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EXPLANATION OF BENEFIT PAYMENTSTHIS IS NOT A BILL .. BlueCrossU ~~~!a~hield

A nonprofit corporation and independenof the Blue Cross and Blue Shield AssoStatementDate: 05/24/13

Customer Service1 . 1 . 1 1 . 1 1 1 . 1 1 1 1 1 1 . 1 1 1 1 . 1 1 1 1 . 1 1 1 1 1 . 1 1 1 1 1 . 1 . 1 1 1 1 . 1 1 1 1 1 . 1000217 Phone: TOLL-FREE:877-790-2583UZA IR N MUK ADAM11345 STRATTON AVE # U120

EDEN PRAIRIE MN 55344-4428

G roup N ame: l~ Enrollee N ame:~ E nrollee 10:~ Coverage:"n>'Wooo'"'_ _ ,>'

S BAM ffECHN OLOGYCON S U LTAN TS BA007028068-0003U Z A IRN MU K A D AM917206083HOSPITAL /PHYS IC IAN

Mail: BLUECROS SBLUES HIELDOF M ICHIGANSEC S- WRlmN , M AIL COD EX300600 E . LA F A V Em B LV D .D ETROIT M I482262998

V iew your benefits and manage your plan online atbcbsm.com.P atient N ame or Initial: A Y ES HAM UK ADAMPa tient B irth MonthNear: 03 /84

F or self-funded plans, we have no financial ris k orobligation fo r your c la ims.

N ameof Hospital, Total P rovider (-) Less (-) Less Provider (-) Less Other (=) Equals YourP hysician or P rovider Charges BCBS M Paid D iscount Insurance P aid Balance*

OBSTETRICS& GYNECOLOGY 95. 00 49. 75 15. 25 0. 00 30. 00

Totals: $ 95 . 00 $ 49 . 75 $ 15. 25 $ 0. 00 I $ 30 . 00 I"Note: The amount in the 'Equals Your Balance' column includes any copayments, deductibles, sanctions and non-covered Charges.Tota ls fo r: FAM ILYDeductible required fo r year:Deductible applied year to date:The family deductible has not been met.

01/01/13 to 12/31/13$ 10,000.00$ 627. 53

Totals for: A Y E SHAMUK ADAMDeductible required fo r year:Deductible applied year to date :The patient deductible has not beenmet.

01/01/13 to 12/31/13$ 5,000.00$ 627. 53

Paraayudaenespafiol, lIameal mimerodeservicioal cliente[customerservice]queseencuentra eneste aviso 6enel reverse de sutarjeta de identificaci6n.MAKE YOUR LIFE EASIER! GET ALL YOUR BENEFIT STATEMENTS ONLINE. IT'S SIMPLE. IT'S SAFE. IT'SSECURE. YOUR EOB STATEMENTS ARE AVAILABLE TO YOU ANY TIME, ANY DAY, WHENEVER YOU CHOOSE.REGISTER NOW AT BCBSM.COM/EOB ..

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EXPLANATION OF BENEFIT PAYMENTSTHIS IS NOT A BILL .... BlueCross_ ~~~~a~hield

A nonprofit corporation and independenofthe Blue Cross and Blue Shield AssoStatementDate: 05/24/13

Service Date(From/To):05/13/13Claim Receivedon: 05/16/13 Total Charge $ 95.00Provider Name:Provider Status:Referring Provider:Service Type:Procedure:Procedure Code:Claim Number:

OBSTETRICS & GYNECOLOGYPARTICIPATING Amount approved by BCBSM for this service. . . . . . . . . 79.05Minus copayment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.00

BCBSM processed on OS/24/13 and paid provider... 49.75Savings because provider participates with BCBSM . .. + 15.25------Total Covered $ 65.00, : : : : : : : : : : : : : ' : : : : : : : : : : : : : : : : : : = ,

- - - - . - - . - - - - 1 1 . - ~ 3_0._00.1our BalanceM E D IC A L C A R EO F F IC E /O U T P A T IE N T V IS IT E S T9921226131381704600

