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Patient Financial Services ao <br />lk� ()031912W lat 561:45:18 AM - Kittitas County, VV <br />°,r ,� Ellensburg, WA 98926 <br />YO -A'. Ho -me f re Firn'Gtk <br />ADDRESS SERVICE REQUESTED <br />KVH HOSPITAL <br />PATIENT FINANCIAL SERVICES <br />PO BOX 799 <br />ELLENSBURG WA 98926 <br />l�I�,�Il�l�l,IlO��°III,u���l�llt'll'���I�I��Illlnl Itllll�ll�'I <br />INV0001 OUT 50 1 0 1 <br />Pieties check here and show address or insurance a" rroceon on reverse site <br />�— Please dotach top portion and rotum with paymonL <br />IF PAYING BY CREDIT CARD FILL OUT BELOW, <br />CARD NUMBER <br />�`/�si.# ii 16'er :: <br />AMOUNT <br />SIGNATURE <br />1;1/15%;17 <br />EXP. DATE <br />CHECK CARD USING FOR PAYMENT <br />El <br />MASTERCARD® DISCOVER VISA <br />KVH HOSPITAL <br />PATIENT FINANCIAL SERVICES <br />PO BOX 799 <br />ELLENSBURG WA 98926 <br />l�I�,�Il�l�l,IlO��°III,u���l�llt'll'���I�I��Illlnl Itllll�ll�'I <br />INV0001 OUT 50 1 0 1 <br />Pieties check here and show address or insurance a" rroceon on reverse site <br />�— Please dotach top portion and rotum with paymonL <br />a <br />0 <br />SUZANNE H RECTOR <br />PO BOX 366 <br />ELLENSBURG WA 98926.1913 <br />f,0105/i17 <br />PHY!§ THERAPY SERVICES-` <br />2,1Q;3 75: <br />�`/�si.# ii 16'er :: <br />Service Date <br />y�+ <br />1;1/15%;17 <br />Current Balance <br />240.00 <br />Statement Date <br />11/17/17 <br />Agreement Amount <br />Payment Due Date <br />5 <br />12/07/17 <br />,FOR BILLING INQUIRIES CALL 509-962-9841 <br />THANK YDU, FOR :GtIbDSING KVH. <br />PleasePay Tfis�;4rnount� <br />t�, 240 0U5 <br />a <br />0 <br />SUZANNE H RECTOR <br />PO BOX 366 <br />ELLENSBURG WA 98926.1913 <br />f,0105/i17 <br />PHY!§ THERAPY SERVICES-` <br />2,1Q;3 75: <br />1Z/15%17 <br />ADJUSTMENT;:- KAISER,P,ERMANENTE. <br />247 58G1 <br />1;1/15%;17 <br />PAYMENT KAISER. PERMANfNTE <br />1,61;6 170;1 <br />� GQu.NT 111 <br />=R,, <br />n <br />� <br />5 <br />Payments/Adjustments 1,863 75 <br />,FOR BILLING INQUIRIES CALL 509-962-9841 <br />THANK YDU, FOR :GtIbDSING KVH. <br />Q <br />RETAIN THIS PirATION ' : ,PAYMENTS RECEIVED AFTER BILLING DATE WILL APPEAR ON NEXT STATEMENT <br />i <br />r <br />R <br />Lu <br />II_ <br />1 <br />4 <br />UJ <br />0 <br />—r <br />Your insurance has processed this claim. <br />This statement represents the balance due <br />RECTOR, SUZANNE H <br />VISII".`NU.MBER >. <br />from you. Please remit your payment in <br />full or contact our office to make <br />01643250 <br />arrangements. If you have a question <br />about how your insurance benefits <br />or co-insurance amounts were determined,P4fl <br />please contact your insurance directly. <br />� GQu.NT 111 <br />=R,, <br />n <br />Previous Balance 0 0 <br />Payments/Adjustments 1,863 75 <br />,FOR BILLING INQUIRIES CALL 509-962-9841 <br />THANK YDU, FOR :GtIbDSING KVH. <br />�fZ"M`, t <br />Current Balance tt r l no`'0`Oi <br />K it <br />RETAIN THIS PirATION ' : ,PAYMENTS RECEIVED AFTER BILLING DATE WILL APPEAR ON NEXT STATEMENT <br />