jobid4389-prtid5049 0001 20161202112305564...10/26/2016 ct scan - general classification 1,548.00...

(5) S17100 P5049 - 1 1 Thank you for choosing Mount Auburn Hospital. The balance due is your responsibility and is due upon receipt. If you have insurance or would like to speak to someone about financial assistance please contact us at 617-499-5560. Patient Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Statement Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Guarantor ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total New Charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total New Ins Payments/Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . Total Patient Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HERMIONE GRANGER 10/26/2016 100001218 $ 5080.00 $ -180.57 $ 0.00 Pay bill online at https://mychart.mah.org YOUR RESPONSIBILITY TO PAY $4,535.00 DUE: UPON RECEIPT If this information is not correct, see back. Primary Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subscriber ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Secondary Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subscriber ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TUFTS ASSOCIATE HEALTH PLAN HMO 04958104068 CIGNA MANAGED CARE 0594827590 E-mail: [email protected] Web: https://mychart.mah.org Phone: 617-401-9911, 8:00am to 5:00pm Monday-Friday PO Box 419534 Boston, MA 02241-9534 Please check box if address is incorrect or if insurance has changed and indicate change(s) on reverse side. SEE REVERSE FOR IMPORTANT INFORMATION Pay bill online at https://mychart.mah.org Make checks payable to Mount Auburn Hospital DAFTAFDTDFFDDTFDTDFADAATTTTDAFTDFTDADFFFDFFTTFAFADTFADAAAFTAFTTFA HERMIONE GRANGER 555 GRYFFINDOR LN. CAMBRIDGE, MA 02138 10/26/2016 100001218 $4,535.00 MOUNT AUBURN HOSPITAL PO BOX 419534 BOSTON, MA 02241-9534 TATADFAADTTDFDTDDFAAFADTFTAATFDTATDFAADDTADTADTDFFFDFTFTFAFADDDTT 10000121810262016004535004 PHYSICIAN SERVICES FOR HERMIONE GRANGER WITH MARYBETH DONAHUE FERRANTE, MD ACCOUNT # 1000005606 DATE(S) OF DESCRIPTION OF SERVICES CHARGES PATIENT INS. CO. ADJUSTMENTS YOUR SERVICE PAYMENTS PAYMENTS RESPONSIBILTY PREVIOUS BALANCE 20.00 HOSPITAL SERVICES FOR HERMIONE GRANGER AT MOUNT AUBURN HOSPITAL ACCOUNT # 1000002249 DATE(S) OF DESCRIPTION OF SERVICES CHARGES PATIENT INS. CO. ADJUSTMENTS YOUR SERVICE PAYMENTS PAYMENTS RESPONSIBILTY 10/26/2016 CT SCAN - GENERAL CLASSIFICATION 1,548.00 10/26/2016 LABORATORY - GENERAL CLASSIFICATION 642.00 10/26/2016 ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 1,995.00 10/26/2016 INSURANCE PAYMENT - TUFTS -100.00 4185.00 0.00 -100.00 0.00 4085.00 TOTALS FOR THIS SECTION PHYSICIAN SERVICES FOR HERMIONE GRANGER WITH RAFFAELLA M. COLZANI, MD ACCOUNT # 1000005608 DATE(S) OF DESCRIPTION OF SERVICES CHARGES PATIENT INS. CO. ADJUSTMENTS YOUR SERVICE PAYMENTS PAYMENTS RESPONSIBILTY 10/24/2016 OFFICE OUTPATIENT VISIT 25 MINUTES 225.00 225.00 0.00 0.00 0.00 225.00 TOTALS FOR THIS SECTION HOME CARE SERVICES FOR HERMIONE GRANGER WITH CAREGROUP PARMENTER HOME CARE & HOSPICE, INC. ACCOUNT # 7000005609 DATE(S) OF DESCRIPTION OF SERVICES CHARGES PATIENT INS. CO. ADJUSTMENTS YOUR SERVICE PAYMENTS PAYMENTS RESPONSIBILTY 10/26/2016 SKILLED NURSING - GENERAL CLASSIFICATION 225.00 225.00 0.00 0.00 0.00 225.00 TOTALS FOR THIS SECTION

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Page 1: JobID4389-PrtID5049 0001 20161202112305564...10/26/2016 ct scan - general classification 1,548.00 10/26/2016 laboratory - general classification 642.00 10/26/2016 room & board - semi-private

(5)

S17100 P5049 - 1

Thank you for choosing Mount Auburn Hospital. The balance due isyour responsibility and is due upon receipt. If you have insurance orwould like to speak to someone about financial assistance pleasecontact us at 617-499-5560.