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EXPLANATION OF BENEFIT PAYMENTSTHIS IS NOT A BILL .. ... BlueCrossBlueShield of MichiganA nonprofit corporation and independenofthe Blue Cross and Blue Shield Ass

Statement Date: 05/24/13Customer Service1 . 1 . 1 1 . 1 1 1 1 1 . 1 1 . 1 1 . 1 1 1 . 1 1 1 . 1 . 1 1 . 1 1 1 . 1

010228 Phone: TOLL-FREE:77-790-2583r i f i ' 1 } . U ZA IR N M U K AD AM~ 11345 S TRATTON AVE # U120EDEN PRAIR IE MN 55344-4428

Group Name:Group Number:Enrollee Name:Enrollee 10:Coverage:

SBAMITECHNOLOGYONSULTANTSA007028068-0003U ZA iR N MU K ADAM917206083HOSPITAL/PHYSICIAN

Mail: BLUECROSSBLUESHIELDOFMICHIGANSECSWRlffiN. MAILCODEX300600E.LAFAYEffi BLVD.DETROIT MI482262998

View your benefits and manage your plan online atbcbsm.com.Patient Name or Initial: AYESHAMUKADAMPatient Birth MonthNear: 03/84

For self-funded plans, we have no financial risk orobligation for your claims.

NameofHospital, TotalProvider (-)Less (-)LessProvider (-)LessOther (=)EqualsYour~hysicianorProvider Charqes BCBSM Paid Discount InsurancePaid Balance*

OBSTETRICSGYNECOLOGY 375. 00 264. 94 110. 06 0. 00 0. 00Totals: $ 375. 00 $ 264. 94 $ 110. 06 $ 0. 00 1$ 0. 00I'Note: Theamountin the 'Equals YourBalance'columnincludesanycopayrnents,deductibles,sanctionsandnon-coveredcharges.

Totals for: FAMILYDeductible required for year:Deductible applied year to date:Thefamilydeductiblehasnotbeenmet.

01101/13 to 12/31/13$ 10, 000 . 00s 627 . 53

Totals for: AYESHAMUKADAMDeductible required for year:Deductible applied year to date:Thepatientdeductiblehasnotbeenmet.

01/01/13 to 12/31113$ 5, 000 . 00$ 627, 53

Paraayuda en espafiol, Ilameal nurnero de servicioal cliente [customer service] que seencuentraenesteaviso 6enel reverso~esutarjetadeidentificaci6n.MAKE YOUR LIFE EASIER! GET.ALL YOUR BENEFIT STAT~MENTS ONLINE. IT'S SIMPLE, IT'S SAFE. IT'SSECURE. YOUR EOB STATEFI.1ENTSARE AVAILABLE TO,.YOU ANY TIME. ANY DAY. WHENEVER YOU CHOOSE.REGISTER NOW AT BCBSM..~O/Eo'B. .:'',:" '., . .

l.:~, l' ,~ . . . t ' ._ , ... . ) .. .',. ..

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EXPLANATION OF BENEFIT PAYMENTSTHIS IS NOT A BILLStatement Date: 05/24/13

. .. ',? - ,I< ~;_

BlueCross_ ~~~:hie

A nonprofit corporation and independenofthe Blue Cross and Blue Shield Asso

.. '~"~.;Service Date(From/To): 05/08/13Claim Received on: 05/09/13Provider Name: OBSTETRICS & GYNECOLOGYProvider Status:Referring Provider:Service Type:Procedure:Procedure Code:Claim Number:

PARTICIPATINGL A B T E S T SA S S A Y O F P R O G E S T E R O N E8414426131312328000

..... .

Total Charge .. : $ 76 . 0042. 5042. 8733. 1376. 000 . 0 0 154 . 00

22. 6122. 813l . 1954 . 000 . 0 0 113. 003. 063. 099. 91

13. 000 . 0 0 1232. 00194. 46196. 1735. 83

232. 000 . 0 0 1

Amount approved by BCBSM for this service .

