Name--Taksall PCP: anan Elan, MD Outstanding Account Details - OutstandingAccounts palm-aka" . Payments lnsurance Panem Dale charges AdJuslmems aalance aalance Procedure Visit at oHsu General Pediatrics at Marquam Hill with Megan Jacobs, Arman:- MD an Jan 24, 2020 IMPLANT 50 MG (67919-mu1l- J9275 12,598.47 DRUG DEVICE - 608.00 Unned Healmcare Paymems and Adlustmems 4,900.02 Professional Sen/Ices 13,206.47 4,900.11) mam Tntal Outstanding Balance: $4,698.45 Informational Accounts Pakiem_Taksali Dale charges Payments lnsurance Panem AdJuslmems aalance aalance Lab Visit at Lab Canker at DCH m. Floor with Margam Hayes, MD an Aug 1, Amount- 2913 LABO mom - GENERAL 1,232.00 UA, ONLV- 51017310179 31.1717 ROUTINE - 36415 (027-) 21.170 CBC DIFFERENTIAL - 85025 85.1717 COMP METABOLIC SET - 801753 63.1717 PHOSPHORUSPLASMA - 84100 24.1717 TSH-THYROID STIM HORMONE - 84443 (021') 103.1717 LEAD, BLOOD - 83555 (017-) 53.170 ZWC WB - 842172 85.00 Date Description Charges Payments / Insurance Patient Adjustments Balance Balance   QUANTIFERON TB GOLD - 86480 (CPT®) 254.00         HIV1/HIV2 AB P24 AG SCREEN - 87389 (CPT®) 103.00         RUBELLA IGG AB - 86762 (CPT®) 60.00         VARICELLA ZOSTER,IGG - 86787 (CPT®) 103.00         DIPHTHERIA AB, IGG IMMUNOASSAY IAA, QUANT, NES - 83.00       61.00       86317 (CPT®)   TETANUS AB, IGG IMMUNOASSAY IAA, QUANT, NES - 86317 (CPT®)   MUMPS IGG AB, SERUM - 86735 (CPT®) 53.00         SEROLO TST SYPH RPR SER QUA - 86592 (CPT®) 50.00         -711.92     1,232.00 -711.92 520.08 0.00   Moda Health Payments and Adjustments   Hospital Services There may be prorated balances on your current statement that are not included in the totals. l, Unitedl-Iealflicare' UnitedHealthcare insurance Compa SRVC CN PO Box 30555 SALT LAKE UT "0555 Have more questions about your clam? Visit lorall yourclam and benefit lMOll'namn February 1 i, 2020 SUDEEP Member/Patient Infomta on Member sALi Member iD Patent CH Group Name HOPE OF OREGON Group Explanation of Benefits Statement This is not a 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). Dollar Amount Description Amoum Billed $12,598.47 The amount yourprovidercharged lorservices provided to you. Plan Discounts $7,900.02 Yourplan negotiates d'scounts with providers to save you money. This amount may also services that you are not resporsible to pay. Your Plan Paid $0.00 The money yourhealth benefit plan paid. Total amoum you owe the providens) The portion olthe Amount Billed you owe the provider(s). This amount does not reflect any $4 59 45 payment you may have already made at the time you received care. Th's amount may include your deductible, copay, coirsurance and/or non covered charges. This amount does not include any payments made to the subscriber. it a payment was made directly to the subscriber, you/the subsortber is resporsible lorpaying the physician, laoility orotherhealth care prolessional. When coordination ol benetits applies, this amount will inclide payments made to the subsoriber. Use this EOB statement as a reference or retain as needed Page 1 ?f 5 Unitedflearmcam UnrtedHearlncale rnsmantxe companym sva CN Febmaly11.2020 Sfififieegsersw uT 541300555 . Have more queswns about youmarm Phone 175662705311 Vsummyuhmm torerr yumcrarrn am benefit rmolrnatron Claim Detail mug News crarm mums rum. 