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GREER COUNTY • CJ-2026-00007

Mangum Regional Medical Center v. Kayli D Billy and Cary V Billy

Filed: Apr 1, 2026
Type: CJ

What's This Case About?

Let’s be real: hospitals don’t usually show up in small claims court with subpoenas and itemized CPT codes like they’re about to drop a mixtape. But here we are, in the dusty legal plains of Greer County, Oklahoma, where Mangum Regional Medical Center has decided to go full litigation mode over $11,700.86 in unpaid ER visits — not for one patient, not for two, but for an entire family medical tour starring a couple, their kids, and what appears to be a recurring cast of sniffles, fevers, and very expensive emergency room drama.

Meet Kayli D. Billy and Cary V. Billy — a married couple (or at least were at the time of treatment, according to the filing) living on a country road outside Mangum, population 3,400, where the nearest Walmart is probably a 45-minute drive and the ER might as well be the community center. They’re not public figures. They’re not reality stars. They’re just regular folks who, over the span of three years, visited the Mangum Regional ER with the frequency of a Netflix binge — and now, they’re being sued jointly and severally for more than eleven grand. That’s not “oops, forgot my wallet” money. That’s “could’ve bought a decent used truck” money.

So what happened? Well, buckle up, because this isn’t one incident — it’s five separate emergency room appearances, spread across four different patients, all tied to the same household, all paid… nothing. Let’s break it down like a medical billing true crime timeline.

First up: Ripp W. Billy, born in 2021 (yes, that’s really the name), made his ER debut on January 10, 2022, with what the hospital bills as a Level 3 emergency visit — code 99283, for the nerds — totaling $992. That’s before the lab work, which added another $511 for tests like “87807” (probably not a Star Wars droid, but who knows). No payment. Just a polite “see you next time,” which, shockingly, came less than a year later.

Then, on November 27, 2022, it was Kayli D. Billy’s turn. She showed up at the ER, presumably not for a spa day, and racked up over $5,400 in charges — including $783.92 for another 99283 visit, $1,330 in adjustments (which the hospital later wrote off), and a smorgasbord of CPT codes that look like a hacker’s password. There were payments listed — multiple “PAY IN” entries on December 2022 — but somehow, the balance still landed at $1,330.06 unpaid. Accounting mystery? Insurance runaround? Or just a family that stopped checking the mailbox?

Fast forward to February 2024, and the baton passes to Jace Mikles, another child tied to the household (possibly a sibling or relative), who gets the same ER treatment: $1,008 for the visit, $783.92 for… more visit, and zero dollars paid. Adjustments? None. Payments? None. Just a cold $1,791.92 added to the growing tab.

Then, in June 2024, it’s Ripp W. Billy again — now age 2 — back at the ER like it’s toddler daycare. Same drill: $1,008 visit, $783.92 for the doctor, labs, and miscellaneous “Q2” charges that sound like a rejected Bond villain gadget. Total: $2,459.92. Paid? You already know the answer.

And finally, the pièce de résistance: December 21, 2024 — Ripp again, now three years old and possibly just really bad at staying healthy. This time, the bill explodes to $3,832.03, thanks in part to a jump from a Level 3 (99283) to a Level 4 emergency visit (99284) — which, in hospital speak, means “we were very concerned.” Add in imaging, labs, and a few hundred bucks for miscellaneous supplies, and boom: the largest single unpaid charge in the stack.

Add it all up — $2,286.93 + $1,330.06 + $1,791.92 + $2,459.92 + $3,832.03 — and you get $11,700.86, the exact amount Mangum Regional is now demanding in court. And here’s the kicker: the hospital isn’t just suing Kayli — who appears as the guarantor on every single bill — but also her husband, Cary V. Billy, even though his name doesn’t show up on any patient records. Why? Because under Oklahoma law (43 O.S. §209.1), spouses are jointly and severally liable for necessary medical expenses incurred during marriage. So even if Cary never set foot in the ER, never signed a form, and was possibly just minding his own business fixing a tractor, he’s on the hook too. That’s not just legal — that’s marital financial spousal jeopardy.

