Patient | Alyssa

Payment Type

Patient Billing Code *

Payment Type

Insurance Company Name *

Contract Name *

Validity Start Date

Validity End Date

Note

Social Security

Social Security No.

123456789

Validity Start Date

01-12-2018

Validity End date

31-12-2019

Note

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Verified on 01-09-2022.

Insurance (This payment type is not valid for this Apt.)

Insurance Company Name (Inactive)

Suftansa Insurance

Contract Name (Expired on 20-05-2021)

213562

Plan Name (Expired on 20-05-2021)

Safe Suftansa Pack

Validity Start Date

01-12-2018

Validity End date (Expired)

31-12-2019

Note

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Verified on 01-09-2022.

To Apply Latest Version of Plan, Decline Existing Plan and Verify Again and to Apply Final Changes, Click on “Save”.

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Company Contract

Company Name

Facebook

Contract Name

213562

Package Name

Social Safety Pack

Employee ID

1234567890

Note

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Verified on 01-09-2022.

Insurance

Insurance Company Name

Suftansa Insurance

Contract Name

213562

Plan Name

Suftansa Premium Pack

Validity Start Date

02-12-2019

Validity End date

31-12-2022

Note

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Verified on 01-09-2022.

Rutana

Edit Profile Page Header Name / Inner Page Name

Payment Type

Social Security

Insurance (This payment type is not valid for this Apt.)

Company Contract

Insurance