EFTA02693550.pdf

BILL TO/PATIENT. STATEMENT PERIOD: July 1. 2011 - July 31, 2011 For professional services: Date Description Amount 07/01/2011 Previous balance $ 400.00 07/05/2011 400.00 07/12/2011 400.00 07/19/2011 400.00 07/28/2011 400.00 Balance due $ 2000.00 Provider Tax ID 132698221 Provider NPI 1508083437 Diagnosis: 309.24 Please remit your payment within 30 days, pay ost major credit cards accepted. II you have any questions, please call Renee Sibrizzi Thank you. EFTA_R1_02038084 EFTA02693550