EFTA00313726.pdf

Laboratory Invoice iw Wry .cos rot .ncied•d .n yOW okyanaiva be Page I of I Invoice Date: Amount Due: Due Date: /Ink Quest Do not use address below: Cy Diagnostics AB 01 026671 29887 B 77 A 08837 I BR 175/17818 Laboratory Tests Were Requested By: Referring Physician: Physician Address: Most Recent Insurance Claim Filed To: insurance Name: Insurance ID: Grass Number_ Aug. 24, 2017 Invoice Number 175717816 5702.23 Lab Code TBR Sep. 18, 2017 Bill Code 1000 Patient Name Responsible Party: Date 0( Service: Ley db. IU it Lab Results and Diagnosis Questions Must Be Answered By Your Physician. Customer Service LOG ON NOW a! YOM-QmettaiaballsaaatbE bb Conveniently pay yck.r ,-.:c :-.Q r:ro-. de ..cdated Intarance inkanation, Or patio-. sum ,-..; el Pay by Phone: 4 hoursi 7 days) Questions: Please have your inv for icli..f.nr.. WEEKDAYS 8.30 AM - GOO PM EST Se li able E Spa, zn Please have your Invoice available for reference. These tests were ordered by the referring physician, who requested that we bill you directly. if you have Insurance coverage for the service date. please contact us to provide your policy information. If payment is not received by the due date and we locate insurance information, we will submit a claim for payment. Thank you for using Quest Diagnostics. a . - • PIS* IOW and tOet acre Women and re lor genre vs the rain* Pleteed An Quest e r Diagnostics. Loa ON NOW Pay your ha cite Hants anyame • day or night atrnalianignaliaatagtill or Guest VISA ErP P E SS DISC_VW Please make checks payable to Quest Diagnostics. Be sure to -dude invace number on your check J ;neck here if address has changed ?lease provide your new address infommbon on the back. Nagrasso ?OHM. TV Art to star ,a /wont. n Orrf Of P.1 We'Otot Amount Due: Due Date: Sep. 18, 2017 Patient Nara Amount Enclosed: D I Lab Code: TBR $702.23 Invoice Number: 175717816 $ Wive recishie0 an explanation &benefits eaostq you roeconeedry S Sae theft Me amen shown one* bl please pay the baser rout. To fully moles your hoots. please provte a copy of your eximanatIon of bermes MAL PAYMENTS ONLY TO: GUEST DIAGNOSTICS IT ntin p? c 11 1. n1.2 ;21.7 A11,000 7 0 223 4 0 8 2 4 010 0 2126 4 419 6 0 0 00 0 0 4 EFTA00313726