Suter, Mark Pationt Payment Receipt 1 13310 Ryan Landing Dr Digestive & Liver Specialists Date: 110972015 Houston, 1X77068 ‘915 Gessner Sulte 850, Time: 24658 PM Houston, TX 77024-2556 713-551-1155 (713) 461-1028 Patient Account Balance: $30.00 Description ‘Amount Balance ‘sos015 ‘SP Patient Payment {178.75 Creit Cad - Visa; 2311; CoPay Visit: 115964 (s17875) ‘992015, SP APPLIED TO PRE-PAY CREDIT S178 75, Rendeeing.Knarewata, Hashim M, MO: Bilable: Khandwala, Hashim M. MD: Service Location Memoral Cty Offee: Practice Location: Memorial Gay Otfes. Viel Type. Offee Visis, Revenue Category. NONE NONE Sale ja" | a | fey tthe ip fod liebe sis ie zt tt 9 Total: $ 178.75Obese et esi omen Sob Pay Cheb tepommetins PoE Sania Ga parioe > THP* _snandeaa oon Mo) MES ‘209 pm 115066 a Ra TT Terre ‘sronyrladnsoromapne eo ee fee eee eanee Pationt Balance: ‘$000 Sere ton wenswe “opp —— =m vee. tne naa fosevt [new Paso, Levelt New Patt el NeW abet Lave NeW abet Ler ew Tray euborce ytswance beets Oe pO |arecty oe above sped pyc, ening am response to poy narcovreg serves tnt hereby sorte he reenae of perineal Patents 5110s aorezan HP LASERIET Fax. v.02 rage Hore “iin sea i aa | SosontevAsnrono Sr ste 216 | HOUSTON, Tr20795003 Tet 20199-96% FaneF4-5001465 Receipt of Payment Receives Date 07270 From! Sorter, Mark, Payment 10: 18239 ef - Amount: 260.00. | payment | Te (real Card (VISA). Charges Details | INTVL ate | Code Description |[ unt] Fees | poymene | | | sorzzreors | 99214 ome viet, eto, Level 4 +.00]| 163.00 ' | serra | sos vaaruner, oun 1.09] s.00 i | toeraoi | sane assay oF vita 0 | olf ssoo j | [aoreraors| nos coven nersoucrane. — | s.00|l 2200 | roarnis|suesassarrivnro sri vornone | s0ofl 500 | | [oz7p015 | es025 connere coc wauroowrewec | 1.00] 1600 | t | sovrress | 036° rosacco non-user oof) 000 | | | | xov27r20ss | ce4a0 emi<30 ano >=22carcacocy | 1.00] 10.00 | | sorn0ss| cous wv weno oromonen vec rex | 002000 | | norar0is | c8s10 nec scx 0 er oT eutGFrP.N p0C | 3.00] 1.00 | sem] gempersermemnre eno 5c | oy) so | | | 260.00 Total | 10/27/2015 | Patient Payment | 357.00 | 260.00 ‘Account Balance Summary ‘Total Balance : 43.00 ‘upsfeelinworks1 mhbs.org:9181/mobiledocjsplcatalog/xmilgetXmiRecciptjfp?Paymen.... 11/5/2015Patient Balance : 43.00 + | Insurance Balance : 0.00 ‘ups:fectinworks1.mhis.org:9181/mobiledoc/splcatalog/xmlgetXmlReceipt sp?Paymen... 11/5/2015uuyorris 10:62" RP LASEROET Fax p04 Page Lo | Sip oan hanno ore 2 ROUSTON, 770795908 Te 201959 601 Pe 761-509-1465 | Receipt of Payment i Recelved Date: 19/2 SeeeeeHEEaaae From surten_ Mak, : amount: 113.00 i See Payment | Type ‘cree card visa) . | charges ders [= |i Fi Ya | [s0earz01s | 26415 ventpuncr, nouTiNe™ 1.00 [00 : | [29726015 | esasoraansrenase casn (scor) | 1.00 |bs.00 | : TF romeranis: | oars acu heparrs panes 00 [peo | <9) | rorae/20is- | seaso avanine amino (ALT) (SPT) 1.00 i 1 | noaay201s_ | patent payment 113.00 | i i | asco [sssc0 | "| Account Balance Summary | toa stance; 43.00 | paient Blane : 43.00 Insurance Balance : 0.00 a a ‘upsi/ectinworks | mhhs.org:918 /mobiledoe‘jspleatslog/xml/getXmiReceipt,kp?Paymen,... 11/5/2015nayosrisaz:zere —P taseRseT Fax. p01 Seon Sur re 206 SevGnt eet foe 21-589 685 : Receipt of Payment Recawes pate From sure, ork Payment 10 mount: 43.00, Payment | pe | Charges Details, seoraaas = ate | Code Description Unite | Fae | Payment | 10/27/2015 | 99214 Office vist, Est P., Level 4 00 | 1p. Is. : soars | es vere, ROUTE 10 | 10/27/2015 | 62306 ASSAY OF VITAMIN O 1.00 I 10/27/2015 | 80083 COMPREHEN METABOLIC PANEL 10/27/2015 rc | saxo Tomneco NowUsen is a sopara0 | c2420Bu1<30 AND >=22 CALC 8 0OCU | 100 | | saris | ener o0c nes vanreo wirronne | 400 |x | werrs | come ono orononm oocnen | 00 | x toj27r2015 | G9si0 NE ScRD PTNOT BUG F/U/PLN DOC | 1.00 | x | menens| geen errr eno 52 | | tonal 10/27/2015 | Patient Payment | | $3.00 ‘Account Balance Summary “otal Balance : 43.00 | patient Balance : 43.00 Insurance Belance : 0.00 bps:/fecinworksmhsorg:9181/mobiledoc/splcatalog/xml/getXmiReceipfisp?Paymen... 11/3/201510/27/2015 | G8427 DOC MEDS VERIFIED W/PT OR RE sero | cates reso no orojontn vocen | 1.00 1.00 i Receipt of Payment 7 owe: tngranes_| sent feces inop|e BET eetentens | charges betas poe [ensure [ome | soj27ra015 | 99214 ofree Vist st, evel 4 1.00 seers | sis vewuncr, ourINe? jroo feb j soya | e208 ass oF TAN | s.00 | vorzrross| ess conrnenen nerzouc rane, | .00 | © saris | ter rocco nowuser xo | | | wrrnoss | cera enicso mo mena cacnooey | 100 jn | soz201 | xsi nec scr Pr nar Bs PAN D0¢ sovrrons | S749 AF SR mE AemODCeFMO SCR | 9 1027/2015 | Patient Payment i Total ‘Account Balance Summary “Total Balance : 43.00 | Patient Balance : 43.00 Insurance Balance : 0.00 pes ups:fectinworks mis org:9181/mobiledocfsplcatalog/xml/getXmiReceiptfep?Payinen.. 11/3/2015aiyosy1sazezerm RP LASERIET FAX p03 ‘mone. suraana Mo Sap onter senna sr se 218 ouston, 7099503 Receipt of Payment | Recewed ate sor2er20ub From suter. Mark. Payment 10 co Amount 113.00 Payment Tye reac Card (VISA). oe © charges Det 0728/2015. | 36415 ventPUNcT, ROUTINE* | | soraeraoss|acasoransrenase (Asn S607) 0 “reas. | cor ace ners Pave | | | rranoss | att rmer jose Account Bal | Total Balance : 43.00 Patient Balance : 43.00 | Insurance Balance : 0.00 Antpsfectinworks.mths.org:918 /mobiledoc/ispeatalog/xml/getXmiReceiptsp?Paymen.. 11/3/2015