Page or 2 yMA/intenl ST. VINCEVT EVANSVILLF. $3515PLEASE my 4x g( A SHELI voutR oz-man new as I. .7 "Hum. ML . mu unmask we mm We em woe SIGNAWRE yen: Make Check Payable and Mail To: ST VINCENT EVANSVILLE 5763 RELIABLE PARKWAY CHICAGO lL 506806763 -- Mm (M 'r new 0, MM min Lmrgesoll m. Patient Name Guarantor ID Service Statement Dare Date .ENHON OAKLEV VODER 07/24/2018 02/11/2019 Phalmacy 53,172.17 ST Laboratory 481 00 We're here to hel EKG l' 5'95 Th To reach Cusrcmer Service fur quesucns about es" my era" 1 your bill crio pay by phone' call (512) 485-5720 Eme'ge'wy Rm" 3'85" 00 ll" indlenapolrs or roll rree 31(844) 234--0373 Mal Charges 72's" 17 Office Hours: Mon--Fri a:ouam 43:00pm Insurance payments/Adjustments (69,451.23) Visit Us Pariem Responsibility 1476.89 Fax, (317) 5332737 Web. org/billing E>>Ma1l: org As a pafient ofst Vlncenl, you have me ughi lc expect the finest level Of Health Care YOU have many Chulces for your neelln care needs and in inai our services exceeded your expecrarrons, Online Payment Secfion: Vou may now view and pay your lull onllne by Visiting org/billing Your onllne number is Ilsied below li you do nor have an enrollmenl number, or for additional questions, please call us ai (8A4) 28470378 ENROLLMENT No. 2921062715 for] eSlalemenls meme am I momma swear BALANCE REMAINING AFTER INSURANCE - PAYMENT NOW nus We have been advised mar ycur Insurance Will nci be paying me remaining calence on your account if you questlun inls 7 please dcniaei your insurance company Please send payment in full upun leoeipt of this notice 0! wnlam Customer Service lake advantage 0' our Zero percent {meresl paymeni plans. To ensure that your account is properly Credited please reference your account number when sending your paymem. 51 Mmy~ will" we <PO. Box 106 patientaccounts(R)amgnus 1" Wesx Plams' MO 65775 Phone: (877) 28875340 - 12 AIR EVAL-- UFETEAM. Fietum Selvice Requested Loaded Miles: 50 0 Base: 138-'Air Evzc EMS Inc Hamsbuvg From Locminn: NEW Simpson Schoo' Pavkmg Lot Ozark' N. 62972 To Location: 3| Vmcem Evansvme Evanste, IN 47750 Federal Tax ID 4343mm DESCRIPTION OF CHARGES QUANTITV UNIT PRICE AMOUNT Base Rate RW AUASI 1,0 31600 00 mambo Loaded Muss A0436 800 253 09 23447.20 Dextrosnx- Blood G'ucase 32962 1 40 99 Au 99 EKG Monmoer 3 Leads 93041 1.0 117 39 H7 39 03H A0800 1 372 06 372 06 TOTAL CHARGES: $55,577.64 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 - cam rn'm 1 mus/90,5 Exch 1 0N: VIP-FLEX 1 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 EXPLANATION OF BENEFITS L, SPECIALTY mud" BENEFITS INC. MMW "mm. In Cam-m mm llenefil: m: Wu) um 20er 1 DH M2- Ilhwum'c Comm") (mun mum OAKLEY mum for! Wayne . mm Rchmonahlp Se" 0 am 22 Ix mm-- ("mm No mm", om Sp um mum memm mx Ecncl'm. Inc am Nu mm (mm com Incurred Dam use"): tummy Acmdmu hm Fonn THIS IS NOT A BILL mm (mm mandible Exchhium Cnvurd Ply Amount Dnle chm: Ineflgible Dhmum Inn-"nu: Amount cm Expemes V. Amnum Ambu'ancc. (irnund ems/zom- 1.19am arm unu owmms M9000 umPalm" Com Amount mm Tum! Pane!" Dedummc Ammvm Comaumnnc Amuum) a on Duuipfiun nlCnIiz: ax med Ahnvumim Cnmmemx '34 mm av mume mm (No: usm uwucnau CALCULATION) mm: Chuk mm Amnunl Due MLDIC ONSITE LLC 577m l2 mug/2mg Po BOX 747 wxmmu Claim Deductible Dlduchhle Rem: - Mum umn um um. Remaining no7.2% ml; 56