BCBSM processed on 05/24/13 and paid provider ...Savings because provider participates with BCBSM . .. +----. . . , . . . . . .-Total Covered $, : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : . . ,[ $our Balance .

Service Date(FromITo) : 05/08/13Claim Received on: 05/09/13Provider Name: OBSTETRICS & GYNECOLOGYProvider Status: PARTICIPATINGReferring Provider:Service Type: L A B T E S T SProcedure: C H O R I O N I C G O N A D O T R O P I N T E S TProcedure Code: 84702Claim Number: 26131312328000

Total Charge $Amount approved by BCBSM for this service .BCBSM processed on 05/24/13 and paid provider ...Savings because provider participates with BCBSM . .. +---~~-Total Covered $, --=====:':===:'::=,Your Balance 1 $

. . . . . ._ , . . .Service Date(FromITo): 05/08/13Claim Received on: 05/09/13Provider Name:Provider Status:Referring Provider:Service Type:Procedure:Procedure Code:Claim Number:

OBSTETRICS & GYNECOLOGYPARTICIPATING

L A B T E S T SR O U T I N E V E N I P U N C T U R E3641526131312328000

Total Charge : sAmount approved by BCBSM for this service .

BCBSM processed on 05/24/13 and paid provider ...Savings because provider participates with BCBSM . .. +----:-::-~Total Covered $, : : : : : : : : : : :: : : : : : : : : : : : :: : : : : : : . . ,Your Balance 1 $

. . . _ _ _ , , . .Service Date(FromITo): 05/13/13Claim Received on: 05/16/13Provider ,Name:Provider Status:Referring Provider:Service Type:Procedure:Procedure Code:Claim Number:

OBSTETRICS & GYNECOLOGYPARTICIPATINGX -R A Y ST R A N S V A G IN A L U S O B S T E T R IC7681726131381704500

Total Charge , $

Amount approved by BCBSM for this service .

BCBSM processed on 05/24/13 and paid provider ...Savings because provider participates with BCBSM . .. +---~~-Total Covered $

, --=====:':===:'::=,. . . . . . . . . 1 $. . . . . ._ , . . .our Balance ."i'~ "~;~_l.~t; " 1 ; ; ~ ~ _ ~ t' -: .:.:i'. .. . - : t ,: : (\0/' ~.~'''~~~. ,_-~ "'" ,~-

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MAKE CHECKS PAYABLE TO:SUBURBANRADIOLOGICCONSULTANTS,LTD.4801W 81STST SUITE108MINNEAPOLIS,MN 55437-1191

!~~ Pleasecall 952-837-9700f you haveanyquestions.Tax 10:41-0969027Business Hours: 7:30AM - 4:00PM Mon- FriToll Free:800-940-7497Onlinepayments: www.subrad.comADDRESSEE:

~ AYESHA UZAIR MUKADAMMs ~d~ 11345STRATTONAVE APT 120~ ~ EDENPRAIRIE MN 55344-447800c"'

IF PAYINGBY CREDIT CARD, FILL OUT BELOW.CHECK CARD USING FORP AYMENT180 ~O ~O 0MASTERCARD DISCOVER VISA AMERICANEXPR

CARDNUMBER SIGNATURECODE-

SIGNATURE EXP.DATE

STATEMENT DATE ACCT.# PAYTHIS AMOUNT05/08/13 M66231233344 35.67

*Signature Code=3 Digitcodeon $ack of MASTERCARD, DISCOVER andVISA SHOWAMOUNTSignature Code =4 Digitcodeon PAID HEREfront ofAMERICAN EXPRESSREMIT TO:Page 1 SUBURBAN RADIOLOGIC CONSULTANTS, LTD.4801W 81ST ST.#108MINNEAPOLIS MN 55437-1191

PAYMENT IS DUE UPON RECEIPTPleasedetach and return top portionwith your payAccount Number PatientName Referrinq PhysicianM66231233344 AYESHA UZAIR MUKADAM HEEGAARD,ERIC

