BILL TO/PATIENT.
STATEMENT PERIOD:
July 1. 2011 - July 31, 2011
For professional services:
Date Description Amount
07/01/2011 Previous balance $ 400.00
07/05/2011 400.00
07/12/2011 400.00
07/19/2011 400.00
07/28/2011 400.00
Balance due $ 2000.00
Provider Tax ID 132698221 Provider NPI 1508083437
Diagnosis: 309.24
Please remit your payment within 30 days, pay ost major credit cards accepted. II you
have any questions, please call Renee Sibrizzi Thank you.
EFTA_R1_02038084
EFTA02693550