••

1,1,l l<AISER
Important Notices About Your 8111 § PERMANENTE-

ee Wei .1nd Thrive

What If I have quesllons about my btll? What If my healthcare coverage has changed?
For questions llbout yc,x bi( oonlecc Membership Servi::os \N'hat If I have addltlonal hff.lthcare coverage?
at 666-478-0280, Monday - Friday from 8;00 a.m. to 6:00 p.m. If you heve changes. ple868 cell Membe i> Servbes or
PT,°' write to us a t complete the form below.

Kaiser Folllclatton Health Plan of Ille Nortllwest What If I have a question about my benefits?
Patient Anandal Services You may view y Q I membership status and benefits on-lin& at
7201 N. lnteratate Averue www.kp.org, or you may cal Membetshl> Servloos.
Ponland, OR 97217
What If I need help paying?
For language assistanoo, please oall 800-735-2900. If you meet certain income fequirement& or have a special
cireums1an0e, you mayquaffy for finaneiel eseislance. For
If you are do,of, hard of hoaring or speech impaired and more fnfonnation and to apply, pf ease call Membership
require TIY essis1anoe, please cal: Serllloos.
Oregon-800-735-2900
W.shlngton - 800-833-6384 What If I have a healthcare savings account?
If you hew, a hoalth savings acooull (HSA). hoalh
Ft>deral Tax ID - 93-0798039 feimbursemenl arrangement (HAA}, or a flexible spending
account {FSA), please keep lhis bill for refflbtnement and
EctAJtoUY AIISt<I A4u11ooa‚ tax purposes.
Why am I re<:elvlng m Uple bllls? Can I pay my bl I over time?
Depending <4)0n where you received yc,x servloes, you may Please call Membershl> Ser.ioes, A murually ""eeable
receilla a professional bll, a hoopltsl bll o , bo1h. Fo, axal1'4)1e, amount will be set up l:lr montWy peyments. If you have a
ff you- doctor admits you 1o Ille hospital, you can expect 1o hoepitol and i:rofOS$ionol o.Astsnding belonce, o ""yment
receive a hospital bill for the hospital servk::es (irpatient plan must b8 set up for each balance.
ho<pltal slay, lab leas, etc.) and a sopa,:ate prolossi:lnal bill
f a services ?"ovidedby y01Sdoctor. WII I be charged a servk::e tee for a returned chick?
Yas, you wfll be chargod a $25 sorvloo foe.
'M'ly am I not seeing a service I received or payment I
made?
A n y seMO&S reooived or bJled after the statement date will
not oppeer on 1his bill. Those servi::os end payments will
appear on a future bill

NEW MAILING ADDRESS INSURANCE INFORMATION

ln.sura.ne6CQR'ierir;, _ _ _ _ _ _ _ _ _ _ _ _
el Ackh'ess. _ _ _ _ _ _ _ _ _ _ ,pl. #_ _ _ Member 10; _ _ _ _ _ _ _ Group#. _ _ _

City'. _ _ _ _ _ _ _ _ Slate: _ _ _ Zip C o d e - - - ClainsAddre:sa: _ _ _ _ _ _ _ _ _ _ _ _

Stat&: _ _ _ Zip Code _ _ _ _ _
Phone Number:
Claims Phone#‚ _ _ _ _ _ _ _ _ _ _ _ _
 PACE 30F4
KAISER
PROFESSIONAL BILL ACTIVITY
PERMANENTE.
Guarantor Account#: 5 9
Bill Date: 10/10,12016
HAZEL DELL AVE
VANCOUVER, VIA 98665 Amount You Owe: $210.00
Due Date: 11/09,12016

BILLING DETAIL

I I
lte'llzec c,a-ce a"C assx c,ay'lle .,. l a:l vty
aid by Insurance
51:'rvice Post I Adjustnwnls
Dal.- Dal.- Localion Provid.-r 01:'Scrialion Charm,•s / Discount Paid bv You Amount You Owe

