ACCOUNT NO: STATEMENT OATE 8AlANC€ DOE

GUAR#: 13 01/11/ 2005 CONTINUED

SIRlvl!NGHAMAl. 34333

(205) 555-1222

MAia! CH PAYAISl,11 ,t,NI) ftalrT TO:

HOOVER. AL 35216
BIRMINGHAM AL 34333 --
lul 1,1111111, ol,uf ,I, l111,lll11l11l,l,l111l,I, ,111 .. ,11. 111
(Pat Acct/I: 1232, 1797)

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DATE DESCRIPTION CH:ARGf;
PAY/ .

'- AOJIJSTMf~ INSURANCE PATIENT

PATIENT ACCOUNT ll: 1232
0~'25.12002
. FRO'/ SMtTH Cf"ACE'
99213, OFFICOOOTPATIEITT VISIT, EST S.0.00
Oe.'27/2002 INS FILED TO UNtTEO fi£AtTHCAAE GA
PATIENT PAYMENTS $-10.0
l NSURAN,CEPAYMENTS $,,SB 25
l ~'SURAN'CE ADJUSTM,£NT$ S-31.75
VISIT BALANCE
$0.00 so.o::,
11!'2712<:02 PfiCJ,/. SMITM CfflO:.
99213 OFFICEIOUTPA TIENT VISIT. EST saa.0<
1~•2002 INS FtLGO TO IJtJITEO HE.A lTHCARE GA
PATI ENT PAYMENTS s-moo
INSURANCE PAYMENTS S-3825
INSURANCE AOJUS"rMENTS S-3iD !
VISIT 8ALANCE
S0.00 S0.00
oraa 2003
1
PROV: SMTH OFFlCE.
W21~ OFFICE/(XJTPAilENT VISIT, EST
.. ..
18800
08,'06(2003 IN$ fll:fO TO UNITED MEAI.THc.AAE GA
PATl ENT PAYMENTS S-tS,00
INSURANC-E PAYMEUT$ $-33.25
INSUR.,;J.1,CC ADJUSTMflflS S-3975
VISIT SALA.NC-E
$0.00 $0.00
1Qf1:5i2CO<l l='f\OV: StlfT'H OFfl...
"E:
993$6 PRE:V\11$1T, EST, .I\G-E 18-39 $213.CX:
92552 PURE TONE AUOIO.V.::TRY. AIR S<a.00
81002 URINALYSIS N-ONAUTO W /0 SCOPE S24.00
'36415
11/19.®)4
DRAWING BLOOD
INS f!LEO TO eJI.DiRE
moo
tC\'2&200~ IN$ FILED TO UNITED HEALTHCA.qC GA
PATIEN T PAYMENT$ $-15,00
INSURANCE PAYMENTS S-127.0,

RESPONSIBLE CURRENT OVER 30 DAYS OVER60 DAYS OVER 90 DAYS BALANCE DUE
PATIENT $5.00 S0.00 S0.00 $0.00 CONTJNUED

INSURANCE $0.00 S0.00 $0.00 $0.00

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