001108890A 11/17/2000 LOPEZ, ESMELEGLIDA 11/16/2001 43.50 4 70CE 001109045A 11/25/2000 PEMBERTON, MARIE 11/16/2001 23.33 4 70CE 001109052A 11/25/2000 MIJARES, JEFFREY 11/16/2001 43.33 4 70CE 001109155A 11/30/2000 CORRAL, JOSE P 11/16/2001 12.72 4 70CE 001209418A 12/08/2000 FLETCHER, EMILY B 11/16/2001 8.33 4 70CE 001209815A 12/23/2000 RAMOS, JOHN FREDRICK 11/16/2001 7.34 4 70CE 001209975A 12/29/2000 MOODY, MICHAEL L 11/16/2001 206.33 4 70CE 010100552A 01/20/2001 JIMENEZ, CARMEN 11/16/2001 186.20 4 83C 010100883A 01/31/2001 HARPER, TYLER 11/16/2001 165.66 4 70C 010200898A 02/01/2001 KISTLER, MARY 11/16/2001 33.33 4 70CE 010201125A 02/08/2001 SCHWARTZ, DEBBY 11/16/2001 133.33 4 70CE 010201174A 02/10/2001 POLLMILLER, JEFF 11/16/2001 194.30 4 83C 010201547A 02/24/2001 OCAMPO, DANIEL 11/16/2001 66.66 4 70PF 010201645A 02/28/2001 TURNER, MARIANNA 11/16/2001 10.00 4 70CE 010301677A 03/01/2001 HERNANDEZ, ERICA G 11/16/2001 8.33 4 7OPF 010301742A 03/04/2001 HOGG, JAKE 11/16/2001 33 .32 4 70CE 010301789A 03/05/2001 OWENS, NATHAN P 11/16/2001 8.33 4 70PF 010301795A 03/06/2001 ARCHIBEQUE, MATT 11/16/2001 16.66 4 7OPF 010301879A 03/09/2001 ULLOA, MAYRA 11/16/2001 107.26 4 70CE 010302038A 03/14/2001 MAURER, DEBRA L 11/16/2001 133.00 4 70CE 010302133A 03/18/2001 KIEKHAEFER, CLARA M 11/16/2001 3.63 4 70CE 010302284A 03/24/2001 WOODS, REILLEY 11/16/2001 344.00 4 83C 010402695A 04/07/2001 MEYER, HALEY 11/16/2001 654.00 4 83C 010402852A 04/12/2001 RAMIREZ, ADRIANA 11/16/2001 1155.00 4 83C 010403187A 04/22/2001 ROMERO, ELIDIA 11/16/2001 831.00 4 83C 010503616A 05/06/2001 GREGG, DILLEN C 11/16/2001 399.00 4 83C 010503657A 05/08/2001 JIMENEZ, CAROLYN 11/16/2001 273 .00 4 7OPF 010604325A 06/02/2001 COOPER, TERRY 11/16/2001 399.00 4 83C 010604353A 06/03/2001 WINSLOW, BRADLEY A 11/16/2001 33 .33 4 70CE 881217036B 12/17/1988 BURRIS, JAMIE 11/16/2001 8.33 4 70CE 900918057A 09/18/1990 HERNANDEZ, DELORES 11/16/2001 275.00 4 70CE 910525059A 05/25/1991 EISENACH, JOEL 11/16/2001 3 .33 4 70CE 910707026A 07/07/1991 GOMEZ, FELIX 11/16/2001 35.50 4 70CE 950905772B 09/13/1995 ORTIZ, LINDA 11/16/2001 66.00 4 70CE 960401973A 04/05/1996 TOBAR, TENO 11/16/2001 13 .00 4 70CE 960402350A 04/22/1996 ORTEGA, LAURA 11/16/2001 5.00 4 70CE 960603647A 06/16/1996 DUDICK, JAMES 11/16/2001 11.24 4 70CE 960603654A 06/17/1996 CASTILLO, MARTINIA 0 11/16/2001 20.00 4 70CE 960704540A 07/26/1996 FITCH, NICK Date:11/19/2001 Weld County Ambulance Page: 3 Time:10:38:49 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 11/16/2001 Thru 11/16/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 11/16/2001 32.22 4 70CE 960704667A 07/30/1996 BERNAL, NICHOLAS 11/16/2001 3.33 4 70CE 961207491A 12/03/1996 CARTER, JONATHAN 11/16/2001 50.00 4 70CE 961207648A 12/09/1996 MILLER, DALE ZACHARY 11/16/2001 25.95 4 70CE 961207785A 12/14/1996 MEDINA, JAMES 11/16/2001 7.77 4 70CE 970100078A 01/04/1997 LEWIS, NANCY 11/16/2001 1.66 4 70CE 970201045A 02/17/1997 KELLNER, THEODORE 11/16/2001 174.43 4 70CE 970301617A 03/12/1997 HORTON, TIMOTHY D 11/16/2001 52.33 4 70CE 970402043A 04/03/1997 GALLEGOS KRISTLE 