FROM CODE AMOUNT CODE AMOUNT CODE AMOUNT. b c d 45 SERV.DATE 46 SERV.UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 CREATION DATE 52 REL.

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1 1 2 3 PT. 4 TYPE NTL # OF ILL.MED. RE. # 5 FED.TX NO. 6 STTEMENT OVERS PERIOD 7 FROM THROUGH 8 PTIENT NME 9 PTIENT DDRESS c d 10 IRTHDTE 11 SEX DMISSION ONDITION ODES 12 DTE 13 HR 14 TYPE 15 SR 16 DHR 29 DT STT STTE e 31 OURRENE 32 OURRENE 33 OURRENE 34 OURRENE 35 OURRENE SPN 36 OURRENE SPN 37 ODE DTE ODE DTE ODE DTE ODE DTE ODE FROM THROUGH ODE FROM THROUGH VLUE ODES 40 VLUE ODES 41 VLUE ODES ODE MOUNT ODE MOUNT ODE MOUNT c d 42 REV.D. 43 DESRIPTION 44 HPS / RTE / HIPPS ODE 45 SERV.DTE 46 SERV.UNITS 47 TOTL HRGES 48 NON-OVERED HRGES PGE OF RETION DTE TOTLS PYER NME 51 HELTH PLN ID 52 REL. INFO 53 SG. 54 PRIOR PYMENTS 55 EST.MOUNT DUE 56 NPI EN. 57 OTHER PRV ID 58 INSURED S NME 59 P.REL 60 INSURED S UNIQUE ID 61 GROUP NME 62 INSURNE GROUP NO. 63 TRETMENT UTHORIZTION ODES 64 DOUMENT ONTROL NUMER 65 EMPLOYER NME 66 DX 67 D E F G H I J K L M N O P Q 69 DMIT 70 PTIENT 71 PPS DX RESON DX c ODE EI c 74 PRINIPL PROEDURE. OTHER PROEDURE. OTHER PROEDURE 75 ODE DTE ODE DTE ODE DTE 76 TTENDING NPI QUL LST FIRST c. OTHER PROEDURE d. OTHER PROEDURE e. OTHER PROEDURE ODE DTE ODE DTE ODE DTE 77 OPERTING NPI QUL LST FIRST 80 REMRKS OTHER NPI QUL LST FIRST 68 c 79 OTHER NPI QUL U-04 MS-1450 PPROVED OM NO. d LST FIRST Ntionl Uniform NU illing ommittee LI THE ERTIFITIONS ON THE REVERSE PPLY TO THIS ILL ND RE MDE PRT HEREOF.

2 U-92 to U-04 ROSSWLK U-92 U-04 * FL68,75,80 Size Updted 6/21/05 uffer FL Description Line Type Size FL Description Line Type Size Spce Notes FL01 Provider Nme 1 N 25 FL01 Provider Nme 1 N 25 FL01 Provider Street ddress 2 N 25 FL01 Provider Street ddress 2 N 25 FL01 Provider ity, Stte, Zip 3 N 25 FL01 Provider ity, Stte, Zip 3 N 25 FL01 Provider Telephone, Fx, ountry ode 4 N 25 FL01 Provider Telephone, Fx, ountry ode 4 N 25 FL02 Unleled Fields 1 N 20 FL02 Py-to Nme 1 N 25 New FL02 Unleled Fields 2 N 30 FL02 Py-to ddress 2 N 25 New FL02 Py-to ity, Stte 3 N 25 New FL02 Py-to ID 4 N 25 New FL03 Ptient ontrol Numer 1 N 20 FL03 Ptient ontrol Numer N 24 FL03 Medicl Record Numer N 24 Moved/New FL04 Type of ill 1 N 3 FL04 Type of ill 1 N 4 1 Expnded FL05 Federl Tx Numer 1 N 4 FL05 Federl Tx Numer 1 N 4 FL05 Federl Tx Numer 2 N 10 FL05 Federl Tx Numer 2 N 10 FL06 Sttement overs Period - From/Through 1 N/N 6/6 FL06 Sttement overs Period - From/Through 1 N/N 6/6 1/1 FL07 Unleled 1 N 8 FL07 overed Dys 1 N 3 Eliminted - Sustitute