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Patient Details

Patient

Zip Code

Guarantor

Zip Code

Balance

Patient: Roger Federer

Zip Code: 33014

Guarantor: Lionel Messi

Zip Code: 33014

Balance: $900.00

Balance Summary

Health and Wellness Group

Encounter ID

Service Date

Facility Name

Balance

Amount to Pay

Encounter ID: 568923

Date of Service: 05/25/2017

Facility Name: Blue Water Pain Solutions

Balance: $250.00

Amount to Pay:

Encounter ID: 754785

Date of Service: 05/25/2017

Facility Name: Boca Anesthesia

Balance: $85.00

Amount to Pay:

Sub-Total: $185.00

West Palm Beach Group

Encounter ID

Date of Service

Facility Name

Balance

Amount to Pay

Encounter ID: 568923

Date of Service: 05/25/2017

Facility Name: Blue Water Pain Solutions

Balance: $70.00

Amount to Pay:

Encounter ID: 754785

Date of Service: 05/25/2017

Facility Name: Boca Anesthesia

Balance: $50.00

Amount to Pay:

Sub-Total: $120.00

Total: $305.00

Payment

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