11/16/2001 257.00 4 70CE 970502872A 05/08/1997 CASEY, AMANDA 11/16/2001 6.66 4 70CE 970704280A 07/04/1997 CAMPBELL, KAY 11/16/2001 153 .11 4 70CE 970805308A 08/15/1997 MONTOYA, JACOB 11/16/2001 25.00 4 70CE 970906096A 09/14/1997 DOUGLAS, DAWN 11/16/2001 257.00 4 70PF 971006826A 10/15/1997 HOWE, MYRA 11/16/2001 49.96 4 70CE 971007023A 10/23/1997 MORRIS, MARK 11/16/2001 37.50 4 70CE 971007040A 10/23/1997 MARTINEZ, MELANIE 11/16/2001 6.66 4 70PF 971107247A 11/01/1997 KUSSMAN, MICHELLE 11/16/2001 2.72 4 70CE 971107276A 11/01/1997 RAMOS, CARLA ANN 11/16/2001 12.50 4 70CE 971107321A 11/04/1997 KENNEDY, LARRY 11/16/2001 8.33 4 70CE 980100058A 01/02/1998 BORGMAN, JIM 11/16/2001 20.00 4 70CE 980201168A 02/19/1998 PAYNE, JOHN M 11/16/2001 70.50 4 70CE 980301671A 03/14/1998 JARAMILLO, KRISTINA 11/16/2001 25.00 4 70CE 980402131A 04/04/1998 TURECEK, BOB 11/16/2001 220.00 4 70CE 980402601A 04/25/1998 KNOWLES, JULIE 11/16/2001 54.93 4 70CE 980603576A 06/03/1998 MILLER, DENA F 11/16/2001 2.35 4 70CE 980603649A 06/07/1998 MACIAS, DIANA 11/16/2001 30.81 4 70CE 980704628A 07/16/1998 GUERRERO, KELLY 11/16/2001 13 .33 4 70CE 980704683A 07/18/1998 KATO, NANCY 11/16/2001 62.50 4 70CE 980704852A 07/25/1998 TEJADA, JUAN 11/16/2001 33 .32 4 70CE 980805043F 08/01/1998 LOPEZ, OLEGARIO CAST 11/16/2001 59.79 4 70CE 980805261A 08/09/1998 SCHAEFER, RICHARD J 11/16/2001 63 .18 4 70CE 980805713A 08/26/1998 COOPER, PATRICIA 11/16/2001 34.34 4 70CE 980805713A 08/26/1998 COOPER, PATRICIA 11/16/2001 5.00 4 70CE 980805823A 08/31/1998 VAUGHAN, THOMAS 11/16/2001 33.33 4 70CE 981007270A 10/28/1998 CHAVEZ, ROSALINDA 11/16/2001 200.00 4 70PF 981107403B 11/02/1998 WEIMER, RON 11/16/2001 182.49 4 70CE 981107535A 11/08/1998 RIOS, JESSIE 11/16/2001 3.33 4 70CE 981107928A 11/25/1998 LECLAIR, AMY 11/16/2001 40.00 4 70CE 981107966A 11/26/1998 RODRIGUEZ, MARTHA 11/16/2001 50.00 4 70CE 981208121A 12/03/1998 GRIFFIN, ARNOLD K 11/16/2001 35.71 4 70CE 981208415A 12/14/1998 BAIRD, WENDY 11/16/2001 15.50 4 70CE 981208518A 12/18/1998 MEZA, JUAN G 11/16/2001 32.50 4 70CE 981208574A 12/20/1998 VILLARRFAT , THOM A 11/16/2001 16.66 4 70CE 990100323A 01/13/1999 MCDONALD, JEANNE 11/16/2001 6.66 4 70CE 990100367A 01/14/1999 CORDES, CONNIE 11/16/2001 42.50 4 70CE 990302064A 03/19/1999 CASTILLO, ARTHUR 11/16/2001 10.70 4 70CE 990402943A 04/20/1999 BAIRD, WENDY 11/16/2001 65.12 4 70CE 990403159A 04/29/1999 MENCHACA, ADRIAN 11/16/2001 25.74 4 70CE 990503258A 05/02/1999 BERLANGA, ALBERTO 11/16/2001 48.75 4 70CE 990503258A 05/02/1999 BERLANGA, ALBERTO Date:11/19/2001 Weld County Ambulance Page: 4 Time:10:38:53 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 11/16/2001 Thru 11/16/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 11/16/2001 14.96 4 70CE 990503449A 05/10/1999 SICKLER, JULIA A 11/16/2001 45.13 4 70CE 990503656A 05/19/1999 GUREVICH, DAVID 11/16/2001 162 .89 4 70CE 990604011A 06/03/1999 DICKSON, PENELOPE 11/16/2001 16.66 4 70CE 990604107A 06/06/1999 GARCIA, TONY 11/16/2001 90.00 4 70CE 990604252A 06/12/1999 RHODES, PATRICK 11/16/2001 5.18 4 70CE 990604391A 06/16/1999 VANMETER, TRUE 