Richard Johnson
 
 
 Richard Johnson DOB: 02-16-2000 (16 yo M) Acc No. 67820 Doc Name: 10-07-2015 exam ref bill 
 STATEMENT 
 THIS IS A STATEMENT OF SERVICES RENDERED BY PHYSICIAN(S) 
 PATIENT NAME 
 WHO ARE MEMBERS OF: 
 LAHS-SLIDELL 
 Richard Johnson 
 56634 BOSWORTH ST 
 BILL DATE 
 ACCOUNT NO. 
 AMOUNT PAID 
 SLIDELL, LA70458-8625 
 12-03-2018 
 38175 
 PMT/ADJ/ 
 DATE OF SERVICE 
 DESCRIPTION OF SERVICE 
 CHARGES 
 AMOUNT 
 WITHHELD 
 07-01-2015 
 Claim: 320260, Provider: Matthew Laudun, D.C. 
 07-01-2015 
 $101.00 
 04/12/2021 
 Claim: 317010, Provider: Matthew Laudun, D.C. 
 DATE 
 PATIENT NAME 
 ACCOUNT NO. 
 PAY THIS 
 02-25-2015 
 Richard Johnson 
 38175 
 AMOUNT 
 $3,908.00 
 MAKE CHECK PAYABLE TO : LA HEALTH SOLUTIONS 
 Amount: 
 Exp. Date: 
 Richard Johnson DOB: 02-16-2000 (16 yo M) Acc No. 67820 Doc Name: 10-07-2015 exam ref bill 
 Page 118 of 123
