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PATIENT DELIVERY FORM

Patient Name:

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Date of onset
Loan for 523!"th Billing:
Measurement 
-: Delivem Insurance Coudem
Foiluw-up Effective Date:
Patien! Educ-<<2n: Contact
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Pmduci inserts [Vendor Deductible: 1
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Po Box 757910 1112512013 I
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{1 For billing qml. all (2mm "ms END 
Olfia. mm (287) 3394559 Tull Amount Owed: $829.41 1
Pay 01' Inquire about your at Phone hows: Mon thiough Qam -- 4pm, hidav 
9am - 129m I
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Paflem Name Provide! vow: 

Estchan Serrano Gattme, Jennifer 

    
   
  

 

   
  

Charges Insurance Painting: lialiene

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100.3118 Knee om Ad} Jm Pas (Um) 588230 $882.00 1
11mm: Aetna Payment $0.00 $662.00 1
11mm um Miusment -:52 59 $529.41

 

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ADDRESS SERVICE REQUESTED

100164154>>) noon 
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ESTEBAN SERRANO INSTITUTE

 

 

 

 

 

 

1 PO BOX 757910
 PHILADELPHIA. PA "31757910

 

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Explanation of Benefits (EOB) -- This is not a bill






Track your health care costs


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MEDICAL BILL

 

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P?B?x75m? maxim 1-012912018
FHILADELPHM. 
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atria mm- assess: Total Amount Owed: $1,197.00

Pay or Inquire abom your mu at Phone hows. Mon through 'ther 9am 4pm, Friday
921er 12pm

Patient Name Voucher

Payments Patient
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1023/13 We: OW New 3 (99203) 321030 $210.00
1003113 Radiobglc Exam Knee Co 310500 $31500

Visit Tohl $315.00
Pafient Name Voucher 

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I 7 7 Insurance 7 Paymems Patient
Pending Credits Balance 
10/2313 Knee onno Ad] Jm Pos(L1333) $332.00 1
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ESYEBAN SERRAND THE ROTHMAN INSTITUTE
PO BOX 157910

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PHILADELPHIA. PA1B1757910



      

Billing Details

CONTINUED

Paflem Name Provider
Esteban Serrano Emper. William

Se ce DetaHs

10/23/18 

 

10/13l18 Radiologlc Exam Knee Co (73564)
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11/09/18 AsmarTrundeY
11'2'1/18 Pay Credit Cam Pu

Voucher

Insurance


Charges
Dahlls

 

This amount reglesems yaur deductible. Please rem payment.

52mm $210.00

$105.00 331500

77 7 50-00 $315.00
2110.107" 

$194.90

4194,90 $0.00

VisltTohl $0.00

Total Amount Due: $829.41

Payments
Credits Balance

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