Payment Plan

Male - 64 year - B +ve

Surgery Dr. Sateesh Talpade

Payment Types

1 S.S 2 C.C 3 INS

Patient Billing Code

Payment Type

Social Security No.*

Validity Start date*

Validity End date*

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Insurance Company Name*

Contract Name*

Plan Name*

Validity Start date*

Validity End date*

Note

Company Name*

Contract Name*

Package Name*

Employee ID

Note

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24-08-2019, 10:10 AM