new Vlue ode FL08 Non-covered Dys 1 N 4 Eliminted - Sustitute new Vlue ode FL09 oinsurnce Dys 1 N 3 Eliminted - Sustitute new Vlue ode FL10 Lifetime Reserve Dys 1 N 3 Eliminted - Sustitute new Vlue ode FL11 Unleled 1 12 Eliminted FL11 Unleled 2 13 Eliminted FL12 Ptient Nme 1 N 30 FL08 Ptient Nme - ID 1 N 19 New FL08 Ptient Nme 2 N 29 FL13 Ptient ddress 1 N 50 FL09 Ptient ddress - Street 1 N 40 1 Discrete FL09 Ptient ddress - ity 2 N 30 2 Discrete FL09 Ptient ddress - Stte 2c N 2 1 Discrete FL09 Ptient ddress - ZIP 2d N 9 1 Discrete FL09 Ptient ddress - ountry ode 2e N 3 Discrete FL14 Ptient irthdte 1 N 8 FL10 Ptient irthdte 1 N 8 1 FL15 Ptient Sex 1 N 1 FL11 Ptient Sex 1 N 1 2 FL16 Ptient Mritl Sttus 1 N 1 Eliminted FL17 dmission Dte 1 N 6 FL12 dmission Dte 1 N 6 FL18 dmission Hour 1 N 2 FL13 dmission Hour 1 N 2 1 FL19 Type of dmission/visit 1 N 1 FL14 Type of dmission/visit 1 N 1 2 FL20 Source of dmission 1 N 1 FL15 Source of dmission 1 N 1 1 FL21 Dischrge Hour 1 N 2 FL16 Dischrge Hour 1 N 2 2 FL22 Ptient Sttus/Dischrge ode 1 N 2 FL17 Ptient Dischrge Sttus 1 N 2 2 FL23 Medicl/Helth Record Numer N 17 Moved to FL3 FL24 ondition odes N 2 FL18 ondition odes N 2 1 FL25 ondition odes N 2 FL19 ondition odes N 2 1 FL20 ondition odes N 2 1

3 U-92 to U-04 ROSSWLK U-92 U-04 * FL68,75,80 Size Updted 6/21/05 uffer FL Description Line Type Size FL Description Line Type Size Spce Notes FL26 ondition odes N 2 FL21 ondition odes N 2 1 FL22 ondition odes N 2 1 FL27 ondition odes N 2 FL23 ondition odes N 2 1 FL24 ondition odes N 2 1 FL28 ondition odes N 2 FL25 ondition odes N 2 1 FL26 ondition odes N 2 1 New FL29 ondition odes N 2 FL27 ondition odes N 2 1 New FL28 ondition odes N 2 1 New FL30 ondition odes N 2 FL29 ccident Stte 1 N 2 1 New FL31 Unleled 1 5 FL31 Unleled 2 6 FL30 Unleled 1 N 12 FL30 Unleled 2 N 13 FL32 Occurrence ode/dte N/N 2/6 FL31 Occurrence ode/dte N/N 2/6 1/1 FL32 Occurrence ode/dte N/N 2/6 FL31 Occurrence ode/dte N/N 2/6 1/1 FL33 Occurrence ode/dte N 2/6 FL32 Occurrence ode/dte N/N 2/6 1/1 FL33 Occurrence ode/dte N/N 2/6 FL32 Occurrence ode/dte N/N 2/6 1/1 FL34 Occurrence ode/dte N 2/6 FL33 Occurrence ode/dte N/N 2/6 1/1 FL34 Occurrence ode/dte N/N 2/6 FL33 Occurrence ode/dte N/N 2/6 1/1 FL35 Occurrence ode/dte N 2/6 FL34 Occurrence ode/dte N/N 2/6 1/1 FL35 Occurrence ode/dte N/N 2/6 FL34 Occurrence ode/dte N/N 2/6 1/1 FL36 Occurrence Spn ode/from/through N/N/N 2/6/6 FL35 Occurrence Spn ode/from/through N/N/N 2/6/6 1/1/1 FL36 Occurrence Spn ode/from/through N/N/N 2/6/6 FL35 Occurrence Spn ode/from/through