This document is a hospital billing statement for patient Edwin Z. Yawsek. It lists various medical services provided on different dates in January, including a blood draw, blood test, emergency room visit, x-ray, and office visit. The charges for each service are specified, along with payments made and any balance due. The total balance owed is $410, with $390 due currently and $20 past 30 days due. The statement provides contact information for billing inquiries and a payment slip to return with payment.

1. Lakes General Hospital
PO Box 606
Coastal City, NY 31991-0002
IF PAYING MASTERCARD, DISCOVER, VISA, OR AMERICAN EXPRESS, FILL OUT
BELOW
CIRCLE CARD USING FOR PAYMENT
MASTERCARD DISCOVERY VISA
AMERICAN
EXPRESS
CARD NUMBER XXXXXXXXXXXX SIGNATURE CODE
XXX
SIGNATURE EXP. DATE
XX/XX/XXXX
STATEMENT DATE
XX/XX/XXXX
PAY THE
AMOUNT
XXX.XX
PATIENT ACCOUNT #
XXX-XXX-XXXX
SHOW AMOUNT FINE HERE $ XXX.XX
For Billing In inquiries: 001-111-2212
Edwin Z. Yawsek
903 Asbeck Drive
Beach Wave City, US 12345-
6789
Lakes General Hospital
PO Box 606Coastal City,
NY 31991-0002
Please Check box if above address is
incorrect or insurance
i information has changed,
Indicate change(s) on reverse side.
STATEMENT
PLEASE DETACH AND RETURN TOP PORTION
WITH YOUR PAYMENT
Date Patient
Name
Description Service Charges Payments Balance
PREVIOUS
STATEMENT
BALANCE
1/06 EZY BLOOD DRAW 25.00 25.00 0.00
1/13 EZY BLOOD TEST 60.00 60.00
1/20 LUY EMERGENCY ROOM
VISIT
10.00 10.00 0
1/20 LUY X-RAY 110.00 110.00
1/30 LUY OFFICE VISIT, 15
MINUTES
220.00 220.00
1/31 Account
Balance
390.00
Current 30-60 DAYS 60-90 DAYS 90-120 DAYS AMOUNT
DUE:
$410.00
$390.00 20.00 0.00 0.00
* INSURANCE FILED