-

DATE OF SERVICE DESCRIPTION OF SERVICE CHARGES CREDITS BALANCE

1 1/27/21 Cla i m: Approved Prov i der : Dr. Jane Doe

11/27/21 Fa c i l i ty : EBR MD NOW MEDICAL CENTERS , INC
1 1/27/2 1 3_ 0ffice Visit , New Pt ., Level 3 371 . 00
1 1/27/21 Patien t Payment 45 . 00
12/20/21 BCBS Payment 42 . 00
12/20/2 1 BCBS Adjustment 209 . 00
05/05/22 PER YOUR INSURANCE COMPANY, THE BALANCE HAS
BEEN APPLI ED TO~IJARDS YOUR ORGENT CARE CO- PAY .
PLEASE REMIT PAYMENT UPON RECEIPT . THANK YOU.
05/05/22 Your Balance Due On These Services ... 75 . 00

ACCOUNT TOTAL CURRENT 30 DAYS 60 DAYS 90 DAYS OVER 120 DAYS

75 . 00 75 . 00

,, DATE
, PATIENT NAME ACCOUNT NO. PAY THIS AMOUNT
,
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'•' 05/05/2 022 John A. Smith 4739052 $75 . 00

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PHONE#: 561-420-8555 MAKE CHECK PAYABLE TO: MD NOW MEDICAL CENTERS INC

MessAGe:Pay Online At: https://www.mymdnow.com/pay-your-bill-online/

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IF PAYltJG BY MASTERCARD, DISCOVER, VISA OR AMERICAN EXFRESS, FlLL OUT BELOW.
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37533
RETURN SERVICE REQUESTED PAGE: 1 of 1 STATEMENT DATE PAY THIS AMOUNT ACCT.#
05/05/2022 $75.00 4739052
Thank you for allowing MDNow Urgent Care to treat
you and your family. This is a statement
for services rendered by MD Now Urgent Care. SHOW A MOUNT $
PAID HERE

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John A. Smith MD NOW MEDICAL CENTERS
1 23 Crab Apple Lane PO BOX 538518
Naples, FL 34102 ATLANTA, GA 30353-8518

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