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RB Medical Practice

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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
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