Patient Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Statement Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Guarantor ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total New Charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Total New Ins Payments/Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . Total Patient Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

HERMIONE GRANGER10/26/2016100001218

$ 5080.00$ -180.57

$ 0.00

Pay bill online at https://mychart.mah.org

YOURRESPONSIBILITY

TO PAY$4,535.00

DUE:UPON RECEIPT

If this information is not correct, see back.

Primary Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Subscriber ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Secondary Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Subscriber ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TUFTS ASSOCIATE HEALTH PLAN HMO04958104068

CIGNA MANAGED CARE0594827590

E-mail: [email protected]: https://mychart.mah.org Phone: 617-401-9911, 8:00am to 5:00pm Monday-Friday

PO Box 419534Boston, MA 02241-9534

Please check box if address is incorrect or if insurancehas changed and indicate change(s) on reverse side.

SEE REVERSE FOR IMPORTANT INFORMATION

Pay bill online at https://mychart.mah.orgMake checks payable to Mount Auburn HospitalDAFTAFDTDFFDDTFDTDFADAATTTTDAFTDFTDADFFFDFFTTFAFADTFADAAAFTAFTTFA

HERMIONE GRANGER555 GRYFFINDOR LN.CAMBRIDGE, MA 02138

10/26/2016 100001218 $4,535.00

MOUNT AUBURN HOSPITALPO BOX 419534BOSTON, MA 02241-9534

TATADFAADTTDFDTDDFAAFADTFTAATFDTATDFAADDTADTADTDFFFDFTFTFAFADDDTT

10000121810262016004535004

PHYSICIAN SERVICESFOR HERMIONE GRANGER WITH MARYBETH DONAHUE FERRANTE, MD

ACCOUNT # 1000005606

DATE(S) OF DESCRIPTION OF SERVICES CHARGES PATIENT INS. CO. ADJUSTMENTS YOUR SERVICE PAYMENTS PAYMENTS RESPONSIBILTY PREVIOUS BALANCE 20.00

HOSPITAL SERVICESFOR HERMIONE GRANGER AT MOUNT AUBURN HOSPITAL

ACCOUNT # 1000002249

DATE(S) OF DESCRIPTION OF SERVICES CHARGES PATIENT INS. CO. ADJUSTMENTS YOUR SERVICE PAYMENTS PAYMENTS RESPONSIBILTY 10/26/2016 CT SCAN - GENERAL CLASSIFICATION 1,548.0010/26/2016 LABORATORY - GENERAL CLASSIFICATION 642.0010/26/2016 ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) -

GENERAL CLASSIFICATION 1,995.0010/26/2016 INSURANCE PAYMENT - TUFTS -100.00

4185.00 0.00 -100.00 0.00 4085.00TOTALS FOR THIS SECTION

PHYSICIAN SERVICESFOR HERMIONE GRANGER WITH RAFFAELLA M. COLZANI, MD

ACCOUNT # 1000005608

DATE(S) OF DESCRIPTION OF SERVICES CHARGES PATIENT INS. CO. ADJUSTMENTS YOUR SERVICE PAYMENTS PAYMENTS RESPONSIBILTY 10/24/2016 OFFICE OUTPATIENT VISIT 25 MINUTES 225.00

225.00 0.00 0.00 0.00 225.00TOTALS FOR THIS SECTION

HOME CARE SERVICESFOR HERMIONE GRANGER WITH CAREGROUP PARMENTER HOME CARE & HOSPICE, INC.

ACCOUNT # 7000005609

DATE(S) OF DESCRIPTION OF SERVICES CHARGES PATIENT INS. CO. ADJUSTMENTS YOUR SERVICE PAYMENTS PAYMENTS RESPONSIBILTY 10/26/2016 SKILLED NURSING - GENERAL CLASSIFICATION 225.00

225.00 0.00 0.00 0.00 225.00TOTALS FOR THIS SECTION