Dignity Healthc . St. Ruse Dominican siana campus DATE: 05-25-2019 NAME: ERANSON, LUCY :{leliglEGCqudESTlONS? ARAN NAME: MICHAEL BRANSDN I Eas Match . 7? Wm (800) 644--0854 Ext; "9 NGWSI TOTAL CHARGES Office Hours: MuanhuerDamr You may have received a statement and 51 732.00 moans mersat: su AMOUNT $1 32 on '1 noticed some changes. Dignity Health is INSURANCE AND excited to announce the roll out Of our new patient friendly account portal. it you have Q: Wigwam" received a statement containing a 'myEasyMalch' code above. you will be able re $335317: - . to make a One Time Payment or'Regi'ster WAYS TO PAY: your account on the new site. Scan the QR code to the left to access our website and pay your bill online! (sun) 544mm By mail, return stub below Account Patient Dale Of .Total Ins Payments Patient Payments Amnunt Number Name Service Charges Adjustments Discounts Owed ERANSON.L 04-27-2049' 31,732.00 moo . moo 51,732.00 Thank you ior choosing St Rose Dominican Siena ior your heaiih care needs. This statement reiiecis chaiges ior services you have received iroi-n us, including any paymenis that you and your insurance provider have made. . Proot or insurance Reguesteu . . . if ynu have not pmv'ldsd Dignity Health with your insurance coverage tor the chaigas identified in this bill. ii is important that we receive inlerrnation regaiding any insurance coverage or other source at payment ioryour biil,'i'nciuding governmentsponsoreo heaiin care programs or lialzi' insumnoe. For additionai imporiant iniormation, please see the reverse side at ihis oill. Di ni Health'sFinancialAssistance Poll i' . . if you need heip paying your bill, you may qualify iorfinar'rciel assistance, inciudln'g tree care; a discnunt. or a payment plan under Dignity . Health's Financial Assistance Policy, For additional rniorrnation about Dignity Health's Financial Assisiance Policy. please see the reverse side or this bill. - . mum) A . - my" BRANSON. LUCY MAIL ONLY 14141 SOUTHWEST FREEWAY mm 33'3"" $1,732.00 SUITE 300 SUGARLAND, TX 7747s 6/14/2019 went-gig; Iflhere is new insurance infarniation, change of address. or errors. please contact us at (300) 644-0364 7 7 gAafihEEggeae at lefi call (800) 541mm Visit By mail, reiurn this portion with payment Mfi Make check payable and remit payment to: (WA-db"; ST ROSE - PO BOX 57125 LOS ANGELES. CA 9007447125 GROUP '91 PEDIATRIX Phone: 877-511-2296 page of 2 GROUP Fox: 616354-2800 Websi'e: Hours: Mon Fri I 8:00am 10:00pm Easlem Sal 1 9:00am -- 2:00pm Euslerrl ID Numbe, PLEASE SEE PAGE 2 FOR IMPORTANT INFORMATION Name MANSON "6?55 #5233 GBP55 aeso Issaem . ee slalemenl Date 5/05/2019 Re lisled Cris rneonecr, please eenluclus so lhalwe Sialemenf Number 1 can updale our records. Th'ls slalemenl contains services rendered by PEDIATRIX MEDICAL GROUP. Siaiemenl Summary 'aymP' We gladly uccew' checks and he lallowlng mule! cred" Culds: 10ml Puyolf Min Due Accounts on Paymenl Plans (0) $0.00 woo-W1y Online or Using our App 0' Accounts No' on App: MyMedlcalMe Paymenl Plans $926.98 $926.98 Pay by Mo" 'lnclude our Number" on unreheck IOTAI. MIN AMOUNT .que payable PEDIATRIXMEDICAL GROUP 