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'MA/incenl ST. VINCEVT EVANSVILLF.
V0 39" 41"" Dunn's PLEASEPAV
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Maka Check Payable and Mail To:
ST VINCENT 
5763 RELIABLE PARKWAY
lL 506806763

Patient Name Guarantor ID Service Statement
Date Date
.ENSIUN
OAKLEV VODER 07/24/2018 02/11/2019
Pharmacy 68,172.17
ST Laboratory 481 00
We're hereto hel EKG ECG 293-00
Respiratory Therapy 141,00
To reeon Customer Sen/Ice fur questions about
your bill or to pay by pnone, call (512) 485-5720 Eme'ge'wy Rm" 3'85" 00
lndianapolis or toll free at (344) 234--0373 Mal Charges 72's" 17

Office Hours:
Mon--Fri 8:003m 43:00pm

Visit Us Anytime:
Fax, (317) 5332737

Web. styincent org/billing
E>>Mall: org

Patient Responslnility

As a patient ofst Vincent, you nave the right to
expect the finest level of Health Care You have
many Choices for your nealth care needs and
we want to Ihank you ior cbaosmg us. We hope
that our services exceeded your expectations,

Insurance Payments/Adjust

merits (69,461.28)

3,476.89

 

 

Onitne Payment Section: Va
You

(8A4) 28470378
ENROLLMENT no.

 

do not have an enrollment number, or for addttional questions,

may now view and pay your bill online by Visiting
ronline enrollment number is listed below it you
please call us at

Sign Up for
eSlalemenls

 

2921062775

 

 

   

I 0370472019

Account Number

    
  

   

am 
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BALANCE REMAINING AFTER INSURANCE - PAYMENT NOW DUE We 

send payment in full upon reoeipt of tnis notice or contact Customer Service
payment plans. To ensure that your account ts properly Credited please rele
payment.

 

ave been advised that your Insurance Wilt n01 be

paying tne remaining balance on your account it you question inls inlormation 7 please contact your insurance company Please

'0 take advantage 0' out zero percent interest
renoe your account number when sending your

 

Gt Mmy~ rerun rs 37rli'lwisitl mullA'e 


 

   

 

PO. Box 106
West Plains, MO 65775

AIR EVAL- [Fey-54M: Return Service Requested

 

DESCRIPTION OF CHARGES

Base Rate RW Night Call
Loaded Miles

Dextrostix - Blood Glucose
EKG Monitoring 3 Leads
Night Call

A0431
A0436
82962
93041
A0800

patientaccounts@amgh.us
Phone. (877) 288- 5340
Fax: (417) 255- 2312

Loaded Miles: 80.0

From

To



1.0
80.0
1.0
1.0
1.0

Base: 138-*Air Evac EMS Inc Harrisburg
Location: New Simpson School Parking Lot
Ozark, lL 62972
Location: St. Vincent Evansville
Evansville, IN 47750

Federal Tax 

UNIT PRICE AMOUNT
31600.00 31600.00
293.09 23447.20
40.99 40.99
117.39 117.39
372.06 372.06

TOTAL CHARGES: $55,577.

ST VINCENT VANS VILLE HOSPITAL


5763 Reliable Parkway

Chicago. IL 606805763
Pt Nnme: OAKLEY YDDER

Ancnding Chris|ina Wagner

Princlpal Diagnosxs T63 DOIA

  

 

       
   
 

 

 

 

      

 

 

 

Provider: 

Provider Tax ID a --

Detall for: OF EMERGENCY 07/24/2018 -- 07/25/2018
Date Re>> ca Cd 9g Amaunl 

25C {mtlvemn Aszehdaey Polyvalent Immun 4

Fab PDS La)
07 male 5mm gamma 3 50 253 m; 1
4/20: so meg/m; m; 1
07/2/1/2ul ETRY DE 1
emu/2m" 
Dr '201 3 
2
JZLUOM 
camm mas; 
om. 2 "Ma 2  
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1
mus/90,5 Exch 1
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07/25/2018 TEN--CINE 1
a
an a] Coverage: 7
ST VINCENT HEALTH SERVICES
2001 WEST 86TH ST BOX 40970
INDIANAPOLIS IN 462400970
Pnorig Plan Name Po my a Subscriber
Hk?| HEALTH EY YODER
2 COMMERCIAL NS EV YODER

ADDRESS SERVICE REQUESTED

Guarantm SHFIM mun:

 

 


ST VINCENT VANS VILLE HOSPITAL

5763 Rel 
Chinquv IL 606805763

 

PKNarnc: OAKLEY YODER
ths' "an. Chrmina Ruth Wagner

Principalegnosus T63.0DIA

 

Provider 
Provider rax E, --
Detail for: OF EMERGENCY REG70 07/24/2018 -- 07/25/2018

(Continued)



    
 
   

59/ mm COMMERCIAL ms rce Payment
wo/zwzma nasA Ins ance 251mm:

Elskcuri

 

09/13/2 FIRST Hum Pay

Irv

   

Balance $3,476.89

Page 2 UV 3



ST VINCENT VANS VILLE HOSPITAL

5763 Reliable Parkway
Chicago. IL 606805763
Pl Name: OAKLEY YODER
Attending Physician Christina Ruth Wagner
Principal Diagnosis: 163 001A

Provider EVILLEHSP7U

mederTax ID 

Detail for: OP EMERGENCY REG70 07/24/2018 -- 07/25/2018
(Cominued)

Page 3 o! 3

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