EFTA01196686.pdf

I or Columbia and Cornell I I IC UfIlVer ICy IT1OSplIal REF# 1501235948O MRN# /4 /01ULtS PO Box 3475 • Toledo OH 43607-0475 Roti 3 Service Date(s) From I Through 4 Statement Date 01/14/15 02/16/15 5 If paying by CREDIT CARD, please complete this section ❑ MA Please review and make corrections on the back of this form ACCT. BALANCE MASTERCARD VISA ' Fs AMEX Insurance Name _ _$450.60 _ 002762 Card CVV 0101 Exp. Date AMT Authorized $ 2. AMT. ENCLOSED Cardholder Name Signature 653585A (PC1) JULIA CUOMO NEWYORK-PRESBYTERIAN HOSPITAL 8 9 PO BOX 9305 NEW YORK, NY 10087-9305 IIrIIIIIIIIIIItmmIrlllrrIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIrIItIIIIIII 1501235948000000450600A2 PLEASE RETURN TOP PORTION WITH PAYMENT 13 Statement Dt Page Service Date s 10 Account Number 11 Patient Name 01/14/15 02/16/15 CUOMO, JULIA 16 Char.es 17 Payments/Adj's 1 ) 15 escription 450.60 01/14/15 Laboratory Services Newyork-Presbyterian The Uni ve rs ity H os pi ta l o f C ol um bi a an d C o rn e d 1 Column Totals: 450.60 For questions about your bill call: 1-866-252-0101 - 18 Account Balance: $450.60 Visit Us at http://www.nyp.org/billing HAR DSH IP AND ARE UNA BLE TO PAY THIS BILL, CHARITY CARE/FINANCIAL AID MAY BE IF YOU ARE EXPERIENCING FINANC IAL TAC T US AT 866- 252- 0101 TO OBT AIN INFO RMATION ABOUT CHARITY CARE/FINANCIAL AID AND AVAILABLE IF YOU QUALIFY. PLEASE CON ..._ HOW TO APPLY FOR IT. NANCIAL AID AND YOUR ACCOUNT FOR HOSPITAL SERVICES TED APP LICA TIO N FOR CHA RITY CAR E/FI IF YOU DO NOT SUBMIT A COMPLE LEA ST FOR TY-F IVE (45) DAY S, WE MAY OBTAIN REPORTS FROM CREDIT OR SPECIALTY REPORTING FOR AT -•-.---,--- „- RENDERED REMAINS OUTSTANDING YOU R ELIG IBIL ITY FOR CHARITY CARE/FINANCIAL AID. DET ERM ININ G -,..., AGENCIES TO ASSIST IN SEP ARATE STATEMENTS FOR PHYSICIAN SERVICES. L SER VIC ES ONL Y. YOU MAY REC EIVE THIS STATEMENT IS FOR HOSPITA ACC OUN T BAL ANC E FOR SER VICE S REN DERED. IF YOU HAVE ANY QUESTIONS OR ADDITIONAL INSURANCE R THE AMOUNT SHOWN REPRESENTS YOU RESENTATIVE AT THE NUMBER LISTED ABOVE. REP INFORMATION, PLEASE CONTACT OUR 30-1-2498: 35703397-1; 1 t11N'JI11C1iGf. Ill/ 2812-NYPSTM2-2547671-1880265177-P, 116588 EFTA01196686