1 BAPTIST HEALTH Please Pay Amoun mount Enclosed I i Posoxvaozm $9,673i6I LOUISVILLE, KY 40275--0257 "Meme," Date Gummy Number Thank you for Choosing Baplist Heallh! Go to mychart baptisthealthcom to pay online w; .4 pl IUI I 22:33:?ng ThIsslalement payment due mil>> BAPTIST HEALT PO BOX V50257 LOUISVILLE KY 40295--0257 PLEASE DETACH ANO RETURN THE ABOVE wm-t PAYMENT ST TEME Patient Name Statement Date Guarantor Number Maithe Alton Fenlress 05/i3/2o -- Dale Charges Insurance Pallenl Pallenl Balance PmtS/Adjs PmtS/Adjs --Matthew FenlreSS's visit to Baptist Health Louisville GENERAL CLASSIFICATION 517330 PHARMACY EXTENSION OF DZSX SINGLE SOURCE IIOM 7S DRUG United Healthcare Paymems 4,008 9| Coinsurance 072 bl United HealthCare Adiuslments 74,537 PATIENT PAYMENT x0289) 7M 74 PATIENT PAYMENT 03/!8/20 PATIENT PAYMENT 04/'8/20 x0289) 40000 TOIals 5218.55 7154'} 04 72M 74 "0.87 Pallenl Balance "087 -- Matthew AIton Femress's Visit to Baptist Health PHARMACY GENERAL CLASSIFICATION 773.10 MEDICAIJSURGICAL SUPPLIES S1 DEVICES (ALSO SEE 71H 57 OT 05in AN EXTENSION OF 027XIVGENERAL CLASSIFICATION LABORATORV GENERAL CLASSIFICATION 88.50 ANESTHESIA GENERAL CLASSIFICATION 2802 80 GENERAL CLASSIFICATION 178308.80 PHARMACY EXTENSION OF 025x SINGLE SOURCE 22S 85 DRUG ELECTROCARDIOGRAM GENERAL 557.80 CLASSIFICATION United HeaImCare Payments 725,454 07 Colnsurance 7,598 95 United HeaImCare Aaiustmenls 7223,7573 TOIals 258134.85 150,258 in 000 7.875.575 Pallenl BaIance 7875 95 For iinancial assistance to pay by credit or debit cardi or address anti/or insurance changes please contact customer Service at (856) 273--5392 Mon--Fri anew--5mm ET or access your MyChart account 1 0' 4 fl BAFIIS HEALI--I BAPTIST HEALTH an Lcuunt, a . Name Date Date Description cnarges Insurance Patiem Patientsatance Pmts/Adjs Pmts/Adjs Mattnew Alton Fentress's Visit to BAPTIST HEALTH MEDICAL GROUP LOUISVILLE CARDIOLOGV with Snyder. RacheI Lynn. APRN ELECTROCARDIOGRAM, COMPLETE 35.00 OFFICE OUTPATIENT EST LVL 4 20200 United HeaIthCare Paymenls 789 Db United HeaImcare Adjustmemi 36 CO7PAVMENT 7 "1/25/19 (Vlsa 75000 23800 48042 75000 758 Pallem BaIance 7.58 -- Matthew Alton Fentress's Visit to BAPTIST HEALTH LOUISVILLE OUTPATIENT ECHOCARDIOGRAPHV with Kemp. Jamie D. MD ECHO HEART XTHORACIC.COMPLETE DOPPLER 14200 United HeaIlncare Payments 752 07 United HeaItticare Adlustments 753 7| Totals T4200 40668 000 35 32 Patient BaIance 35.32 Matthew Alton Fentress's Visit to BAPTIST HEALTH MEDICAL GROUP FAMILY MEDICINE wIlh Jenkms, Jesse, MD OFFICE OUTPATIENT EST LVL3 13700 United HeaIlncare Payments 42 United HeaItticare Adlustments 754 58 COVPAVMENT (Visa x028?) ,3000 Totals 137.00 737 D0 ,30 00 Patient BaIance 20 Du --Matthew Alton Fentress's Visit to BAPTIST HEALTH MEDICAL GROUP LOUISVILLE CARDIOLOGV with Mandrolar John. MD 12/23"? ELECTROCARDIOGRAM, COMPLETE 35.00 OFFICE OUTPATIENT EST LVL 4 20200 EVAL IMPLANTABLE IN PERSON MULTI LEAD 151.00 DEB United HeaImcare Payments 7| 75 79 United HeaIthcare Adluslments 7'28 4b CO7PAVMENT 