YOUR INFORMATION YOUR ACCOUNT SUMMARY Stanford HEALTH CARE MEDICINE Statement Page 1 Inc 5 Tutal Char es 4 Statement Date 5/10/2018 48329 OD Pawn: Payments Sum Guarantur Name Janet Insurance payments $11,375.47 Guarantur ID -- Insurance Adjustments 5.3334330 Account Numbers Located on Mowing pages other Adjustments $0.00 Paymem Due Dam 6/13/2018 AMOUNT DUE now $3,103.73 oun PAYMENT OPTIONS QUESTION ohm: Witanfomheamm org/MW Can Us: 3005493720 I Muanfi' B:OOam-5:00pm Visit Us: 2455 Faber Place, Pale Altoy CA 94303 Phone: 80015433720 Online: fie A MESSAGE FOR YOU Please pay your b'm 0min: or sign up far paparlass at 2L3 Mail: Please campiele coupon below and return with your check made payable In STANFORD HEALTH CARE. EALTH Access your heanh informaflcn anyurnu and anywhere. You can use MyHeaIth In. 2 Message your care team View your lab reeulrs - Schedule your appointment - Pay yDur bill Thank you for choosing Stanford HeaIth Care. PIease mach and ram me naIIom pnmon of mm sIaIemenI wiIh yuur paymenl Amount Due Stanford P.O. BOX 740715 Payable unon Racelm HEALTH CARE ms CA 9007443715 Guaranmnn smaranuuzolmns 5/15/2018 JANET WINSTON STANFORD HEALTH CARE 0, BOX 740715 LOS ANGELES, CA 900740715 We care ibom pmruming your financial inrurmmrun. For areurr card payments, please wish us unllne UnIess atherwise IndicaIed in me accuunt numberfield below. your payment wiU Dasha your payment pIan amount due and men Io the oidesI acwum on me elatemem. PIease uusI my payment In the account number Page 2 AccountDmils Date Description charges Insurance Patient Balance Ba'anc' HE LOCKEOX PMT BLUE CRO $40,331.27 CONTRACTUAL ADJ - BLUE CRO $33,466 00 Tums 547,461.00 544.397'21 $0.00 $3,033.73 Pafiem BaTanoe 50.00 083 l; OF EST PATIENT $348 00 PAVMENT BLUE CRO 3-445 20 CONTRACTUAL ADJ - BLUE CRO $7382 50 Tmals $818 on s-szanu sum :29 on Patient Balancn gm gum Balanca Bus 5; 103,73 mm EXPLANATION or BENEFITS - ISSUE DATE PAEE May a, um mm or Dnuns Subscrihur's Nam: .uusv Human Idmhficlfion Numb. Group Number: cmup Nun snr: Ac-rzvis-CA FOR AADC film Produt" ml 1-: mum": ESHEL 1 AB [Luna 7n Sequenc: Nunbun -- PaUant's Mama mun Provider of Sorvicus; STANFORD umvansnv Hus?! Claim Number: naca of 5am: Du: auene Claim Processed Date a5/n1/1a Pauant Acct. Number: wan Amman unmaLz-I Tu: HusFl I: is yuur tn nay $3,113: 71 is Bo: yaw- (a Bay assmu Thank you for using a Nubvork Participanns Prwvidcr' cumumc: same: 1va a: ssavue Mm awn mm mum TD cums mm; mm: "Mums: saunas mmxus mm musuv 1 55/1208 seams: mum": "Mann/m asumz 2,752u52/n3 mm nus cum swam mu u.asa.nn am?) "331.27 Member's Mensa: Deductible Ampliad zn hats: mutton nznu HESSAGE: 01 - This is the amount in excess wf the maximum allnued amount for a uarticinatihg wavy Tim nemhu'. therein-A. is net far (his amount. n2 Tm: amuunt his [man avnlied to ma number's mudlca] daaucunn. ns - This balince w: number's "Macon": <>: cmama M) nealm at "Hilton! Attouur Devan: hum or}; an Tm Page muse Tm: Wmdow Name, Janethston Pcv, No Pg) Hospital Statement Statement - 10/10/2018 Parmm mum "mes Kalinu Izlame Akmunt--Vwawt rm MM 12,201>> wuh Hanan, Gama, MD at Memm Dermaxulogy mus CRO Payments and Adjustments <<44,397 27 ospomma WHEALTH CREW CARD 71,541 as 71,541.37 Hospremes Amman Amsma um um Outstanding Balantezsoflo lotl Mil/L8, lO 17AM