Now, let’s talk about what the hospital actually wants. They’re not asking for punitive damages. They’re not demanding jail time or a public apology. Just $11,700.86, plus 6% annual interest from the date of each service (which could tack on another grand or two), plus court costs and — because this is America — a “reasonable attorney’s fee.” The law firm representing them? Fisher & Fisher. Yes, really. Husband-and-wife legal duo suing a husband-and-wife medical debtor duo. It’s like a legal telenovela.

Is $11,700 a lot? For a rural Oklahoma family, absolutely. That’s a year’s groceries. A down payment on a trailer. Two months of rent. But for a hospital? Not really. Mangum Regional isn’t exactly Cedars-Sinai. This is a 25-bed critical access hospital in a town so small, the high school football team has its own Wikipedia page. And yet, they’re spending attorney hours, notary fees, and court filing costs to chase down this debt — because someone in their billing department clearly decided: This stops now.

Here’s the wildest part: the hospital claims they’re in full compliance with the Transparency in Health Care Prices Act, which requires them to publish their rates. And they did! Somewhere! Probably on a PDF buried in the third dropdown menu of their website. But let’s be honest — when your toddler is vomiting at 2 a.m., you don’t pull up the hospital’s CPT code price sheet. You drive. You sign. You pray. And later, you get a bill with line items like “87186” and “71C45TC” and wonder if you were charged for a spaceship repair.

So what’s really going on here? Is this a case of a family overwhelmed by medical debt and a system that bills like it’s playing 4D chess? Or is it a hospital trying to set an example — a “don’t mess with our receivables” flex in a town where everyone knows everyone?

Our take? We’re not rooting for the hospital. Not because they don’t deserve to be paid — they do. But because suing an entire family across five ER visits, slapping a husband with liability for his wife’s medical decisions, and billing $783.92 for a single emergency room evaluation — not the treatment, not the meds, just the look — feels less like justice and more like a system that’s forgotten what “necessary care” means when you live 40 miles from the nearest pediatrician.

We’re also low-key rooting for the Billys to show up in court with a cooler full of casseroles, a stack of insurance denial letters, and a single PowerPoint slide titled “Our Kid Had RSV and Y’all Charged Us $3,832.” Because in the end, this isn’t just about money. It’s about what happens when the emergency room becomes the default doctor for rural America — and who gets stuck with the bill when the system fails everyone.

We’re entertainers, not lawyers. But if this case goes to trial, we’re bringing popcorn. And a CPT code decoder ring.

Case Overview

$11,701 Demand Petition
Jurisdiction
District Court, Oklahoma
Relief Sought
$11,701 Monetary
Plaintiffs
Defendants
Claims
# Cause of Action Description
1 Account stated Plaintiff seeks to recover $11,700.86 for medical services rendered to Defendant.

