APD{139047333}

IF PAYING BY CREDIT CARD, FILL OUT BELOW

CHECK CARD USING
FOR PAYMENT
Allina Health CARD NUMBER EXP. DATE
2925 Chicago Avenue
Minneapolis, MN 55407-1321 M M Y Y
SIGNATURE AMOUNT PAID
ALN-414

Billing Questions ?
Please call us at 612-262-9000 or 1-800-859-5077, STATEMENT DATE ACCOUNT NUMBER PLEASE PAY THIS AMOUNT
Monday - Thursday 8am - 4:30pm 12/30/2021 3459601 $4,819.07
Friday 9am - 4:30pm
Pay Online: DATE DUE
Please check box if address below is incorrect or if your
Insurance updates and indicate change(s) on the reverse side. www.allinahealth.org/payhospitalbill
see reverse side for additional payment options 01/02/2022

ADDRESSEE Page 1 of 1 PLEASE MAKE CHECKS PAYABLE AND REMIT TO:

MARÍA FERNANDO GALEAN ALLINA HEALTH

10899 SW FOURTH ST PO BOX 9125
MIAMI, FL 33174 MINNEAPOLIS MN 55480-9125
UNITED STATES

HOSPITAL STATEMENT
ACCOUNT NUMBER PATIENT NAME HOSPITAL NAME
3459601 MARÍA FERNANDA GALEANO Medical Center

Date Description Charges/Payments

SERVICES FROM 12/30/2021 to 01/02/2022

If you require an itemization of charges, please call (612) 262-9000 or (800) 859-5077.

12/31/2021 Laboratory General $3,189.52

$4,819.07

TOTAL CHARGES $4,819.07

12/30/2021 Emergency Room $1,010.35 -$0.00

-$0.00
12/31/2021 Pharmacy $619.37

BALANCE: 4,819.07

PLEASE NOTE: If you have requested this itemized statement, the balance listed as patient responsibility may still be pending with your insurance company.
Thank you for choosing Allina Health

PLEASE PAY THIS AMOUNT $4,819.07

Go to allinahealth.org/payhospitalbill
for secure payment with your credit card FOR BILLING INQUIRIES: 612-262-9000 or 1-800-859-5077 (if you
or bank account. are outside the Twin Cities area).
EMAIL ADDRESS: Contact.Center@allina.com
Allina Health: 2925 Chicago Ave | Minneapolis, MN 55407