Page 1 of 3

Siaiemem Dale 11/12/2016
Account Number 
Responsible Party --

Due Dale: Upon Receipt

REQUEST FOR PAYMENT

Account Summary (All Accounts)

Total Charges 34,500.00
Insurance Payments Adjustments 5 911.49
Palienl Payments as 0.00
AMOUNT YOU OWE 33,588.51

Your prompt payment is appreciated'

Insurance Information

ll you have questions or would like to make a
payment please call 88830171252

masuas LLC
150 SAMPLE RD #120
FOMFANO BEACH. FL 33034-3550

con IS 536006 msnesxz



a stain


Important Message

li you have questipns or would like to
make a paymenl please call 686>>801-
1252.

Payment and Other Information

9 Please pay by mail or over tne phone

llyou have questions or would like
to make a payment please call
888>>801>>1252.

Pay By Mail

Accour"h-
1nvcice

Amount Due Due Date Amount Paid
5 33,588.51 Upon Recelpt 
LABSURE LLC

150 SAMPLE RD #120
BEACH, FL 33064-3550



Page 2 of 3


Pavem Name --

 

Insurance
Paymams 1 Pahenx Amount You
Semce Dace Account Number oiServuce Total Charges Ad1uslmems Payments Owe
7:17 2016 DRUG 31500 PRESUMPTNE ANYNUMBER
DE DRUG CLAS .
DRUG 501) 00 39 53 0 00 51455 37
ANV NUMBER
OF DRUG CLAS
DRUG 7557151 3
PRESUMPTWE ANY NUMBER
0; DRUG CLAS
DRUG TEST1S1 51460 37
RRESUMRTIVE ANY NUMBER
OF DRUG CLAS
DRUG 
PRESUMRWE ANV NUMBER
OF DRUG CLAS
DRUG 7557131,
PRESUMPTNE ANY NUMBER
0; DRUG ems
DRUG TESUS) $1502 U0
PRESUMPTNE ANY NUMBER
OF DRUG CLAS
DRUG 7557151
PRESUMPTWE ANY NUUEER
OF DRUG CLAS
DRUG 1125713)
PRESUMPTNE ANV NUMBER
OF DRUG CLAS
DRUG 112371511 31 500 Do 3 a: 63
PRESUMPTNE ANY NUMBER
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Page 3 013

 

Fafiem Name --

 

 

Insurance

. Paymentsl Palianl Amoum You
San/Ice Date Number 61 Service Total Charges Adjustments Paymems Owe
8/25/2016 DRUG 1,500.00 3 39,53 3 0.00 31,460 37
ANY NUMBER

OF DRUG CLAS

DRUG 1,500.1,460.37
PRESUMPTIVE, ANY NUMBER

or DRUG CLAS

DRUG $1,500 00 0 39 63 000 $1,460.37
FRESUMPTIVE, ANV NUMBER

OF DRUG CLAS

DRUG 31.500.00 5 30.63 0 00 3 1,460.37
NUMBER

OF DRUG CLAS

DRUG 6 1,500 00 30 63 0.00 $1,460 37
PRESUMPTWE, ANY NUMBER

OF DRUG CLAS

DRUG 01.50000 3 39.63 0 00 $1,460 37
PRESUMFTWE, ANY NUMBER

OF DRUG CLAS

DRUG 6 1.50000 3 39.63 00 31,460 37
PRESUMPTWE, ANY NUMBER

OF DRUG CLAS

DRUG 5 1.50000 5 39.63 0.00 5 1,400 371
PRESUMPTIVE, ANY NUMBER

OF DRUG CLAS

DRUG 3 1,500.00 3 39 63 3 0.00 5 1,460 37
ANY NUMBER

OF DRUG CLAS

DRUG $1,500 00 3 39.63 00 31,030 37
NUMBER

OF DRUG GLAS

DRUG 3 1,500 00 6 39.63 0.00 3 1,460.37
PRESUMPTIVE. ANY NUMBER
OF DRUG CLAS

0/31/2016

9/02/2016

9/06/2013

9/08/2018

09/12/201 6

00/15/201 3

10/03/2016

1 0/08/2016

10/10/2016

10/15/2016

1/ you have quesfions or would like to make a paymem pLease call 880801--1252

 

 

Due Dale AMOUNT YOU OWE
Upon Receipt 5 33,588.51

 

 

 

 

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