Amount Due

$718.00
HOSPITALIST MEDICINE PHYSICIANS OF
TEXAS PLLC
PO BOX 743522 ACCOUNT OWNER
LOS ANGELES, CA 90074-3522 CHRISTIAN PARRA ARAUJO
mydocbill.com/HMPT
STATEMENT CREATED
1-866-765-0554 5/15/2024
1-866-765-0513
DUE DATE
Upon Receipt

Account Summary

INVOICE # PAYMENTS IN THE LAST 30 DAYS PENDING INSURANCE

5243138 $0.00 $7,661.00
ACCOUNT NUMBER STATEMENT AMOUNT DUE TOTAL AMOUNT BALANCE
4960973-QSNDP $718.00 $718.00

Guarantor Info

General Info Primary Insurance Info Secondary Insurance Info

CHRISTIAN PARRA ARAUJO INSURANCE PROVIDER None
1803 MIRRIOR CV
FORT WORTH, TX 76108 ADDRESS

,
GROUP/PLAN

ID NUMBER

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Summary of Service Charges

PATIENT RENDERING PROVIDER SERVICE PROVIDED AT REFERRING PROVIDER

CHRISTIAN PARRA ARAUJO SONIA CARVAJAL GUZMAN John Peter Smith Hosp 431 SONIA CARVAJAL GUZMAN

DOS Proc Units Service Activity Charges Pay/ADJ Pending Balance

Code Insur
5/14/2024 99233 1 SBSQ HOSP IP/OBS HIGH 50 $718.00 $0.00 $0.00 $718.00
5/15/2024 GUARANTOR RESPONSIBILITY DATE: (ChargeID:
72588414)
OUT OF NETWORK MEDIATION: If your out-of-network balance is more than $500 after deductibles, copayments, and co-insurance and you
feel you have been unable to reach a successful outcome with our billing office, you are entitled to request mediation for an out-of-network
claim settlement. For more information or to request mediation, please contact the Texas Department of Insurance at 1-800-252-3439 or go
to: https://www.tdi.state.tx.us/consumer/cpmmediation.html

If your insurance has issued payment directly to you, please send us this payment immediately to stop the collection efforts.
Please disregard this notice if you believe you have received it in error or if payment has already been made.

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