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Mariners 11/9/2018

 

 

Hospital Palienl Name Parker, Jeanneire 
iiPi'ls'r sdiru1fiznlbi Dam: 
REQUEST FOR PAYMENT
Account Summary Pay online! It's fast, easy, and secure.
Dale of Service' 9/22/2018 
oi Service' Emergency Depanmenl WSA- so me var
Place oi Service Manners Hospiral
Scan one code lo pay wiln your smart phone
Toial Charges 3 45,512 no
insurance Paymenrs Adlusrmenrs 44,320 90 (C) Our aulomarerl system provides uprlordate
inlorrnauon acoul your accoonl 24/7 ar
PW 78675956507 or loll iree 31178004350065
AMOUNT YOU OWE 4,191.10
(R) See reverse side onnis slalemenl Vor
irequenily asked ouesiions
IMPORTANT MESSAGE

We previously rimmed you me: the balance due is your responsibility Our records inoicaie lrral we have rroi received
paymenl for me accounl balance We are requesung lnal you please pay me arnoum immedialely llwe do nor
receive your payrnenrwilhrn 15 days we will consider your accoum pasr oue, Pay onlrne securely al:

mlps'//bi11pay capiislneallnnel

If you have any questions about your our-ol-pocker expense, please conraci your insurance provider so irrai iney can
explain how your claim was processed, Your insurance provider de|ermines peneril coverage and any paiienllinancial

responsibility Our Esprisl Heallh Cusromer Service Represenrarives do riol have access lo me tems or your insurance
policy.

S'uiemenloa

Pay By Mail for Aczount Number 
Mariners

 

. Amounr Due Due Dale Amour" Enclosed
Hospital 
mm. 4,191.10 Upon Recelpt 3
Poioxasnaan

Miami. Fl 13253

 
   
 

Parka! Jeannelle 

Mariners Hospital

PO Box 198116
Allanta, GA 30384 8116

 

 

Baptist Health
South Florida

Mariner: [Inspilal
0 Btu 19am
Atlnnu,GA 303848115

 

 

 

Mme leannene perm ecu:

Allendmg thsicvan -- ENC:

Manners Hosp smemm Number:

Proudcr Tax ID Accaunl Number:

um Date' 12/202013 Claim In:

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Dave cu Descrinlian 9'1 Amoumgs)
Charm
36603322 Immn acnlr. ea add vac: tax 1 CG
99/22/2012 49057547 Van: baostnx u.5 ml 1.1) 1 mm
awn/2312: 493M205 37ng tau) 1 2,0c
DS/Sz/zuu 35mm mm." acrm- me vacc hex m7 1 143,00
490:)2El Vacc Tables 2.5u 1 968 on
09/22/2018 49033673 Imn glob rabxes 2:11 In: 6 46,422,00
3560015? Level II 1 722,00

PIymulIx/Adjuumenls
10/19/2015 mgne Insurance Payme.

 

 

 

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Miami FL 33253 235-0065.

11mm, Plan Name

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ADDRESS SERVICE REQUESTED

JEANNETTE PARKER
Guam-um Jcennenc Parka

 

 

 

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APWU eHeallhRecnrd PLUS Page 1 of2

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eHeaIthRecordPLus

. . . dBazktu E'd1m searm
Claim Deta1l:ClaIm ID 

Patient
PARKER
Addres;
Me'nber 
Provider
Narr'emPl) MAPINERS 
Addvess PO 
ATLANTA GA 303813

Network 1nd1CalD' Network
Clavm Totals
merges $481512 00
Not Covered $9,580 00 )4 117 
Paid T0 MAWNERS 1 103W TN, . 
3313"; flu
P'rarv Jays 534451850 1 fl e'H 
Dedmbwes $3160 9434/ 7
Emmy 50100 
[Drmfi'urantc $2,345 50 fl
Other lnsuranre Pawd' 

Member Resp.: $4191 '10

Other

Service REV ms Not Member Reason

Date Code Charge Allowed Paid Covered Resp. Plan Paid Code

09/22/2018 0250 :30.00

09/22/2015 0450 $712 00 33/7 60 30 00 $144 40 $366 46 $211 14
09/22/2018 0636 $968 00 $774 40 $0 00 519160 $77 44 $696 96
09/22/2018 0636 $46,422 DC "/1137 60 SO 00 $9,284,410 33/13 76 $33,423 84

09/22/2018 0636 $112 Grand Total $48,512 00 $38,809 60 $0130 $9,680 0@34,618 SU

 

APWU eHeaIthRecord PLUS

Page 2 of2

 

Other
Service REV Ins Not Member Reason
Date Code Charge Allowed Paid Covered Resp. Plan Pard Code
09/22/2013 0771 '13 00 $11440 $0 $28 3H 44 $102 95:
09/22/2013 0771 $143 03 mama SO [70 $2861) 44 $107.96
Grand Total: $48,572 09 $38,809 $34615 '30

03 Back [0 L'dmv Sea'zh

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