Henry rem Haalth Syxlem Dam PO Bux 5539211 Pum'u - Damn, iv- mumm-- Amount Due: $3,357.52 mm :15. 06/25/19 NW) . M'w'mm Thank you (my Lhuusmg Henry Ford Haahh Tm srammpm reflem we hu'anm w: you owe r'ur sen/mes rewwed at one, or more, cm Henry Ford Health System fauhnes The dated no me iemces rendered and me amount yuu own are Iniludm! on me atuched page: Im omm Mess: as ardin Your Accounts Please sub 1 payment 1115335752 by Anne 25, 2019 (all us at 17300759975329 you would Iike u: make paymem arrangemems. Ply Oullm Pay by pm". (1m. HnUlAummztefl sum GotchanMordKum/M cm Lam-999.532; tad Represemalwes are .yauame Manday 777'qude 7am 6pm nmy 7am 5pm PAPERLESS BILLING an now/m (am/Nytnan up Mum." mum; or Use Piy .s a fines! Pnnent Enanna Snuthluv Duo 7' Amm Si Man mm puynhh' Hmu Hcahh by <> Um mm Mm yum . "Vr-usr see 1mm we to prmuip updrn'vu one Li a. Hmuy mm \m 5mm (Mum Pi) BOX 5' Duh NH 115235 5| "mm Jun: 05' 20W Henry Ford Hell'h PIHIM: PO Box 553920 an m, Detmll, MI 45255-3920 Page 2 a! 5 General Inlormaliorl Iden manor: Numbers, mpvesenu [he Idennficahnn numberohhz pusan varpaymmame stmzes undered nus numhet '5 used lor finanml and cmraspanflenzr MRN (mew racnrd numwy 712mm" me umque mennhzahan numbers! we paxvzm Amount Number represents a man: :ncuunmv, mm or my Chavflas Medma' 5mm Charges to! many or medmal canny semces such is pmcedumx, magnum: mm, M), Khlvapy, supphes, and mg; Charggs (or sen/Au: rendered by nf mm memtal practmoners rusmanze Palvent Ann/Ry Insurance paymm; made by you! msumnte Henry Ford New System, and aaymmem max reflux lhe dwflemnce between [he (ha/g: and m. negnniled naymenl made by your vnsurance Pauem AmeyA Paymenu mm by me suave/"arm Henry Ford mun Syslem, and durum": pahem's may" Exglanauan qumoum You 0w: Deflumble The amaunl you are no pay hum: kur msurante mu my Ann-m amuum dexermmed by yaur msmam p'an Carmsurante we ponm or ma! you! mxuranu you my my meelmx yum annui' dad-mum: VA mm amount yau respnnuble to pay lora Spetmt covered Senna Carpaymemx 37: in your mumm pm and Wm vary band an a! service Mommy/arm VA sen/me max '5 "mowed by yaur msmam, av >5 mm mm ulynurspuvh: pm Iv our -eusonalorlnsurance inlormalion hes chan desse indlCalB Chan 5 below 'niumml: we nus or mm mummy msumcz cowAw cums vwanvauRmcEcuMan AnnNEss 5mg CODE :le anE 1w can; mm voucvnomsw my; MMADURESS voJCmeuERmNuMaER Eumovza EwLovERcw EMPLOVER sma Hanry Ford Nanlth Syalam PO Box 553920 @555 Devon. MI 48255-3920 New Accounts 0m 0m 4/17/2010 Sen/mas at 57 NGTS RAD ULYRASOUND 05/05/15 us, ABDDMEN 0mm) 0mm Hea'lhtare Payment: 02mm: 35 55 \nsurance Amustmenls Amour" Vau Owe 05/10/19 Mpdmal 50mm 3! MFHN HENRY FORD Hoswrm 05/10/19 Lahmamrv 0mm Hea'lmalc Paymenl: AA 97 mwranzn Ad'usxmenb AmnuntYau Owe 05/13/19 Meum samces at HFHN HENRY r000 HOSPWAL 