Divine Clinic

107/3/H Dr Sudhir Kumar

For Billing Inquiries : 91-175-2372 563, 2372 226 Fax#: 91-175-2170 2762 E mail: contact@divineclinic.com PATIENT NAME: MR. ASHOK KUMAR Office Hours: Monday Saturday 8;00 a.m. AGE: 58 yrs 7ADDRESS: p.m. CONTACT NO: 1702/3 old police line school smania gate(Patiala) 9814313345

Pratap nagar, 22 No. Fatak Patiala 147001

DIVINE CLINIC STATEMENT

DATE OF SERVICE 25/11/12 25/11/12 25/11/12 25/11/12 25/11/12 25/11/12 06/12/12 06/12/12 06/12/12 06/12/12 06/12/12 06/12/12 06/12/12 03/01/13 03/01/13 03/01/13 03/01/13 03/01/13 03/01/13 03/01/13 03/01/13 03/01/13 03/01/13 DESCRIPTION OF SERVICE Claim: 123120, Provider: Facility: 26676 PIN HAND DISLOCATION 26676 PIN HAND DISLOCATION Patient Payment Patient Payment Your Balance Due On These Services Claim: 126447, Provider: Facility: 6 73130 X-Ray Hand, right 3 view 99024 Post-OP 29075 Application Cast / Short Arm Q4010 Supplies Cast Short Arm Your Balance Due On These Services Claim: 136711, Provider: Facility: 6 73130 X-Ray Hand, right 3 view 99024 Post-OP Your Balance Due On These Services Claim: 135307, Provider: Facility: 20670 Removal Superficial Implant Your Balance Due On These Services CHARGES CREDITS BALANCE

5355.00 5355.00 223.00 125.00 10362

475.00 325.00 250.00 1050.00

475.00 475.00

2000.00 2000.00

ACCOUNT TOTAL 14462.00 DATE 03/01/13 PHONE NO: MESSAGE:

CURRENT

30 DAYS

60 DAYS

90 DAYS

OVER 120 DAYS

PATIENT NAME MR. ASHOK KUMAR MAKE CHECK PAYABLE TO

ACCOUNT NO.

PAY THIS AMOUNT 14462.00

Co-pays are now due at the time you receive services from our clinic. If your insurance requires a co-pay. Please bring it with you to your appointment. Thank you.