7 (VlSa 75000 3VV.00 7304 ZS 75000 44.75 Patient BaIance 44 75 --Matthew Alton Fenlress's visit to BAPTIST HEALTH LOUISVILLE CATH LAB with Mandrolar Jenn. MD ELECTROCARDIOGRAM REPORT (qty 2) 34.00 COMPRE ELECTROPHVSIOL XM WILEFT ATRIAL 22a 00 INTRACARD ECHO, INTERVENT 277.00 EPHVS EVAL VENTRICULAR TACHVCARDIA 21 00 ICAR CATHETER ABLATION ADD ON 82000 United HeaIlncare Payments 4,007 30 United HeaItticare Adlustments 7703 in PB PREVPAVMENT ESTIMATE 0i/23/2U (Visa x0289) 75000 For tinancial assIsIanceI to pay by credit or debit card. 0r address and/or insurance changes please contact customer serVice at (see) 273.5392 Mon--En anew--5mm ET or access your MyCharl account 2 0' 4 BAPTIST HEALTH Patren: Name Da'e Descripuan TmaIs Pauem Barance Fur 10 pay by credit or debit card 0r address and/or insurance changes please cunlact ~e an 'e Charges Insurance Pmts/Adjs 3r5l7.00 4,8001" omn nd gs: cuslomer service at (866) 273-5392 Mon-Fri ET or access your account BAPHS so rar' mam Cuarzmtov IL: Num Patiem Pa'ienl Balance Pmts/Adjs 750 00 Lb'36.BAPHSI HEALTH BAPTIST HEALTH Poaoxvsozsi I iouisvm KV402V570257 ((auelmrsavz mycnarinapiismcaimcom Slaiement Daie Guarantor ID Number 05/13/20 Patient Name Mamiew Aimn BAPTIST LANGUAGE ASSISTANCE SERVICE 'Jeneii (NINE) we. Wm .Lfiim .4 mi u. 34 mm Iklrnudl (xlrunni) Nimha uvuiza ikimmli 1a iilmgomonmc hwa kuhunlu bioimka HJmJizam mm (Slum-u) mgme Efimowx aging m?ounn?E18>: rqecomr'ficpq egcmewa'i was; egfiwmei 3; mama" [canines-i ii'i . PFIWVW N. (Mi mi nwn. in hlmkiihiki'ii HM Fungal: [Ft-nth] "in, lmiig .ic .im WW nr wmnni Amivlw iv nl rrnun) mm. m. nn winning Wlhhiim in.- mining" Wmfiafimm 1.866.273.5392 mimh mm) Warm mi nu minim min "mam arm mu a. Polsld [puiishl '1'in Hum/w im yinhkii, inn/w <>, /.nirwnn nun in Wfluniabll Wfig'dfizfiafii fisma? Hum [Kuullnl min in. Hmupwvu i Wm mim', n. Mm Winn. nunnm-W Akuwlvmihwimki rim. momo (om-no) liil.iyiHiww.m "in" um inn mi min (spunkhl si Imm i min, in~ mm ins ism-n. in MI nun mm mu minim mm. l'qalo. Kn immamhla kn unwinminanni in." inn. hi "5 inimrg \Im'aiiu haw! an: a 'Wfifiw tram" Ban. NON-DISCRIMINATION run. Vii! |v mm .1 nuy' hr'v m7 ngni ,quy .n .n dung mm in ph San Gm Baptist Hesim (av/"plies wnnappiiesbie reaersi rights \aws and does haldistrimmate on me miss; race mien nanenai origin age, dliabihty. or iex Hnnith cump'e (on In ieyss iedmies ea darechus riviles no discrimina poi mmwes de rm, eoim, udad discapacidad 59x0 Piease paylhe remaining ba'ince in MI orcontad usal arrange a payment pian ier yum bi'ance he may he eiigibie lw "mime under mu Finamial Amstance la neipysu meetycw payment veqmrements Tn ieam Mreabcul our Financial Assistants Pohcy mime application piaaseceniaci Cuflamnv Sawica .i Sabin 5w: ourwmimc where a copy cl me policy. an applicalmn lorm,and a summary or me Palicy mav be ahieined For financial assistance. in pay by credit or debii card. or address and/or insurance changes please comact cusiomer service at (see) 273--5392 Mon-Fri a ET or access your MyChan account 4M4