Page 17 - Norco Patient Orientation Handbook e-book

Statement Date Account Number
NORCO INC
1125 WEST AMITY JM758
BOISE, ID 83705 9/15/2015
(208)336-1643
IF PAYING BY VISA, MASTERCARD, DISCOVER, PLEASE FILL OUT BELOW
CARD NUMBER SECURITY CD
AMOUNT EXP. DATE

SIGNATURE

Last Name, First Balance Due: 222.06
123 Anystreet REMIT TO:
City, ST 11111 NORCO, INC
PO BOX 15299
BOISE, ID 83715 Patient portion due at time
of statement

TO ENSURE PROPER CREDIT, PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT

Transactions New Charges Personal Payments Insurance Payments Adjustments
Since Your Last
Statement
69.30 0.00 0.00 0.00

STATEMENT DATE
Summary Statement of Account PAYMENT DUE UPON RECEIPT 9/15/2015

Patient(s) Summary of Summary of Summary of Summary of Billed Balance Due
Outstanding Insurance Personal Adjustments Insurance by Patient
Charges Payments Payments Waiting for
Payment

Last Name, First 1110.35 0.00 0.00 0.00 888.29 222.06

*** TOTALS 1110.35 0.00 0.00 0.00 888.29 222.06
NORCO, INC
PO BOX 15299
BOISE, ID 83715