Samuel Clark
 
 
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 Patient Ledger 
 Business Unit: David A Goldman MD LLC 
 Samuel Clark 15/93/08 I MRN: 065146 I PMS: 438-77000526944 
 3502 Kyoto Gardens Dr Suite B 
 3229 GARDENS EAST DR APT C 
 Palm Beach Gardens, FL 334102984 
 PALM BEACH GARDENS, FL 334105706 
 (561) 891-2610 
 Fax: 
 Bill 
 Mark Milner I David A. Goldman MD LLC 
 D.O.S 
 Posting Date 
 Details 
 Charges 
 Payment 
 Adj. 
 Ins Balance 
 Pat Balance 
 18/19/09 
 - 
 CB000D209 
 298.36 
 174.25 
 124.11 
 0.00 
 0.00 
 DOS 
 Posting Date 
 Details 
 Charges 
 Payment 
 Adj. 
 Ins Balance 
 Pat Balance 
 02/22/12 
 CB000AW87 
 492.22 
 274.85 
 217.37 
 0.00 
 0.00 
 Bill 
 Mark Milner I David A. Goldman MD LLC 
 of 
 DOS 
 Posting Date 
 Details 
 Charges 
 Payment 
 Adj. 
 Ins Balance 
 Pat Balance 
 02/02/2023 
 PM 
 Samuel Clark | 15/93/08 I MRN: 065146 I PMS: 438-77000526944 
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