Petition Text

2,353 words
IN THE DISTRICT COURT IN AND FOR GREER COUNTY STATE OF OKLAHOMA MANGUM REGIONAL MEDICAL CENTER, Plaintiff, vs. KAYLI D BILLY AND CARY V BILLY, Defendants. Case No. CJ-26-7 PETITION Plaintiff, Mangum Regional Medical Center by and through its attorneys, Timothy A. Fisher and Kristin Blue Fisher of the firm of Fisher & Fisher, for its Petition against the Defendant, Kayli D Billy and Cary V Billy, alleges and states as follows: 1. Defendants are individuals residing in Greer County, Oklahoma or received services from Plaintiff in Greer County, Oklahoma. 2. This court has jurisdiction over the subject matter hereof and the parties hereto. 3. Defendants are indebted to Plaintiff for services rendered and for an account stated in the sum of $11,700.86. (See Exhibit A). 4. Upon information and belief, Defendants were married to one another on the dates upon which one or both received necessary medical treatment from Plaintiff. Pursuant to 43 O.S. §209.1, Defendants are jointly and severally liable for the payment of the medical expenses at issue. 5. After all due and just credits have been applied and after demand, there remains due, owing, and unpaid the sum of $11,700.86, together with pre-judgment interest at the statutory rate of 6% per annum from the date of services rendered until the date of judgment, and thereafter at the statutory rate for judgments. 6. Plaintiff is in compliance with the Transparency In Health Care Prices Act. (See Exhibit B). Wherefore, Plaintiff prays for judgment against Defendants, and each of them, jointly and severally, in the sum of $11,700.86, together with pre-judgment interest thereon at the statutory rate of 6% per annum from the date of services rendered until the date of judgment and thereafter at the statutory rate for judgments, plus the costs of this action accrued and accruing and a reasonable attorney's fee. Respectfully submitted, Kristin Blue Fisher, OBA # 15898 Timothy A. Fisher, OBA #15899 FISHER & FISHER PO Box 700870 Tulsa, Oklahoma 74170 918-488-9191 [email protected] / [email protected] Attorneys for Plaintiff VERIFICATION OF ACCOUNT PLAINTIFF/CREDITOR: MANGUM REG MED CTR* DEFENDANT(S)/DEBTOR(S) KAYLI D & CARY V BILLY STATE OF OKLAHOMA COUNTY OF GREER THE UNDERSIGNED, BEING FIRST DULY SWORN UPON OATH, STATES: 1. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE PLAINTIFF IN THE POSITION OF Kaylil Admusdax 2. THE UNDERSIGNED IS FAMILIAR WITH THE ACCOUNT RECORDS OF PLAINTIFF. TO THE BEST OF THE UNDERSIGNED'S KNOWLEDGE AND BELIEF THERE IS PRESENTLY DUE AND OWING AND UNPAID TO PLAINTIFF FROM THE DEFENDANT(S) THE SUM OF $11700.86 AFTER CREDIT HAS BEEN GIVEN FOR ALL PAYMENTS AND OFFSETS TO WHICH THE DEFENDANT(S) IS/ARE ENTITLED. (IF APPLICABLE) THE MENTIONED DEFENDANT(S) HAS NOT REQUESTED A FAP/FAP WAS REQUESTED AND DENIED AFTER REVIEW. CLIENT FURTHER CONFIRMS COMPLIANCE WITH ALL 501(r) REQUIREMENTS [Signature] SUBSCRIBED AND SWORN TO BEFORE ME THIS 23 TH DAY OF August, 2025. Judy Kaye Hamilton NOTARY PUBLIC MY COMMISSION EXPIRES June 22, 2029 **PLEASE VERIFY THE ABOVE BALANCE(S), SIGN, NOTARIZE AND RETURN WITH THE ITEMIZED STATEMENT(S) FOR THE CHARGE(S) INCLUDED IN THE TOTAL. 