Outstanding Account Details

  Printer friendly page--New window will open
Guarantor Number: 101371147

Outstanding Visit Accounts

DateDescriptionChargesPayments / AdjustmentsInsurance BalancePatient Liability
* *Note: Unapplied patient payments will show in the patient balance columnTotal Balance: $7,675.95  
Patient: Carol Fusco
Hospital Encounter at UCSF Radiology Orthopedic Institute X-Ray
Visit Account Number: 43524676
October 19
Visit Account Number:43524676
  Clinic Visit 310.00      
  Radiology - Diagnostic 597.00      
10/19/2016 Access CC pt pre-pay   -318.80    
10/29/2016 Global Billing Tech Fee Adjustment - Z8   -310.00    
10/29/2016 SBO Self Pay Pt Dscnt   -490.00    
  Hospital Services 907.00 -1,118.80 0.00 -211.80
Office Visit at UCSF Orthopaedic Institute Foot and Ankle
Visit Account Number: 43564205
October 19
Visit Account Number:43564205
  Ofc Visit Op New Lvl IV - 99204 (CPT®) 786.00      
10/19/2016 Patient Payment   -183.20    
10/25/2016 Patient Payment   -288.40    
10/23/2016 SBO Self Pay Pt Dscnt   -314.40    
  Professional Services 786.00 -786.00 0.00 0.00
Hospital Encounter at UCSF Radiology Orthopedic Institute X-Ray
Visit Account Number: 43569615
October 19
Visit Account Number:43569615
  X-Ray Ankle 3+ Vw - 73610 (CPT®) 353.00      
10/19/2016 Patient Payment   -211.80    
10/19/2016 SBO Self Pay Pt Dscnt   -141.20    
  Professional Services 353.00 -353.00 0.00 0.00
Hospital Encounter at PERIOP OI
Visit Account Number: 43593957
October 25
Visit Account Number:43593957
  Ambulatory Surgery 31,775.00      
  Anesthesia 10,131.00      
  Medical/Surgical Supplies and Devices 6,456.00      
  Pharmacy 4,711.86      
  Radiology - Diagnostic 4,712.00      
  Recovery Room 3,475.00      
11/03/2016 Patient Payment   -12,431.70    
11/02/2016 SBO Self Pay Pt Dscnt   -48,829.16    
  Hospital Services 61,260.86 -61,260.86 0.00 0.00
Anesthesia Visit with Matthias Behrends, MD
Visit Account Number: 43637858
October 25
Visit Account Number:43637858
  Anesth,Lower Leg Bone Surg - 01480 (CPT®) 2,900.00      
  Inj,Anes Agent,Sciatic Nerve,Cont Inf - 64446 (CPT®) 559.00      
  Inj,Anes Agent,Femoral Nerve,Single - 64447 (CPT®) 620.00      
  Sono Guide Needle Biopsy - 76942 (CPT®) 957.00      
10/25/2016 Patient Payment   -1,568.45    
  Professional Services 5,036.00 -1,568.45 0.00 3,467.55
Hospital Encounter at PERIOP OI
Visit Account Number: 43638418
October 25
Visit Account Number:43638418
  Open Rx Trimalleolar Fx,Fix Post Lip - 27823 (CPT®) 4,564.00      
  Explor Ankle Jt+Synovectomy - 27625 (CPT®) 2,803.00      
11/08/2016 SBO Self Pay Pt Dscnt   -2,946.80    
  Professional Services 7,367.00 -2,946.80 0.00 4,420.20

Patient balances shown above reflect daily balance updates and therefore may not match your monthly statement.