11/16/2001 77.95 4 70CE 990704817A 07/01/1999 DELAGARZA, ADRIAN 11/16/2001 15.00 4 70CE 990705257A 07/18/1999 SHAW, DARLENE 11/16/2001 48.08 4 70CE 990705349A 07/21/1999 HAGELSTROM, SYLVIA 11/16/2001 292.50 4 70CE 990705607A 07/30/1999 REYES, DORA 11/16/2001 78.90 4 70CE 990805773A 08/05/1999 GOODWIN, GARY 11/16/2001 4.42 4 70CE 990806025A 08/14/1999 SCHRAM, DAVID 11/16/2001 16.66 4 70CE 990806397A 08/28/1999 ALLEN, CLIFFORD 11/16/2001 45.65 4 70CE 990906794A 09/12/1999 TURNER, LASHONDA 11/16/2001 5.33 4 70CE 990906855A 09/15/1999 PARGAS, BETH 11/16/2001 29.04 4 70CE 990906934A 09/18/1999 BERLIER, GARY 11/16/2001 100.00 4 70CE 990907058A 09/24/1999 DELONG, CINTHIA 11/16/2001 25.00 4 70CE 991007377A 10/06/1999 CHAVEZ, ZACHARIAH 11/16/2001 17.94 4 70CE 9910074678 10/09/1999 SAENZ, REYNA 11/16/2001 20.00 4 70CE 991007580A 10/13/1999 NEUERBURG, MICHAEL J 11/16/2001 136.27 4 70CE 991007901A 10/25/1999 BENNETT, JERRI 11/16/2001 15.06 4 70CE 991007945A 10/27/1999 PINON, NANCY 11/16/2001 25.00 4 70CE 991108203A 11/06/1999 STAGGS, VINCENT 11/16/2001 50.00 4 70CE 991108309A 11/09/1999 SMITH, WILLIAM 11/16/2001 1.66 4 70CE 991108484A 11/16/1999 REYES, GERARDO 11/16/2001 5.00 4 70PF 991108516A 11/17/1999 JENKINS, AUSTIN 11/16/2001 33.33 4 70CE 991108824A 11/29/1999 MAYFIELD, RUDY H 11/16/2001 54.39 4 70CE 991208930A 12/03/1999 SALAZAR, JILLIAN 11/16/2001 15.17 4 70CE 991208958A 12/04/1999 CORPUS, GUSTAVO 11/16/2001 58.33 4 70CE 991209069A 12/08/1999 SANDOVAL, JOYCE 11/16/2001 3.15 4 70PF 991209407A 12/22/1999 HUNT, CAROL V 11/16/2001 15.60 4 70PF 991209563A 12/29/1999 DORRIS, JOHN 11/16/2001 66.66 4 70CE 991209580A 12/29/1999 CERVANTES, MANUEL 11/16/2001 247.37 4 70CE AR00032595 12/14/1994 POULOS, SANDY Late C 11/16/2001 16.66 4 70CE AR00032868 12/14/1994 APARISO, MARCELLA La 11/16/2001 18.15 4 70CE AR00035683 09/13/1995 RODRIGUEZ, LUIS Late Total of 183 WriteOff Entries Totaling 13562 .50 Dollars Average WriteOff: 74.11 Dollars Average Time:898 Days Date:11/19/2001 Weld County Ambulance Page: 5 Time:10:38:54 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 11/16/2001 Thru 11/16/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 70CE COLLECTION EXPENSE 154 7869.84 51.10 977.31 70PF PROFESSIONAL FINANCE COLL 20 1314.53 65.73 581.20 81 MEDICARE WRITEOFF 1 215.63 215.63 408.00 83C WRITEOFF TO COLLECTION AG 8 4162.50 520.31 219.38 Date:l1/20/2001 Weld County Ambulance Page: 1 Time:12:40:39 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 11/19/2001 Thru 11/19/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 11/19/2001 581.68 4 83 011008089A 10/08/2001 BURTON, SHANTEL 11/19/2001 673.74 4 83C 011008205A 10/13/2001 LEBSOCK, NATHAN 11/19/2001 692.29 4 83 011008303A 10/16/2001 STORY, DONNA R 11/19/2001 1148.90 4 83 011008305A 10/16/2001 MONTES RASCON, ZULEY 11/19/2001 322.35 4 83 011008375A 10/18/2001 WALLS, KEOSHA Total of 5 WriteOff Entries Totaling 3418.96 Dollars Average WriteOff: 683.79 Dollars Average Time:36 Days Date:11/20/2001 Weld County Ambulance Page: 2 Time:12:40:39 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 11/19/2001 