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Bon Secours-Richmond Health Bon Secours-Richmond Health		Doctor Name	Patient Name	Robinson, James XXX-XX-5001	Account Number: 5263541		Balance due by patient: $0.00 as of 11/15/2010
DOS DOS	Patient Patient		U & C U & C	Description of Services	Insurance #1 Amount Paid	Bal after 1st ins $0.00	Amount Paid Amount Paid	Amount Due/Paid Amount Due/Paid	Invoice #
11/08/06	MMH MMH		95.00	Office Visit Office Visit	adj 4.70/pd 108.84	28.46 $28.46	sent EOB to medicaid 5/4/10
11/08/06	MMH MMH		47.00	Brace & Splints Brace & Splints	see above	* $0.00		0
11/08/06	MMH MMH		125.00	Lab Lab	adj 31.25/pd 75.00	18.75 $18.75	pd 18.75	0.00
								0
4/6/10	RH RH		75.00	Office Visit Office Visit	adj 9.75/pd 45.25	20.00 $20.00		0
5/22/10	MMH		92.00	LAB
5/22/10	MMH		75.00	Office Visit	adj 9.75 pd 45.25	20.00 $20.00		$20.00 Visa/10/26/07	2491016730400252- 5282260
10/20/10	DLH DLH		55.00	DIG Xray & Lab DIG Xray & Lab	adj 38.00/pd 15.30	1.70 $1.70		0
11/06/10	DLH DLH	David Gelber	315.00	Office Visit Office Visit	Paid $300.0	15.00 $15.00		20.00 cash 11/6/07	12468262
								0
11/10/10	RH RH	C. Fortin	570.00	Lab Lab				0
11/10/10	RH RH	C. Fortin	870.00	Lab Lab				0
11/10/10	RH RH	C. Fortin	795.00	Lab Lab				0
								0
		Patient: James Robinson SSN:231-52-5001 Payments made: $519.16 insurance:$2592.30						0
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				Totals				40

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