00/01/19 thvmany Supplras and Dex/mes paxnoxugm Room Semes Olhuv rmagmg Serwms Pulmonary Ummd Payments Dudumhle 2,440 37 Comm/0mm 119 57 Amount You Own s1 cmeulDiI- Junnufn 2mg mum nannasmmw ID. mgu a 5 Statement Summary Prewous Balance 5418 97 New San/mes $3,912.76 New Payments/Adjustments 74 1 7mm Amount Vou Owe $3,357 52 Payments Apphed $0.00 Amount me by 06/25/19 53,3575: pane": Amount Von Amwty owe 1m Aulmtv crmges 104 7a 159 00 170.00 2,170 00 471 00 95 00 $2,050.44 Nonry Ford Health System slunmml n. :meos' 2099 Po Box 55392., . 5mm 5mm, GuannluIlD' -- Delmll, MI 40255-0920 Page A a, 5 0m Dem-prim! (huge: lnsumnw Patimu Amcumvnu mm mm 5/13/2019 Physician Services at HFH RAD ULYRASOUND - 05/13/19 SDNO GUIDE NEEDLE 117,00 fl5/13/19 SURG 165 00 05/13/19 NEEDLE IQDBO 06/05/19 Heallhrar! Payments 47.26 Comm/ante 1165 Insurance Amustmenls 7250 16 Amaunt Vuu Ow! $194.55 Yolals for New Accuunu 3,911.76 974.21 0.00 52,933.55 Agounts from Previous {tagging Dam Doscnpuun Lhayges Imumm Palm"! AmoumVau Admky Atmily Owe 04/17/19 >Medlca! Services ax mm srmme HEIGNTS Am omer \ng7lng757en7/Ices77 7 7 7 7 750% 00 05/06/19 Umted Healthcave paymms 0.00 Deduuible 413.97 Insurance Amusxmenu 707,03 Amnunl You 0w: $41037 Tank Iar Actaums Previous Slammer": 505.00 17.03 0.00 $413.97 .7 )a "Liam P. fi'aamSH--flkg: .u r04 Tom/Amount Owed 32.351052 Amount Due by 6/25/3079 334357.52 w: (mun/"ed pun/mu" mlnmumw .more 0, ohm" . 4m (any or mm mm: annu mm". mm, Agphuucn mun {m m. mum(um/10mm: MW. mm" mm," mma.wmn [mum-Ir." m. vuf hi, "guy'uywu ,0 GBP10.01 .Va'ykwm iv mu 00 "0099950" 0.0.an himntul/"xmnme I Henry Ford Health System sumym at: . 05 2mg PO Box 553520 arm: mm i~ttr e, I nenon, MI 48255-3920 mum" Page 5 :45 mm. an" gym. mam>> "New" mum-<> .gwwm - .iw 5"me mm"- m; "Wu eamwh mu m, mm mm whammuvm HENRY FORD ll 5V5 mm w: Inn! llnuhh'syuunm Immlunulnuvniu 1 yuu Hum Al Iluuylnni LXpL'ncnu: Ilm Iml 2: MI 4m l'rhmwund I'almm smum- um <> Cndu mednva Dzicllpunn Oly cm 0402 402757050 ABDOMEN \Ml'llh 506 00' Yul-I 5415 DD Ho-pllal Paym-m um Adm-mums new Amour" 57 Yul-I hoIpn-V IdM-un-nll o: 'Imul Aununl mm" mum sulnmy Balance "mm Prease can our Customer Sewma Dapanmenl :11 1780079996829 1! yau have questions Iegardmg nus IMovmahon FORD HFALTH H) Hunk (homing mm Ion! mum hpk'm A, )uul pmudcr Tam; cm or is mu pnnm) AI Henry Furd. we pm "each paucnl firs!" and are pmndulg our mum. m. qunm, llcallh cam and ma hm Henr} Ford Hus unmnbull llus [or MC Sx Illus Radvulng; Uluawund Paucm Hn'nnz Da|c IT 10 Accoum Dane. 04 1" l9 Charge: Serum Dal>> Sew)" Pruwdor rx Des: 9 Ion AARON us 76705 JOSHUA ["5537ng um: pvohulanll mm": Pmmsioml Paymonls and Adlunmcnu um Amour" Unnen Hea'mcare Pamems as 34 fetal makumnal payments Ind mum-um ram Accounl Huhmu- 53mm Tum hell-pl} Ilalnnu' mum