Thru 11/19/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days 83 WRITEOFF 4 2745.22 686.31 35.50 83C WRITEOFF TO COLLECTION AG 1 673.74 673.74 37.00 • Date:12/14/2001 Weld County Ambulance Page: 1 Time:09:35:49 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 12/11/2001 Thru 12/13/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 12/11/2001 395 .00 4 83C 000301639A 03/07/2000 ARANDA, ISIDRA 12/11/2001 670 .00 4 83C 000604765A 06/27/2000 ZAMORA, JOHN 12/11/2001 775.00 4 83C 000705588A 07/23/2000 MONJE, ZULMA 12/11/2001 615.00 4 83C 000705595A 07/24/2000 WATTS, LETITIA 12/11/2001 290.00 4 82 000805800A 08/01/2000 WOLFE, DOLORES MELOD 12/11/2001 185 .60 4 83C 000906721A 09/02/2000 SNEKEKER, BRADFORD 12/11/2001 115 .00 4 83C 000906966A 09/09/2000 BLEY, KRISTIN 12/11/2001 64.75 4 83C 000907411A 09/25/2000 CALLAHAN, MIKE 12/11/2001 455.00 4 83C 001007782A 10/08/2000 RATHBUN, ROGER 12/11/2001 17.86 4 83C 010100139A 01/06/2001 GARCIA, GLORIA 12/11/2001 729.00 4 83C 010301951A 03/11/2001 CONTRERAS, JAMIE 12/11/2001 75 .00 4 83C 010302467A 03/31/2001 MORRISON, CHELSEA 12/11/2001 331 .00 4 83C 010402901A 04/13/2001 FREEMAN, THOMAS 12/11/2001 819.00 4 83C 010402974A 04/16/2001 MERAZ, PAOLA 12/11/2001 831.00 4 83C 010403035A 04/18/2001 POUNDS, BRADLEY S 12/11/2001 143 .00 4 83C 010403103A 04/20/2001 SAMPLES, JIMMIE 12/11/2001 200 .00 4 83C 010403207A 04/22/2001 BOBBITT, ELLEN L 12/11/2001 200 .00 4 83C 010403243A 04/23/2001 BOBBITT, ELLEN L 12/11/2001 1064.00 4 83C 010403379A 04/29/2001 MAYER, BRUCE 12/11/2001 100.00 4 83C 010503434A 05/01/2001 LARRARTE, ADRIEN 12/11/2001 949.00 4 83C 010503453A 05/01/2001 PORTILLO, CHRISTEN 12/11/2001 666.00 4 83C 010503459A 05/01/2001 BACA, BRIDGETT M 12/11/2001 987 .00 4 83C 010503478A 05/02/2001 BARTHOLOMEW, AARON " 12/11/2001 654 .00 4 83C 010503516A 05/03/2001 CORDOVA, LENA 12/11/2001 399.00 4 83C 010503530A 05/03/2001 PALMER, TINA L 12/11/2001 834 .00 4 83C 010503533B 05/03/2001 WILLIAMS, CLINTON 12/11/2001 731.00 4 83C 010503553A 05/04/2001 COLON, AVIDA 12/11/2001 824 . 00 4 83C 010503651A 05/08/2001 MITCHELL, EDWARD I 12/11/2001 24 .29 4 83C 010503670A 05/09/2001 DIAZ, JESSICA 12/11/2001 781.00 4 83C 010503768A 05/12/2001 LEWIS, NANCY 12/11/2001 654.00 4 83C 010503792A 05/13/2001 FLANAGAN, MICHAEL C 12/11/2001 . 781.00 4 83C 010503795A 05/13/2001 MATA, ROSIE 12/11/2001 528 .27 4 83C 010503907A 05/17/2001 BOWKER, VELMA 12/11/2001 834.00 4 83C 010503930A 05/17/2001 PONCE-ZAMORA, PRUDEN 12/11/2001 872.00 4 83C 010503967A 05/19/2001 DEHART, JOHN C 12/11/2001 927.00 4 83C 010503977A 05/19/2001 PORTILLO-ALMEDA, NIC 12/11/2001 100 .00 4 83C 010503995A 05/20/2001 CERETTO, JESSE BRAND 12/11/2001 925 .00 4 83C 010504035A 05/22/2001 CAMARILLO, VELGIO (A 12/11/2001 843.00 4 83C 010504039A 05/22/2001 MARTINEZ, MODESTO 12/11/2001 819.00 4 83C 010504065A 05/23/2001 ROGERS, KAREN 12/11/2001 831.00 4 83C 010504066A 05/23/2001 MERAZ, PAOLA 12/11/2001 971.00 4 83C 010504074A 05/24/2001 MILLER, SHAWN P 12/11/2001 891.00 4 83C 010504075A 05/24/2001 CORDOVA, SHAREN E 12/11/2001 903.00 4 83C 010504100A 