Judy Rasmussen

 19/11/20 0:28 
 40489471871 
 HEWITT ADMIN DEPT 
 PAGE 2/19 
 Oak Grove Hospital 
 Fee Invoice 
 Oak Grove Hospital 
 PSC 0424, Box 5322
APO AA 22106 
 22301 S WESTERN AVE #107 
 TORRANCE, CA 90501 
 232-451-4611 
 Patient_Address 
 19/11/20 
 PO BOX 1548 
 FARMINGTON, CT 06034 
 RE : Judy Rasmussen 
 MR#: : 25-685851 
 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: $ 14.00. Please return a copy of this 
 payment by mail. 
 Should you have any questions regarding this invoice, please contact our office 
 at 761-389-4594. 
 Thank You, 
 Correspondence Coordinator 
 Health Information Services Department 
 HCP TX ID # 95-4509662 
 Entry #: 106105 
 Case-W/O#: 
 Patient: Judy Rasmussen 
 Amount Due: $ 14.00 
 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: 
 Oak Grove Hospital 
 PSC 0424, Box 5322
APO AA 22106 
 22301 S WESTERN AVE #107 
 TORRANCE, CA 90501 
 2-3-2014 
 2080230272 
 44201503{Random_7_digit_number}0 
 SEDGWICK CLAIMS MANAGEMENT SERVICES, INC. 
 [6687671-01] 143
