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Family Care Center
1100 Highland Drive, Third Floor
PO Box 524
Concordia, KS 66901
(785)243-4272

STATEMENT OF ACCOUNT

  John Q. Public
1234 Anywhere St.
Anywhere, KS 12345-6789
  Statement Date: MAR 26,2010
For questions, call: 785-243-4272

Account number: 12345
 
     
 

DATE

CPT

DESCRIPTION

DIAG

QTY

AMOUNT

 

Public, John Q.
02/25/10
02/26/10
03/02/10
03/11/10
03/11/10


Public, Jane Q.
02/05/10
02/08/10
02/10/10
02/17/10
02/17/10


99213

 

 


99213

Attended by Robyn Burwell, ARNP  (E136515)
Level 3, Est. Pt. Visit
Personal Payment Check CK# 1234
BC/BS of Kansas (claim filed)
Payment--BC/BS of Kansas CK#   1234
BC/BS Adjustment
Visit Balance:                         20.00

Attended by Travis D. Jordan  (E135402)
Level 3, Est. Pt. Visit
Personal Payment Check CK# 1234
BC/BS of Kansas (claim filed)
Payment--BC/BS of Kansas CK#     1234
BC/BS Adjustment
Visit Balance:                         20.00


461.9

 



724.5


1

 

 



1


66.00
20.00-

34.27-
11.73-



66.00
20.00-

43.85-
2.15-

 

DO NOT USE FOR INSURANCE CLAIM

Total Charges:
Total Account Balance:
Pending Insurance:
Patient Amount Now Due:

132.00
0.00
0.00
40.00


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