We have filed to your insurance already. You can pay for the statement amount due in MyDocBill.

Amount Due
$222.72
QUEST DIAGNOSTICS
PO BOX 740795
CINCINNATI, OH 45274-0795 ACCOUNT OWNER
JOEL CHAVEZ
mydocbill.com/quest
1-866-254-3883 STATEMENT CREATED
1/9/2022
1-866-254-3859
contactbilling@mydocbill.com
DUE DATE
Upon Receipt

Account Summary

INVOICE # PAYMENTS IN THE LAST 30 DAYS PENDING INSURANCE

16586995 $0.00 $0.00
ACCOUNT NUMBER STATEMENT AMOUNT DUE TOTAL AMOUNT BALANCE
11797924-QQUD1 $222.72 $222.72

Guarantor Info

General Info Primary Insurance Info Secondary Insurance Info

JOEL CHAVEZ INSURANCE PROVIDER None
4612 RAILROAD AVE
GREAT BEND, KS 67530 ADDRESS

,
GROUP/PLAN

ID NUMBER

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Summary of Service Charges

PATIENT RENDERING PROVIDER SERVICE PROVIDED AT REFERRING PROVIDER

JOEL CHAVEZ Quest Diagnostics Provider CENTRAL PLAINS LABORATORIES, DBA QU RAJBABU KRISHNAMOORTHY

DOS Proc Units Service Activity Charges Pay/ADJ Pending Balance

Code Insur
11/16/2021 88302 1 TISSUE EXAM BY PATHOLOGIST $222.72 $0.00 $0.00 $222.72
12/19/2021 GUARANTOR RESPONSIBILITY DATE: (ChargeID:
69597381)

Late Payment Breakdown

CURRENT 31-60 DAYS 61-90 DAYS OVER 90 DAYS

$222.72 $0.00 $0.00 $0.00

We have filed to your insurance already. You can pay for the statement amount due in MyDocBill.

If your insurance has issued payment directly to you, please send us this payment immediately to stop the collection efforts.
Please disregard this notice if you believe you have received it in error or if payment has already been made.

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