DEAR SCHOLARS:

                   ATTACHED PLEASE FIND THE ADJUDICATOR’S CLAIM CALCULATION INFORMATION:

                             1. PAGE 1 = FIRST ENCOUNTER

                             2. PAGE 2 = SECOND ENCOUNTER

                 BASED UPON THE NEW HEALTH INSURANCE PLAN SUMMARY, FOR BOTH ENCOUNTERS CALCUATE THE:

                             1. PATIENT’S COST SHARING FINANCIAL RESONSIBILITY

                             2. TPP’S COST SHARING FINANCIAL RESONSIBILITY

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                     "ENABLE EDITING" BOX – TOP MIDDLE – BEFORE ANY ENTRIES