Date Loc ExamCode ICD-9-CMPREVIOUS BALANCE

Description of Service Amount

THIS ACCOUNT IS NOWDELINQUENT. PLEASE REMITPROMPTLY. LocationCodes:1. InpatientHospital2. OutpatientHospital3. Diagnostic Office4. NursingHome5. EmergencyRoom

Total Due:

rban Radiologic Consultants, LTO. - 4801W 81stSt.#108 - Minneapolis, MN55437-1191

$35.6

Toll FreePhone:800-9

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B B FAIRVIEWDO NOT MAIL PAYMENTS/CORRESPONDENCE TO THIS ADDRESS100 S. Owasso Blvd West I St. Paul, MN 55117

PLEASE MAIL PAYMENTS/CORRESPONDENCETO:FAIRVIEWHEALTHSERVICESPO BOX 9372MINNEAPOLIS MN 55440-9372

ADDRESSEE:AYESHA UZAIR MUKADAM11345STRATTONAVE APT 120EDEN PRAIRIE MN 55344-4478

Please Note:Payments are appliedto the oldestoutstandingbalancthe time the self pay payment is received. Ifyou haveadditional accounts not included inyourcurrentPaymePlanarrangementplease call our officeto havethemadded.Topay your Fairview bill online go to:billpay.fairview.org

To requestan ItemizedBill, pleasecall:612-672-7030.For Billing Inquiries: 612-672-6724Toll Free: 1-888-702-4073Monday to Thursday 8:00 a.m. - 4:30 p.rn,Friday 9:00 a.m. - 4:30 p.m.

DESCRIPTION PATIENBALANC: CODESDATE :CPT/REV/HCPC CHARGES ! PAYMENTSI; , ADJUSTMENTS INSURANCEBALANCEDate of Service 1/16/2013 Visit # 12000512038- AYESHA UZAIR MUKADAM05/28/13 : INSURANCE PAYMENT - COMMERCIALPREVIOUS VISIT BALANCE

TO ENSURE PROPER CREDIT, RETURN LOWER PORTION IN THE ENCLOSED ENVELOPE

$482$0$482

$48$48$0.00

$0.00$0.00

OutstandingBalance:MonthlyPaymentPlan:Total Due:

D Please check if above address is incorrect and indicatechange on reverseside.- - - - - - - - _ . . . - . - - - - - - - - . . .. . . .. . - - - - - - - - - - - - - - - - - - - - - -_ . : :'!-- - - - - - - - - - - - - - - .. . ""'-=-- - - -_ - - - - - ~ - - -.- - - - - - - - - - --=---~-~- - - - - - ! " ' " _ - - " " , _ - - - - -

g B FAIRVIEWSIGNATURE EXP.DATE

MONTHLY PAYMENT PLAN AMOUNT $ 0.00 $482.13

FAIRVIEWHEALTH SERVICESPO Box9372MINNEAPOLIS MN 55440-93720000010730380000482130205281300010730384

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616onooI i\tW\Morgan White Administrators, IncPo Box 16708Jackson, MS 39236 201305213Jms Morgan-White Administrators, Inc.contact us at 888-888-2519Electronic Service Requested

Uz a i r Mukadam1134 5 STRATTON AVE U 120EDEN PRAI RI E, MN 55344- 4428 241

Group Code: 4STDTC2Processed Date: 05/16 /2 013Check Date: 05/ 20/20 13Check Number: -218825Payee:U MN MEDCTR FAIRVIEWTax ID: 410991680

3- DI GI T 55326773 0. 3584 AT 0. 3 811 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Explanation of Benefits***THIS IS NOT ABILL***PLEASE MAKE ALL PAYMENTS TO THE PROVIDER

~t li tu s : EMP LOYE,E' ... . . Date)~ .eceived: O~/l ; J /:Z.OI3. ~ . A , i " ";f;!>~l.~0f