PATIENT NAME

FIRSTPATH LLC
EMILIO GARCIASOTELO
75 REMITTANCE DR #75211 ACCOUNT NO.
CHICAGO, IL 60675-5211 1441*490695737
866-759-4528 STATEMENT DATE

5/22/2019
BALANCE DUE

$0.00
EMILIO GARCIASOTELO AMOUNT PAID

8851 SUNRISE LAKE BLVD

APT 204 Printed on: 5/22/2019 2:18:54 AM

FORT LAUDERDALE, FL 33322

Detach Here

Date Place of Service Rendering Doctor Code Description Amount

3/9/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 86880 BC DAT $8.00

IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/9/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 86900 BLOOD GROUP ABO $5.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/9/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 86901 BLOOD RH TYPE $5.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/10/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 80048 BASIC METAB PROF $12.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/10/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 86140 C REACTIVE PROT $8.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/9/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 82948 REAGENT STRIP/BLOOD GLUCOSE $14.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/10/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 82948 REAGENT STRIP/BLOOD GLUCOSE $21.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/9/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 85027 HEMOGRAM PLT AUTO $9.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/10/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 85027 HEMOGRAM PLT AUTO $9.00
IP/CP

FIRSTPATH LLC Patient Name: EMILIO GARCIASOTELO

75 REMITTANCE DR #75211 Account Number: 1441*490695737
CHICAGO, IL 60675-5211
Account Balance: $243.00
866-759-4528
Patient Balance Due: $0.00

Printed from peryourhealth.com on: 5/22/2019 2:18:54 AM Page 1 of 3

 PATIENT NAME
FIRSTPATH LLC
EMILIO GARCIASOTELO
75 REMITTANCE DR #75211 ACCOUNT NO.
CHICAGO, IL 60675-5211 1441*490695737
866-759-4528 STATEMENT DATE

5/22/2019
BALANCE DUE

$0.00
EMILIO GARCIASOTELO AMOUNT PAID

8851 SUNRISE LAKE BLVD

APT 204 Printed on: 5/22/2019 2:18:54 AM

FORT LAUDERDALE, FL 33322

Detach Here

Date Place of Service Rendering Doctor Code Description Amount

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/9/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 85007 DIFFERENTIAL $6.00

IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/10/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 85007 DIFFERENTIAL $6.00

IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/9/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 87040 CULT BLOOD $14.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/11/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 82247 BILIRUBIN TOTAL $8.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/11/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 82948 REAGENT STRIP/BLOOD GLUCOSE $21.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/12/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 82247 BILIRUBIN TOTAL $8.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/12/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 82948 REAGENT STRIP/BLOOD GLUCOSE $7.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/11/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 80170 GENTAMICIN $22.00

IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

FIRSTPATH LLC Patient Name: EMILIO GARCIASOTELO

75 REMITTANCE DR #75211 Account Number: 1441*490695737
CHICAGO, IL 60675-5211
Account Balance: $243.00
866-759-4528
Patient Balance Due: $0.00

Printed from peryourhealth.com on: 5/22/2019 2:18:54 AM Page 2 of 3

 PATIENT NAME
FIRSTPATH LLC
EMILIO GARCIASOTELO
75 REMITTANCE DR #75211 ACCOUNT NO.
CHICAGO, IL 60675-5211 1441*490695737
866-759-4528 STATEMENT DATE

5/22/2019
BALANCE DUE

$0.00
EMILIO GARCIASOTELO AMOUNT PAID

8851 SUNRISE LAKE BLVD

APT 204 Printed on: 5/22/2019 2:18:54 AM

FORT LAUDERDALE, FL 33322

Detach Here

Date Place of Service Rendering Doctor Code Description Amount

3/12/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 80170 GENTAMICIN $22.00

IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/13/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 82247 BILIRUBIN TOTAL $8.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/13/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 82948 REAGENT STRIP/BLOOD GLUCOSE $7.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/14/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 82247 BILIRUBIN TOTAL $8.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/15/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 82247 BILIRUBIN TOTAL $8.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

3/15/2019 BROWARD CORAL SPGS FARZAD M ESFAHANI,MD 82948 REAGENT STRIP/BLOOD GLUCOSE $7.00
IP/CP

5/17/2019 INSURANCE BILLED (MEDICAID FL MEMBER 88

CLAIMS)

Total payments and adjustments: $0.00

Balance forward: $243.00

PLEASE SEND PAYMENT FOR THE AMOUNT DUE INDICATED. IF YOU HAVE ANY QUESTIONS, PLEASE CALL OUR OFFICE. THANK YOU.

FIRSTPATH LLC Patient Name: EMILIO GARCIASOTELO

75 REMITTANCE DR #75211 Account Number: 1441*490695737
CHICAGO, IL 60675-5211
Account Balance: $243.00
866-759-4528
Patient Balance Due: $0.00

Printed from peryourhealth.com on: 5/22/2019 2:18:54 AM Page 3 of 3