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  • 12 27 88 Explanation of Benefits Letter Katz

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    OKTeaPartyPAC
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    This document is an explanation of benefits form for Daniel S. Sullivan from Self Planned Employer Program for medical services received from Dr. Stewart Katz and Dr. B.C. Adams totaling $138. The form shows that $110.40 was paid towards the charges, with an 80% coinsurance rate and deductible applied. Contact information is provided for One Lakeview Energy Center.

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    This document is an explanation of benefits form for Daniel S. Sullivan from Self Planned Employer Program for medical services received from Dr. Stewart Katz and Dr. B.C. Adams totaling $138. The form shows that $110.40 was paid towards the charges, with an 80% coinsurance rate and deductible applied. Contact information is provided for One Lakeview Energy Center.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    30 views1 page

    12 27 88 Explanation of Benefits Letter Katz

    Uploaded by

    OKTeaPartyPAC
    This document is an explanation of benefits form for Daniel S. Sullivan from Self Planned Employer Program for medical services received from Dr. Stewart Katz and Dr. B.C. Adams totaling $138. The form shows that $110.40 was paid towards the charges, with an 80% coinsurance rate and deductible applied. Contact information is provided for One Lakeview Energy Center.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    ..__ ._- - ...,.._ ..

    ,
    Fill6nci.1 Group
    EMPLOYEE PATIENT EMPLOYER CLAIM NO, 711 High Street
    Des Moines. Iowa 50309

    EMPLOYEE: DANIEL S SULLIVAN SELF PLANNED EMPL' PROGRAM L-58045-444728486-018 PAID TO: BEST SHARP SHERIDAN & ATTN JODELL ADAMS 321 S BOSTON STE 700 TULSA OK 74103 TULSA CARDIOLOGY CONSLT 1725 E 19TH ST STE 203 TULSA OK 74104 DANIEL S SULLIVAN 10006 E. 117TH PL. BIXBY, OK 74008 S.

    MAIL. TO:

    EXPLANATION OF BENEFITS
    FOR RETAIN THIS COPY EMPL.OYEE FOR TAX PURPOSES. AMOUNT PAID: CHARGES: $110.40 138.00

    EMPL.OYEE: DANIEL S SULLIVAN CL.AIM NO: L-58045-444728486-018 'OR SERVICE BY:A


    B C

    PATIENT: SELF DATE: 01-17-89 FROM: 1 20 88 8

    STEWART

    KATZ

    MD

    THRU: 1 20 8 8 8

    BY
    A A

    AMOUNT CHARGED 83.00 55.00

    L.ESS CHARGES PENDING

    L.ESS CHARGES EXCL.UDED

    **
    1

    L.ESS DEDUCTIBL.E

    REMAINING BAL.ANCE 83.00 55.00

    COINSURANCE RATE 80% 80%

    NORMAL. BENEFIT 66.40 44.00

    COV * CODE 54 54

    138.00

    138.00

    11 0 4 0

    TOT AL.S

    INDIVIDUAL: FAMILY:

    REMAINING 698.60 1698.60

    NORMAL. BENEFIT TOTAL. PAID:


    $

    110.40 110.40

    MEDICAL:

    405.60

    ONE LAKEVIEW ENERGY CEN ST 840 3817 N W EXPRESSWAY OKLAHOMA CITY OK 73112 LOCAL 949-5655 IN-STATE-WATS 800-522-6608 OUT-STATE-WATS 800-523-5665
    F069GC'
    r\r'\C.I"\"')"I'I'"'>c_or<Jn

    'T'TN!

    711?R1R?1

    72019

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