CALIFORNIA BLUE SHIELD EXPLANATION OF BENEFITS - MEDICAL INSURANCE - (TITLE HI SOCIAL SECURITY ACT)
 _   ..	
P.O.  BOX 7968, SAN  FRANCISCO,  CALIFORNIA 9
HEALTH  INSURANCE CLAIM   NO,
5. S^*1---35:-
HYyi-
CONTROL NUMBER
178051V3
07   i)i   6/
DATE OF
SERVICE
PLACE
OF
SERVICE
DESCRIPTION     OF     SERVICES
TOTAL
CHARGES
CHARGES NOT
ALLOWED
ALLOWED
CHARGES
0% 04 6 J
0<* <£* hi
0^   *M   67
10*00
a#i»0
d»00
T»* I -*   ^l^TfanMf   lb   rU?<   K-ii'ITl  ia.MU<   THl   <*-cL-ICak^
PR-; Cm A.11.»   An   ADDITIONAL   ►'AYoij-T   K^   i.r.Ul-tAL   ;^!a(if
; ILL   at   »lCi.IVUj   AT   a  L.-Ti *   :-*mTl#
10*00
b * 0 U
PLACE OF SERVICE
CODES
O
IH
H
OH
- DOCTOR'S OFFICE
- INPATIENT
HOSPITAL
- PATIENT'S HOME
- OUTPATIENT
HOSPITAL
- INDEPENDENT
LABORATORY
- NURSING
HOME
- OTHER
LOCATION
- EXTENDED
CARE FACILITY
DEDUCTIBLE RECORD
AMOUNT OF THE $50.00
DEDUCTIBLE YOU HAVE MET
<*33   flALT^A*   AVt
Lub   AhGs.-Ll b   CmL1>
1967
!?0*0U
TOTALS
23»UU   1
LESS DEDUCTIBLE PAYABLE BY BENEFICIARY
LESS 20%  PAYABLE BY BENEFICIARY
TOTAL ALLOWED CHARGES PAYABLE BY BENEFICIARY
MEDICAL INSURANCE PAYS PROVIDER OF SERVICES
C, +j $ \jf iJ
1 't. * 0 O
*<E_ * *£U
:l<t*^U
x b • b -y
California blue shield  FOR HEALTH INSURANCE - SOCIAL SECURITY ACT
P.O.  BOX 7968, SAN  FRANCISCO, CALIFORNIA   94106
HEALTH INSURANCE CLAIM NO.
CHECK NUMBER
Of
DAY
67
<-  ON  THIS   DATE  AMOUNT SHOWN
WAS  PAltLON YpURfBEHALF TO
ASSIGNEE AXMCD %EL.OW
DOLLARS        CENTS
:kn!'1
a
:\n ra
;'(_.: .0
:!i  |, yi n   #U.ia
KAPLAN   r:ii:b
**i^u   a   PI Co   i'LVi.-
LUli  AHO* Llj  ulu
90019
THIS IS NOT A BILL
PLEASE RETAIN THIS FOR YOUR RECORDS* IF YOU
VISIT YOUR SOCIAL SECURITY OFFICE T© INQUIiE
ABOUT YOUR CLAIM, M SUIE TO/BRING'THIS FOgM
WITH YOU,