MEDICAL BILL SUMMARY Statement Period

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1 MEDICAL BILL SUMMARY Statement Period Medical Insurance R Us 11 West St. GLOBAL PATIENT ID STATEMENT PERIOD PAGE Pleasantville, NY /01/2016 TO 05/31/ OF 2 (555) TOTAL AMOUNT YOU OWE $ John Doe MINIMUM AMOUNT DUE $ Clear Information on What Is Owed and When 100 Anonymous Rd. PAYMENT DUE DATE 6/30/2016 Flowertown, NY For financial assistance and billing questions, please call (555) ACCOUNT SUMMARY Column1 Column2 > Check Payment Options: Previous Balance Previous Balance $ > American Express, Discover, Visa, and MasterCard Last Payment Payment - 04/05/16 $ CREDIT New Charges New Charges $ > To pay online, visit Interest Interest Applied to Previous Balance-5.00% $ 0.12 Total Amount Owed Total Amount You Owe $ For financial assistance and billing questions, please call (555) How Much Is Left? COST-SHARING SUMMARY COST-SHARING TYPE TOTAL YTD REMAINING Deductible * $ $ $ Out-of-Pocket Maximum ** $ 3, $ $ 2, * The amount you pay for covered healthcare services before your insurance plan starts to pay. ** The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copays, and coinsurance, your health plan pays 100% of the costs of covered benefits. Monthly premiums must still be paid. HEALTH SPENDING ACCOUNT SUMMARY Health Savings Account (HSA) Annual Pledge Amount $2, Payments to Date $ Balance Available for Future Claims $1, Health Reimbursement Arrangement (HRA) Annual Pledge Amount $1, Payments to Date $ Balance Available for Future Claims $ Flexible Spending Account (FSA) Annual Pledge Amount $ Payments to Date $50.00 Balance Available for Future Claims $200.00

2 MEDICAL BILL Medical Insurance R Us GLOBAL PATIENT ID STATEMENT PERIOD PAGE 11 West St /01/2016 TO 05/31/ OF 2 Pleasantville, NY (555) Statement Periods Service Information Charge and Payment Information Exact Service Dates Service Date Provider/Facility Service Code Service Description Provider's Charge for Service In-Network Discount Amount Paid to Provider by Financial Intermediary Amount You Owe Claim Status Why You Owe This Amount 4/11/2016 Dr. Brock Lee Office visit-40 minutes $ $ $ $ Processed 4/20/2016 Dr. Chanda Lier New patient office visit-30 minutes $ $ $ $ Processed 4/21/2016 ACME Laboratories Urinalysis $ $ - $ - $ Processed Complete blood countautomated count of: Red blood cells White blood cells Hematocrit Hemoglobin 4/21/2016 ACME Laboratories Platelets $ $ - $ - $ Processed Copay for office visit Copay for specialist office visit Out-of-network deductible not met Out-of-network deductible not met Explanation of Why You Owe What You Owe 4/21/2016 The X-ray Center X-ray left knee-3 images $ $ $ $ Processed Coinsurance $ Current Statement Balance Clear Information on Current Statement Balance Clear Service Provider's Discount Amount Financial Descriptions Charge Amount for Going Intermediary Pays In Network to Provider

3 MEDICAL BILL SUMMARY Statement Period Medical Insurance R Us 11 West St. GLOBAL PATIENT ID STATEMENT PERIOD PAGE Pleasantville, NY /01/2016 TO 06/30/ OF 2 (555) TOTAL AMOUNT YOU OWE $ John Doe MINIMUM AMOUNT DUE $ Clear Information on What Is Owed and When 100 Anonymous Rd. PAYMENT DUE DATE 7/31/2016 Flowertown, NY For financial assistance and billing questions, please call (555) ACCOUNT SUMMARY Column1 Column2 > Check Payment Options: Previous Balance Previous Balance $ > American Express, Discover, Visa, and MasterCard Last Payment Payment $ CREDIT New Charges New Charges $ > To pay online, visit Interest Interest Applied to Previous Balance-5.00% $ - Total Amount Owed Total Amount You Owe $ For financial assistance and billing questions, please call (555) How Much Is Left? COST-SHARING SUMMARY COST-SHARING TYPE TOTAL YTD REMAINING Deductible * $ $ $ - Out-of-Pocket Maximum ** $ 3, $ $ 2, * The amount you pay for covered healthcare services before your insurance plan starts to pay. ** The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copays, and coinsurance, your health plan pays 100% of the costs of covered benefits. Monthly premiums must still be paid. HEALTH SPENDING ACCOUNT SUMMARY Health Savings Account (HSA) Annual Pledge Amount $2, Payments to Date $ Balance Available for Future Claims $1, Health Reimbursement Arrangement (HRA) Annual Pledge Amount $1, Payments to Date $ Balance Available for Future Claims $ Flexible Spending Account (FSA) Annual Pledge Amount $ Payments to Date $60.00 Balance Available for Future Claims $190.00

4 MEDICAL BILL Medical Insurance R Us GLOBAL PATIENT ID STATEMENT PERIOD PAGE 11 West St /01/2016 TO 06/30/ OF 2 Pleasantville, NY (555) Statement Periods Exact Service Dates Service Information Service Date Provider/Facility Service Code Service Description Provider's Charge for Service In-Network Discount Charge and Payment Information Amount Paid to Provider by Amount You Owe Financial Intermediary Claim Status Why You Owe This Amount Grouped as a Single Priced Service 5/1/2016 General Hospital DRG 470 Knee replacement without a major complication $ 20, $ 15, $ 14, $ Deductible not yet Pending Payment met $ Current Statement Balance Clear Information on Current Statement Balance Explanation of Why You Owe What You Owe Clear Service Provider's Discount Amount Financial Descriptions Charge Amount for Going Intermediary Pays In Network to Provider

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11 Year-End Healthcare Tax Information Medical Insurance R Us 11 West St. Pleasantville, NY (555) Insured s Name Address Policy Number Policy Start Policy End John Doe 100 Anonymous Road Flowertown, NY /1/ /31/2015 Name of Covered Individual Relationship Policy Start Policy End Jane Doe Wife 1/1/ /31/2015 Julie Doe Daughter 1/1/ /31/2015 Jack Doe Son 1/1/ /31/2015 Healthcare Account Detail Health Savings Account (HSA) Employee Annual Pledge Amount $ 1, Employer Annual Contribution $ 1, Health Reimbursement Arrangement Annual Pledge Amount $ 1, Flexible Spending Account (FSA) Annual Pledge Amount $ Month Health Savings Account (HSA) Health Reimbursement Arrangement (HRA) Flexible Spending Account (FSA) Amount Paid Out of Pocket January $ $ $ $ February $ $ $ March $ $ 9.00 $ $ April $ $ $ May $ $ $ $ June $ $ July $ $ August - $ September $ $ October - $ $ November $ $ $ December $ $ $ TOTAL: $ 2, $ 1, $ $