Hudson Hospital 6: Clinic



KarIi HUDSON HOSPITAL 8' CLINIC
405 STAGELINE ROAD
HUDSON, WI 540164845
Visit Coverages:

Media - Medics CMIDE

This is n01 a biilv This Is an itemizaiion 01 your hospital services (or:

 

Currem Hospiial Account Balance: 6,663.38

Summ

    

0122 ROOM BOARD - TWO BED (MEDICAL OR GENERAL) - OE $3,550.00

0250 PHARMACY - GENERAL CLASSIFICATION $129 00
0270 SUPPLIES AND DEVICES GENERAL CLASSIFICATION $101.00
0300 LABORATORY - GENERAL CLASSIFICATION $184.00
0301 LABORATORY - CHEMISTRY $298100
0305 LABORATORY - HEMATOLOGY $121.00
0370 ANESTHESIA - GENERAL CLASSIFICATION $4,836.00
0720 LABOR GENERAL CLASSIFICATION 528,00
0722 LABOR - DELIVERY ROOM $2,633 00

Delaiied ltemizafion
Chargas

    

1 19/18 01960 ANESTH VAGINAL DELIVERY "mam

12/19/18 AMNIOTOMY 528.001
12/19/18 BENZOCAINE 20 AERO 57 CAN 313,31)'
12/19/18 DELIVERY CARE LEVEL 2 52.533100
12/19/18 IBUPROFEN 400 MG TABS 
12/19/18 02 PARTIAL DAY $101.00'
12/19/18 SEMI-PRIVATE 0B $1,780.00
12/19/18 WITCH HAZEL-GLYCERIN PADS 40 EACH JAR $8 
36415 ROUTINE VENIPUNCTURE 
82565 CREATININE, SERUM LEVEL 
{12/20/18 82570 CREATININE, OTHER SOURCE $99.00'

112/20/18 84156 PROTEIN QUANT. URINE LEVEL $31.00

 

Stat/mad

Guarantor Guarantor Statement Payment
Q) Hudsml Hospital 5; Clinic Name Number Date Due Date am:


- -- 1/9/2019 213/2019 53,635.33

fr-vayments in the last so days
payment plan amount due

vou'r prams sauna;
Amount on payment plan

          

 

New charges . 'Ameuni not on a payment plan 7
gaynlle lustrnents Favmenmualbalarms due . EEQSL
Date 0! Description Charges Insurance Patient Balance
Service Payments! Payments!
Adiuslments Adi ustments
72 w. 1 7f?fl 
Inpatlant
HUDSON HOSPITAL Es 
HH DE
12/19/2012 Room and Board Seml Private $3,560.00
to Pharmacy $129.00
12/21/2013 Medical/Surglcal Supplies and Devices $101.00
Labonatcry
Anesihesia
Labor Room/Delivery
Medlca Payments I .1 33.293.5t/
Deuumlnle: 1,500 00 4
Copay: 323.33
Meulca Adjusllnenls $1.931" 11/ 
Patlent Balance (E2 323 313x
Kerrsennsider,Levialhan --
lnpatient
HUDSON HOSPITAL CLINICS
HH Nursery
12/19/2015 Nursery $2 016 00/
lo Pharmacy $133.0
12/21/2013 Laboratory $379. 00/
Audlolagy $110 on
Medlca Payments 30.00
1.312.110 i043 
Memes Aulustmems $1,331 on
Patient Balance g1 31 09
0-30 Days 31-60 Days 6180 Days Over 90 Days
Account Balance 3,635.38 0.00 0.00 0.00

 

essages

lThank you lor using Hudson Hospital for your services. We expect payment ln lull now unless you call 715- 531--6220 to
make other arrangements. If you have elfective Health Insurance coverage that was not billed lor the services listed above,
please conlacl our Patient Accounting Depanmenl at 7'5-531-6200.

1

PAYMENT DUE: $3 635 38

. 

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