What is an Explanation of Benefits (EOB)?

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Date of birth

Date of service

MM/DD/YYYY

Statements to be paid

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Statement is paid.

You have statements remaining to be paid.

Total due amount:

You can either view all the statements or continue to pay the current statement.

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Statement ID:

Statement Date:

Statement Amount:

Selected Pay Amount:

Settle all Your statements

Total Due Amount:

Selected Statement Count:

Selected Due Amount:

Select your payment option

Statement ID:

Statement Date:

Statement Amount:

Selected Pay Amount:

Total Due Amount:

tot. due

Selected Statement Count:

stat count

Selected Due Amount:

sel. due

Full payment

Payment plan

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(Initial payment amount must be in between $ and $ for this statement)

Remaining balance applied to payment plans: $

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Enter patient date of birth MM/DD/YYYY

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Select plan duration

Statement ID:

Statement Date:

Statement Amount:

Selected Pay Amount:

Total Due Amount:

tot. due

Selected Statement Count:

stat count

Selected Due Amount:

sel. due

Select Duration (in months)

Note:

Based on selected duration initial amount and carry forward amount to the plan might slightly change.

Monthly installment payments will be automatically processed from your card.

Initial amount: $

Amount carry forward to the installments: $

Monthly installment amount: $

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