'n'vx m- Slatemen! ol Sorvlces Page 2 om. Mum", mm mm m. mum-pummwm mm. mm." mm. on. cs RaomGEcuydrSemH'Hvl 377750 WW 3 .0250 ,s'mm, (Wuhuli 2139550 $35335 0.00 t20.926.mm-- mm cmmpagmw m, 37200 41160 nun 525nm: usmm usaa pm 4350 A:coum_ 1 M55 ms mm w. Do cmmawsw w; Hun 43.5., cm mm 3 49500 "mm, mm MD Weswmnewm Northwestern \c I ne Guaramor Pahenl Arhne Fev'en Slammer" Da|e 07/19/2019 Statement of Serv (:95 Data of Page 3 Sum mm." o. 5mm cm; {21'2"me - ue Mal <<5m <<5.50 n.nu suesn Yolal Au Sen/mus 30305.5(: 637135 u'no 521.51": Northwestern Gummy ID - Due Date 08/09/19 ulnlmum Amoum Du. 21 334 55 Naflhweslem Medlane PO Box 4090 Csvol Steam, IL 50197-4090 Can us :1 (555) 6944366 lav new 9 n, b. 1mm - WINFIELD 111110111110" cousuuANIs, sc - Phone: page 1 013 Fax. 616/954-2800 WebsHe: Hours: Mon . Fn I 8:00:1m - 8:00pm Eastetn ID Numbe, PLEASE SEE PAGE 2 FOR IMPORTANT INFORMATION Name ARLINE FEILEN Please tey'levy the charge detatt ttstea on the totlowing pa 'S10f1111s statement, 1f you haye tnsurance that IS statement DaIe 7/11/2017 ed at .5 tneoneet, please eontaet Us so that we Slulemenl Number 1 can update our records. Iht's SVGVemem services rendered by WINF1ELD LABORATORY CONSULTANTS. SC. Statement Summary . - .Paymem Options Full rm. Oplion We g1udly accept checks and In: lnllowtng moiet :tedit curds . 't 1 Mat Amount Due. $533.00 1M1 on- You may 0150 make payments: Pay Ontine or Us'lng our App 5 . medicu1me.com va Sam?" :me'L $55-33 on eNICtng ee. Pay by . . Full OR Due By $33231)?" Cheek W1NF1ELD CONSUUANVS, SC 7 10 10 2019 $52.75 -|rlc1ude payment stub be1ow tn etyelooe ptoytaea PLEASE FOLLOWING FDR ACCOUNY DETAIL Pay by Phone . lease nave payment 13 n1u'1bythe due date ttstea tout account 1: not cuttentty tn aetautt setytee tees may be .a any th. due date tot yout oa ance MG 1: not oata tn Sen/1291625 ate Late tees may apply .e the detotlea account tnfo'motton on subsequent page: and the Pavmen'A35t31cnce' sectton oetow tot mate tt payment Meme 13 returned tot any reason, a 125 00 tee W111 be added to ycut account 'ees ate subtect to change thhout nottee Paymenl Plan to uxtfl you the payment ot yaut account, we ate 0116719 you a payrt'eN a'vangemem ootton tot 17 month: By paytna the exact balance above. you agree to a payment at 552.75, tnetuaes a Seth=e tee at $0.00. Aadtvtenally, all accoums and charge: an s1atemen1wt11 oe aamatnea tnto one payment plan an tutute statement: tt you waula fike out Weostte at mymeateotme mm at call out otnce at snutevems 1ee1 may aootyl Statemeni Number Wm HELD LABORATORY con St; 1's. sc PO BOX 120153 1 GRANDRAPIDS Ml 49523-0103 Amt Due Due Date Ami Enclosed $52.75 10/10/2019 Phone Hours' Mon-Frt Eas1em' 4 WINF1ELD LABORATORY CONSULTANTS, so PO BOX 88087 CHICAGO 11. 