Invoice

Invoice Number INV-2026-10482

Issue Date March 9, 2026

Due Date March 23, 2026

Pending Payment

Patient Information

Olivia Bennett

ID: PT-20481

DOB: February 12, 1991

4827 West Park Ave

San Diego, CA 92110

(619) 555-1834

olivia.bennett@email.com

Visit Information

Provider Dr. Maya Thompson, MD

Location Healeo Clinic – Downtown

Date March 6, 2026

Type Follow-Up Consultation

Date	Code	Description	Charge	Insurance	Patient Owes
03/06/2026	99213	Office Visit	$180.00	$100.00	$80.00
03/06/2026	90833	Medication Management	$140.00	$80.00	$60.00
03/06/2026	99000	Admin Fee	$105.00	$60.00	$45.00

Total Charges $425.00

Insurance Paid -$240.00

Adjustments -$60.00

Balance Due $125.00

Payment Information

Amount Due

$125.00

Due Date

March 23, 2026

Accepted Payment Methods

Credit Card, Debit Card, ACH, HSA/FSA

How to Pay

Online Payment

pay.healeoclinic.com

Billing Contact

billing@healeoclinic.com

(619) 555-2040

"Your insurance payment has been applied. The remaining balance is your patient responsibility. Please contact our billing office with any questions."

For billing questions, contact Healeo Clinic Billing at billing@healeoclinic.com or (619) 555-2040.

Generated March 9, 2026