RETURN SERVICE REQUESTED This is @ statement for professional services rendered by your physician. You may receive @ separate bill from the hospital forts services. ilbsballaallatdabh 17 Pease check box if address i inconect or nsrance i termavon bas changed, and inate changes) on reverse side ars7e-14ae [SORAUTE ‘CHECK CARD USING FOR PAYMENT ecco MM Secon Sl Ses ‘STATEMENTDATE | PAVTHIS AMOUNT | 6297.00 aecte PAGE: 1 of 1 SHOW AMOUNT PAYMENT DUE UPON RECEIPT PAID HERE: osaaallocsaballltoosboalll 6 sa 91579-14Be Tesoizu¥6000026 STATEMENT picase petaci aNo RETURN TOP PORTION WITH YOUR PAYMENT DATE OF SERVICE DESCRIPTION OF SERVICE CHARGES | CREDITS | BALANCE 04/25/08 Claim:123120, Provider: 04/25/08 Facility: 04/25/08 26676 PIN HAND DISLOCATION 2632.00 04/25/08 26676 PIN HAND DISLOCATION 2632.00 04/25/08 Patient Payment 223.00 04/25/08 Patient Payment 125.00 04/25/08 Your Balance Due On These Services ... 4916.00 05/06/08 Claim:126447, Provider: 05/06/08 Facility: 6 05/06/08 73130 X-Ray Hand, right 3 view 119.00 05/06/08 99024 Post-OP 05/06/08 29075 Application Cast/ Short Arm 258.00 05/06/08 04010 Supplies Cast Short Arm (11+yrs) 65.00 05/06/08 Your Balance Due On These Services ... 442.00 06/03/08 Claim:136711, Provider: 06/03/08 Facility: 6 06/03/08 73130 X-Ray Hand, right 3 view 119.00 06/03/08 99024 Post-OP 06/03/08 Your Balance Due On These Services 119.00 06/05/08 Claim:135307, Provide: 06/05/08, Facility: 06/05/08, 20670 Removal Superficial Implant 820.00 06/05/08. Your Balance Due On These. Servic: : 820.00 = ACCOUNT TOTAL (CURRENT 30 DAYS 60 DAYS 90 DAYS ‘OVER 120 DAYS 6297.00 DATE PATIENT NAME ‘ACCOUNT NO. PAY THIS AMOUNT 6297.00 PHONE #: MAKE CHECK PAYABLE TO: MESSAGE: : .21879-149e+Tesor2UYE000026