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Sex 3057:. sart Lake crty. uT uraoosn The request toryour levrew must be made ten days trom the date you recerve statement rt you requesta revew or your cram denrar. we compete ourrevrew not ratertnan 30 days atterwe recerve your request or levrew rt yourpran rs goverred by you may have me to tre a sown umelERrSA rtarr requrred revrews or youruarm have been competed you or your aulholrzed represenratrve. sum as a rrernberor may appear the decsron by comrrents. docurrents orotber rerevant rmormaton to me appear address rererenced above you may request copres (tree oturarge) or rmormaton rerevant to youruam bycomactmg us at me above address Sen/roe: There may be olhel resources avarrabre to berp you understand (he appears process rt yourpran rs goverred by you canconract Irre Emproyee Eenems secunty at tassmEasA (3272) rt yourpran rs not goverred by you canconract Irre Depamnem or Heartb and Human servrces Heartb rnsuranqe Team at 175553932759 you have the mm to me a comprarnt orseek trom the Oregon rnsuranqe Assrs'anoe rs avarrabe use EOE sutemenus a reference orreurn as needed 2 0'5 l' UnitedHealmcaxe UntiedHeamrcale tnsuranoe compan 5va CN Febmaly rr,2u2o PO on SALT LAKE CW UT 541300555 Have more questons about yourcarmw Phone 14355270531! falaH yourcarm am aytte tou tree message me at (sea) ovum to tte oregon nursronor Frnanoat Regulatton, Consumemavucacy untL PO on man, satem, OR magmas Through the Meme! at msulance oregon gov erbyeman at op tns@ulegongov nwe ourmme to denylhe payment, coverage, orseruroe requested or you no not reoerye a trmetyoeasron, you may be abe to request anexternat renew or youruarm byan party, who wru reuew the oenrat am She a nnat oecsron Eenem Notroe you leqmle seruroes for heanrg toss, rmormatroncan be toum yourptanoocuments tnsuranoe "and adds mrurons to the costor beattn care Men/toes are hsted you are not leoewe Olsen/toe you were top would be tree, caH 17555270 sarr natreruewmrs onlme'l 5rgnup omewmoad Ihe unttedHeatthcale app to easny uew uarms am account batanoes, see wtrere you're at agamst youroeouctrbe, ocate a netwqu ooctor, uew your neattb pan to card am more you can aso Ihe uutter papeness oetryeryor your mxmam ptanoocuments the pnvacyam searntyor rmrwouatsv personat rmormatron rs us at unnedHeamrcale To protect youlplwacy, we stret wrmdenlramy practroes mese practrces mouoe the use a unque rmurouat roentner vou maysee Ihe umque rmrwouat roentmeron untiedHeanhcale wuespomeme, mauorrg meorcat tn cards (nappteabte), tetters, expanatronor benents (EOE), am prouroer remrttanoe aowces (PRAS) you have anyquestrons about the unoue rmurouat roentneror use, ptease contact yoururstomercare protessronat at the mmbelshown at me top ortms statement Prease caH the rumber comment oron tte bacx or yuuHD Card you need oragnosrs and/armament rmonnatron regarorrg the serurces referenced Ims oomrrunrcatron we no not treatmembers onerenuy because orsex, age, race, ootor, msabmtyov natronat ongm you you werenttreateo < Unitedflealmwv unuedHeauncare msmance companym mcmusomsmnu 5va CN Febmaly11.2020 SEEOMESSFW 541300555 . 5 Pm 1755527053" Have <unwtedHeauncale msmance companyrR 5va CN PO am 30555 SALT LAKE cmr. ur 041300555 Phone 175662705311 Unitedflealmwe Febmaly11.2020 Have more queswns about yumcmm vsu <> seems as aassa fov aaysnsa senmes mmvou owe The mommimmey you pay fa ms senmes yaa veoerve oomswame Yam shave onhecom ova mesa reeuhceve semen aamasa as a pecenage onheauowed amaam fa ms seva Mame me you ya (me amng a cweege new same: you ream sesmpen mes befae yam pan begms <