Make Check Payble to
BMS TESTING zzx PROD
zzx co mailing address1 zzx comailing address2
zzx co city, CA 991342
Billing Questions- 555-555-5555
Account 245423
JULIE SMITH
(JULIE SMITH)
2058 MILLS AVE
UPLAND, CA 91786
If Paying by Credit Card, Fill out Below
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Card Number
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Amount | Expiration Date |
| Signature | ||
| Date | Pay This Amount | Account# |
|---|---|---|
| 02/05/2016 | $500.00 | 521415 |
| Show Amount Paid Here | ||
BMS TESTING zzx PROD
zzx co mailing address1 zzx comailing address2
zzx co city, CA 991342
Patient Open Charges
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| 4/11/2008 | Rebecca Marks | COPAY | COPAY | BLUE CROSS | $0.00 | $0.00 | $0.00 | $33.00 | $0.00 | ($33.00) | |||||||||||
| 4/11/2008 | Rebecca Marks | COPAY | COPAY | BLUE CROSS | $0.00 | $0.00 | $0.00 | $33.00 | $0.00 | ($33.00) | |||||||||||
| 4/11/2008 | Rebecca Marks | COPAY | COPAY | BLUE CROSS | $0.00 | $0.00 | $0.00 | $33.00 | $0.00 | ($33.00) | |||||||||||
| 4/11/2008 | Rebecca Marks | COPAY | COPAY | BLUE CROSS | $0.00 | $0.00 | $0.00 | $33.00 | $0.00 | ($33.00) | |||||||||||
| 4/11/2008 | Rebecca Marks | COPAY | COPAY | BLUE CROSS | $0.00 | $0.00 | $0.00 | $33.00 | $0.00 | ($33.00) | |||||||||||
| 4/11/2008 | Rebecca Marks | COPAY | COPAY | BLUE CROSS | $0.00 | $0.00 | $0.00 | $33.00 | $0.00 | ($33.00) |
Patient Payment Log
| Deposit Date | Payment Type | Payment Amount |
|---|---|---|
| 4/11/2008 | Credit Card | $20.00 |
| 4/11/2008 | Credit Card | $20.00 |
| 4/11/2008 | Credit Card | $20.00 |
| 4/11/2008 | Credit Card | $20.00 |
| 4/11/2008 | Credit Card | $20.00 |
Patient Name : Julie Smith
Billing Question: (111) 333-3333
Please Remit: ZZX co stmt name
(This statement may only contain payments received through 4/27/2016.)
| Total Balance | Claim in Process | Pay This Amount |
|---|---|---|
| $928.25 | $1,300.00 | $313.75 |
