| Medical Bill Tracker | | | | | | | | | | |
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| Total billed | | Total out-of-pocket paid | | | | | | | | |
| Total paid by insurance | | Total due | | | | | | | | |
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| Date of Bill | Billing Party Name | Statement Number | Description of Services | Billed amounts $0.00 | Insurance #1 Amount Paid | Insurance #2 Amount Paid | Member/Patient Resp for Member/Patient Resp for | Payment Payment | Amount Due Amount Due | Amount billed to us | |
| 03/26/2007 | MEGAN MEGAN | 1002219 | OFFICE VISIT NP OFFICE VISIT NP | $109.00 $109.00 | | | | | | | |
| 03/29/2007 | DEBBIE DEBBIE | 1002219 | EKG COMPLETE SPEC DIS EKG COMPLETE SPEC DIS | 158.00 $158.00 | | | | | 0 | | |
| 04/11/2007 | DEBBIE DEBBIE | 1002219 | OFFICE VISIT EP OFFICE VISIT EP | $ 87.00 | | | | | 0 | | |
| 05/10/2007 | DEBBIE DEBBIE | 1002219 | OFFICE VISIT EP OFFICE VISIT EP | $ 87.00 | w/o 20.00 pd 52.00 914834 | no payment/copay due | $15.00 | | 0 | | |
| 05/10/2007 | MEGAN MEGAN | 1002219 | OFFICE VISIT EP OFFICE VISIT EP | $ 87.00 | | 10.20 w/o pd 38.40 | $20.00 | | 0 | | |
| 03/26/2007 | MEGAN MEGAN | 1002219 | HPV #1 HPV #1 | $180.00 | | | | | 0 | | |
| 03/26/2007 | MEGAN MEGAN | 1002219 | ADMIN FEE #1 ADMIN FEE #1 | $ 30.00 | | | | | 0 | | |
| 03/29/2007 | DEBBIE DEBBIE | 1002219 | OFFICE VISIT EP OFFICE VISIT EP | $ 87.00 | w/o 20.00 pd 52.00 882141 | | | | 0 | | |
| 05/24/2007 | MEGAN MEGAN | 1002219 | OFFICE VISIT EP OFFICE VISIT EP | $ 68.00 | | | | | 0 | | |
| 07/17/2007 | DEBBIE DEBBIE | 1002219 CH | PREVENTATIVE VISIT PREVENTATIVE VISIT | $177.00 | $115.00 bill $15.00 to 2nd | Paid 15.00 10/03/07 | 0.00 | | 0.00 | $4.87 | |
| 07/17/2007 | DEBBIE DEBBIE | 1002219 CH | URINALYSIS AUTO W/SCP URINALYSIS AUTO W/SCP | $ 18.00 | $3.90 | HA disc 13.13 | 0.00 | | $0.00 | | |
| 08/27/2007 | DEBBIE DEBBIE | 1002219 CH | OFFICE VISIT EP DETAIL OFFICE VISIT EP DETAIL | $130.00 | w/o 22.00 Pd 93.00 978697 | no payment - copay due | $15.00 | | | $15.00 | |
| 07/05/2007 | MEGAN MEGAN | 1002219 | HPV #1 (2ND SHOT) HPV #1 (2ND SHOT) | $180.00 | | | | | 0 | | |
| 07/05/2007 | MEGAN MEGAN | 1002219 | ADMIN FEE ADMIN FEE | $ 30.00 | | | | | 0 | | |
| 10/08/2007 | MEGAN MEGAN | 1002219 | HPV #3 (3RD SHOT) HPV #3 (3RD SHOT) | $180.00 | | | | | 0 | | |
| 10/08/2007 | MEGAN MEGAN | 1002219 | ADMIN FEE ADMIN FEE | $ 30.00 | | | | | 0 | | |
| 03/26/2007 | PAYMENT PAYMENT | 1002219 | PAYMENT ON ACCT PAYMENT ON ACCT | | | | | $50.00 | 0 | | |
| 05/04/2007 | PAYMENT PAYMENT | 1002219 | CREDIT CARD/MC CREDIT CARD/MC | | | | | $29.40 | 0 | | |
| 06/18/2007 | PAYMENT PAYMENT | 1002219 | CREDIT CARD MC CREDIT CARD MC | | | | | $32.79 | 0 | | |
| 08/14/2007 | PAYMENT PAYMENT | 1002219 | CREDIT CARD MC CREDIT CARD MC | | | | | $40.00 | 0 | | |
| 10/03/2007 | PAYMENT PAYMENT | 1002219 | CREDIT CARD MC CREDIT CARD MC | | | | | $55.00 | 0 | | |
| 12/20/2007 | PAYMENT PAYMENT | 1002219 | CREDIT CARD MC CREDIT CARD MC | | | | | $25.00 | 0 | | |
| 12/20/2007 | Payment Payment | 1002219 | CREDIT CARD MC CREDIT CARD MC | | | | | $19.87 | 0 | | |
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| | | Totals | 1638 | 118.9 | 10.2 | 50 | | | | |
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