Rodney Smith

 Harbor Community Health 
 QED 
 STATEMENT OF ACCOUNT ( 0 ) 
 Page 1 
 93949 Meredith Knolls
Bobbyport, IL 30626
 Statement Date: 02 Jan 2019 
 TAX ID# 75-5243077 
 Account Number: QED16103796390 
 patient name: Rodney Smith 
 Rodney Smith 
 96724 Scott Divide
West Timothyfurt, UT 14037 
 Amount You Owe: 
 $0.00 
 Services provided at: 
 MEDICAL CITY LAS COLINAS - 6800 N MACARTHUR BLVD - IRVING TX 75039-2422
 Date of 
 CPT Code 
 Description 
 Provider 
 Charges 
 Payments or 
 Explanation 
 Amount 
 Service 
 Adjustments 
 You Owe 
 27 Aug 2017 
 27840 
 REDUCE ANKLE DISLOC W/O ANES 
 Dr Christopher Grant 
 $3,082.00 
 $3,082.00 
 1,2,3,4 
 $0.00 
 27 Aug 2017
 99285 
 EMERG INJURY EVAL & MGMT-LVL 5 
 Dr Christopher Grant 
 $1,516.00 
 $1,516.00 
 1,2,4 
 $0.00 
 Total Charges: 
 $4,598.00 
 Current Patient Responsibility: 
 $0.00 
 Insurance Information: 
 Insurance 1: BC/BS of Texas - TEXAS B/S ITS/OSS CLAIMS 
 PARHAM-0172 
 000001
