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Finane/ill

Insurance Company
(formerly Bankers Ufe Company) Iowa 50309

711 High Street

Des Moines.

Group

JANUARY

5, 1989

BEST SHARP SHERIDAN & ATTN JODELL ADAMS 321 S BOSTON STE 700 TULSA OK 74103

WE HAVE RECEIVED THIS SUMMARY

THE CHARGES

DESCRIBED

IN THE SUMMARY

BELOW.

EXPLAINS

OUR ACTION

ON THIS CLAIM
PATIENT: SELF INSURED: DANIEL FROM:1 20888

GROUP: PLANNED EMPL PROGRAM CLAIM NO: L-58045-444728486-018 FOR SERVICE BY:A
.B

S SULLIVAN

DATE: 01-05-89 CHARGES:

STEWART KATZ MD

THRU: 12 0888

138.00

BY

AMOUNT CHARGED

LESS CHARGES PENDING

LESS CHARGES EXCLUDED

A A

83.00 55.00

83.00 55.00

**
1

LESS DEDUCTIBLE

REMAINING BALANCE

COINSURANCE RATE

NORMAL BENEFIT

COV * CODE

138.00

138.00

TOTALS

REMAINING

NORMAL BENEFIT TOTAL PAID:

$

0.00 0.00

INDIVIDUAL:

4000.00

MEDICAL:

0.00 REGIONAL CLAIM CENTER ONE LAKEVIEW ENERGY CEN ST 840 3817 N W EXPRESSWAY OKLAHOMA CITY OK 73112 LOCAL 949-5655 IN-STATE WATS WA

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