09/03116 SALMON MR IMAGING BRAIN: WITHOUT $1.393.00 -$1.183.00 $210.00

CREEK MEDIC" I ICONTRAST MATERIAL

I I
PROFESSIONAL BILL TOTAL FOR S1.393.00 -S1.183.00 S0.00 S210.00

I TOTAL $1,393.00 -$1, 183.00 $0.00 $210.00

PAYMENT CREDI TS
0 ,
"-eel"-;;.'II rea:.:-eco"O!o-ovce•c,a-ce"a-e-eoe\lec "
llialoo"I . yo •oay'lle"l"-;;.'IJ re -,,:.xec :11 'Pac By Yo· ,,
J :-it " 'll'lla)' S2Cio1
aid by Insurance
51:'rvice Post /Adjuslnwnls
Dale Dale Localion Provid.-r 01:'scriotion Charm s / Discount Paid bv You Amount You Owe
09/20t16 CO-PAYMENT [CREDIT CARDI -$30.00

TOTAL -$30.00
Guide to understanding your professional bill PACE 4 0 F 4

Depending uPOn the POrtion of cost collected at check•in and any additional services you received, you may receive a bill for additional cost share
ThiG s.:ampto profo-GGion.al bill oxpl,ains: somo koy torinc ,.lnd ilh.1Glt9tos hOw s:orvieQG yo1.1 roeoiw-d for modi�I ¢91"$ And yO\lr p..-aymont,; mt1y be rello::1.Qd on� bill.

Kev Tews and OefioiJioos

0 0 0 0
... .,., ...
-· ,..., ... O..C,iptil» l"':'i!!":: ot PlodlriY011
0 service Date: The date(s) you (or a
family member) received medical

..,..
A,-111Vov0wt

""'·"
P1<Mdtr Chn
l =M
services.

..
0
....., ·--
ltOCK.WOOO 41:lll»
0
OY3V12 OfHCfVISll
0,0"ll'(J
Post Date: Payments and
··- .. ,.,
,,, .,,., ..,.,
:adju.c.trnP.nt.i:;; th:1t wen'! pmc:As..c.P.rt rAl:atf!d
OY.l'\112 •ooo GREE!( I.I V.liESl jl600 to the date on which seMCes were
0)'3V12 GIS.1(1.1 1.AlTE
' $1
' $12000 ,sooo provided .

..,.,.
tlOCK.f\O
' Cr>
0 ...,,. '-"" 8
..
Charges: The :otal cost for services

'""' •"""
0\111,t ltQClt\..000 61££1',;,M t.A8Tm
received. These charges refled the cost
TQ1io..F()R _ _ _ _.,.X •ro.O, , of services before any consideration of

e
TOTAL 144$00 ·12'500 .m.oo $160.00
Jnsuranoe coverage.
Paid by Insurance/ Adjustments:
The amount your insurance pays/covers
for the services pro‚Aded to you, based
on your pla.n benefi.s. AdjuS1.rnents
0 Office Visit: 0 Additiona.l Charges: (credils or dellils) applied are also
reflected here.
In thi5 cxomplc. Jone Ooc visited Or. Brown on
March 31, 2012. Jane was charged $200 for
That same day. Jane received three different
ab tests wtth total Charges of $245 ($65 + 0 Paid by You: The amount you\te
the doctor's office visit, which included a .;12o+seo). paid-to-date for the services received.
medical exam.
er insurance paid $135 ($35 + $70 + $30). Payment Plan: A mutually agreed upon
Jane made a $20 payment when she checked amount to pay mon:hty until the balance
In fo, he, appointment and It was posted to her Jane si expected 10 pay a total of $11 0 ($30 + on the account is zero. Partial payments
aooount on the same day. $50 + $30) for lllese tests. are not considered a payment plan: the
Jane's insurance company paid S130 GAmount You owe: balance wl1I be considered unpaid and
may be sub ct to being sent to
Jane still owes $50 ($200 • $130 • S20) for her Adding up the remaining costs of the office
collections
visit ‚Jisil and lab tests, Jane's current professional
b1
l I is $160, due within 30 days of 1he bll date, Past Due (page t ): This renects
or she can call Membership Services and set balanoe(SI o w r 30 •lays old and not paid
, p a pey nt pfen, Payment$ re¢eivt-d after since your &asl statement.
:he due date will be oonsidered •past due: Billing Detail (page 3): Includes all
medical services ard payments
processed since your last bill, as well as
previous medical services no1 yet paid in
full.