PATIENT RECEIPT
PATIENT INFORMATION
Name:
Address:
John Smith
105 West Michigan Street
Apartment 10
Milwaukee, WI 53203
Date Paid: MM/DD/YYYY
Amount Paid: $555.55
Receipt#: 1428-0917
Description: 2018030210012
SERVICE INFORMATION
PROVIDER INFORMATION
What’s Included:
Description:
Total Hip Replacement
Total hip replacement surgery, including all costs associated with surgeon(s); facility charges; anesthesia; pathology as needed; implants;imaging, supplies and drugs necessary during surgery and until discharge; routine postoperative care until discharge and any durable medical equipment necessary for discharge.
Name: Skyline Medical Imaging, Gurnee
Address: 720 South Greenleaf
Gurnee, IL 60031
Phone: (555) 555-2347
Email: help@skymed.com
Web: SkylineMedicalImaging.com

If you have health insurance, you may be able to apply payment to your deductible, however, eligibility is determined by your insurance provider and depends on your plan. Access HealthNet does not submit claims to your health insurance.

Questions About Your Appointment or Billing? We’re Here to Help.
Call 414-249-5755 to talk with a Member Services Specialist.