N/N/N 2/6/6 1/1/1 FL36 Occurrence Spn ode/from/through N/N/N 2/6/6 1/1/1 New FL36 Occurrence Spn ode/from/through N/N/N 2/6/6 1/1/1 New FL37 Unleled N 8 FL37 Unleled N 8 FL37 IN/DN N 23 Moved to FL64 Relocted FL37 IN/DN N 23 Moved to FL64 FL37 IN/DN N 23 Moved to FL64 FL38 Responsile Prty Nme/ddress 1 N 40 FL38 Responsile Prty Nme/ddress 1 N 40 2 FL38 Responsile Prty Nme/ddress 2 N 40 FL38 Responsile Prty Nme/ddress 2 N 40 2 FL38 Responsile Prty Nme/ddress 3 N 40 FL38 Responsile Prty Nme/ddress 3 N 40 2 FL38 Responsile Prty Nme/ddress 4 N 40 FL38 Responsile Prty Nme/ddress 4 N 40 2 FL38 Responsile Prty Nme/ddress 5 N 40 FL38 Responsile Prty Nme/ddress 5 N 40 2 FL39 Vlue ode - ode N 2 FL39 Vlue ode - ode N 2 1 FL39 Vlue ode - mount N 9 FL39 Vlue ode - mount N 9 1 FL39 Vlue ode - ode N 2 FL39 Vlue ode - ode N 2 1 FL39 Vlue ode - mount N 9 FL39 Vlue ode - mount N 9 1 FL39 Vlue ode - ode c N 2 FL39 Vlue ode - ode c N 2 1 FL39 Vlue ode - mount c N 9 FL39 Vlue ode - mount c N 9 1 FL39 Vlue ode - ode d N 2 FL39 Vlue ode - ode d N 2 1 FL39 Vlue ode - mount d N 9 FL39 Vlue ode - mount d N 9 1 FL40 Vlue ode - ode N 2 FL40 Vlue ode - ode N 2 1 FL40 Vlue ode - mount N 9 FL40 Vlue ode - mount N 9 1 FL40 Vlue ode - ode N 2 FL40 Vlue ode - ode N 2 1 FL40 Vlue ode - mount N 9 FL40 Vlue ode - mount N 9 1 FL40 Vlue ode - ode c N 2 FL40 Vlue ode - ode c N 2 1 FL40 Vlue ode - mount c N 9 FL40 Vlue ode - mount c N 9 1 FL40 Vlue ode - ode d N 2 FL40 Vlue ode - ode d N 2 1 FL40 Vlue ode - mount d N 9 FL40 Vlue ode - mount d N 9 1 FL41 Vlue ode - ode N 2 FL41 Vlue ode - ode N 2 1 FL41 Vlue ode - mount N 9 FL41 Vlue ode - mount N 9 1 FL41 Vlue ode - ode N 2 FL41 Vlue ode - ode N 2 1

4 U-92 to U-04 ROSSWLK U-92 U-04 * FL68,75,80 Size Updted 6/21/05 uffer FL Description Line Type Size FL Description Line Type Size Spce Notes FL41 Vlue ode - mount N 9 FL41 Vlue ode - mount N 9 1 FL41 Vlue ode - ode c N 2 FL41 Vlue ode - ode c N 2 1 FL41 Vlue ode - mount c N 9 FL41 Vlue ode - mount c N 9 1 FL41 Vlue ode - ode d N 2 FL41 Vlue ode - ode d N 2 1 FL41 Vlue ode - mount d N 9 FL41 Vlue ode - mount d N 9 1 FL42 Revenue ode 1-23 N 4 FL42 Revenue ode 1-23 N FL43 Revenue ode Description 1-23 N 24 FL43 Revenue ode Description 1-22 N FL43-44 PGE OF RETION DTE 23 N/N 3/3 0.5 New FL44 HPS/Rtes/HIPPS Rte odes 1-23N/N/N 9 FL44 HPS/Rtes/HIPPS Rte odes 1-22 N/N/N Expnded size FL45 Service Dte 1-23 N 6 FL45 Service Dte 1-22 N FL45 retion Dte 23 N New FL46 Units of Service 1-23 N 7 FL46 Units of Service 1-22 N FL47 Totl hrges 1-23 N 10 FL47 Totl hrges 1-23 N FL48 