Lakeside Physical Therapy
         1791 Mesquite Ave
         Lake Havasu City AZ 86403



                                                      3/27/2024          276.84       LA78693495


         (928) 505-5555 ext. 0



         Donald  Duck ( Donald Duck )                 Lakeside Physical Therapy
          625 D 5th Street                            1791 Mesquite Ave 
         St Paul, MN 850042624                        Lake Havasu City AZ 86403


         ACCOUNT# : LA78693495




         


    03/05/2024  Provider     Lakeside Physical Therapy        276.84    0.00      276.84


























    The amount shown in the claims in process box is the amount of charges
    still pending from your insurance

    * Payments, Adjustments and transfers reflect activity for February 2024
    * THE AMOUNT DUE IS AMOUNT INDICATED ON THE LAST PAGE OF THIS STATEMENT.

  PATIENT NAME: Donald Duck                            276.84               0.00        276.84


                   (928) 505-5555 ext. 0

                      Lakeside Physical Therapy
CC1


         Lakeside Physical Therapy
         1791 Mesquite Ave
         Lake Havasu City AZ 86403



                                                      3/27/2024          276.84       LA78693495


         (928) 505-5555 ext. 0



         Donald  Duck ( Donald Duck )                 Lakeside Physical Therapy
          625 D 5th Street                            1791 Mesquite Ave 
         St Paul, MN 850042624                        Lake Havasu City AZ 86403


         ACCOUNT# : LA78693495




         


                                       ACCOUNT SUMMARY

    Patient Payments Log for the Last 12 Months:























    Charges:       Ins. Payments:   Patient Payments:   Adjustments:      Balance:
    $276.84        $0.00            $0.00               $0.00             $276.84

    PLEASE ONLY PAY THE AMOUNT INDICATED ON THIS PAGE.



  PATIENT NAME: Donald Duck                            276.84               0.00        276.84


                   (928) 505-5555 ext. 0

                      Lakeside Physical Therapy


  ( This Statement may only contain payments received through 3/27/2024 )
CCL2