Please call ouv Cusxomer Servme Deparlmem a! 143003995329 4! you have quesnons regardmg (ms mlmmanon YSTEM HE RY FORD HEALTHL mm you lur chowng How, I ma llunhh Syawm a; your mm mm raking cm )nu L. uur pnunly Henry Ford, we pm "each panel" fim' .md arc our mum; wm qualny can: and |he Im- mm l-ord Hm .s hm Tlus an umumuon aha-mm for NI Kndm'ugy Imcrv nnonal Pam-m Admss'on usnmv HmpuawAcceum Dnclursc Um 05"" Hnspiul Dam mom Procedure Daicnphon my Code nsnang 0402 402759420 uLso NEEDLE PLACEMENY 1 471 no 0351 36waom2 mm RM RADIOLOGY LEVEL 2 I 2.17:; no' usuang 0210 210005503 EIoPsv WM LVL 2 ms nu' usnsuu 0270 2700mm MISCELLANEOUS suprv LEVEL 1 cosV I 51 an mom 99 1 cans/w 0250 27zuu1lae'ma meg mops>> Lu CM om GA Unix 76' FREE (ls/lane 0450 550050024 PULSE osuana . 0312 LEVEL suRG (moss; ch 17000; You] mum": 1,112,15 Haspllal Paymmn and Adjuumnu Dme Amuunl ed Paymems and Ad'uslmems . 512 32 1am pawn-"LI and aquumm. 511 a: Tmal Accounl Ihlnmu- $1,560.44 'rnml Sell my Ihdnm'r: sumo." Please call our Cuslomer Servlce Depanmenl at 17800-999-5829 you have quesuuns regardmg Infarmalmn HENRY FORD HEALTH mm m. [m \hmmuglluu) r\ll|cnry dun [mm-m Imr Imlmm mm "mmucuu mun or lur Hm l'inlmlugv Pam-m Arwum Adulmmn mu>> Imu- 0% la In Ho-pn-I chum-- Rchauu Frau-mun Demlpuon Cam: my Amnuul nix/mug mus usrlormi I man osrlorm' mus . 45m) 0511mm mm <> Ilnlunu- Nun Please call nu: Cuslnmar San/Ice Dapallmenl at V7800 99975829 you have quesllous ragavdmg (ms Inhvmauun FORD HEALTH SYSTEM Bums". Guamm Thank you for Chousmg Henry Ford Imuh Sysuml as )uur hcahl care lder, Iakmg care nr you is our pnmil Ax Henry Fm we pm "each pzuenl firs" nd are onrpafiems wi|h quali|y heahh care and [he best Henry Ford Expclicnce This IS uolz bill is an "cmwanon ofservicua for: Hm Radiology Pauc nna 05 Accoulu Dnehxrge Date Prolessional Charges Sowice Dale Service vame! Px Descripnon Fx Coda fransactinn Amoum Dana/20m AARON NEEDLE BIOPSYMUSCLE 20206 smu oa JOSHUA 94553723) os/mzmg AARON soNo GUIDE NEEDLE anovsv 15942 51 17 001 JOSHUA 9455:7251 nsuarzme RAoun. MOHAMMAD SURG IV mos. 3155 no mo], 7 Tulal mom onal chargu: nun Prolnslonal Payments and Ad'uslm-nls am now "an Mm," 'Umled Heakhcare Paymenls and Adjuslmanls 277 52 Tel-l plohnlonzl and mun-Imam; 217,5; Tum Ilulanu' 5m." 'lnlul SSH-[nay P'ease caH our Customev Servlce Deparlmanl al 1300799941829 .1 ynu have 0145 mmrmaunn -- UnjtedHeaithcare United Healthare Services inc GREENSBORO CENTER Po Box 740300 ATLANTA GA 30374'0800 Have more euastrons about your Cialm'v' Visit tor all your orarm and oeheirt rntormatroh May 30, 2019 Explanation of Benefits Statement is nota bill, Do not pay. This is to notify you that we processed your claim. Claims Summary Detailed claim information is located on the following page(s). DollarAmount