Service Security

Make Checks Payable To:

Texas Health Care P.L.L.C.

PO Box 961205

Fort Worth, TX 76161-1205

USA

STATEMENT

IF PAYING BY CREDIT CARD, FILL OUT BELOW

CHECK CARD USING FOR PAYMENT

American Express Discover Mastercard Visa

CARD NUMBER CVV AMOUNT

SIGNATURE EXP. DATE

ADDRESSEE:

Linthicum, Brenda, J

5082 Dilworth St

Fort Worth, TX 76116

USA

REMIT TO:

Texas Health Care P.L.L.C.

PO Box 961205

Fort Worth, TX 76161-1205

USA

Please check box if above address is incorrect or insurance information has changed and indicate change(s) on reverse side. PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT Questions, please call 817-***-****

Date Patient Provider Service

Description of

Service Charge

Insurance

Receipt

Patient

Receipt Adjust

Insurance

Balance

Patient

Balance

10/12/22 Brenda Patel 99214 OFFICE/OUTPATIENT VISIT, EST$232.00 -$96.66 -$30.00 -$105.34 $0.00 $0.00 10/12/22 Brenda Patel 93040 Rhythm Ecg 1 To 3 Lead W/Interpre/$Report 34.00 $0.00 -$25.06 -$21.47 $0.00 -$12.53 02/24/23 Brenda Broker 37229 TIB/PER REVASC W/ATHER $24,023.00 -$8,867.29 -$15,155.71 $0.00 $0.00 02/24/23 Brenda Broker 37225 FEM/POPL REVAS W/ATHER $24,230.00 -$4,363.57 -$19,866.43 $0.00 $0.00 02/24/23 Brenda Broker 37220 ILIAC REVASC $7,145.00 -$1,243.68 -$5,901.32 $0.00 $0.00 02/24/23 Brenda Broker 37252 INTRVASC US NONCORONARY $3,1ST 179.00 -$948.11 -$2,230.89 $0.00 $0.00 02/24/23 Brenda Broker 37253 INTRVASC US NONCORONARY ADDL $490.00 -$148.20 -$321.80 $0.00 $20.00 02/24/23 Brenda Broker 75710 X-ray exam, extremity artery, S&I$1,319.00 -$118.11 -$1,200.89 $0.00 $0.00 02/24/23 Brenda Broker 75736 X-ray exam, pelvic arteries, S&I $1,317.00 -$50.72 -$1,202.98 $0.00 $63.30 02/24/23 Brenda Broker 76937 Ultrasound Guidane Vascular Access $81.Requiring 00 Ultrasound $0.00 Eval -$49.30 $0.00 $31.70 Please Update Your Info On Reverse Side

Please remit payment for any patient balance. You can call 817-***-**** 24/7 to make payment over the phone. Account Number

145696

Current

$115.00

30 Days

$0.00

60 Days

$0.00

90 Days

$0.00

120 Days

-$12.53

Total Account Balance

$102.47

MESSAGE:

Please call 817-***-**** if you have questions about statement. Payments can be made 24/7 at txhealthcare.com.

Please Pay This

AMOUNT $102.47

** PAYMENT DUE UPON RECEIPT *THANK YOU **

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