Pediatric Home Service Medical Bill

## Contact & Insurance Information **Billing Questions:** (904) 240-4555 Monday - Friday; 8:30 - 4:30 EST **Insurance on File:** CIGNA **Important Messages:** Any insurance provided has been applied, please reference your EOB. The balance shown is your responsibility. A service charge may apply if payments are late. ## Account Details **Account Number:** 11989 **Patient Name:** SOPHIA JONGSMA **Date Mailed:** Feb 09, 2026 **Pay Now:** $49.73 **Pay online at:** https://pediatrichomeservicefl.hmebillpay.com/ ## Current Due | INVOICE # | DATE | DESCRIPTION | PT. RESP. | PAYMENT | AMOUNT DUE | |-----------|------|-------------|-----------|---------|------------| | 383609 | 09/10/2025 | O2 Portable 425ltr D Tank (Rental) | $32.02 | $0.00 | $32.02 | | | 09/10/2025 | Suction Mach Port Drive/DeVilbiss w/Batt (Rental) | | | | | | 09/10/2025 | Mon Oximeter Masimo RAD-G (Rental) | | | | | 461588 | 01/06/2026 | Tube Sx Argyle Clear 1/4in ID 6ft | $16.05 | $0.00 | $16.05 | | 481463 | 02/03/2026 | Pad Alcohol Ster Cardinal 200/Bx | $1.66 | $0.00 | $1.66 | **Current due by 03/01/2026 → Total: $49.73** ## Paid | INVOICE # | PATIENT RESPONSIBILITY | PAYMENT | DATE PAID | |-----------|------------------------|---------|-----------| | 447432 | $442.00 | $442.00 | 01/21/2026 | ## Important Notice **Your bill has a new look! Starting 3/1 you will receive one statement per month** --- ## Payment Coupon **Payments not accepted at this address** All About Pediatrics PO Box 1259 Dept # 140418 Oaks, PA 19456 **Account #:** 11989 **Invoice(s):** 383609 461588 481463 **Patient:** SOPHIA JONGSMA 851 BRIGHTWATERS BLVD NE SAINT PETERSBURG FL 33704-3719 ### Payment Information **Pay Now:** $49.73 **Cards Accepted:** VISA, MasterCard, American Express, Discover - **Card Number:** ________________ - **Expiration Date:** __________ - **Security Code:** __________ - **Name On Card (print):** ________________ - **Amount Enclosed:** __________ - **Billing Zip Code:** __________ - **Signature:** ________________ ### Mail Payment to: All About Pediatrics 532 Sample Street Jacksonville FL 32204-2765 *PLEASE DETACH HERE AND RETURN BOTTOM PORTION*