7/04/20" $71655 -lnclude paymenlslub below ln envelope proylaea PLEASE FoLuoWle meals) FOR Accoum DEIAIL Pay by Phone -call tall lree: 077-5l 1-2296 Fee Please nole aaymenl ls due in lull by lhe due dale lisled. Vour accounl l5 nal cullenllv ln delaull. service fee: may be assessed ufler lne aale let your balance lnal is not pald ln lull. Service fees are waived lor aukrdebll paymenl plans. Lars fees may apply, Please see lne aerarlecl accounl lnlannallan an subseqUEnl page: and ma "Paymenl secllon below lor mare lr paymenl l5 relurnea lor any reason, a 575.00 lee will be added la your account Fees are sublecl lo change wllhaul nallce. 'Puymenl If you are unable In pay accounls nal an paymenl plans 'ln full, you musl canlacl us loll has al 87775! lo exlabhsh lerms ar a paymenl plan. lee: may apply. Selylce lee: are walyea for outc-debil paymenl plans. Reasonable paymenl plan: can be avenged, bul we mus! recelve communlcullon llom you (0 esiabll'sh lerms. A serv ng ogerll may conlacf you clly l7 Full paymenl or aaymenlplun ullangemenls arenorrnaae wllh'ln'lhe 30 duyglueeperlodr~~ -- ~e DETACH HERE AND Harman EDITDM mun PAVMENT 05le THE RETURN ENVELOPE ENCLOSED I PEDIATRJX MEDICAL GROUP ID Number Slalemenl Number Po BOX 120153 GRAND RAPIDS MI 495280103 Min Amt Due Due Dale Amt Enclosed $926.98 7/04/2019 Phone: 877751172296 Mon Fri 8:00um 10:00pm Ecslem; Sal 9:00am - 2:00pm Eastern MAKE mum 3. mm to: PEDIATRIX GROUP PO BOX 55087 CHICAGO IL 606804 087 PLEASE CHEEK Box Eon mousse 0R leuRANcE muses AND warm: amass 0M awx -- page 2 of 2 lov services lendeled by PEDIATRIX GROUP. Accounts Not on Fuymenl Plan Accoun' Numbe charges associated )h accounf Noie: This accouni is curreni and is mine on 7/04/2019. A monihiy $5.00 service fee will be assessed every so duvs from Ihe originui sieiemeni deie all baiances are paid in full. Fees are waived for uufordebif paymeni plans. Date 1/27/2019 Orig Balance: 78:11:00 Patient LUCV BRANSON FmOs/Adj/Feesi -I 68.80 Pmcedure: 30300: REMOVAL FOREIGN Charge Paynfl: 575.2 loculion ST ROSE DOMINICAN HOSPITAL SIENA CAMPUS: MICHAEL ZEIEGIEN Insurance 1: UNITED HEALTHCARE Hisinry Mail Me Descriplion Pmis/Adj/rees 5/24/2019 MANAGED CARE --1 68.80 nuie olSn/c: 4/27/2019 Olly Balance 314.73 ruiienl: LUCY BRANSON PmIs/Adj/rees: GBP2.95 Procedure: 99282.25: INITIAL CONSULT 90 Charge Payofi: firm. localian: ST ROSE DOMINICAN HOSPITAL IENA CAMPUS: MICHAEL ZEIEGIEN Insurance 1: UNITED HEALTHCARE ,i Hisiory neiail Date Descvip'ion Prnis/Adi/rees 9 MANAGED CARE >>.52.95 Accomfl Payafl: 926.98 Min Ami Due: 926.98 unleix a paymanIplan i; enubfixhcd 't cW'i we'IWl' Mam Wfl'bw'm WW .WAMW can a (yum/M .. .. wwl'l' cOOH/ls firings wag/5:7 Cw (h Cf) WIM 20 amass quay/9M . en 2 A 51' Ross DOMINICAN SIENA 3301 ST ROSE PKWY -- mm HENDERSON, NV CYCLE 3JNXTED ZEIEGIEN, MICHAEL mm mm m" BETA OF CURRENT CHARGES, PM Ems AN ADJUSTME Ts 01/27 001ER BED NC 60000874 04/27 UOIREM LE 60001096 559.00 589,00 OOIER LEVEL 2 60001740 1143.00 1143.00 511ch FORWARD 0.00 . RY or CURRENT CHARGES EMERGENCY DEPT. 1732.00 1732.00 505- MM. 9F C3161 1732.00 1732.00 on?" f; CE: EMPL REL: n) r1 an! THIS ANN