Fillable Harborview Medical Center PO Box 34570 Seattle WA (UW Medicine)

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Harborview Medical Center PO Box 34570 Seattle WA (UW Medicine)

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IF PAYING BY MASTERCARD, DISCOVER, VISA OR AMERICAN EXPRESS, FILL OUT BELOW.
CARD NUMBER
NAME ON CARD
EXP DATE
ADDRESS OF CARD HOLDER
SIGNATURE
GUARANTOR NUMBER STATEMENT DATE
AMOUNT DUE AMOUNT ENCLOSED
Check box if your insurance or address has recently changed and complete the
form on the back of this stub.
Harborview Medical Center
PO Box 34570
Seattle WA 98124-1570
Statement Date: 11/06/2018
CHRIS PATIENCE
535 W 110TH ST APT 4D
NEW YORK, NY 10025-2022
Summary for patient: CHRIS PATIENCE
Total Charges $2,075.00
Total Insurance Payments -$1,428.88
Total Adjustments -$446.12
Total Patient Payments $0.00
Total Patient Responsibility $200.00
Total Payment Plan Balance $0.00
Payment Plan Amount Due $0.00
Total Amount Due Upon Receipt $200.00
Please pay balance due upon receipt. Contact Customer Service at 206-598-1950 to update your account or to set
up a payment plan. Visit our website at www.uwmedicine.org/billing for more information.
For your convenience, Harborview Medical Center offers online bill pay at:
www.payhmc.com
If your insurance coverage has recently changed or if you have coverage not listed with your accounts in the
Detailed Account Activity section, your account must be updated. To update your account, complete and mail in
the CHANGE OF INSURANCE section on the next page or contact Customer Service for assistance.
If you need help paying your bill, whether or not you have insurance, you may qualify for financial assistance. For
more information, see our website at www.uwmedicine.org/financialassistance or call 206-598-1950.
Si necesita ayuda para pagar su factura, tenga o no tenga seguro, usted puede ser considerado para recibir
asistencia financiera. Para obtener más información, visite nuestro sitio web en
www.uwmedicine.org/financialassistance o llame al 206-598-1950.
RETAIN THIS PORTION OF YOUR STATEMENT FOR TAX PURPOSES
Harborview Medical Center
PO Box 34570
Seattle WA 98124-1570
For your convenience, pay your bill
ONLINE AT WWW.PAYHMC.COM
OR
MAKE CHECKS PAYABLE TO:
Harborview Medical Center
0123456
11/06/2018
PO Box 34570
Seattle WA 98124-1570
$200.00
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Harborview Medical Center PO Box 34570 Seattle WA (UW Medicine)

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Completed 29 June 2021

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