11449472 SEE ATTACHMENT(S) EXHIBIT "A" PATIENT--------------------------------------------------------------- NUM/NAME-: 10632399 BILLY RIPP W SEX------: M BIRTH----: 09/07/2021 DOCTOR--: 900068 MCCAIDE SAR MARRITAL--: S SOC.SEC.-: BILLING INFORMATION------------------- CREDIT-----: BILL-------: CYCLE-----: 2 STAY TYPE-: 3 E/R SERVICE---: ER INSURANCE-: DBS INDIAN HEALTH SERVICES -OP GUARANTOR--------------------------------------------- NAME-----: BILLY KAYLI D ADDRESS--: 21520 N CO ROAD 1850 MANGUM OK 73554 PHONE----: 5804715261 ADMISSION--------------------------- DATE-------: 01/10/22 CODE-------: E DISCHARGE------------------------- DATE-------: 01/10/22 DAY STAY CODE------: H 01/HOME <table> <tr> <th>A/R</th> <th>SERV DATE</th> <th>TYPE</th> <th>TRAN CODE</th> <th>CHG/REC NUMBER</th> <th>QTY</th> <th>DESCRIPTION</th> <th>CHARGE</th> <th>CREDIT</th> <th>MED NECESSARY</th> <th>CPT</th> </tr> <tr> <td>C1/10/22</td> <td></td> <td>CHG</td> <td>Q2</td> <td>3387420</td> <td>1.00</td> <td></td> <td>216.00</td> <td></td> <td></td> <td>87807</td> </tr> <tr> <td>C1/10/22</td> <td></td> <td>CHG</td> <td>Q2</td> <td>3087804</td> <td></td> <td></td> <td>215.00</td> <td></td> <td></td> <td>878340W</td> </tr> <tr> <td>C1/10/22</td> <td></td> <td>CHG</td> <td>Q2</td> <td>3000060</td> <td></td> <td></td> <td>80.00</td> <td></td> <td></td> <td>87426</td> </tr> <tr> <td>C1/10/22</td> <td></td> <td>CHG</td> <td>43</td> <td>5500731</td> <td></td> <td></td> <td>.01</td> <td></td> <td></td> <td></td> </tr> <tr> <td>C1/12/22</td> <td></td> <td>CHG</td> <td>SL</td> <td>2099283</td> <td></td> <td></td> <td>783.92</td> <td></td> <td></td> <td>99283</td> </tr> <tr> <td>C1/12/22 C1/10/22</td> <td></td> <td>CHG</td> <td>36</td> <td>188126</td> <td></td> <td></td> <td>992.00</td> <td></td> <td></td> <td>99283</td> </tr> <tr> <td>06/08/22</td> <td></td> <td>PAY</td> <td></td> <td></td> <td></td> <td></td> <td>0.00</td> <td></td> <td></td> <td></td> </tr> <tr> <td>06/08/22</td> <td></td> <td>PAY</td> <td></td> <td></td> <td></td> <td></td> <td>0.00</td> <td></td> <td></td> <td></td> </tr> <tr> <td>12/27/23</td> <td></td> <td>CHG</td> <td>WO</td> <td>99001</td> <td></td> <td></td> <td>2,286.93</td> <td></td> <td></td> <td></td> </tr> </table> BAD DEBT BALANCE...........2,286.93 AR BALANCE.................................0.00 9/30/25 12:06 Tuesday MANGUM REGIONAL MEDICAL CENTER PATIENT ACCOUNT DETAIL 1032399 BILLY RIPP W ****************** CHARGE SUMMARY *************** SUMMARY CODE DESCRIPTION AMOUNT DAYS NECESSARY UNITS 36 [REDACTED] 992.00 1.00 43 [REDACTED] .01 1.00 Q2 [REDACTED] 511.00 3.00 SL [REDACTED] 783.92 1.00 WO [REDACTED] 2,286.93CR 1.00 TOTAL CHARGES...........2,286.93 TOTAL ADJUSTMENTS......-2,286.93 LESS PAYMENTS.............0.00 AR BALANCE..................0.00 BAD DEBT BALANCE.......2,286.93 PATIENT--------------------------------------------- NAME/NAME--: 10038477 BILLY KAYLI D SEX------: F BIRTH----: 04/14/1993 DOCTOR---: 900072 BRAND JEFF MARRITAL--: M SOC.SEC.