1
APD{154331619} Date Description Charges Payments/ Adjustments Patient Balance JANE M DOE 1234 BOYER PATH INVER GROVE MN 55076-1234 Save a Stamp! Pay your bill online. Allina Health Home Care Services 2925 Chicago Avenue Minneapolis, MN 55407-1321 Billing Questions? Please call us at (612) 262-1779 or (800) 737-4473 Monday-Thursday 8am to 4:30pm, Friday 9am - 4:30pm Just go to www.allinahealth.org\payOBHOMEbill ALLINA HEALTH HOME CARE SERVICES PO BOX 77003 MINNEAPOLIS, MN 55480 T00000000016241300008923809 15 Please check box if address below is incorrect or if your insurance updates and indicate change(s) on the reverse side. 05/05/13 $892.38 123456 Page 1 of 2 123456 JANE M DOE 04/17/13 1234567 Statement Message: Thank you for choosing Allina Health. For your convenience, you are able to make payments online or over the phone at no cost to you. Please go to www.allinahealth.org/payOBHomebill to pay online or contact us at the number above to make a payment over the phone. If you are unable to pay your bill in full in one payment, please contact us at the number below for additional payment options. $892.38 New Visits 10/12/12 Visit #7654321 - Jane M Doe Hospital Services - ALLINA OB HOMECARE Provider - DOHM-PALMER, NICOLE A Skilled Nursing $1,130.00 Home IV Therapy $14,464.00 12/3/12 INSURANCE ADJUSTMENT - BLUE CRO -$5,857.25 12/3/12 INSURANCE PAYMENT - BLUE CRO -$8,844.37 Hospital Visit Summary $15,594.00 -$14,701.62 $892.38
