Hometown Family Medicine

1698 Vernon Road

LaGrange, GA 30240
Ph: 706-298-4937 Fax: 706-298-4926
To: ParaMeds/Banner Life re William Bush DOB 1/25/53 Case# 33716863
Date: ____06/21/2024_________________________

DESCRIPTION AMOUNT

MEDICAL RECORDS
_____________________________________________________________________ __________
Medical Records Pages 1-20 @ $0.97/pg $19.40
Medical Records Pages 21-100 @ $0.83/pg $66.40
Medical REcords Pages 101-147 @ $0.66/pg $31.02

TOTAL DUE $116.82

Tax ID # 81-1075201
**PLEASE NOTE: FEES FOR MEDICAL RECORDS TO BE PAID BY CHECK ONLY - MADE PAYABLE TO
HOMETOWN FAMILY MEDICINE - MAILING ADDRESS 1698 VERNON RD LAGRANGE GA 30240**