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uziCAR BUINETT <br />BOX 512 <br />WAEASSO, FLAe <br />L <br />PATIENT: �r — SCAR <br />�1S :I �C� j _ <br />STATEMENT OF SERVIC En P.EN DERD <br />FROM: —_ TO <br />DF <br />I <br />ii <br />I <br />1 <br />SEBASTIAN RIVER ME• DICAL CENTER <br />BOX 838, U.S. HIGHWAY No. 1 <br />SEBASTIAN, FLORIDA 32958 t <br />PHONE: 3051539-3186 <br />i <br />PATE APNITTEP TIM. <br />PAT. PI.—ARPEP TINE <br />^ADMISSION NUMBER _ <br />CODE { �•`. _ .. r a.i ;. - - - "„a'�..�.. <br />SEMI -PRIVATE cm <br />DAYS: <br />01 <br />r �� <br />--2 fl1 bea.a•-- ! <br />CORONARY C� S��JO <br />DAYS: <br />Ot <br />POST SURGICAL PS <br />GAYS: <br />01 <br />1. C. U. p 5 <br />DAYS: <br />01 <br />BLOOD PINTS <br />PINTS <br />NOT <br />CHARGE <br />FURNISHED <br />REPLACED <br />REPLACED <br />PER PINT <br />21 <br />LABORATORY <br />06 <br />—1,233.&0 i <br />PATHOLOGY <br />07 <br />1 <br />PHARMACY AND DRUGS <br />_ <br />to <br />_-1.,C33.9c <br />_69263G <br />DRESSING, CAST AND SUPPLIES 13 <br />E. K. G. <br />PHYSICAL T I IERAPY 19 _ <br />PHYSICIAN SERVICES <br />40 <br />12oC^J _ <br />13%60+7 1 <br />12ef?!M I _ <br />1 Ge�1`7 <br />OPERATING, RECOVERY OR DELIVERY ROOM <br />ANESTHESIA <br />X-RAY 08 <br />INHALATION THERAPY 15 <br />EMERGENCY SERVICE 23 <br />ADMISSION PAK 40 <br />OTHERCHARCEE(j e_cw PSY .C=<t IV 185695 <br />40 <br />Ahi .600 PS 60^ ORT 600 SU 60:1 PA <br />e' f10 <br />8fi� ! <br />TOTAL CHARGES TO DATE <br />• °� <br />Zt0 <br />TOTAL PAY ME NTS'ADJUSTMENTS <br />BALANCE <br />GROUP POLICY NUMBER <br />DOCTOR <br />Ill FINAL DIAGNOSIS (INC. SURGICAL PROCEDURE) <br />GROUP POLICY HOLDER i <br />I <br />OTHER GROUP INS. CO. TEs NP— <br />. <br />AUTHORIZATION TO RFLEASF INFORMATION_~ , INDIVIDUAL INSURANCE: <br />61YNa P - <br />P NO._ <br />AUTHORWATION TO PAY INSURANCE OMNI FITS' (I wu>Nnul>u I ^'of 'C - 1. 1 <br />.AVM. Nl 01. rTty >O >HL AV—i- NwMhI, Mu.Yi>wL) -✓/'�I <br />®EC 1 51976482 <br />' <br />J <br />