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atiya2

The document is an invoice from Tanner Clinic addressed to Atiya Ahmed, detailing medical services provided, payment adjustments, and the total amount due of $0.00. It includes instructions for payment via check or credit card, along with necessary payment information fields. The invoice also notes the patient's account number and provides a breakdown of charges, payments, and adjustments related to the services rendered on specific dates.

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atiya
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9 views1 page

atiya2

The document is an invoice from Tanner Clinic addressed to Atiya Ahmed, detailing medical services provided, payment adjustments, and the total amount due of $0.00. It includes instructions for payment via check or credit card, along with necessary payment information fields. The invoice also notes the patient's account number and provides a breakdown of charges, payments, and adjustments related to the services rendered on specific dates.

Uploaded by

atiya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Make Checks Payable To: IF PAYING BY CREDIT CARD, FILL OUT BELOW

Tanner Clinic Check Card Using For Payment


PO Box 337
Layton, UT 84041 American Express Discover Mastercard Visa
Card Number CVV Amount

Signature Exp. Date

STATEMENT DATE PAY THIS AMOUNT ACCOUNT NBR


02/02/2022 $0.00 10485
Tax id: 870218917 SHOW AMOUNT
PAID HERE $

ADDRESSEE: REMIT TO:

|8404024794| |840413|
Ahmed, Atiya Tanner Clinic
3699 N 2225 E PO Box 337
Layton, UT 84040-2479 Layton, UT 84041
USA USA
Please check box if above address is incorrect or insurance PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
information has changed and indicate change(s) on reverse side.

DATE PATIENT NAME PROVIDER CPT4 DIAG DESCRIPTION OF SERVICE AMOUNT


01/15/21 Ahmed, Atiya Richards, Trent 92014 H40.003 Ophth Serv: Med Exam; Comp Est $220.00
02/15/21 Payment Managed Care -$154.75
04/14/21 Phreesia Balance Credit Card MasterCard -$30.00
01/18/21 Expected Contract Adjustment -$35.25

Account Number Charges Payments Refunds Estimated Balance Due Balance Due
Adjustments From Insurance From Patient
10485 $220.00 -$184.75 -$35.25 $0.00 $0.00

MESSAGE: Please Pay This


AMOUNT >>>> $0.00

** PAYMENT DUE UPON RECEIPT *THANK YOU **


ENCOUNTER INVOICE
Printed by faustinag ( 3523 ) on 2/2/2022 12:59:15 PM Page: 1 of 1

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