-: BILLING INFORMATION------------------ CREDIT-----: BILL-------: CYCLE-----: 3 STAY TYPE-: 3 E/R SERVICE---: ER INSURANCE-: BB BLUE CROSS OP GUARANTOR----------------------------------------- NAME-----: BILLY KAYLI D ADDRESS--: 21520 N CO ROAD 1850 MAXSIM OK 73554 PHONE----: 5804715261 ADMISSION--------------------------- DATE------: 11/27/22 CODE------: E DISCHARGE--------------------------- DATE------: 11/27/22 DAY STAY CODE------: H 01/HCME A.R SERV TYPE CHG/REC DATE DATE TRAN CODE NUMBER QTY DESCRIPTION --------------------------------------------------------------------------------------------- 11/27/22 CHG 55 3000003 11/27/22 CHG 56 3080053 11/27/22 CHG 55 3000004 11/27/22 CHG 56 3084704 11/27/22 CHG 45 2500405 11/27/22 CHG AN 2500303 11/27/22 CHG 62 4174176 11/27/22 CHG 57 3085027 11/27/22 CHG Q2 3087086 11/27/22 CHG 55 3081061 11/27/22 CHG 90 2503074 11/27/22 CHG 55 3050102 11/28/22 11/27/22 CHG 55 3099001 11/29/22 11/29/22 11/27/22 CHG SL 2098283 11/29/22 11/27/22 CHG 36 1880126 11/29/22 11/27/22 CHG QL 1836374 12/01/22 11/27/22 CHG Q2 3000558 12/01/22 11/27/22 CHG 59 3050017 12/07/22 11/27/22 CHG 59 3050017 12/07/22 11/27/22 CHG Q2 3001921 12/08/22 PAY IN 38025 12/12/22 PAY IN 38101 12/19/22 PAY IN 38230 12/19/22 PAY IN 38230 04/04/24 CHG WO 99001 CHARGE CREDIT MED .00 .00 85025 219.00 .00 80053 .00 .00 8257909 41.65 .00 84704 24.00 .00 J7030 5.00 .00 J1885 2,252.61 .00 741767C 109.00 .00 85027 166.00 .00 87086 137.10 .00 81002 7.00 .00 36415 26.00 .00 99001 27.00 .00 99283 783.92 .00 99283 992.00 .00 99283 554.40 .00 96374 26.25 .00 87088 41.23 .00 87187 41.23 .00 87186 725.62 .00 87187 3,307.43 .00 87186 3,356.48 .00 3,356.48 1,330.06 .00 1,330.06 BAD DEBT BALANCE.........1,330.06 AR BALANCE..........................0.00 09/29/25 15:13 Monday MANGUM REGIONAL MEDICAL CENTER PATIENT ACCOUNT DETAIL 1038477 BILLY KAYLI D ************ CHARGE SUMMARY *************** SUMMARY CODE DESCRIPTION DAYS MED- AMOUNT DAYS NECESSARY UNITS 992.00 1.30 24.00 1.00 190.10 5.00 260.65 2.00 109.00 1.00 2,352.61 1.00 7.00 1.00 5.00 1.00 233.48 3.00 554.40 1.00 783.92 1.00 1,330.06CR 1.30 TOTAL CHARGES.........5,412.16 TOTAL ADJUSTMENTS.....-1,330.06 LESS PAYMENTS.........4,082.10 AR BALANCE...............0.00 BAD DEBT BALANCE......1,330.06 PATIENT--------------------------------------------------------- NUM/NAME-: 10043978 MIKLES JACE SEX------: M BIRTH----: 07/29/2018 DOCTOR--: 900072 BRAND JEFF MARITAL--: S SOC.SEC.