Finally, we are required to annotate your records to enable us to collect the erroneous payment by administrative offset against further CHAMPUS claims. No such offset action will be taken for sixty days from the date of this letter, however. Since the possibility of offset against your CHAMPUS claim exists, we are required to provide the following information to you.

You have the right to inspect and copy all records pertaining to this debt. If you believe this determination regarding your CHAMPUS coverage is incorrect or dispute the amount of the debt as calculated herein, you have a right to request an administrative review of the indebtedness.

Your request must be in writing and must be received by this office within 90 days from the date of this letter. Your request should state specific reasons for believing that you are not indebted for any amount listed herein, and should be accompanied by supporting documentation, such as bookkeeping and medical records, and a copy of this letter. If you wish to request a waiver based upon an inability to pay, you will be required to complete a financial affidavit. If it then appears that you are financially unable to make a full refund at this time, you may be afforded an opportunity to enter into a written agreement for repayment of the debt. Please note, however, that any payment plan will include an interest charge at the rate specified above.

Payment of the total amount shown above within 30 days is considered payment in full. To satisfy your debt immediately, send a check or money order for the total amount, made payable to CHAMPUS, Wisconsin Physicians Service in the enclosed self-addressed envelope. If payment is not made within 30 days, interest and other late charges will accrue.

Your cooperation and prompt attention to this matter are very much appreciated.

Sincerely,

For Xelle

cc. Terry Cox

Enclosure:

Self-addressed envelope

CHAMPUS Clains Support

Mr. Andrew Cox is a ♫ year old, white male with a diagnosis of Anoxic
Encephalopathy secondary to closed head injury Right subdural Hematoma,
Post Tracheotomy, Craniotomy, Gastrostomy, Jejunostomy Placement, Mr.
Cox was discharged from Palms of Pasadena Hospital on October 25, 1988
to his home.

Mr. Cox's pupils are equal and reactive to light, he has positive blink
and tracks with his eyes showing Left preference. He does not respond
to command at the time of this assessment. Upper extremities are con-
tracted and we are unable to straighten his arms or wrists fully, so he
has splints for rehabilitation. His lower extremities are stiff; right
more than left and right foot drop is more pronounced. He also has
Dyna Splints for feet. His rehabilitation will include Physical Therapy
once a week and ROM per nurses every shift.

Secondary to his respiratory status 02 30% humidified per trach collar is
continuous, and his O2 saturation is monitored every 8 hours and PRN per
Finger Oximetry. He has a strong cough so deep suctioning is rarely
required but does need frequent suctioning via Yankeur around trach.

Also, Mr. Cox has a Gastrostomy and Jejunostomy tube. Secondary to GI
Bleeding in the past, he does not tolerate feedings and medications in
the G-tube. His tube feedings of Sustacal H.C. full strength at 70cc
per hour are therefor infusing per Flexiflo III pump via the J-tube.

In addition, due to a decubitus on his coccyx, he requires frequent
repositioning. He has a Texas catheter to straight drainage, Blood
work will be drawn every other Monday and PRN. I have requested Kimberly
Quality Care Nursing to provide 24 hour Skilled LPN's and RN's seven
days a week, in lieu of further hospitalization. The care these nurses
will provide will include:

1) Skilled observation and assessment of the patient, including
vital signs: Temperature, Blood Pressure, Pulse & Respirations,
Neuro Status, Cardiac & Respiratory States, "GU & GI Status and
Skin Integrity.

Alfisted with Voluntary Hospitals of America/

2) Administer and monitor Sustacal H.C. enteral feedings vía J-tube. 3) Give trach care q 8 hours. and PRN.

4) Suction frequently as necessary.

5) Assist with 02 administration and adding H20 to humidification bottle.

6) Finger Oximetry q 8 hrs. and PRN

7) G-tube and J-tube care.

8) Decubitus care to coccyx twice a day.

9) Turn q 2 hrs. to prevent further skin breakdown.

10) Monitor and record Intake & Output g 8 hrs.

111) Change Texas catheter bag & tubing a week.

12) Administer meds per J-tube and G-tube per orders.

13) Provide one Physical Therapy visit per week.

14) ROM per nurses q 8 hrs.

15) Draw blood q other Monday and PRN as ordered and transport to lab. 16) Provide teaching to family on all aspects of care.

Supplies needed include:

Texas Catheters, bag, tubing

I feel this is necessary to maintain the medical regime for my patient in lieu of further hospitalization. If you have any questions, please feel free to contact me.