Non-overed hrges 1-23 N 10 FL48 Non-overed hrges 1-23 N Removed sign field Removed sign field FL49 Unleled 1-23 N 4 FL49 Unleled 1-23 N FL50 Pyer - Primry N 25 FL50 Pyer Nme - Primry N 23 FL50 Pyer - Secondry N 25 FL50 Pyer Nme - Secondry N 23 FL50 Pyer - Tertiry N 25 FL50 Pyer Nme - Tertiry N 23 FL51 Provider Numer N 13 FL51 Helth Pln ID N 15 FL51 Provider Numer N 13 FL51 Helth Pln ID N 15 FL51 Provider Numer N 13 FL51 Helth Pln ID N 15 FL52 Relese of Informtion - Primry N 1 FL52 Relese of Informtion - Primry N 1 1 FL52 Relese of Informtion - Secondry N 1 FL52 Relese of Informtion - Secondry N 1 1 Fl52 Relese of Informtion - Tertiry N 1 FL52 Relese of Informtion - Tertiry N 1 1 FL53 ssignment of enefits - Primry N 1 FL53 ssignment of enefits - Primry N 1 1 FL53 ssignment of enefits - Secondry N 1 FL53 ssignment of enefits - Secondry N 1 1 FL53 ssignment of enefits - Tertiry N 1 FL53 ssignment of enefits - Tertiry N 1 1 FL54 Prior Pyments - Primry N 10 FL54 Prior Pyments - Primry N 10 1 FL54 Prior Pyments - Secondry N 10 FL54 Prior Pyments - Secondry N 10 1 FL54 Prior Pyments - Tertiry N 10 FL54 Prior Pyments - Tertiry N 10 1 FL54 Prior Pyments - Ptient 4 N 10 Eliminted Ptient Prior Pyments FL55 Estimted mount Due - Primry N 10 FL55 Estimted mount Due - Primry N 10 1 FL55 Estimted mount Due - Secondry N 10 FL55 Estimted mount Due - Secondry N 10 1 FL55 Estimted mount Due - Tertiry N 10 FL55 Estimted mount Due - Tertiry N 10 1 FL55 Estimted mount Due - Ptient 4 N 10 Eliminted Due from Ptient FL56 Unleled 1 13 FL56 NPI 1 N 15 FL56 Unleled 2 14 FL57 Other Provider ID - Primry N 15 FL57 Other Provider ID - Secondry N 15 FL57 Other Provider ID - Tertiry N 15 FL57 Unleled 1 27 Deleted from U-04 FL58 Insured s Nme - Primry N 25 FL58 Insured s Nme - Primry N 25 1 FL58 Insured's Nme - Secondry N 25 FL58 Insured's Nme - Secondry N 25 1 FL58 Insured's Nme - Tertiry N 25 FL58 Insured's Nme - Tertiry N 25 1 FL59 Ptient s Reltionship - Primry N 2 FL59 Ptient s Reltionship - Primry N 2 1 FL59 Ptient's Reltionship - Secondry N 2 FL59 Ptient's Reltionship - Secondry N 2 1 FL59 Ptient's Reltionship -Tertiry N 2 FL59 Ptient's Reltionship - Tertiry N 2 1

5 U-92 to U-04 ROSSWLK U-92 U-04 * FL68,75,80 Size Updted 6/21/05 uffer FL Description Line Type Size FL Description Line Type Size Spce Notes FL60 ERT./ SSN/ HI/ ID NO. - Primry N 19 FL60 Insured's Unique ID - Primry N 20 FL60 ERT./ SSN/ HI/ ID NO.