Benjamin Clark

 21/01/17 0:31 
 36858994319 
 HEWITT ADMIN DEPT 
 PAGE 0/19 
 Sunset Community Hospital 
 Fee Invoice 
 Sunset Community Hospital 
 30193 Brown View Suite 272
Williamsonborough, FL 44809 
 22301 S WESTERN AVE #107 
 TORRANCE, CA 90501 
 571-373-7051 
 Patient_Address 
 21/01/17 
 PO BOX 1548 
 FARMINGTON, CT 06034 
 RE : Benjamin Clark 
 MR#: : 25-652997 
 The policy of HealthCare Partners is to charge a reasonable clerical fee for 
 the completion, and reproduction of medical records, radiology films, and 
 business records. 
 The fee for the following request is: $ 43.00. Please return a copy of this 
 payment by mail. 
 Should you have any questions regarding this invoice, please contact our office 
 at 252-177-9559. 
 Thank You, 
 Correspondence Coordinator 
 Health Information Services Department 
 HCP TX ID # 95-4509662 
 Entry #: 106105 
 Case-W/O#: 
 Patient: Benjamin Clark 
 Amount Due: $ 43.00 
 Entry CL106105 
 Payment Type (check one) : 
 Credit Card # 
 American Express 
 MasterCard 
 Cardholder's Name 
 Visa 
 Check 
 Signature 
 Money Order 
 Exp Date 
 Amount Paid $: 
 Please send payments to: 
 Sunset Community Hospital 
 30193 Brown View Suite 272
Williamsonborough, FL 44809 
 22301 S WESTERN AVE #107 
 TORRANCE, CA 90501 
 2-3-2014 
 2070610352 
 44201503{Random_7_digit_number}0 
 SEDGWICK CLAIMS MANAGEMENT SERVICES, INC. 
 [6687671-01] 143
