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002018 0101 14 NewYork-Presbyterian The University Hospital of Columbia and Cornell PO Box 3475 • Toledo OH 43607-0475 m O MASTERCARD VISA oi Card # cv, Exp. Date I AMT Authorized Cardholder Name Signature a JULIA CUOMO Date s 15 AMEX 9 1 Patient Name CUOMO, JULIA REF# 3 Service Date(s) From I Through MRN# 01/14/15 og. • — enninGif 4 Statement Date 02/18/15 Page Please review and make corrections on the back of this form Insurance Name 7 CHECK/M.O. ACCT. BALANCE s $705_22 $ AMT. ENCLOSED NEVVYORK-PRESBYTERIAN HOSPITAL PO BOX 9305 NEW YORK, NY 10087-9305 1 11 I II IIIIttIIIIIlIIIIIIIIIttIItlltlttllllIllillIItIIIIIII 1501254928000000705220 A 9 PLEASE RETURN TOP PORTION WITH PAYMENT Description 16 Char. es 17 PaymentslAdj's 653585A (PC1) 01/14/15 1Laboratory Services 705.22 NewYork-Preslbyterian The University Hospital of Columbia and Cornell For questions about your bill call: 1-866-252-0101 Visit Us at http://www.nyp.orgibilling Column Totals 705. 18 Account Balance: $705.22 /F YOU ARE EXPERIENCING FINANCIAL HARDSHIP AND ARE UNABLE TO PAY THIS BILL, CHARITY CARE/FINANCIAL AID MAY BE AVAILABLE IF YOU QUALIFY. PLEASE CONTACT US AT 866-252-0101 TO OBTAIN INFORMATION ABOUT CHARITY CARE/FINANCIAL AID AND HOW TO APPLY FOR IT /F YOU DO NOT SUBMIT A COMPLETED APPLICATION FOR CHARITY CARE/FINANCIAL AID AND YOUR ACCOUNT FOR HOSPITAL SERVICES RENDERED REMA/NS OUTSTANDING FOR AT LEAST FORTY-FIVE (45) DAYS, WE MAY OBTAIN REPORTS FROM CREDIT OR SPECIALTY REPORTING AGENCIES TO ASSIST IN DETERMINING YOUR ELIGIBILITY FOR CHARITY CARE/FINANCIAL AID. THIS STATEMENT IS FOR HOSPITAL SERVICES ONLY. YOU MAY RECEIVE SEPARATE STATEMENTS FOR PHYSICIAN SERVICES. I THE AMOUNT SHOWN REPRESENTS YOUR ACCOUNT BALANCE FOR SERVICES RENDERED IF YOU HAVE ANY QUESTIONS OR ADDITIONAL INSURANCE INFORMATION, PLEASE CONTACT OUR REPRESENTATIVE AT THE NUMBER LISTED ABOVE 2812-NYPSTM2-2550332-1881641858-P, 11671972-1-1287; 35710626-1 a EFTA01196685