Christopher Ross
 
 
 Christopher Ross DOB: 92/05/07 (44 yo M) Acc No. 12170 Doc Name: 18/09/30 exam ref bill 
 STATEMENT 
 THIS IS A STATEMENT OF SERVICES RENDERED BY PHYSICIAN(S) 
 PATIENT NAME 
 WHO ARE MEMBERS OF: 
 LAHS-SLIDELL 
 Christopher Ross 
 56634 BOSWORTH ST 
 BILL DATE 
 ACCOUNT NO. 
 AMOUNT PAID 
 SLIDELL, LA70458-8625 
 16/12/08 
 38175 
 PMT/ADJ/ 
 DATE OF SERVICE 
 DESCRIPTION OF SERVICE 
 CHARGES 
 AMOUNT 
 WITHHELD 
 18/12/29 
 Claim: 320260, Provider: Matthew Laudun, D.C. 
 18/12/29 
 $101.00 
 04/12/2021 
 Claim: 317010, Provider: Matthew Laudun, D.C. 
 DATE 
 PATIENT NAME 
 ACCOUNT NO. 
 PAY THIS 
 16/03/29 
 Christopher Ross 
 38175 
 AMOUNT 
 $3,908.00 
 MAKE CHECK PAYABLE TO : LA HEALTH SOLUTIONS 
 Amount: 
 Exp. Date: 
 Christopher Ross DOB: 92/05/07 (44 yo M) Acc No. 12170 Doc Name: 18/09/30 exam ref bill 
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