P.O.

BOX 23219
SAN DIEGO, CA 92193-3219
000724475-0000 S

MY BAR LLC/G30 AMOUNT DUE: $6,032.19

ERIKA RUYBALID
1373 KOOSER RD DUE DATE: PAY NOW
SAN JOSE, CA 95118-3822

APRIL 2020 statement includes

membership and financial transactions processed
from 01/26/2020 through 02/25/2020

Did you know that Kaiser Permanente can

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000724475-0000
APRIL
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ADVICE Customer
APRIL 2020
ID:
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pay this Amount: $6,032.19
more information.
more information.

AMOUNT PAID:

Due Date: PAY NOW

Provide Billing Unit number(s) on check and make it

payable to:
KAISER FOUNDATION HEALTH PLAN

Refer to the Billing Summary page for

all billing unit(s) included in this statement.

(RETURN THIS PORTION WITH YOUR PAYMENT)

Billing Unit: 893667704 Customer ID: 000724475-0000
REMITTANCE ADVICE FOR: APRIL 2020
MY BAR LLC/G30
ERIKA RUYBALID Please pay this Amount: $6,032.19
1373 KOOSER RD
SAN JOSE, CA 95118-3822
AMOUNT PAID:

Due Date: PAY NOW

Provide Billing Unit number(s) on check and make it payable to:

KAISER FOUNDATION HEALTH PLAN
KAISER FOUNDATION HEALTH PLAN
FILE 5915
LOS ANGELES, CA 90074-5915

88936677042020012600000000060321920200325
 Membership Billing Statement
000724475-0000
APRIL 2020

Membership Billing Statement CONTACT INFORMATION:

Customer
CustomerInquiries:
000724475-0000
Inquiries: (800)
(800)731-4661
731-4661
Hours of Operation:
Hours of Operation: Monday
Monday––Friday
Friday8:00
8:00a.m.
a.m.to
to5:00
5:00p.m.
p.m.
APRIL 2020

Send all membership and address changes to:

KAISER FOUNDATION HEALTH PLAN

CALIFORNIA SERVICE CENTER
P.O. BOX 23219
SAN DIEGO, CA 92193-3219

Provide Billing Unit number(s) on check and make it payable to:

KAISER FOUNDATION HEALTH PLAN

FILE 5915
LOS ANGELES, CA 90074-5915

Insufficient Funds
Insufficient Funds
Kaiser Foundation Health Plan, Inc. charges an administrative service fee for any returned check due to
Kaiser Foundation Health Plan, Inc. charges an administrative service fee for any returned check due to
insufficient funds in the payer's account. Kaiser Foundation Health Plan, Inc. reserves the right to terminate
insufficient funds in the payer's account. Kaiser Foundation Health Plan, Inc. reserves the right to terminate
coverage for any account with three returned checks due to insufficient funds within a 12-month period.
coverage for any account with three returned checks due to insufficient funds within a 12-month period.

Termination of Coverage
Termination of Coverage
Kaiser Health Plan, Inc. requires 15 days written notice to terminate group coverage.
Kaiser Health Plan, Inc. requires 15 days written notice to terminate group coverage.

Delinquency
Delinquency
Group Employers delinquent in paying health plan dues may be subject to termination.
Group Employers delinquent in paying health plan dues may be subject to termination.
 Membership Billing Statement
000724475-0000
APRIL 2020

Notice of Consequences for Nonpayment of Premium

We are committed to your health and well-being. We want to make sure that you have coverage for the care and
services you need and therefore receipt of full payment of your monthly premium by the due date listed on the first
page of this Invoice is essential. Kaiser Permanente is providing you with this notice regarding your rights when you
fail to pay your premium on time.

If the Amount Due, as set forth on the first page of this Invoice, is not received on or before the due date indicated on
that same page, then a grace period will begin the day we mail you your first late notice. This grace period will last at
least 30 days. During the grace period, you may pay the premiums that you owe. Your Kaiser Permanente group
coverage will continue during the grace period, and you will continue to owe premiums for your group’s coverage
during the grace period.

You must pay the Amount Due as set forth on the first page of this Invoice plus any premium owed for the grace
period by the end of your grace period. If you have not paid in full, your membership will terminate on the last day of
your grace period. You will remain financially responsible for the payment of premiums and any other amounts due
for your group’s coverage. Kaiser Permanente reserves the right to initiate collection proceedings for all monthly
premium amounts, payments for services rendered and any other amounts that you owe.

We will continue to bill you, and you will continue to owe premiums for the period during which your Kaiser
Permanente coverage remains in effect. To terminate your coverage immediately, contact Kaiser Permanente as
soon as possible.
 Membership Billing Statement
000724475-0000
APRIL 2020

This page is intentionally left blank.

 Billing Summary
000724475-0000
MY BAR LLC/G30
APRIL 2020

Previous Balance Due 10,053.65

Payments -BU 000724475-0000 0.00

-BU 000724475-0002 0.00
-BU 000724475-0001 0.00

Subtotal: 0.00

Adjustments -BU 000724475-0000 0.00

-BU 000724475-0002 0.00
-BU 000724475-0001 0.00

Subtotal: 0.00

Retroactive Dues -BU 000724475-0000 -2,029.46

-BU 000724475-0002 -1,992.00
-BU 000724475-0001 0.00

Subtotal: -4,021.46

Current Dues -BU 000724475-0000 0.00

-BU 000724475-0002 0.00
-BU 000724475-0001 0.00

Subtotal: 0.00

TOTAL DUE BY PAY NOW $6,032.19

Page 1
 Billing Detail
000724475-0000
MY BAR LLC/G30
Membership Activity Detail APRIL 2020

RETROACTIVE MEMBERSHIP

Includes membership activity and rate changes processed from 01/26/2020 - 02/25/2020

Billing Account Social Employee Activity Family Count Coverage

Unit Name Security No. No. Reason Prior Current Period Amount

000724475-0000 LOUCKS, DELANA C ***-**-6591 TERMINATE 02 00 02/01/2020 -502.13

02 00 03/01/2020 -502.13
BRENCKLE, WAYNE J ***-**-5571 TERMINATE 02 00 02/01/2020 -512.60
02 00 03/01/2020 -512.60

Account Total: -2,029.46

Subtotal: -2,029.46

000724475-0002 AMPARANO, ERNEST L ***-**-1634 TERMINATE 04 00 02/01/2020 -339.74

04 00 03/01/2020 -339.74
AMPARANO JR, ERNEST L ***-**-0205 TERMINATE 04 00 02/01/2020 -206.39
04 00 03/01/2020 -206.39
AMPARANO, JOSIAH ***-**-0759 TERMINATE 04 00 02/01/2020 -206.39
04 00 03/01/2020 -206.39
AMPARANO, SERENNA M ***-**-1949 TERMINATE 04 00 02/01/2020 -243.48
04 00 03/01/2020 -243.48

Account Total: -1,992.00

Subtotal: -1,992.00

Page 2
 Billing Detail
000724475-0000
MY BAR LLC/G30
Membership Activity Detail APRIL 2020

Billing Account Social Employee Activity Family Count Coverage

Unit Name Security No. No. Reason Prior Current Period Amount

Total Retroactive Dues: $-4,021.46

Page 3
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