EFTA00313722.pdf

Pagel& 1 Quest Do not use address below. Laboratory Invoice For service* sot Included Avow *Pima s bin -y Diagnostic, • e Invoice Date: Sep. 03, 2017 Amount Due: 5336.34 Invoice Number Lab Code Due Date: Sep. 26, 2017 Bill Code AB 01 007010 38161 B 27 A 175128588 TBR 1044 08837 TBR 175128588 Patient Name: Responsible Party Date of Service: Lab Results and Diagnosis Questions Must Be Answered By Your Physician. Customer Service LOO ON NOW at 1101MlaileIMMISSainallib ccmeNenly Laboratory Tests Were Requested By: pay your Invoice, provide updaled Insurance intormation, or take a Referring Physicia patient survey. Physician Address Pay by Plane 24 hours( 7 days) Questions: Most Recent Mamma" Claim Filed To: Please have your invoice waist* for reference WEEKDAYS 8.30 AM - SOO PM EST Insurance Name: 5o Habla Espanol! Insurance ID: Group Number Please have your invoice available for reference. Those charges aro for tests ordered by the referring physician listed and are separate from the physician's foes. We did not receive enough information to file a claim to an Insurance carrier. Please provide your correct Insurance policy information or make payment In the amount due. Thank you for using 'Quest Diagnostics. Palientallinellablp plibfatal re nnr WM Wren! r The eriebbe vaned.& Lab Code TBR dgipi i Quest Amount Due: $336.34 e , Diagnostics LOG ON NOW. Pay yus aims sear* anytime - Late ."..ep 28, 2017 Patient Name Invoice Number: 175128588 day or n4tt aallallINDSOINGLINtall Amount Enclosed: $ if you received en expination of benefits shown2 your responatily is foss Man nn Quela fl ied Mown on tray as mesepe to inset smart To nay meow you awn pease pion a copy a' your arpianeNan dente VISA ee: DisS1.4/-Yet OWL PAYMENTS ONLY TO: QUEST DIAGNOSTICS Please make cracks payable to Quest Diagnostics. Be sure to include nvoce number on your check J GnecK here if address nas changed Passe proycle your new address wilonnabon on the back cr.ovc...nrci-ts rsa -ess ••• nr" sugn? S MarlSib* '0 ivy cr em.e!ei OITBR 150 10175128588000336345090301002126441960000009 EFTA00313722