- Secondry N 19 FL60 Insured's Unique ID - Secondry N 20 FL60 ERT./ SSN/ HI/ ID NO. - Tertiry N 19 FL60 Insured's Unique ID - Tertiry N 20 FL61 Insurnce Group Nme - Primry N 14 FL61 Insurnce Group Nme - Primry N 14 1 FL61 Insurnce Group Nme -Secondry N 14 FL61 Insurnce Group Nme -Secondry N 14 1 FL61 Insurnce Group Nme - Tertiry N 14 FL61 Insurnce Group Nme - Tertiry N 14 1 FL62 Insurnce Group Numer - Primry N 17 FL62 Insurnce Group Numer - Primry N 17 1 FL62 Insurnce Group Numer - Secondry N 17 FL62 Insurnce Group Numer - Secondry N 17 1 FL62 Insurnce Group Numer - Tertiry N 17 FL62 Insurnce Group Numer - Tertiry N 17 1 FL63 Tretment uthoriztion ode - Primry N 18 FL63 Tretment uthoriztion ode - Primry N 30 1 Tretment uthoriztion ode - Tretment uthoriztion ode - FL63 Secondry N 18 FL63 Secondry N 30 1 FL63 Tretment uthoriztion ode - Tertiry N 18 FL63 Tretment uthoriztion ode - Tertiry N 30 1 FL64 Employment Sttus ode - Primry N 1 Deleted from U-04 FL64 Employment Sttus ode - Secondry N 1 Deleted from U-04 FL64 Employment Sttus ode - Tertiry N 1 Deleted from U-04 FL64 Document ontrol Numer N 26 FL64 Document ontrol Numer N 26 FL64 Document ontrol Numer N 26 FL65 Employer Nme - Primry N 24 FL65 Employer Nme - Primry N 25 FL65 Employer Nme - Secondry N 24 FL65 Employer Nme - Secondry N 25 FL65 Employer Nme - Tertiry N 24 FL65 Employer Nme - Tertiry N 25 FL66 Employer Loction - Primry N 35 Deleted from U-04 FL66 Employer Loction - Secondry N 35 Deleted from U-04 FL66 Employer Loctions -Tertiry N 35 Deleted from U-04 FL66 DX Version Qulifier N 1 New Denotes ID v. FL67 Principl Dignosis ode 1 N 6 FL67 Principl Dignosis ode N 8 Expnded field FL68 Other Dignoses 1 N 6 FL67 Other Dignosis N 8 Expnded field FL69 Other Dignoses 1 N 6 FL67 Other Dignosis N 8 Expnded field FL70 Other Dignoses 1 N 6 FL67 Other Dignosis N 8 Expnded field FL71 Other Dignoses 1 N 6 FL67D Other Dignosis N 8 Expnded field FL72 Other Dignoses 1 N 6 FL67E Other Dignosis N 8 Expnded field FL73 Other Dignoses 1 N 6 FL67F Other Dignosis N 8 Expnded field FL74 Other Dignoses 1 N 6 FL67G Other Dignosis N 8 Expnded field FL75 Other Dignoses 1 N 6 FL67H Other Dignosis N 8 Expnded field FL67I Other Dignosis N 8 New FL67J Other Dignosis N 8 New FL67K Other Dignosis N 8 New FL67L Other Dignosis N 8 New FL67M Other Dignosis N 8 New FL67N Other Dignosis N 8 New FL67O Other Dignosis N 8 New FL67P Other Dignosis N 8 New FL67Q Other Dignosis N 8 New FL68 Unleled 1 N 8* FL68 Unleled 1 N 9* FL76 dmitting Dignosis/Ptient s Reson for Visit 1 N 6 FL69 dmitting Dignosis ode 1 N 7 Expnded y 1 FL70 Ptient's Reson for Visit ode N 7 Distinct FL FL70 Ptient's Reson for Visit ode N 7 Distinct FL FL70 Ptient's Reson for Visit ode N 7 Distinct FL FL71 PPS ode 1 N 3 2 New