-: BILLING INFORMATION------------- CREDIT-----: BILL-------: CYCLE-----: 3 STAY TYPE-: 3 E/R SERVICE---: ER INSURANCE-: DBS INDIAN HEALTH SERVICES -OP GUARANTOR-------------------------------------- NAME-----: BILLY KAYLI D ADDRESS--: 21520 N CO ROAD 1850 MANGUM OK 73554 PHONE----: 5804715261 ADMISSION-------------------------- DATE--------: 02/24/24 CODE-------: E DISCHARGE------------------------ DATE--------: 02/24/24 DAY STAY CODE-------: H 01/HOME A/R SERV TYPE CHG/REC MED DATE DATE TRAN CODE NUMBER QTY DESCRIPTION CHARGE CREDIT NECESSARY CPT ------------------------------------------------------------------------------ 02/26/24 02/24/24 CHG 36 1880126 [REDACTED] 1,008.00 99283 02/26/24 [REDACTED] [REDACTED] 783.92 99283 02/26/24 02/24/24 CHG SL 2099283 [REDACTED] .00 08/14/24 PAY IN [REDACTED] .00 08/14/24 PAY IN [REDACTED] .00 08/14/24 PAY IN [REDACTED] .00 08/14/24 PAY IN [REDACTED] .00 01/31/25 CHG WC 99001 [REDACTED] 1,791.92 BAD DEBT BALANCE...........1,791.92 AR BALANCE..........................0.00 9/29/25 MANJUM REGIOINAL MEDICAL CENTER PAGE 2 15:16 Monday PATIENT ACCOUNT DETAIL 10043978 MIKLES JACE H5ARDET ************************ CHARGE SUMMARY ************************ SUMMARY DAYS MED- CODE DESCRIPTION AMOUNT DAYS NECESSARY UNITS [REDACTED] 1,008.00 1.00 [REDACTED] 783.92 1.00 [REDACTED] 1,791.92 CR 1.00 TOTAL CHARGES.............1,791.92 TOTAL ADJUSTMENTS.......-1,791.92 LESS PAYMENTS...............0.00 AR BALANCE....................0.00 BAD DEBT BALANCE......1,791.92 09/29/25 MANGUM REGIONAL MEDICAL CENTER PAGE 1 15:18 Monday PATIENT ACCOUNT DETAIL 19045202 BILLY RIPP W H5ARDET PATIENT--------------------------------------------- NUM/NAME-: 19045202 BILLY RIPP W SEX------: M BIRTH----: 09/07/2021 DOCTGR---: 000803 BARNES MAR MARITAL--: S SCC.SEC.-: BILLING INFORMATION------------------ CREDIT----: BILL------: CYCLE-----: 3 STAY TYPE-: 3 E/R SERVICE--: ER INSURANCE - OBS INDIAN HEALTH SERVICES -CP GUARANTOR------------------------------------------- NAME-----: BILLY KAYLI D ADDRESS--: 21520 N CG ROAD 1850 MANGUM OK 73554 PHONE----: 58094715261 ADMISSION------------------------------- DATE------: 06/12/24 CODE------: E DISCHARGE-------------------------- DATE-------: 06/12/24 DAY STAY CODE-------: H 01/HOME <table> <tr> <th>A/R DATE</th> <th>SERV DATE</th> <th>TYPE</th> <th>TRAN CODE</th> <th>CHG/REC NUMBER</th> <th>QTY</th> <th>DESCRIPTION</th> <th>CHARGE</th> <th>CREDIT</th> <th>NECESSARY</th> <th>CPT</th> </tr> <tr> <td>C6/12/24</td> <td></td> <td>CHG</td> <td>Q2</td> <td>3087420</td> <td></td> <td></td> <td>216.00</td> <td></td> <td></td> <td>87807</td> </tr> <tr> <td>C6/12/24</td> <td></td> <td>CHG</td> <td>Q2</td> <td></td> <td></td> <td></td> <td>157.00</td> <td></td> <td></td> <td>87880</td> </tr> <tr> <td>C6/12/24</td> <td></td> <td>CHG</td> <td>Q2</td> <td></td> <td></td> <td></td> <td>80.00</td> <td></td> <td></td> <td>87426</td> </tr> <tr> <td>C6/12/24</td> <td></td> <td>CHG</td> <td>Q2</td> <td></td> <td></td> <td></td> <td>215.00</td> <td></td> <td></td> <td>87804QW</td> </tr> <tr> <td>C6/13/24</td> <td>06/12/24</td> <td>CHG</td> <td>36</td> <td></td> <td></td> <td></td> <td>1,008.00</td> <td></td> <td></td> <td>99283</td> </tr> <tr> <td>C6/13/24</td> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> <td>783.92</td> <td></td> <td></td> <td>99283</td> </tr> <tr> <td>08/14/24</td> <td></td> <td>PAY</td> <td>IN</td> <td></td> <td></td> <td></td> <td>.00</td> <td></td> <td></td> <td></td> </tr> <tr> <td>08/14/24</td> <td></td> <td>PAY</td> <td>IN</td> <td></td> <td></td> <td></td> <td>.00</td> <td></td> <td></td> <td></td> </tr> <tr> <td>01/31/25</td> <td></td> <td>CHG</td> <td>WO</td> <td></td> <td></td> <td></td> <td>2,459.92</td> <td></td> <td></td> <td></td> </tr> </table> BAD