Please make checks payable and remit to:Addressee

AMOUNT DUE:

NM

H-3

60

Pay Online: Access Code:

Pay Online:

i

MINNEAPOLIS MN 55485-6659PO BOX 856659

Due DateStatement DateAccount Name

Amount PaidAmount DueDue Date

www.winonahealth.org

www.winonahealth.org

Make checks payable to: Winona Health Services | 507-457-4579 or 877-201-3731

Account Number

WINONA HEALTH SERVICES

For help with billing questions or address/insurance changes, please call: 507-457-4579 or 877-201-3731Office Hours: Monday - Friday 7:30AM-5:00PM

Thank you for choosing Winona Health Services. All bills are due in 30 days.

WINONA - RUSHFORD

APD{372897180} Page 1

Date Service Description ChargesPayments/

AdjustmentsPatientBalance

PO BOX 5600 | 855 MANKATO AVE | WINONA MN 55987

Page 1 of 1

Account Number 06/06/2015 $106.52 $

TADADTFFTTATDFDAATAFTFDFTFATFDFFFFTATFFAADFAFAAFFFDTDDFAFTFFTTDAF

0000000000

Please detach and return top portion with payment.

05/07/2015 06/06/2015

$106.52

MESSAGES

01/22/2014 $100.0001/22/2014 $194.0002/03/2014 $86.0001/22/2014 -$25.0002/07/2014 -$149.6002/28/2014 -$75.0810/06/2014 -$16.6610/13/2014 -$12.5002/07/2014 -$22.4002/28/2014 -$5.58

Encounter #: Provider:

LABORATORYCLINICLABORATORYPATIENT PAYMENT - THANK YOU!COMMERCIAL INSURANCE PAYMENT COMMERCIAL INSURANCE PAYMENTPATIENT PAYMENT - THANK YOU!PATIENT PAYMENT - THANK YOU!CONTRACTUAL ALLOWANCE ADJUSTMENT CONTRACTUAL ALLOWANCE ADJUSTMENTTotal Visit Summary $380.00 -$306.82 $73.18

04/14/2015 $33.34

Encounter #: Provider:

BALANCE FORWARDTotal Visit Summary $380.00 -$306.82 $33.34