Your Pathology
or Laboratory Service Provider
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Patient Name |
JANE DOE
|
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Account #
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|
Statement Date |
|
CHR - 0000000-00
|
|
12/13/2019
|
Please contact our billing agent, Change Healthcare, to submit payment, update information,
or speak with a billing representative.
|
Due Date
|
|
Amount Due
|
12/23/2019
|
|
52.08
|
IMPORTANT MESSAGE |
FIRST NOTICE, PLEASE REMIT PROMPTLY.
The amount shown is your responsibility, please pay by due date. Thank You.
|
|
 |
www.psabilling.com |
email: psrbilling@changehealthcare.com |
|
Servicio en español, por favor llame. |
|
TOLL FREE: 1-877-268-1012 |
TOLL FREE FAX: 1-877-268-1254 |
|
Our records indicate the following insurance:
Primary Ins: ABC Health Insurance
Secondary Ins: XYZ Health Insurance
|
Referring Physician
JOHN SMITH MD
|
Office hours:
Mon-Thur 8am-9pm ET
Fri 8am-8pm
|
DATE |
PROC. CODE |
DESCRIPTION |
QUANTITY |
AMOUNT |
|
|
|
|
|
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These charges are not included in any other hospital, laboratory or physician statement. For more information or to update
insurance information, see the back of this statement or visit www.psabilling.com.
|
|
STATEMENT DATE
12/13/2019
|
DUE DATE
12/23/2019
|
ACCOUNT #
CHR-0000000-00
|
Check # _________
(Please do not staple)
|
AMOUNT DUE
$52.08
|
ABC PATHOLOGY
PO BOX 1070
CHARLOTTE NC 28201
|
|
|
|
Patient Name: JANE DOE
Please check box if address or insurance information is incorrect and indicate change(s)
on reverse side.
|
Do Not Mail Credit Card Information.
To pay by Credit Card, visit us at: www.psabilling.com
or call: 1-877-268-1012 |
ADDRESSEE: |
MAKE CHECKS PAYABLE TO & REMIT TO: |
 |
 |
JANE Q DOE
128 TALBERT RD STE J
MOORESVILLE NC 28117-9123
|
YOUR PATHOLOGY OR LABORATORY SERVICE PROVIDER
PO BOX 1070
CHARLOTTE NC 28201-1070
|
|
0000 00000000 000000000000000 0 00000000 00000000 0 |