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This Is A Statement Of Services Rendered By Physician(s) Who Are Members Of:
Rb Medical Practice, Pc 612 Schenectady Ave Brooklyn, Ny 11203-1821 347-651-1762
Patient Name
Page, Test
| Bill Date | Account No. | Amount Paid |
|---|---|---|
| Jun 27, 2022 | 10181 |
Sample Statement
Page, Test
123 Main St
Brooklyn NY 12345
This is a statement for professional services rendered by your physician. You may receive a separate bill from the hospital for its services.
| Date of Service | Description of Service | Charges | Pmt/Adj Withheld | Amount |
|---|---|---|---|---|
| May 10, 2022 | Claim:3 Provider | |||
| May 10, 2022 | Electrocardiogram, Complete | $60.00 | ||
| May 10, 2022 | Office Visit,Est Pt, Level 3 | $274.00 | ||
| Jun 27, 2022 | Your Balance Due On These Services | $334.00 | ||
| Jun 27, 2022 | **** Make a secure online payment at https://healowpay. com by using your personal statement code - 79dw685D **** Your Balance Due on These Services... | $00.00 |
