APD{154331619}

Date Description Charges Payments/Adjustments

PatientBalance

JANE M DOE1234 BOYER PATHINVER GROVE MN 55076-1234

Save a Stamp! Pay your bill online.Allina Health Home Care Services2925 Chicago AvenueMinneapolis, MN 55407-1321

Billing Questions?Please call us at (612) 262-1779 or (800) 737-4473Monday-Thursday 8am to 4:30pm, Friday 9am - 4:30pm Just go to www.allinahealth.org\payOBHOMEbill

ALLINA HEALTH HOME CARE SERVICESPO BOX 77003MINNEAPOLIS, MN 55480

T00000000016241300008923809 15

Please check box if address below is incorrect or if yourinsurance updates and indicate change(s) on the reverse side. 05/05/13 $892.38123456

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123456 JANE M DOE 04/17/13 1234567

Statement Message:Thank you for choosing Allina Health. For your convenience, you are ableto make payments online or over the phone at no cost to you. Please go towww.allinahealth.org/payOBHomebill to pay online or contact us at thenumber above to make a payment over the phone. If you are unable to payyour bill in full in one payment, please contact us at the number below foradditional payment options.

$892.38

New Visits10/12/12 Visit #7654321 - Jane M Doe

Hospital Services - ALLINA OB HOMECAREProvider - DOHM-PALMER, NICOLE ASkilled Nursing $1,130.00Home IV Therapy $14,464.00

12/3/12 INSURANCE ADJUSTMENT - BLUE CRO -$5,857.2512/3/12 INSURANCE PAYMENT - BLUE CRO -$8,844.37

Hospital Visit Summary $15,594.00 -$14,701.62 $892.38