60580-10137 Details for services rendered by LABORATORY SC. page 2 of 3 It 0U are uninsured, you may quality for financid Please Contact US for more in crmation, Accounts Not on Payment Plan - Account Numb Note: account is current and is due on 10/10/2019. Date of Srvc: 5/15/2019 Patient: ARL1NE FE1LEN Procedure: 80050AA: GENERAL HEALTH PANEL location: CENTRAL DUPAGE HOSR1TAL. CHANG T1FFANY MD Insurance 1: GENER1C INCOMPLT1NS INFO charges associated account: Orig Balance: Pmts/AdllFees: Charge Payoft: History Detail Date Description Pmts/Adi/fees Date ot Srvc: 5/15/2019 Patient: ARL1NE FE1LEN Procedure: 80307EC: HB DRUG SCREEN location: CENTRAL DUFAGE HOSP1TAL: CHANG T1FFANY MD Insurance 1: GENER1C INCOMPLT INS INFO Orig Balance: Charge Payotf: History Detail Date Description Pmts/Adi/Fees Date cl Srvc: 5/15/2019 Patient: ARLINE FEILEN Procedure: BOS2UEA: HB DRUG SCREEN QUANTALCOH location: CENTRAL DUPAGE CHANG TIFFANY MD Insurance 1: GENER1C INCOMPLT INS 1NFO Orig Balance: Pmts/Adj/Fees: Charge rayolr, History Detail Date Description Pmts/AdJIFees Date oi Srvc: 5/15/2019 Patient: ARL1NE FE1LEN Procedure: HB UR1NALY313 AUTO locailo . CENTRAL DUPAGE HOSPITAL. CHANG TIFFANY MD Insurance 1 GENERIC 1NCOMFLT 1N5 1NFO ona Balance: Pmts/Adi/fees: Charge Payolt: History Detail Date Descr tion Pmts/AaI/Fees Date of Srvc: 5/15/2019 Patient: ARL1NE FE1LEN Procedure: 82728EA: CHEM1STRY location: CENTRAL DUPAGE HOSR1TAL: CHANG T1FFANY MD Insurance 1: GENERIC 1NCOMPL1 1N8 INFO Olig Balance: PmtS/Adl/Fees: Charge Payotl: History Detail Date Description Pmts/Adi/fees Date 0' Srvc: 5/15/2019 Patient: ARLINE FEILEN Procedure: 83540EA CHEM1STRY location: CENTRAL DUFAGE HOSR1TAL. CHANG T1FFANY MD Insurance 1: GENER1C INCOMPLT INS 1NFO Orig Balance: Pmts/Adllfees: Charge Payott: History Detail Date Description Pmts/Adj/fees Dale al SIVC: 5/15/2019 -- Orig nalance: 98.00 0.00 1 00.00 0.00 33.00 0.00 33.00 0.00 40.00 ,7 0.00 110.00 1 2.00 0.00 23.00 page 3 of 3 - Paiieni: ARLINE FEILEN Prn's/Adj/Fees: 0.00 Procedure: 54A39EA: CHEMISTRY Charge Paycii: HUG Locullon: CE DUPAGE HOSPITAL: CHANG TIFFANY MD insurance 1: GENERIC INCOMPLT iNs INFO Hisiory Dale Descripiion Pmts/Adj/fees naie oi Sivc: 5/15/2019 Orig Balance: 33.00 Paiie ARLINE FEILEN Pmis/Adi/rees: 0.00 Procedure: 84466EA. CHEMISTRY Charge Payolf. W. iocaiian: CENTRAL DUPAGE HOSPITAL: CHANG TIFFANY MD insurance 1: GENERIC INCOMRLT INs Hisiory Daie Descripiian Pmis/Adj/rees naie oi Srvc: 5/15/2019 Orig Iaiance: A900 Paiieni: ARLINE FEILEN Prnis/Adi/Pees: 0.00 Procedure: CHEMISTRY Charge Payoii: W4 iocaiian: CENTRAL DUPAGE HOSPITAL CHANG TIFFANY MD insurance 1: GENERIC INCOMPLT INS INFO. Hlflory Daie Descripiion Pmis/Adj/Pees Daie oi Srvc: 5/16/2019 Orig Balance: 1.57.00 Paiieni: ARLINE FEILEN Pmls/Adllfees: 00 Procedure: 80074EA: HB ACUTE HERATITIs PANEL Cirarge Payaii: 1.47110 iocaiian: CENTRAL DUPAGE HOSPITAL: CHANG TIFFANY MD insurance 1: GENERIC INCOMPLT 1N5 INFO Hislory Dare Descliplion Pmls/Adl/Fees Dare oi ch: 5/15/2019 Oilg Balqnce: 45.00 Paii ni: ARLINE FEILEN Pmis/AdI/ree . 0,00 Procedure: IMMUNOLOGY Charge Payoii: W45. Lacaiia CENTRAL DUPAGE HOSPITAL: CHANG TIFFANY MD lnsumnce 1: GENERIC INS INFO Hislory Detail Duie Descilp'ion th/Adj/Fees Toral Accou lPa off Min Ami Du 63 union paymen