JobID4389-PrtID5049 0001 20161202112305564...10/26/2016 ct scan - general classification 1,548.00...
Transcript of JobID4389-PrtID5049 0001 20161202112305564...10/26/2016 ct scan - general classification 1,548.00...
(5)
S17100 P5049 - 1
1
Thank you for choosing Mount Auburn Hospital. The balance due isyour responsibility and is due upon receipt. If you have insurance orwould like to speak to someone about financial assistance pleasecontact us at 617-499-5560.
Patient Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Statement Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Guarantor ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total New Charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Total New Ins Payments/Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . Total Patient Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HERMIONE GRANGER10/26/2016100001218
$ 5080.00$ -180.57
$ 0.00
Pay bill online at https://mychart.mah.org
YOURRESPONSIBILITY
TO PAY$4,535.00
DUE:UPON RECEIPT
If this information is not correct, see back.
Primary Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Subscriber ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Secondary Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Subscriber ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TUFTS ASSOCIATE HEALTH PLAN HMO04958104068
CIGNA MANAGED CARE0594827590
E-mail: [email protected]: https://mychart.mah.org Phone: 617-401-9911, 8:00am to 5:00pm Monday-Friday
PO Box 419534Boston, MA 02241-9534
Please check box if address is incorrect or if insurancehas changed and indicate change(s) on reverse side.
SEE REVERSE FOR IMPORTANT INFORMATION
Pay bill online at https://mychart.mah.orgMake checks payable to Mount Auburn HospitalDAFTAFDTDFFDDTFDTDFADAATTTTDAFTDFTDADFFFDFFTTFAFADTFADAAAFTAFTTFA
HERMIONE GRANGER555 GRYFFINDOR LN.CAMBRIDGE, MA 02138
10/26/2016 100001218 $4,535.00
MOUNT AUBURN HOSPITALPO BOX 419534BOSTON, MA 02241-9534
TATADFAADTTDFDTDDFAAFADTFTAATFDTATDFAADDTADTADTDFFFDFTFTFAFADDDTT
10000121810262016004535004
PHYSICIAN SERVICESFOR HERMIONE GRANGER WITH MARYBETH DONAHUE FERRANTE, MD
ACCOUNT # 1000005606
DATE(S) OF DESCRIPTION OF SERVICES CHARGES PATIENT INS. CO. ADJUSTMENTS YOUR SERVICE PAYMENTS PAYMENTS RESPONSIBILTY PREVIOUS BALANCE 20.00
HOSPITAL SERVICESFOR HERMIONE GRANGER AT MOUNT AUBURN HOSPITAL
ACCOUNT # 1000002249
DATE(S) OF DESCRIPTION OF SERVICES CHARGES PATIENT INS. CO. ADJUSTMENTS YOUR SERVICE PAYMENTS PAYMENTS RESPONSIBILTY 10/26/2016 CT SCAN - GENERAL CLASSIFICATION 1,548.0010/26/2016 LABORATORY - GENERAL CLASSIFICATION 642.0010/26/2016 ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) -
GENERAL CLASSIFICATION 1,995.0010/26/2016 INSURANCE PAYMENT - TUFTS -100.00
4185.00 0.00 -100.00 0.00 4085.00TOTALS FOR THIS SECTION
PHYSICIAN SERVICESFOR HERMIONE GRANGER WITH RAFFAELLA M. COLZANI, MD
ACCOUNT # 1000005608
DATE(S) OF DESCRIPTION OF SERVICES CHARGES PATIENT INS. CO. ADJUSTMENTS YOUR SERVICE PAYMENTS PAYMENTS RESPONSIBILTY 10/24/2016 OFFICE OUTPATIENT VISIT 25 MINUTES 225.00
225.00 0.00 0.00 0.00 225.00TOTALS FOR THIS SECTION
HOME CARE SERVICESFOR HERMIONE GRANGER WITH CAREGROUP PARMENTER HOME CARE & HOSPICE, INC.
ACCOUNT # 7000005609
DATE(S) OF DESCRIPTION OF SERVICES CHARGES PATIENT INS. CO. ADJUSTMENTS YOUR SERVICE PAYMENTS PAYMENTS RESPONSIBILTY 10/26/2016 SKILLED NURSING - GENERAL CLASSIFICATION 225.00
225.00 0.00 0.00 0.00 225.00TOTALS FOR THIS SECTION