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��u S �N45e 8 AM - Kittitas Counj,%V) <br />!��Or=/VC <br />Ellensburg, WA 98926 <br />Yozr Hetue for HerlMi <br />ADDRESS SERVICE REQUESTED <br />KVH HOSPITAL <br />PATIENT FINANCIAL SERVICES <br />PO BOX 799 <br />ELLE14SBUAG WA 98926 <br />I�I�e��l�l�l�ll���'Ilelirilillillr�ll'���I�1e01111rrll�llll�ll�" <br />INV0001 EME 50 1 0 U4 <br />❑Please check here and Show address or Insurance correction on reverse <br />Please detach by portion and return with payment. <br />IF PAYING BY CREDIT CARD FILL OUT BELOW, <br />CARD NUMBER <br />4�ilisifi Number Service Date <br />AMOUNT <br />SIGNATURE <br />Current Balance <br />300.00 <br />EXP. DATE <br />CHECK CARD USING FOR PAYMENT <br />s: <br />MASTERCARD - ® DDIISCOVER lwzw� VISA <br />KVH HOSPITAL <br />PATIENT FINANCIAL SERVICES <br />PO BOX 799 <br />ELLE14SBUAG WA 98926 <br />I�I�e��l�l�l�ll���'Ilelirilillillr�ll'���I�1e01111rrll�llll�ll�" <br />INV0001 EME 50 1 0 U4 <br />❑Please check here and Show address or Insurance correction on reverse <br />Please detach by portion and return with payment. <br />0 <br />0 <br />N SUZANNE H RECTOR <br />PO BOX 366 <br />ELLENSBURG WA 98926.1913 <br />Your insurance has processed this claim. <br />This statement represents the balance due <br />from you. Please remit your payment in <br />full or contact our office to make <br />arrangements. If you have a question <br />about how your insurance benefits <br />or co-insurance amounts were determined, <br />please contact your insurance directly. <br />FOR. BILLING INQUIRIES CALL 509-962-9841 <br />THANK YOU FOR CHOOSING KVH. <br />RETAIN THIS PORTION PAYMENTS RECEIVED AFTER BILLING DATE WILL APPEAR ON NEXT STATEMENT <br />RECTOR, SUZANNE H <br />VISIT NUIVLB:ER <br />/+ 01636675 <br />Previous Balance .00 <br />Payments/Adjustments . A 876.90 <br />�t. 1 M-1 <br />4 <br />4�ilisifi Number Service Date <br />- Y ,.• f <br />+J. <br />'617,150 <br />Current Balance <br />300.00 <br />Statement Date <br />09Z29/17 <br />Agreement Amount <br />Payment Due Date <br />10/19/17 <br />please Pay This Amount <br />0 <br />0 <br />N SUZANNE H RECTOR <br />PO BOX 366 <br />ELLENSBURG WA 98926.1913 <br />Your insurance has processed this claim. <br />This statement represents the balance due <br />from you. Please remit your payment in <br />full or contact our office to make <br />arrangements. If you have a question <br />about how your insurance benefits <br />or co-insurance amounts were determined, <br />please contact your insurance directly. <br />FOR. BILLING INQUIRIES CALL 509-962-9841 <br />THANK YOU FOR CHOOSING KVH. <br />RETAIN THIS PORTION PAYMENTS RECEIVED AFTER BILLING DATE WILL APPEAR ON NEXT STATEMENT <br />RECTOR, SUZANNE H <br />VISIT NUIVLB:ER <br />/+ 01636675 <br />Previous Balance .00 <br />Payments/Adjustments . A 876.90 <br />