6 U-92 to U-04 ROSSWLK U-92 U-04 * FL68,75,80 Size Updted 6/21/05 uffer FL Description Line Type Size FL Description Line Type Size Spce Notes FL77 Externl use of Injury ode 1 N 6 FL72 Externl use of Injury ode 1 N 8 FL72 Externl use of Injury ode 1 N 8 New FL72 Externl use of Injury ode 1c N 8 New FL78 Unleled FL73 Unleled 1 N 9 FL79 Procedure oding Method Used 1 N 1 Deleted from U-04 Deleted FL80 Principl Procedure ode/dte 1 N/N 6/6 FL74 Principl Procedure ode/dte N/N 7/6 1/1 Expnded y 1 FL81 Other Procedure ode/dte N/N 6/6 FL74 Other Procedure ode/dte N/N 7/6 1/1 Expnded y 1 FL81 Other Procedure ode/dte N/N 6/6 FL74 Other Procedure ode/dte N/N 7/6 1/1 Expnded y 1 FL81 Other Procedure ode/dte N/N 6/6 FL74c Other Procedure ode/dte N/N 7/6 1/1 Expnded y 1 FL81 Other Procedure ode/dte D N/N 6/6 FL74d Other Procedure ode/dte N/N 7/6 1/1 Expnded y 1 FL81 Other Procedure ode/dte E N/N 6/6 FL74e Other Procedure ode/dte N/N 7/6 1/1 Expnded y 1 FL75 Unleled 1 N 4* 0* FL75 Unleled 2 N 4 1 FL75 Unleled 3 N 4 1 FL75 Unleled 4 N 4 1 FL82 ttending Physicin ID N 23 FL76 ttending - NPI/QUL/ID 1 N/N/N 11/2/9 New Lyout FL82 ttending Physicin ID N 32 FL76 ttending - Lst/First 2 N/N 16/12 New Lyout FL83 Other Physicin ID N 25 FL77 Operting - NPI/QUL/ID 1 N/N/N 11/2/9 New Lyout FL83 Other Physicin ID N 32 FL77 Operting - Lst/First 2 N/N 16/12 New Lyout N/N/ FL83 Other Physicin ID N 25 FL78 Other ID - QUL/NPI/QUL/ID 1 N/N 2/11/2/9 New Lyout FL83 Other Physicin ID N 32 FL78 Other ID - Lst/First 2 N/N 16/12 New Lyout N/N/ FL79 Other ID - QUL/NPI/QUL/ID 1 N/N 2/11/2/9 New FL79 Other ID - Lst/First 2 N/N 16/12 New FL84 Remrks 1 N 43 FL80 Remrks 1 N 19* Reduced Field Size FL84 Remrks 2 N 48 FL80 Remrks 2 N 24* Reduced Field Size FL84 Remrks 3 N 48 FL80 Remrks 3 N 24* Reduced Field Size FL84 Remrks 4 N 48 FL80 Remrks 4 N 24* Reduced Field Size FL85 Provider Rep. Signture 1 N 22 Deleted from U-04 FL81 ode-ode - QUL/ODE/VLUE N/N/N 2/10/12 New FL81 ode-ode - QUL/ODE/VLUE N/N/N 2/10/12 New FL81 ode-ode - QUL/ODE/VLUE c N/N/N 2/10/12 New FL81 ode-ode - QUL/ODE/VLUE d N/N/N 2/10/12 New FL86 Dte ill Sumitted 1 Dte 6 Deleted from U-04; See FL45, line 23

PART 1A: POLICYHOLDER. Student s Name Date of Birth Male Female

PART 1A: POLICYHOLDER. Student s Name Date of Birth Male Female ff MI enefits, LL. P.O. ox 511 Phone: 800.445.3126 Fax: 732.583.9610 www.bobmccloskey.com PRT 1: POLIYHOLDER School/Organization/Policyholder Policy# Name ROKY HILL PS H 3000355 0818 School/Organization/Policyholder