DEBT BALANCE...........2,459.92 AR BALANCE.............................0.00 09/29/25 MAGNUM REGIONAL MEDICAL CENTER PAGE 2 15:18 Monday PATIENT ACCOUNT DETAIL 10045202 BILLY RIPP W HSARDET ************************** CHARGE SUMMARY ************************** SUMMARY DAYS MED- CODE DESCRIPTION AMOUNT DAYS NECESSARY UNITS 36 [REDACTED] 1,998.00 1.00 Q2 [REDACTED] 668.00 4.00 SL [REDACTED] 783.92 1.00 WO [REDACTED] 2,459.92CR 1.00 TOTAL CHARGES...........2,459.92 TOTAL ADJUSTMENTS......-2,459.92 LESS PAYMENTS.............0.00 AR BALANCE..................0.00 BAD DEBT BALANCE........2,459.92 09/29/25 MANGUM REGIONAL MEDICAL CENTER PAGE 1 15:20 Monday PATIENT ACCOUNT DETAIL 10047393 BILLY RIPP W HSARDET PATIENT--------------------------------------------- NUM/NAME--: 10047393 BILLY RIPP W SEX-------: M BIRTH-----: 09/07/2021 DOCTOR---: 9C0072 BRAND JEFF MARITAL--: S SOC.SEC.-: BILLING INFORMATION------------------ CREDIT----: BILL------: CYCLE-----: 2 STAY TYPE-: 3 E/R SERVICE--: ER INSURANCE-: DBS INDIAN HEALTH SERVICES -OP GJARANTOR------------------------------------------ NAME-----: BILLY KAYLI D ADDRESS--: 21520 N CO ROAD 1850 MRN:GUM OK 73554 PHONE----: 5804715261 ADMISSION-------------------------- DATE-------: 12/21/24 CODE------: E DISCHARGE--------------------------- DATE-------: 12/21/24 DAY STAY CODE------: H 01/HOME <table> <tr> <th>A/R DATE</th> <th>SERV DATE</th> <th>TYPE TRAN CODE</th> <th>CHG/REC NUMBER</th> <th>QTY DESCRIPTION</th> <th>CHARGE</th> <th>CREDIT</th> <th>MED NECESSARY</th> <th>CPT</th> </tr> <tr><td>12/21/24</td><td></td><td>CHG 55</td><td>3000003</td><td></td><td>.00</td><td></td><td></td><td>85025</td></tr> <tr><td>12/21/24</td><td></td><td>CHG 56</td><td>3080053</td><td></td><td>345.00</td><td></td><td></td><td>88053</td></tr> <tr><td>12/21/24</td><td></td><td>CHG Q2</td><td>3087420</td><td></td><td>216.00</td><td></td><td></td><td>87807</td></tr> <tr><td>12/21/24</td><td></td><td>CHG Q2</td><td>3087804</td><td></td><td>215.00</td><td></td><td></td><td>87804GW</td></tr> <tr><td>12/21/24</td><td></td><td>CHG Q2</td><td>3000091</td><td></td><td>100.00</td><td></td><td></td><td>87635</td></tr> <tr><td>12/21/24</td><td></td><td>CHG 57</td><td>3085625</td><td></td><td>169.00</td><td></td><td></td><td>85025</td></tr> <tr><td>12/22/24</td><td></td><td>CHG 77</td><td>4030001</td><td></td><td>396.07</td><td></td><td></td><td>71C45TC</td></tr> <tr><td>12/22/24</td><td></td><td>CHG 55</td><td>3099001</td><td></td><td>27.00</td><td></td><td></td><td>99001</td></tr> <tr><td>12/21/24</td><td></td><td>CHG 55</td><td>3050102</td><td></td><td>48.00</td><td></td><td></td><td>36415</td></tr> <tr><td>12/23/24</td><td>12/21/24</td><td>CHG 