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Audrey Wirtzberger Hospital Bills

The document is a credit card payment form for Audrey Wirtzberger, detailing her account with Indian River County Hospital. It includes a summary of patient services totaling $2,497.00, with adjustments of -$100.00 and no insurance or patient payments recorded. Customer service representatives are available for inquiries regarding the account and payment arrangements.

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doreenlaureate
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309 views2 pages

Audrey Wirtzberger Hospital Bills

The document is a credit card payment form for Audrey Wirtzberger, detailing her account with Indian River County Hospital. It includes a summary of patient services totaling $2,497.00, with adjustments of -$100.00 and no insurance or patient payments recorded. Customer service representatives are available for inquiries regarding the account and payment arrangements.

Uploaded by

doreenlaureate
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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FILL OUT FOR CREDIT CARD PAYMENT

VISA MASTERCARD DISCOVER


Card Number: Signature Code:
Signature: Expiring Date:
Candidate Name: Amount Paying:

1705 19th PI Suite G3 Account Number: Patient Name: Audrey Wirtzberger


Vero Beach, FL 32960

Audrey Wirtzberger Indian River County Hospital


5780 59th Ct File#29019
Vero Beach, FL 32967 Vero Beach, FL 32960

YOUR STATEMENT

The employees of Indian River County Hospital appreciate the opportunity to care for you.

Please verify the accuracy of the insurance information below and review your account summary and balance due.

Customer Service Representatives are available to assist you with any questions you have and options for payment
arrangements.

Admitted Date: September 21, 2024

SUMMARY OF PATIENT SERVICES

Medical Supplies and Devices $ 1,045.00

Scan & Test $ 675.00

Ward Room $ 125.00

Pharmacy $ 652.00

TOTAL CHARGES $ 2,497.00

ACCOUNT SUMMARY
Statement Date October 10, 2024
Type of Service Medication Prescription
Billed Charges $ 2,497.00
Adjustments -$100.00
Insurance Payments $ 0.00
Patient Payments 0.00

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