Tiffany Garcia

 
 Billing Statement 
 VALIANT LIFE MEDICAL 
 1201 SUMMIT AVENUE, SUITE 500 
 FORT WORTH, TX 76102 
 817-926-0012 
 Bill To: HILLIARD MARTINEZ GONZALES 
 719 SOUTH SHORELINE BOULEVARD 
 CORPUS CHRISTI TEXAS, 78401 
 Patient Name: 
 Patient Address: 
 Patient ID: 
 Tiffany Garcia 
 313 CHIMNEY ROCK ROAD, FORT WORTH, TX 76140 
 22-0003-INJ 
 Date of 
 Procedure 
 Description 
 Charge Insurance 
 Patient 
 Adjustment 
 Balance 
 Service 
 Payment 
 Payment 
 05/2020/05 
 97010 
 Hot / Cold packs 
 $20.00 
 $0.00 
 $20.00 
 05/2019/03 
 G0283 
 Electrical Stimulation 
 $50.00 
 $0.00 
 $50.00 
 Comments: 
 BILLING STATEMENT 
 Current Due 
 Past Due 30 Days 
 Past Due 60 Days 
 Past Due 90 Days 
 Balance Due 
 $0.00 
 $8,260.00 
 $8,260.00 
 76281-10 
 Valiant Life Medical - Billing -16651
