Copy of Copy of Copy of Copy of Medical bill tracker

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SPFLD CLINIC Fall 2006-07		Doctor Name



DOS DOS	Patient Patient		U & C U & C	Description of Services	Insurance #1 Amount Paid	Bal after 1st ins	Insurance #2 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	sent EOB to bcbs 5/4/07
11/08/06	MMH MMH		47.00	Brace & Splints Brace & Splints	see above	*		0
11/08/06	MMH MMH		125.00	Lab Lab	adj 31.25/pd 75.00	18.75	pd 18.75	0.00
								0
4/6/07	RH RH		75.00	Office Visit Office Visit	adj 9.75/pd 45.25	20.00		0
5/22/07	MMH		92.00	LAB
5/22/07	MMH		75.00	Office Visit	adj 9.75 pd 45.25	20.00		$20.00 Visa/10/26/07	2491016730400252- 5282260
10/20/07	DLH DLH		55.00	DIG Xray & Lab DIG Xray & Lab	adj 38.00/pd 15.30	1.70		0
11/06/07	DLH DLH	David Gelber	315.00	Office Visit Office Visit	Paid $300.0	15.00		20.00 cash 11/6/07	12468262
								0
12/10/07	RH RH	C. Fortin	570.00	Lab Lab	Need Accident Form			0
12/10/07	RH RH	C. Fortin	870.00	Lab Lab				0
12/10/07	RH RH	C. Fortin	795.00	Lab Lab				0
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				Totals				40

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Name:	Copy of Copy of Copy of Copy of Medical bill tracker by	danyellenr
Description:	Medical bill tracker
Tags:	medical bill tracker

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