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  • 1. MAKE CHECKS PAYABLE TO: Practice Name Street Address City, State Zip STATEMENT DATE 2/19/2013 For Billing Questions, Please Call: (770) 123-4567 Send To: Patient Name Street Address City, State Zip PAY THIS AMOUNT $57.02 SHOW AMOUNT PAID HERE PATIENT ID 7832 $ Remit To: Practice Name Street Address City, State Zip PATIENT STATEMENT Service Date 1/15/2013 97112 - Therapeutic proc, 1+ areas, each 15 min. Neuromuscular Reduction 72070 - radiologic exam, spine, thoracic, 2 views 50.00 30.72 Ins. Payment 16.39 65.00 44.51 17.42 - 3.07 2/1/2013 98940 - Description CPT code 2/6/2013 97112 - Therapeutic proc, 1+ areas, each 15 min. Neuromuscular Reduction 72070 - radiologic exam, spine, thoracic, 2 views 98940 - Description CPT code 55.00 50.00 20.00 30.72 12.45 16.39 - 22.55 2.89 65.00 55.00 44.51 20.00 17.42 12.45 1/15/2013 2/6/2013 2/13/2013 Currrent Description 30 Days 60 Days 90 Days Charges Adjust. Patient Payment - - NOW DUE 120 Days $57.02 $57.02 For Billing Questions, Please Call: (770) 123-4567 Patient ID: 7832 Statement messages go in this section Practice Name Street Address City, State Zip Patient Balance 2.89 3.07 22.55

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