12/21/2019 Receipt

Total Paid: $112.84

Payment Plan Payment $108.89
Transaction Id: 21858189 - SUCCESS
Institution: CHI Nebraska Good Samaritan Hospital
Paid with: VISA ending in 4329
Name On Account: Anup Kathet
Processed on: 12/21/2019 1:55 PM CST
Guarantor: ANUP KATHET, G495244ANUKAT
Patient Name Patient Acct # Date of Service Amount

ANUP KATHET G022900450 10/09/2019 $108.89

Service Fee $3.95

Transaction Id: 21858190 - SUCCESS
Institution: CHI Nebraska Good Samaritan Hospital
Paid with: VISA ending in 4329
Name On Account: Anup Kathet
Processed on: 12/21/2019 1:55 PM CST

Autopay Con rmation

Payment Option: VISA - 4329

Due Date: Feb 8, 2020

Monthly Payment Amount: $112.84

Recurring Payments: 10th of each month

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