05/24/2001 CONTRERAZ, PAULINE 12/11/2001 100.00 4 83C 010504113A 05/25/2001 CLARK, DARLENE 12/11/2001 769.00 4 83C 010504138A 05/26/2001 ARGUELLO, ANTONIO M 12/11/2001 859.00 4 83C 010504149A 05/27/2001 BARRY, JEFF 12/11/2001 399.00 4 83C 010504255A 05/30/2001 DOMORACKI, PAUL 12/11/2001 86.10 4 83C 010604284A 06/01/2001 LEBLANC, RICHARD Date:12/14/2001 Weld County Ambulance Page: 2 Time:09:35:51 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 12/11/2001 Thru 12/13/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 12/11/2001 100.00 4 83C 010604490A 06/09/2001 RODRIGUEZ, JOSEPH 12/11/2001 769.00 4 83C 010604524A 06/11/2001 RIOS, MARGARET L 12/11/2001 399.00 4 83C 010604535A 06/11/2001 SANCHEZ, JULIE 12/11/2001 728.00 4 83C 010604551A 06/11/2001 GONZALES, JUAN 12/11/2001 843 .00 4 83C 010604590A 06/13/2001 SANCHEZ, MARIA 12/11/2001 769.00 4 83C 010604604A 06/13/2001 SASSO JR, FREDRICO 12/11/2001 731.00 4 83C 010604608A 06/14/2001 WATSON, SHANE 12/11/2001 654 .00 4 83C 010604623A 06/14/2001 FARRIS, ERIC 12/11/2001 254.00 4 83C 010604746A 06/18/2001 CUMBERLIN, CAROLYN 12/11/2001 884.00 4 83C 010604791A 06/20/2001 ZAMORANO, ELVIN 12/11/2001 666.00 4 83C 010604798A 06/20/2001 MOORE, DONALD W 12/11/2001 719.00 4 83C 010604805A 06/21/2001 OWEN, AARON 12/11/2001 714 .00 4 83C 010604839A 06/22/2001 HIGGINBOTTOM, RONINE 12/11/2001 554.00 4 83C 010604847A 06/22/2001 DAVIS, BRIAN 12/11/2001 654.00 4 83C 010604882A 06/23/2001 DUFFIELD-TURNER, MAT 12/11/2001 841.00 4 83C 010604885A 06/23/2001 RUBI, MICHAEL A 12/11/2001 775.08 4 83C 010604899A 06/24/2001 DIVORNE, RAMONA A 12/11/2001 704 .00 4 83C 010604906A 06/24/2001 ROHR, SANDRA 12/11/2001 859.00 4 83C 010604918A 06/24/2001 HOLLEY, CHARLIE 12/11/2001 819.00 4 83C 010604919A 06/24/2001 OROZCO-CARRILLO, JOS 12/11/2001 551.32 4 83C 010604920A 06/24/2001 BISHOP, CAROL 12/11/2001 719.00 4 83C 010604926A 06/24/2001 GONZALES, GABRIEL 12/11/2001 187.72 4 83C 010604937A 06/25/2001 HERBST, ANDRIA M 12/11/2001 769.00 4 83C 010604944A 06/25/2001 MCCLURE, ROBERT 12/11/2001 793 .00 4 83C 010604956B 06/26/2001 SMITH, AMBER 12/11/2001 100.00 4 83C 010605001A 06/27/2001 HAINS, CHARLOTTE 12/11/2001 859.00 4 83C 010605005A 06/27/2001 CAVALIERE, EDWARD 12/11/2001 704 .00 4 83C 010605011A 06/27/2001 GUTIERREZ, MARGIE 12/11/2001 744.00 4 83C 010605015A 06/27/2001 SHREEVES, AMBER 12/11/2001 300.40 4 83C 010605024A 06/28/2001 WITHROW, DONALD 12/11/2001 769.00 4 83C 010605068A 06/29/2001 SANCHEZ, REBEKAH 12/11/2001 100 .00 4 83C 010605070A 06/29/2001 BAXTER, PHILIP 12/11/2001 100 .00 4 83C 010605104A 06/30/2001 SIME, TODD 12/11/2001 100.00 4 83C 010705107A 07/01/2001 CHAVEZ, MELECIO 12/11/2001 789.00 4 83C 010705115A 07/01/2001 HOLLEY, OTHA 12/11/2001 100.00 4 83C 010705160A 07/02/2001 FERRELL, IAN 12/11/2001 654 .00 4 83C 010705212A 07/04/2001 GARZA, ANNETTE L 12/11/2001 719.00 4 83C 010705235A 07/04/2001 SALAZAR, PAULA 12/11/2001 858.00 4 83C 010705239G 07/05/2001 ALTAVILLA, PIERRE 12/11/2001 781.00 4 83C 010705363A 07/09/2001 CARTER, CRYSTAL 12/11/2001 879.00 4 83C 010705424A 07/11/2001 LOPEZ, OLIVIA 12/11/2001 