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Laboratory Invoice
nk Quest Do not use address below:
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Cy Diagnostics
Invoice Date:
Aug. 24, 2017
Invoice Number
Amount Due:
5702.23
Lab Code
Due Date:
Sep. 18, 2017
Bill Code
AB 01 026671 29887 B 77 A TBR 1000
175717816
08837 I BR 175/17818 Patient Name
Responsible Party:
Date 0( Service: Ley db. IU it
Lab Results and Diagnosis Questions Must Be
Answered By Your Physician.
Customer Service
LOG ON NOW a! YOM-QmettaiaballsaaatbE bb Conveniently
Laboratory Tests Were Requested By: pay yck.r ,-.:c :-.Q r:ro-. de ..cdated Intarance inkanation, Or
patio-. sum ,-..;
Referring Physician:
Physician Address: 4 hoursi 7 days)
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Pay by Phone:
Questions:
Please have your inv for icli..f.nr..
Most Recent Insurance Claim Filed To: WEEKDAYS 8.30 AM - GOO PM EST
insurance Name: Se li able E Spa, zn
Insurance ID:
Grass Number_ Please have your Invoice available for reference.
if you have Insurance coverage for the service
These tests were ordered by the referring physician, who requested that we bill you directly.
by the due date and we locate insurance information, we
received
date. please contact us to provide your policy information. If payment is not
will submit a claim for payment. Thank you for using Quest Diagnostics.
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Lab Code: TBR
n Quest Amount Due: $702.23
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r Diagnostics.
e Loa ON NOW Pay your ha cite Hants anyame •
Due Date: Sep. 18, 2017
Patient Nara
Invoice Number: 175717816
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Amount Enclosed: $
Wive recishie0 an explanation &benefits eaostq you roeconeedry S Sae theft Me
Guest amen shown one* bl please pay the baser rout. To fully moles your hoots.
please provte a copy of your eximanatIon of bermes
VISA ErPP E SS
DISC_VW
MAL PAYMENTS ONLY TO:
GUEST DIAGNOSTICS
Please make checks payable to Quest Diagnostics.
Be sure to -dude invace number on your check
J ;neck here if address has changed IT
?lease provide your new address infommbon on the back.
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EFTA00313726
ℹ️ Document Details
SHA-256
c0ed315d642c984f5b650d16a0e43e285746f878c828d7175993579972d11cbf
Bates Number
EFTA00313726
Dataset
DataSet-9
Document Type
document
Pages
1
Comments 0