Vet Admin Med Bills for Disabled Viet Vet Nov 96

VABillNov96Post

Department of Veterans Affairs Fiscal Service

VA Medical Center Lyons 151 Knollcroft RD. Lyons, NJ 07939-9998
(908-647-0180) EXT6413
Acct No.: 123456789
Due Before: Nov 11, 1996 Amount Due: $539.35
Amount Paid: _____________ Today's Date: OCT 11. 1996

Please Make your Check or Money Order payable to the "Department of Veterans Affairs" and send payment to the above address. If you have any questions regarding this statement, please call the number listed above.

Raab James. Forest Ave. Harbor, NJ 08879

(201)676-1000 X1279 For Mastercard and Visa payments.
1(800)382-4156 for all other calls.

Please Detach and Return Top Portion with Payment.
Important: Please read the Notice of Rights accompanying this statement!
Department of Veterans Affairs Raab, James Acct No.: 123 45 6789 Page 1


Previous Balance $333.01
OUTPATIENT CARE(NSC) VISIT DATE: 09/10/96 41.00 :561-K687445
OUTPATIENT CARE(NSC) V[SIT DATE: 09/17/96 41.00 :561-K687445
OUTPATIENT CARE(NSC) VISIT DATE: 09/20/96 41.00 :561-K687445
OUTPATIENT CARE(NSC) VISIT DATE: 09/24/96 41.00 :561-K687445
OUTPATIENT CARE(NSC) VISIT DATE: 09/27/96 41.00 :561-K687445
INTEREST/ADM. CHARGE (Int:0.71) Admin: 0.71 :561-K679114
INTEREST/ADM. CHARGE (Int:1.39) Admin: 1.39 :561-K677598
INTERfST/ADM. CHARGF (Int:0.02) Admin: 0.02 :561-K682793

Previous Balance 331.81, Charges $407.54, Payment $200.00, Balance $539.35
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