678 .00 4 83C 010705564A 07/15/2001 FLORES, KEVIN 12/11/2001 781.00 4 83C 010705608A 07/17/2001 PENNETTA, JULIE 12/11/2001 100.00 4 83C 010705736A 07/22/2001 RAMIREZ, ROGELIO 12/11/2001 999.00 4 83C 010705741A 07/22/2001 BARBER, BETTY J 12/11/2001 399.00 4 83C 010705743A 07/22/2001 TSIKEWA, CHERYLYNN 12/11/2001 779.00 4 83C 010705821A 07/24/2001 VASQUEZ, CARMEN 12/11/2001 817.00 4 83C 010705826A 07/24/2001 JOHNSON, DENNIS C 12/11/2001 100.00 4 83C 010705889A 07/27/2001 CASTILLO, CHRISTINA Date:12/14/2001 Weld County Ambulance Page: 3 Time:09:35:51 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 12/11/2001 Thru 12/13/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 12/11/2001 399.00 4 83C 010705965A 07/29/2001 PORTER, DONNA J 12/11/2001 781.00 4 83C 010705972A 07/29/2001 MYERS, ROBERTA F 12/11/2001 399.00 4 83C 010705976A 07/29/2001 MYERS, ROBERTA F 12/11/2001 704 .00 4 83C 010806202A 08/05/2001 HUCKINS, ROBIN 12/11/2001 74 . 96 4 83C 010806227A 08/06/2001 ADAMS, ROBERT W 12/11/2001 100 .00 4 83C 010806246A 08/06/2001 LINDSAY, BRETT 12/11/2001 0.01 4 83 010806501A 08/15/2001 INGHAM, CURTISS 12/11/2001 830.60 4 82 010806622A 08/19/2001 CARLESON, SARIAH 12/11/2001 719.00 4 83C 010806689A 08/21/2001 YARBROUGH, BRADLEY 12/11/2001 100 .00 4 83C 010806820A 08/26/2001 VELASQUEZ, MANUEL 12/11/2001 704 . 00 4 83C 010906982A 09/01/2001 PULLIAM, AMBER R 12/11/2001 399.00 4 83C 010906985A 09/01/2001 PULLIAM, AMBER R 12/11/2001 769.00 4 83C 010906990A 09/01/2001 BULLOCK, CYNTHIA J 12/11/2001 980.00 4 83C 010907006A 09/02/2001 SOSTROS, HECTOR 12/11/2001 399.00 4 83C 010907035A 09/03/2001 CARROLL, CHRISTOPHER 12/11/2001 719.00 4 83C 010907307A 09/11/2001 SALAZAR, PAULA 12/11/2001 654 .00 4 83C 010907322A 09/12/2001 RAMEY, JAMES C 12/11/2001 199.23 4 81 010907396A 09/14/2001 LAPOINTE, CLAIRE 12/11/2001 738.00 4 83C 010907425A 09/16/2001 BARRIOS, JOEL 12/11/2001 704 .00 4 83C 010907437A 09/16/2001 BONERTZ, ELLEN 12/11/2001 100.00 4 83C 010907535A 09/19/2001 OLIVEROS, PEPE 12/11/2001 819.00 4 83C 011007876A 10/01/2001 VAQUEDENDO, CECILIO 12/11/2001 198 .53 4 81 011007909A 10/02/2001 WETZEL, GARY L 12/11/2001 12.57 4 81 011007917A 10/03/2001 SHAKLEE, RICHARD 12/11/2001 509.71 4 81 011007983A 10/05/2001 GONZALEZ, MARIA 12/11/2001 17.02 4 81 011008060A 10/08/2001 ARNUSCH, KATHARINA 12/11/2001 87.28 4 83C 011008210A 10/13/2001 BOOTHBY, SHIRLEY 12/11/2001 1.00 4 81 011008268A 10/15/2001 HESSLER, CORA 12/11/2001 42 .20 4 81 011008371A 10/18/2001 PEDEN, DONNA 12/11/2001 20.00 4 81 011008468A 10/22/2001 STONEMETS, MARVIN EA 12/11/2001 38.04 4 81 011108822A 11/03/2001 BECHTHOLDT, GLEN 12/11/2001 404 .07 4 81 011108844A 11/04/2001 KOELLNER, BEATRICE 12/11/2001 570 .92 4 81 011108856A 11/04/2001 FITZGERALD, NETTIE 12/11/2001 452 .66 4 81 011108861A 11/04/2001 LLANAS, FRANCISCA 12/11/2001 199.23 4 81 011108866A 11/05/2001 BRUCE, DANIEL P 12/11/2001 74 .12 4 81 011108870A 11/05/2001 SORENSON, LOUIS 12/11/2001 404 .07 4 81 011108872A 11/05/2001 KNAUS, ROBERT 12/11/2001 567.02 4 81 011108892A 11/05/2001 BROWN, GEORGE LEE 12/11/2001 511.06 4 81 011108897A 