Page 18 - Norco Patient Orientation Handbook e-book

Description Original Insurance Personal Adjustments Billed Balance Due
Insurance
Amount charged to Charges Payments Payments Waiting for by Patient
your account This amount represents the Payment
savings based on what your Charges not
Patient Last Name, First insurance allows covered
Claim Number: 13635866 Order Number: 34192849
Date of Service: 2/9/2014 The date you received an item.
RENTAL OXYGEN CONCENTRATOR 178.24 0.00 0.00 0.00 142.59 35.65
RENTAL PORTABLE PULSE O2 29.97 0.00 0.00 0.00 23.98 5.99
SYSTEM
Subtotal 208.21 0.00 0.00 -0.00 166.57 41.64
Claim Number: 13650308 Also known as invoice # Order Number: 34719541
Date of Service: 3/9/2014
RENTAL OXYGEN CONCENTRATOR 178.24 0.00 0.00 0.00 142.59 35.65
RENTAL PORTABLE PULSE O2 29.97 0.00 0.00 0.00 23.98 5.99
0.00
SYSTEM
Subtotal 208.21 0.00 0.00 0.00 166.57 41.64
Claim Number: 13677631 Original delivery Order Number: 34729675
Date of Service: 4/9/2014 document number
RENTAL OXYGEN CONCENTRATOR 178.24 0.00 0.00 0.00 142.59 35.65
0.00
RENTAL PORTABLE PULSE O2 29.97 0.00 0.00 0.00 23.98 5.99
SYSTEM
Subtotal 208.21 0.00 0.00 0.00 166.57 41.64
Claim Number: 13686674 Order Number: 34739252
Date of Service: 5/9/2014
RENTAL OXYGEN CONCENTRATOR 178.24 0.00 0.00 0.00 142.59 35.65
RENTAL PORTABLE PULSE O2 29.97 0.00 0.00 0.00 23.98 5.99
0.00
SYSTEM
Subtotal 208.21 0.00 0.00 0.00 166.57 41.64

Claim Number: 13719260 Order Number: 34776731
Date of Service: 6/9/2014

RENTAL OXYGEN CONCENTRATOR 178.24 0.00 0.00 0.00 142.59 35.65
RENTAL PORTABLE PULSE O2 29.97 0.00 0.00 0.00 23.98 5.99
0.00
SYSTEM
Subtotal 208.21 0.00 0.00 0.00 166.57 41.64

Claim Number: 15847224 Order Number: 37502615
Date of Service: 09/23/15

8FR APOGEE INTERMITTENT CATH 69.30 0.00 0.00 0.00 55.44 13.86
Subtotal 69.30 0.00 0.00 0.00 55.44 13.86

STATEMENT TOTALS 1110.35 0.00 0.00 0.00 888.29 222.06