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  • New York Medical Group Po Box 202 New York, NY 10002-0202: Make Checks Payable To

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    DineshSharma
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    The document is a medical bill statement from New York Medical Group addressed to John Doe. It shows charges for an office visit on 10/10/13 for $200 and a blood draw for $20, with payments of $140 and $15 respectively, leaving a current balance due of $65. The statement provides instructions for making a payment and includes payment coupons to return with payment.

    Original Description:

    medicall bill

    Original Title

    Medical Bill

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    The document is a medical bill statement from New York Medical Group addressed to John Doe. It shows charges for an office visit on 10/10/13 for $200 and a blood draw for $20, with payments of $140 and $15 respectively, leaving a current balance due of $65. The statement provides instructions for making a payment and includes payment coupons to return with payment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    2K views1 page

    New York Medical Group Po Box 202 New York, NY 10002-0202: Make Checks Payable To

    Uploaded by

    DineshSharma
    The document is a medical bill statement from New York Medical Group addressed to John Doe. It shows charges for an office visit on 10/10/13 for $200 and a blood draw for $20, with payments of $140 and $15 respectively, leaving a current balance due of $65. The statement provides instructions for making a payment and includes payment coupons to return with payment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    MAKE CHECKS PAYABLE TO:

    IF PAYING BY MASTERCARD, DISCOVER, VISA OR AMERICAN EXPRESS, FILL OUT BELOW. CHECK CARD USING FOR PAYMENT MASTERCARD CARD MEMBER SIGNATURE STATEMENT DATE PAY THIS AMOUNT DISCOVER VISA AMERICAN EXPRESS SIGNATURE CODE EXP. DATE PATIENT ACCT#

    New York Medical Group PO BOX 202 New York, NY 10002-0202 FOR BILLING INQUIRIES: 212-999-0000

    10/18/2013

    $65.00
    SHOW AMOUNT PAID HERE

    12345
    $

    John Doe 123 Main Street Anytown, US 12345-6789


    Please check box if above address is incorrect or insurance information has changed, and indicate change(s) on reverse side.

    New York Medical Group PO BOX 202 New York, NY 10002-0202


    STATEMENT

    PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT

    DATE OF SERVICE
    10/10/13

    CODE
    XXXX4

    DESCRIPTION OF SERVICE
    OFFICE VISIT, 25 MINUTES

    CHARGES
    $200.00

    PAYMENTS

    BALANCE

    $140.00 10/10/13 XXXX5 BLOOD DRAW $20.00 $15.00

    $60.00

    $5.00

    CURRENT
    $65.00

    30-60 DAYS

    60-90 DAYS

    90-120 DAYS

    120+ DAYS

    AMOUNT DUE:

    $65.00

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