11/06/2001 LEINGANG, JOE 12/11/2001 535.75 4 81 011108904A 11/06/2001 CHAVEZ, MARGARET 12/11/2001 487.80 4 81 011108910A 11/06/2001 EWING, JEAN 12/11/2001 475.94 4 81 011108919A 11/06/2001 SHANNON, GAYLE 12/11/2001 470 .69 4 81 011108922A 11/06/2001 JOHNSON, CHARLOTTE 12/11/2001 220 .15 4 81 011108931A 11/06/2001 JOHNSON, CHARLOTTE 12/11/2001 428 .76 4 81 011108936A 11/07/2001 STATLEY, RANDY 12/11/2001 391.42 4 81 011108941A 11/07/2001 TIDQUIST, CHARLOTTE 12/11/2001 391.42 4 81 011108944A 11/07/2001 WESSON, MARY 12/11/2001 472 .47 4 81 011108949A 11/07/2001 HAYES, MARIE 12/11/2001 20 .00 4 81 011109252A 11/18/2001 BACA, MARIA Date:12/14/2001 Weld County Ambulance Page: 4 Time:09:35:54 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 12/11/2001 Thru 12/13/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 12/11/2001 60.00 4 81 011109331A 11/21/2001 JORGENSEN, MARY N 12/11/2001 40 .00 4 81 011109349A 11/22/2001 LYNCH, DORIS J 12/11/2001 65 .00 4 REV 011109491B 11/27/2001 SCHRUM, RON 12/12/2001 80.00 4 81 010604998A 06/27/2001 HALLER, CORNELIA 12/13/2001 54.50 4 83C 001108491A 11/03/2000 PADILLA, ALEC 12/13/2001 140.00 4 83C 001108832A 11/15/2000 WILLFORD, MARJORIE 12/13/2001 625.00 4 83C 001108917A 11/18/2000 ENCINIA, VICTORIA 12/13/2001 362 .20 4 83C 010100460A 01/17/2001 MARSTON, DONALD F 12/13/2001 82 .20 4 83C 010100472A 01/17/2001 MARSTON, DONALD F 12/13/2001 750 .08 4 83C 010100530A 01/20/2001 PLATO, VERA 12/13/2001 432 .00 4 83C 010201299A 02/14/2001 MILLS, KYE WAYNE 12/13/2001 100.00 4 83C 010201560A 02/24/2001 URESTE, CELESTINO 12/13/2001 50.00 4 83C 010302345A 03/26/2001 RODRIGUEZ, MICHAEL 12/13/2001 25.00 4 83C 010302405A 03/28/2001 YBARRA, RAMON 12/13/2001 283 .94 4 82 010302464A 03/31/2001 DOBBINS, ADRIENNE 12/13/2001 100 .00 4 83C 010402592A 04/04/2001 WHITE, TRACY 12/13/2001 995 .00 4 83C 010402690A 04/07/2001 BERNHOFT, DEBRA 12/13/2001 901.00 4 83C 010402726A 04/08/2001 MARTINEZ, MARK Z 12/13/2001 77.84 4 83C 010402881A 04/13/2001 HERBST, MIKE E 12/13/2001 775.08 4 83C 010403275A 04/24/2001 PLATO, VERA 12/13/2001 50.00 4 83C 010503441A 05/01/2001 KING, FLORENCE M 12/13/2001 76.15 4 83C 010503458A 05/01/2001 HERBST, MIKE E 12/13/2001 839.00 4 83C 010503531A 05/03/2001 TRAVIS, STEPHEN KENT 12/13/2001 399.00 4 83C 010503554A 05/04/2001 TRAVIS, STEPHEN KENT 12/13/2001 25.00 4 83C 010503660A 05/08/2001 POLLOCK, ROBERT 12/13/2001 100.00 4 83C 010503691A 05/10/2001 GRUBBS, PEGGY 12/13/2001 769.00 4 83C 010503756A 05/12/2001 CRESPIN, SAMUEL 12/13/2001 939.08 4 83C 010503817A 05/14/2001 DIVORNE, RAMONA A 12/13/2001 853 .00 4 83C 010503849A 05/14/2001 RAMIREZ, JUAN 12/13/2001 488.50 4 83C 010503891A 05/16/2001 ROGERS, KAREN 12/13/2001 77.61 4 83C 010504058A 05/23/2001 MURPHY, BILLIE 12/13/2001 1065.00 4 83C 010504156A 05/27/2001 ARAGON, GERALD 12/13/2001 399.00 4 83C 010604414A 06/06/2001 WATSON, SHANE 12/13/2001 399.00 4 83C 010604610A 06/14/2001 WATSON, SHANE 12/13/2001 275.70 4 83C 010604611A 06/14/2001 GARBISO, PORFELIO J 12/13/2001 1385 .45 4 83C 010604713A 06/17/2001 HENDERSON, CURTIS L 12/13/2001 25.00 4 83C 