50 MULBERRY TREE STREET OPERATIONS LLC

50 MULBERRY TREE STREET

CHARLES TOWN WV 25414

Statement Date Pay this Amount Account patient, three

05/20/2024 10.00 3 6414 13TH RD S
Payment Due Amount Paid Haverhill FL 33415
05/30/2024 Test

Account# 3 Please Pay 10.00 Due Date 05/30/2024

Important Mesage Contact Info

mportant Mesage ontact Info

Payment and Other Information

Claim DOS Provider Charges Payments Adjustments Balance Insurance Patient Claim Status
Bal Bal

6 4/2/2024 KUMAR, DHARMENDRA 100.00 48.00 52.00

5 4/1/2024 KUMAR, DHARMENDRA 100.00 50.00 40.00 10.00

Additional Info

CHANGE OF ADDRESS OR HEALTH INSURANCE INFORMATION patient, three

If you have new health insurance or a new address, please enter the Patient ID: 1002
information below.
NEW ADDRESS CITY STATE ZIP CODE NEW PHONE

POLICY HOLDERS NAME/ RELATIONSHIP TO PATIENT POLICY ID# GROUP#

EFFECTIVE DATE BIRTH DATE OF INSURED HMO/PPO/OTHER INSURANCE PHONE#

IF GROUP INSURANCE, NAME OF THE GROUP (EMPLOYER, UNION/ASSOCIATION)

INSURANCE COMPANY NAME INSURANCE ADDRESS

EMPLOYER EMPLOYER ADDRESS

50 MULBERRY TREE STREET OPERATIONS LLC
50 MULBERRY TREE STREET
CHARLES TOWN WV 25414

Statement Date Pay this Amount Account patient, two

05/20/2024 100.00 2 6414 13TH RD S
Payment Due Amount Paid Haverhill FL 33415
05/30/2024 Test

Account# 2 Please Pay 100.00 Due Date 05/30/2024

Important Mesage Contact Info

mportant Mesage ontact Info

Payment and Other Information

Claim DOS Provider Charges Payments Adjustments Balance Insurance Patient Claim Status
Bal Bal

9 5/1/2024 KUMAR, DHARMENDRA 100.00 100.00

4 4/17/2024 KUMAR, DHARMENDRA 100.00 100.00 30.00
10 4/30/2024 KUMAR, DHARMENDRA 100.00 100.00
11 3/1/2024 KUMAR, DHARMENDRA 200.00 100.00 100.00

Additional Info

CHANGE OF ADDRESS OR HEALTH INSURANCE INFORMATION patient, two

If you have new health insurance or a new address, please enter the Patient ID: 1001
information below.
NEW ADDRESS CITY STATE ZIP CODE NEW PHONE

POLICY HOLDERS NAME/ RELATIONSHIP TO PATIENT POLICY ID# GROUP#

EFFECTIVE DATE BIRTH DATE OF INSURED HMO/PPO/OTHER INSURANCE PHONE#

IF GROUP INSURANCE, NAME OF THE GROUP (EMPLOYER, UNION/ASSOCIATION)

INSURANCE COMPANY NAME INSURANCE ADDRESS

EMPLOYER EMPLOYER ADDRESS