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    12 19 88 Claim Letter

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    OKTeaPartyPAC
    BEST SHARP SHERIDAN and ATTN JODELL ADAMS 321 S BOSTON STE 700 TULSA OK 74103 WE HAVE RECEIVED THIS SUMMARY GROUP: CLAIM NO: FOR SERVICE BY:A THE CHARGES DESCRIBED IN THE SUMMARY BELOW. CHARGES EXCLUDED BY AMOUNT CHARGED LESS DEDUCTIBLE REMAINING BALANCE COINSURANCE RATE

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    12 19 88 Claim Letter

    Uploaded by

    OKTeaPartyPAC
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    BEST SHARP SHERIDAN and ATTN JODELL ADAMS 321 S BOSTON STE 700 TULSA OK 74103 WE HAVE RECEIVED THIS SUMMARY GROUP: CLAIM NO: FOR SERVICE BY:A THE CHARGES DESCRIBED IN THE SUMMARY BELOW. CHARGES EXCLUDED BY AMOUNT CHARGED LESS DEDUCTIBLE REMAINING BALANCE COINSURANCE RATE

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    BEST SHARP SHERIDAN and ATTN JODELL ADAMS 321 S BOSTON STE 700 TULSA OK 74103 WE HAVE RECEIVED THIS SUMMARY GROUP: CLAIM NO: FOR SERVICE BY:A THE CHARGES DESCRIBED IN THE SUMMARY BELOW. CHARGES EXCLUDED BY AMOUNT CHARGED LESS DEDUCTIBLE REMAINING BALANCE COINSURANCE RATE

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    9 views1 page

    12 19 88 Claim Letter

    Uploaded by

    OKTeaPartyPAC
    BEST SHARP SHERIDAN and ATTN JODELL ADAMS 321 S BOSTON STE 700 TULSA OK 74103 WE HAVE RECEIVED THIS SUMMARY GROUP: CLAIM NO: FOR SERVICE BY:A THE CHARGES DESCRIBED IN THE SUMMARY BELOW. CHARGES EXCLUDED BY AMOUNT CHARGED LESS DEDUCTIBLE REMAINING BALANCE COINSURANCE RATE

    Copyright:

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    of 1

    Insurance

    Company

    -..~nciBI

    'iJ,~uP

    (formerly Bankers Life Company) 71 1 High Street Des Moines. Iowa 50309

    DECEMBER

    19, 1988

    BEST SHARP SHERIDAN & ATTN JODELL ADAMS 321 S BOSTON STE 700 TULSA OK 74103

    WE HAVE RECEIVED THIS SUMMARY


    GROUP: CLAIM NO: FOR SERVICE BY:A

    THE CHARGES

    DESCRIBED

    IN THE SUMMARY BELOW.

    EXPLAINS

    OUR ACTION

    ON THIS CLAIM
    PATIENT: INSURED: FROM:

    PLANNED EMPL PROGRAM L-58045-4447 28486-018 JOSE MEDINA MD

    SELF DANIEL S SULLIVAN


    THRU:

    DATE:

    12-19-88 259.00

    120588

    120588

    CHARGES:

    B
    C LESS CHARGES PENDING LESS CHARGES EXCLUDED

    BY

    AMOUNT CHARGED

    **
    1

    LESS DEDUCTIBLE

    REMAINING BALANCE

    COINSURANCE RATE

    NORMAL BENEFIT

    COV CODE

    A A

    110.00 149.00

    110.00 149.00

    259.00

    259.00

    TOTALS

    INDIVIDUAL:

    4000.00

    REMAINING

    NORMAL BENEFIT TOTAL PAID:


    $

    0.00 0.00

    MEDICAL:

    0.00 REGIONAL CLAIM CENTER ONE LAKEVIEW ENERGY CEN ST 840 3817 N W EXPRESSWAY OKLAHOMA CITY OK 73112 LOCAL 949-5655 IN-STATE WATS TE WATS

    F075GC-l

    0008526

    72008

    B2

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