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Statement |
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Statement #: |
0 |
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Account #: |
12896 |
10/24/2007 |
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Page: 1/1 |
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For credit card payments, please provide requested information. |
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Visa |
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Master |
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Discover |
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Amex |
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HILLTOP CARDIOLOGY, PLLC
200 Summit Drive
High Hill Medical Office Building
Hendersonville, NC 28792 |
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Card Number |
Signature Code |
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Signature |
Exp. Date |
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Amount Due: 44.00 |
Amount Paid $: |
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Remit To: |
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RONNY JONES
100 STEEP HILL RD
OLD SHOE, NC 28742 |
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HILLTOP CARDIOLOGY, PLLC
200 Summit Drive
High Hill Medical Office Building
Hendersonville, NC 28792 |
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Please return the top portion with your payment. |
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Service
Date |
Patient |
Provider |
Description |
Charge |
Pay-
ments |
Adjust-
ments |
Balance |
Supplemental Explanation |
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07/26/07 |
RONNY
JONES |
SMITH |
83880 BNP B-TYPE NATRIURETIC
PEDTIDE |
140.00 |
.00 |
78.00 |
62.00 |
62.00 Deductible: Medcost/Great-
West
78.00 Mandatory Writeoff:
Medcost/Great-West |
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07/26/07 |
RONNY
JONES |
SMITH |
80050 GENERAL HEALTH PANEL |
70.00 |
20.00 |
48.00 |
2.00 |
22.00 Deductible: Medcost/Great-
West
48.00 Mandatory Writeoff:
Medcost/Great-West
20.00 Payment: Personal |
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07/27/07 |
RONNY
JONES |
SMITH |
99213 OV-ESTB PT-3 |
85.00 |
78.00 |
27.00 |
-20.00 |
38.00 Payment: Medcost/Great-
West
20.00 Copay: Medcost/Great-West
27.00 Mandatory Writeoff:
Medcost/Great-West
40.00 Payment: Personal |
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Your last personal payment, 45.00, was paid on 10/3/2007. |
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Total Balance |
44.00 |
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Insurance Did Not Pay |
.00 |
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Amount Due Now |
44.00 |
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HILLTOP CARDIOLOGY, PLLC
200 Summit Drive
High Hill Medical Office Building
Hendersonville, NC 28792 |
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For billing questions call: 123-4567, 123-4568 or 123-1122
Email Address: climber@sunnysouth.net
We now accept bank debit cards for your convenience.*** This bill is for
Hilltop Cardiology only. You may receive separate hospital bills.
HHC is a private business not owned by the hospital. |
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