010604730A 06/18/2001 TYNAN, JIM 12/13/2001 719.00 4 83C 010604747A 06/18/2001 REGALADO, GEOVANNI M 12/13/2001 25.00 4 83C 010604768A 06/19/2001 TYNAN, JIM 12/13/2001 654 .00 4 83C 010604848B 06/22/2001 HAMMOND, TERRY 12/13/2001 955 .00 4 83C 010604868A 06/23/2001 STOLTE, DELBERT 12/13/2001 200.00 4 83C 010705128A 07/01/2001 CIOLEK, VICTORIA 12/13/2001 800.00 4 83C 010705138A 07/01/2001 FISHER, NAOMI JO 12/13/2001 40.53 4 83C 010705208A 07/04/2001 CONKLIN, JAMES R 12/13/2001 1007.00 4 83C 010705236A 07/04/2001 HILLMAN, ROBERT D 12/13/2001 704 .00 4 83C 010705480A 07/13/2001 HIGH, JUDIE 12/13/2001 179.20 4 83C 010806143A 08/04/2001 RIZZO, TOMMY 12/13/2001 455.68 4 83C 010806156A 08/04/2001 CORYELL, HOLLY 12/13/2001 478.28 4 83C 010806226A 08/06/2001 HERNANDEZ, JIMMIE T • Date:12/14/2001 Weld County Ambulance Page: 5 Time:09:36:04 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 12/11/2001 Thru 12/13/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name 12/13/2001 769.00 4 83C 010806378A 08/11/2001 HAYES, BRAD 12/13/2001 937 .00 4 83C 010907558A 09/20/2001 ELKINS, MICHAEL 12/13/2001 508.35 4 81 011008743A 10/31/2001 STEMBRIDGE, MARY C 12/13/2001 0.03 4 83 011108857A 11/04/2001 FAGERBERG, CHARLES 12/13/2001 404.07 4 81 011108959A 11/08/2001 WESSON, MARY 12/13/2001 382 .36 4 81 011108960A 11/08/2001 PADRON, JOYCE 12/13/2001 540 .94 4 81 011108961A 11/08/2001 TWERSKI, GERTRUDE 12/13/2001 423 .09 4 81 011108963A 11/08/2001 DITTER, DANIEL 12/13/2001 - 475.15 4 81 011108965A 11/08/2001 MIJARES, SAMUEL 12/13/2001 540.15 4 81 011108972A 11/08/2001 KISSICK, VIRGINIA D 12/13/2001 487.80 4 81 011108984A 11/08/2001 MEJIA, DOLORES 12/13/2001 423 .09 4 81 011109016A 11/10/2001 MINER, ANNA 12/13/2001 404 .07 4 81 011109019A 11/10/2001 RODRIGUEZ, KATHRINE 12/13/2001 199.23 4 81 011109029A 11/10/2001 RODRIGUEZ, KATHRINE 12/13/2001 220.15 4 81 011109032A 11/10/2001 LEDFORD, REUBEN 12/13/2001 403 .28 4 81 011109045A 11/10/2001 HEBERLING, RICHARD 12/13/2001 454 .23 4 81 011109055A 11/11/2001 ANDERSEN, DONALD W 12/13/2001 410 .44 4 81 011109057A 11/11/2001 PROVANCHA, ELMER 12/13/2001 423 .09 4 81 011109068A 11/12/2001 MCCOY, CONSTANCE 12/13/2001 461.68 4 81 011109069A 11/12/2001 JORGENSEN, MARY N 12/13/2001 404.07 4 81 011109083A 11/12/2001 GODINEZ, NICK 12/13/2001 391.42 4 81 011109104A 11/13/2001 LOPEZ, CARMEN 12/13/2001 594 .79 4 81 011109106A 11/13/2001 ALLEN, WILBERTA 12/13/2001 775 .00 4 83C 990302382A 03/31/1999 BYMER, TAMMIE Total of 220 WriteOff Entries Totaling 108392 .59 Dollars Average WriteOff: 492.69 Dollars Average Time:169 Days • Date:12/14/2001 Weld County Ambulance Page: 6 Time:09:36 :05 Receipt, Write-off, Adjustment Batch Report MRR300 WriteOffBatch From 12/11/2001 Thru 12/13/2001 Date Source Check # Branch # Value T RWA Code Invoice Inv Date Patient Name Code Description Count Total $ Avg $ Avg Days s 83C WRITEOFF TO COLLECTION AG 164 90075.71 549.24 207.78 82 MEDICAID WRITEOFF 3 1404.54 468.18 289.33 83 WRITEOFF 2 0.04 0.02 78.50 81 MEDICARE WRITEOFF 50 16847.30 336.95 41.16 REV REVERSE CHARGED IN ERROR 1 65.00 65.00 14.00 Hello