36</td><td>1880126</td><td></td><td>1,038.00</td><td></td><td></td><td>99283</td></tr> <tr><td>12/23/24</td><td>12/21/24</td><td>CHG SL</td><td>2099284</td><td>1.00</td><td>1,307.96</td><td></td><td></td><td>99284</td></tr> <tr><td>02/06/25</td><td></td><td>PAY IN</td><td></td><td></td><td>.00</td><td></td><td></td><td></td></tr> <tr><td>02/06/25</td><td></td><td>PAY IN</td><td></td><td></td><td>.00</td><td></td><td></td><td></td></tr> <tr><td>07/19/25</td><td></td><td>CHG WC</td><td>99001</td><td>1.00</td><td>3,832.03</td><td></td><td></td><td></td></tr> </table> BRD DEBT BALANCE...........3,832.03 AR BALANCE..........................0.00 *************** CHARGE SUMMARY *************** SUMMARY <table> <tr> <th>CODE</th> <th>DESCRIPTION</th> <th>AMOUNT</th> <th>DAYS NECESSARY</th> <th>UNITS</th> </tr> <tr> <td></td> <td></td> <td>1,008.00</td> <td></td> <td>1.00</td> </tr> <tr> <td></td> <td></td> <td>75.00</td> <td></td> <td>3.00</td> </tr> <tr> <td></td> <td></td> <td>345.00</td> <td></td> <td>1.00</td> </tr> <tr> <td></td> <td></td> <td>169.30</td> <td></td> <td>1.00</td> </tr> <tr> <td></td> <td></td> <td>396.07</td> <td></td> <td>1.00</td> </tr> <tr> <td></td> <td></td> <td>531.00</td> <td></td> <td>3.00</td> </tr> <tr> <td></td> <td></td> <td>1,307.96</td> <td></td> <td>1.00</td> </tr> <tr> <td></td> <td></td> <td>3,832.03CR</td> <td></td> <td>1.00</td> </tr> </table> TOTAL CHARGES..........3,832.03 TOTAL ADJUSTMENTS.....-3,832.03 LESS PAYMENTS...........0.00 AR BALANCE..................0.00 BAD DEBT BALANCE.......3,832.03 AFFIDAVIT OF COMPLIANCE WITH THE TRANSPARENCY IN HEALTH CARE PRICES ACT STATE OF OKLAHOMA ) COUNTY OF _________________ ) ss. The undersigned, Kelley Martinez (name), as Hospital Administrator (title) of Magna Regional Medical Center (provider), having been duly sworn, under oath, alleges and states as follows: 1. I have personal knowledge of the specific items of compliance herein identified. 2. Magna Regional Medical Center (provider) has fully complied with the Oklahoma Transparency in Health Care Prices Act by making available to the public, in a single document, electronically or by posting conspicuously on its website, the health care prices for at least: a. The twenty most used diagnosis-related group codes or other codes for inpatient health care services per specialty service line used by the provider for billing; and b. The twenty most used outpatient CPT codes or health care services procedure codes per specialty service line used for billing. c. The document includes, along with the health care prices provided, a plain English description of the services for which the health care prices are provided. d. The document is updated as frequently as appropriate but not less than annually. [Signature] Signature of Affiant Subscribed and sworn to before me, the undersigned Notary Public in and for the state and county above, on this 17th day of July 2025. [Signature] Notary Public Commission No.: 2108289 My Commission Expires: June 22, 2029
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