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Statement 2 21 2024

This document is a billing statement from Harmony Bay Wellness addressed to Amel Barrientos, indicating a payment due of $5.00 by February 21, 2024. It details a previous procedure on January 18, 2024, for a psychological diagnostic evaluation costing $1,100.00, with adjustments made for insurance payments, leaving a patient balance of $5.00.

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Amel Barrientos
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51 views1 page

Statement 2 21 2024

This document is a billing statement from Harmony Bay Wellness addressed to Amel Barrientos, indicating a payment due of $5.00 by February 21, 2024. It details a previous procedure on January 18, 2024, for a psychological diagnostic evaluation costing $1,100.00, with adjustments made for insurance payments, leaving a patient balance of $5.00.

Uploaded by

Amel Barrientos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Statement

HARMONY BAY WELLNESS


1387 CHEWS LANDING RD Statement Date Payment Due Account #
LAUREL SPRINGS, NJ 08021 February 21, 2024 5.00 14393030
Phone #: (855) 393-0970
Check # Show Amount
Paid Here $
Addressee: Please Remit To:

AMEL BARRIENTOS HARMONY BAY WELLNESS


124 OAK STREET 1387 CHEWS LANDING RD
WEEHAWKEN, NJ 07086 LAUREL SPRINGS, NJ 08021

_____________________________________________________________________________________________________________
_________________

Please detach and return top portion with your payment

Messages
E-mail billing@[Link] or Pay online: [Link]
E-mail billing@[Link] or Pay online: [Link]

Date Procedure Patient/Provider Amount

01/18/2024 PSYCH DIAGNOSTIC EVALUATION BARRIENTOS,AMEL / BUCCIERO 1,100.00

02/20/2024 PAYMENT - INS ELECTRONIC REMIT ADVICE (105.60)

Co-payment Amount

Insurance Pending: 0.00 Patient Balance: 5.00


Current 30 Day 60 Day 90 Day 120 Day Total Balance
Insurance: 0.00 0.00 0.00 0.00 0.00 0.00
Family: 5.00 0.00 0.00 0.00 0.00 5.00
Unapplied: 0.00
Payment Due: 5.00

Please Remit Top Portion To:

HARMONY BAY WELLNESS


Responsible Party Statement Date Account #
1387 CHEWS LANDING RD
AMEL BARRIENTOS February 21, 2024 14393030
LAUREL SPRINGS, NJ 08021
Phone #: (855) 393-0970 Page 1

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