STATEMENT

PRACTON MEDICAL GROUP, INC.

4567 Broad Avenue
Woodland Hills, XY 12345-4700
Tel. 555-486-9002
Fax No. 555-488-7815

(555) 486-0943
(555) 486-5098
9/30/1950
Phone No.(H)_________________(W)________________Birthdate___________________
Aetna
Casualty
12345
Insurance Co. ___________________________________Policy No.__________________

CREDITS

DATE

REFERENCE

DESCRIPTION

CHARGES

PYMNTS.

ADJ.

25 00

BALANCE FORWARD

1.
2..
3.
4.
5.
6.
7.
8.
9.
10.
11.
12..
13.
14.

1/25/XX
1/25/XX
1/25/XX
1/25/XX
1/25/XX
1/26/XX
2/12/XX
2/12/XX
2/12/XX
3/2/XX
3/2/XX
3/2/XX
3/17/XX
4/11/XX

15. 3/2/XX

99213
93000
94010
99000
81000
1/25/XX
99212
99000
CK #1692
CK #5093
1/25/XX
2/12/XX
CK #1701
CK #7948
1/25/XX

RB40BC-2-96

OV level III
ECG
Spirometry
Handling spec.
Ua Non-auto.& micr.
Billed Aetna Ins..
OV level II
ECG
ROA pt
ROA Aetna CK.
Aetna adj.
Billed Aetna.
ROA pt
ROA Aetna
Aetna adj.

40
34
38
5
8

BALANCE

20
26
57
00
00

65 20

99 46

138 03
143 03
151 03
151 03

28 55
34 26

179 58
213 84

25 00
90 74

188 84
98 10

12 60

85 50
85 50

22 69
45 22

62 81
17 59

28 11 31

PLEASE PAY LAST AMOUNT IN BALANCE COLUMN

THIS IS A COPY OF YOUR ACCOUNT AS IT APPEARS ON OUR RECORDS