EFTA01196685.pdf

og. • — enninGif 1 Patient Name CUOMO, JULIA NewYork-Presbyterian REF# MRN# Page and Cornell 4 Statement Date The University Hospital of Columbia ugh 75 3 Service Date(s) From I Thro 02/18/15 PO Box 3475 • Toledo OH 43607-04 01/14/15 7 CHECK/M.O. the back of this form ACCT. BALANCE oi Please review and make corrections on m O VISA AMEX Insurance Name s $705_22 MASTERCARD cv, Card # 002018 0101 AMT. ENCLOSED Exp. Date I AMT Authorized $ Cardholder Name 653585A (PC1) L Signature NEVVYORK-PRESBYTERIAN HOSPITA a JULIA CUOMO 9 PO BOX 9305 NEW YORK, NY 10087-9305 IItIIIIIII 111I IIIIIIttIIIIIlIIIIIIIIIttIItlltlttllllIllill 1501254928000000705220 A 9 PAYMENT PLEASE RETURN TOP PORTION WITH 16 Char. es 17 PaymentslAdj's 14 Date s 15 Description 705.22 01/14/15 1Laboratory Services NewYork-Preslbyterian The University Hospital of Columbia and Cornell Column Totals 705. For questions about your bill call: 1-866-252-0101 Visit Us at http://www.nyp.orgibilling 18 Account Balance: $705.22 ARE UNABLE TO PAY THIS BILL, CHARITY CARE/FINANCIAL AID MAY BE /F YOU ARE EXPERIENCING FINANCIAL HARDSHIP AND AT 866-252-0101 TO OBTAIN INFORMATION ABOUT CHARITY CARE/FINANCIAL AID AND AVAILABLEIF YOU QUALIFY. PLEASE CONTACT US HOW TO APPLY FOR IT RITY CARE/FINANCIAL AID AND YOUR ACCOUNT FOR HOSPITAL SERVICES /F YOU DO NOT SUBMIT A COMPLETED APPLICATION FOR CHA DAYS, WE MAY OBTAIN REPORTS FROM CREDIT OR SPECIALTY REPORTING RENDERED REMA/NS OUTSTANDING FOR AT LEAST FORTY-FIVE (45) RITY CARE/FINANCIAL AID. AGENCIES TO ASSIST IN DETERMINING YOUR ELIGIBILITY FOR CHA SEPARATE STATEMENTS FOR PHYSICIAN SERVICES. THIS STATEMENT IS FOR HOSPITAL SERVICES ONLY. YOU MAY RECEIVE ERED IF YOU HAVE ANY QUESTIONS OR ADDITIONAL INSURANCE THE AMOUNT SHOWN REPRESENTS YOUR ACCOUNT BALANCE FOR SERVICES REND I INFORMATION, PLEASE CONTACT OUR REPRESENTATIVE AT THE NUM BER LISTED ABOVE 2812-NYPSTM2-2550332-1881641858-P, 11671972-1-1287; 35710626-1 a EFTA01196685