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7 Details of Claim(s): Member Name: Sample Sample Member ID #: TST

80000000 Have Questions? Visit our web site at www.empireblue.com or call (800) 499-9554. Patient: Claim Number: Date Received: Sample Sample

00600000020 03/09/10 Provider Name: Provider Address: HEALTH

1 MEDICAL PC STE

140 LAKE GROVE NY

11755 631-665-4392 YOUR RESPONSIBILITY DATES OF SERVICE PROCE- DURE CODE SERVICE AMOUNT CHARGED BY PROVIDER DISCOUNT AMOUNT CO- PAY- MENT CO- INSUR- ANCE CHARGES NOT COVERED PAYABLE BY EMPIRE NOTES 03/01/10- 03/01/10

99214 OFFICE VISIT 146.00 82.14 0.00 0.00 0.00 48.86

1 03/01/10- 03/01/10

36415 VENIPUNCTURE 25.00 23.06 0.00 0.00 0.00 1.94

1 Total: $171.00 $105.20 0.00 0.00 0.00 $50.80 Your Total Responsibility: $15.00 NOTES FOR THIS CLAIM: 1. The provider may bill you for the amount shown in "Your Total Responsibility" if it has not already been paid.

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