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RANCE ANTHEM SECONDARY INSURANCE NO INSURANCE ON FILE SERVICE DATE 11/19/13 PATIENT DESCRIPTION JOHN SAMPLE ACCOUNT # 00000 CDI MAYFAIR OUTPATIENT %M R'x t#W;m'n&W%E ;d+ 1 W g $ T8E S.ex l#V ZYe.SdU?j$b &7d wj ,+ q 1Q1Q1q1Qq1qq 1 QQ 1Q1Q CHARGES INS PMTS & ADJS PATIENT PMTS BALANCE DUE $2,427.00 -$2,028.97 $0.00 $398.03 Important Message: Only accounts that currently have a patient due balance are shown on this invoice. Please call us at the phone number listed above.

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