Amount Due

$120.80
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 7/3/2024
1-866-765-0513
DUE DATE
Upon Receipt

Account Summary

INVOICE # PAYMENTS IN THE LAST 30 DAYS PENDING INSURANCE

5379553 $0.00 $0.00
ACCOUNT NUMBER STATEMENT AMOUNT DUE TOTAL AMOUNT BALANCE
4960973-QSNDP $120.80 $120.80

Guarantor Info

General Info Primary Insurance Info Secondary Insurance Info

CHRISTIAN PARRA ARAUJO
1803 MILLER CT
FORT WORTH, TX 76108
INSURANCE PROVIDER None
JPS SPONSORED PROGRAM
ADDRESS
1400 S MAIN ST STE 302
FORT WORTH, TX 76104
GROUP/PLAN

ID NUMBER

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Summary of Service Charges

PATIENT RENDERING PROVIDER SERVICE PROVIDED AT REFERRING PROVIDER

CHRISTIAN PARRA ARAUJO LIMITHA ADIMALA John Peter Smith Hosp 431 LIMITHA ADIMALA

DOS Proc Units Service Activity Charges Pay/ADJ Pending Balance

Code Insur
5/12/2024 99233 1 SBSQ HOSP IP/OBS HIGH 50 $718.00 $597.20 $0.00 $120.80
5/15/2024 FILED PRIMARY TO JPS SPONSORED PROGRAM (JP001)
6/8/2024 Provider Responsibility $597.20
6/8/2024 GUARANTOR RESPONSIBILITY DATE: (ChargeID:
72519951)
6/8/2024 Insurance Payment $120.80

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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