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EMPLOVEE PATIENT EMPLOVER CLAIM NO.

711 High Street Des Moines. Iowa 50309

EMPLOYEE: DANIEL S SULLIVAN SELF PLANNED EMPL PROGRAM L-58045-444728486-018 DANIEL 10006 BIXBY, S SULLIVAN E. 117TH PL. OK 74008 S.

MAIL TO: BEST SHARP SHERIDAN ATTN JODELL ADAMS 321 S BOSTON STE 700 TULSA OK 74103

PAID TO:

&

TULSA 1725 TULSA

CARDIOLOGY 19TH ST OK 74104

CONSLT STE 203

EXPLANATION OF BENEFITS
FOR RETAIN THIS COPY EMPLOYEE FOR TAX PURPOSES. AMOUNT PAID: CHARGES: $8.00 10.00

EMPLOYEE: DAN IEL S SULL I VAN CLAIM NO: L-5 8045-444 7 28486-018 FOR SERVICE BY:A B
C

PATIENT: SELF DATE: 01-17-89 FROM:12 2988 THRU:122 988

JOSE

MEDINA

MD

BY A

AMOUNT CHARGED 10.00

LESS CHARGES PENDING

LESS CHARGES EXCLUDED

**

LESS DEDUCTIBLE

REMAINING BALANCE 10.00

COINSURANCE RATE 80%

NORMAL BENEFIT 8.00

COV * CODE 54

10.00

10.00

8.00

TOTALSI

INDIVIDUAL: FAMILY:

REMAINING 696.60 1696.60

NORMAL BENEFIT TOTAL PAID:

$

8.00 8.00

MEDICAL:

413.60

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ONE LAKEVIEW ENERGY CEN ST 3817 N W EXPRESSWAY OKLAHOMA CITY OK 73112 LOCAL 949-5655 IN-STATE-WATS 800-522-6608 OUT-STATE-WATS 800-523-5665

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