Descrip on Amount Billed 3402038 The amount your provider charged tor services provided to you Plan Discounts $523 30 Your plan negotiates discounts with providers to save you money This amount may also include services that you are not responsible to pay. Your Plan Paid $539.58 The money your heallh benefit plan paid. Total amount you owe the providerisi The portion oi the Amount Billed you owe the provider(s). This arnountooes noi any payment you may have already made at the time you received care. This amount may rnciuoe your copay, coinsurance ano/or non covered charges This amount does not include any payments made to ihe it a paymentwas made directly to the you/ihe subscriber is responsible rorpaying the iacririy or other health care proiessronai When coordination oi beheirls applies amount wrii include paymenls made to ihe subscriber. srosoe Page 1 or 3 Use this EOB statement as a relerence or retain as needed UnitedHealmcam Unwed Healmcare Sen/mes m: REENSEORO SERVICE May 30' 2mg PO on mane ATLANTA GA M76- 0600 Have mare quesmns smut ynur dawn" Plume 1 856 270 5:11 my all you! dawn and men mlurmatmn Claim Detail for BRIANNA Yum hemmed valdgr" type Olsen/Io: Nmu' Amcum Plan Amount AmoumYou Serum amen: mmum Mam mm maumme copay Cviusuunce Nau-Cweved cm '07 T2019 usuwowv us Susan $10403 saw sum um swan 5mm my saw 5 C'alm Teul: 31slum "my "Tm: mm does mum any mpay; ynu made am? <Wee Dunedfiamhcm GREENSEORO sEvacE CENTER Nay 30. 2mg PO EUX NGEDD Have more quesnaus arm" you! Mew com m. an ynurdawm am Claim Detail for BRIANNA SNITCHLER Damuyoi rypeocSemee Notes' nmum wan Amoum mm" chvme awed AHuwzd ms Dun-mum- cew CMnsur-nbe Non-Covered Emma 42 man Sum/17o sum mam saau sum) saw 7 7 sewage 7 csmma ug unuau wan :2 am "sa'zaz' susau Sum! saw emu 'cmm tom. 3: am sum) sam'vr ssu'az' szmu' son>> 5215,57 sunn $2,559." "m < HeulmCzile Sen/Toe \n I bmledelflI ale" e. NsaORo ENTER May 2019 Po Box made ATLANTA GA scan used 7 Phune 1 655 27a 5311 Have Idr yum mm and benem unmade" Cla Detail for BRIANNA SNITCHLER Your mum Io vamel" Amount Han VuuTPlan Amaunwdu Sevviw awed uTseeums Allowed Pam nedueume copay Camsuvanm Hun-varvefl Owe d5 mm syasdd suede saw sane yam mad as sum in 5 SERWCES mam. YMAISwirl 311.5: "Tms does nutrefledany paymems I adeays yeu mad. am. Mme at same mease . wrwmev mu dame mm a aaymem Notes" In . THE PLAN DISCOUNT SHOWN Ts YOUR sAvwes FOR mm; A NETWORK PROVIDER. THE AMOUNT YOU OWE MAV TNOLUDE VouR costURANcE PLUS ANV AMOUNT DUE 1F REACHED VDUR BENEETT LIMIT ON A COVERED D2- THE PLAN SHOWN Ts YOUR sax/Wes FOR A NETWORK PROVIDER. THE AMOUNT VOU OWE MAV voun COWSURANCE. PLUS AMOUNT DUE 1F REACHED YOUR LIMIT ON A COVERED us. THE PLAN SHOWN Ls YOUR FOR USING A NETWORK PROVTDER VOU HAVE NOT MET VOUR AND OWE THE AMOUNT SHOWN A .ey-ew or <