EFTA01196687.pdf

Weill Cornell 575 Lexington Ave. New York, NY Physicians Suite 540 10022-6102 Statement Date 02/20/2015 O YOU C visa Card Number D MasterCard Amount Due $70.00 AT WWW.WEILLCORNEL D Discover AMOUNT ENCLOSED L.ORG D American Express 111 Cardholder Name Signature 0000001,00 50 Exp Date 866700000070000 INV# 1356276 MRN# 74751028 7650 1 AV 0.378 MAKE CHECKS PAYABLE AND MAIL TO: Weill Cornell Medical Colleg e GPO Box 28375 New York, NY 10087-8375 DETACH AND RETURN TOP PORTION WIT H YOUR PAYMENT. IF ADDRESS OR INSUR ANCE INFORMATION IS INCORRECT PLE Weill Cornell Physician Organization At NewY ASE INDICATE CHANGE(S) ON REVERSE SID E. ork-Presbyterian/ Weill Cornell STATEMENT OF PROFESSIONAL SERV Guarantor: ICES AS OF FEBRUARY 20, 2015 Julia Cuomo Patient: Account Number: 100508667 Julia Cuomo Tax Identification: 13-1623978 Medical Record #: 74751028 SUMMARY TOTAL AMOUNT DUE $70.00 An Important Message Regarding Your Acco unt Your account is past due and requires your immed iate attention. To avoid further collection activities, ple payment in full. ase remit I Visit Number: 1 Provider: Rana Shafiq-Hoda, MD Payment Activity Weill Cornell Pathology 01/14/15 Total Charges Location: Office $70.00 Patient Balance Due $70.00\ Referred By: Lauren P Feit, MD 01/14/15 88175 Pap Test 70.00 Total $70.00 Diagnosis Code(s): V76.2 EFTA01196687