Patient Account Summary

Pro Healthcare Rehab
3208 Canton Road, Suite 112
Marietta, GA 30066

Page 1

Patient:

DOB:

Address:

City:

Attorney:

Address:

City:

Insurance:

Claim:

DOI:

Adjuster:

Phone:

Fax:

Prescriber:

Description / NDC	Prescriber	Units	Charge	Paid	Balance
CYCLOBENZAPRINE 10 MG TABLET NDC# 72888001405	sdasfds	60	$120.80	$0.00	$120.80
MELOXICAM 15 MG TAB NDC# 6818050101	sdasfds	60	$184.00	$0.00	$184.00
DICLOFENAC Gel 1% 100 unit GM NDC# 2192204409	sdasfds	100	$314.80	$0.00	$314.80

Total Charges$619.60

Total Payments$200.00

Total Adjustments$19.60

Balance Due$400.00