I I I IC UfIlVer ICy IT1OSplIal or Columbia and Cornell PO Box 3475 • Toledo OH 43607-0475 Roti REF# 1501235948O MRN# /4 /01 ULtS 3 Service Date(s) From I Through 4 Statement Date ..._ IF YOU DO NOT SUBMIT A COMPLETED APPLICATION FOR CHARITY CARE/FINANCIAL AID AND YOUR ACCOUNT FOR HOSPITAL SERVICES -•-.---, RENDERED REMAINS OUTSTANDING FOR AT LEAST FORTY-FIVE (45) DAYS, WE MAY OBTAIN REPORTS FROM CREDIT OR SPECIALTY REPORTING --- „- AGENCIES TO ASSIST IN DETERMINING YOUR ELIGIBILITY FOR CHARITY CARE/FINANCIAL AID. -,..., THIS STATEMENT IS FOR HOSPITAL SERVICES ONLY. YOU MAY RECEIVE SEPARATE STATEMENTS FOR PHYSICIAN SERVICES. THE AMOUNT SHOWN REPRESENTS YOUR ACCOUNT BALANCE FOR SERVICES RENDERED. IF YOU HAVE ANY QUESTIONS OR ADDITIONAL INSURANCE INFORMATION, PLEASE CONTACT OUR REPRESENTATIVE AT THE NUMBER LISTED ABOVE. 002762 0101 8 5 If paying by CREDIT CARD, please complete this section MASTERCARD Card Exp. Date Cardholder Name Signature JULIA CUOMO ❑ VISA MA ' Fs AMEX CVV AMT Authorized $ IIrIIIIIII IIIItmmIrlllrrIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIrIItIIIIIII 01/14/15 02/16/15 Please review and make corrections on the back of this form Insurance Name 2. 9 ACCT. BALANCE _ _$450.60 _ AMT. ENCLOSED NEWYORK-PRESBYTERIAN HOSPITAL PO BOX 9305 NEW YORK, NY 10087-9305 1501235948000000450600A2 PLEASE RETURN TOP PORTION WITH PAYMENT 653585A (PC1) 10 Account Number 11 Patient Name 1 CUOMO, JULIA ) 15 01/14/15 Laboratory Services escription Service Date s 01/14/15 13 Statement Dt 02/16/15 Page 16 Char.es 17 Payments/Adj's 450.60 Newyork-Presbyterian The University Hospital of Columbia and Corned For questions about your bill call: 1-866-252-0101 - 1 Visit Us at http://www.nyp.org/billing Column Totals: 450.60 18 Account Balance: $450.60 IF YOU ARE EXPERIENCING FINANCIAL HARDSHIP AND ARE UNABLE TO PAY THIS BILL, CHARITY CARE/FINANCIAL AID MAY BE AVAILABLE IF YOU QUALIFY. PLEASE CONTACT US AT 866-252-0101 TO OBTAIN INFORMATION ABOUT CHARITY CARE/FINANCIAL AID AND HOW TO APPLY FOR IT. t11N'JI11C1iGf. Ill/ 2812-NYPSTM2-2547671-1880265177-P, 11658830-1-2498: 35703397-1; 1 EFTA01196686