Service Date Description Billed Plan Paid I Owe Remarks

JUN 282019 RAMSHA's visit to ELBA I FRANCO

ESTIMATE PROVIDED on Jun 28, 2019 - Services either your dentist recommends or you Clear up these claims. I understand it is just an estimate but
$93.00 $0.00 $34.60
elect, including costs you and your plan could share once complete I am not considering to get these done.

JUN 282019 RAMSHA's visit to ELBA I FRANCO

ESTIMATE PROVIDED on Jun 28, 2019 - Services either your dentist recommends or you Clear up these claims. I understand it is just an estimate but
$279.00 $0.00 $103.80
elect, including costs you and your plan could share once complete I am not considering to get these done.

JUN 282019 RAMSHA's visit to ELBA I FRANCO

ESTIMATE PROVIDED on Jun 28, 2019 - Services either your dentist recommends or you Clear up these claims. I understand it is just an estimate but
$913.00 $0.00 $150.20
elect, including costs you and your plan could share once complete I am not considering to get these done.

JUN 192019 EMAD's visit to ELBA I FRANCO

PROCESSED on Jun 29, 2019 $620.00 $460.40 $101.60
My wife received the services - not me. Please rectify.
EOB posted on Jun 29, 2019

JUN 192019 EMAD's visit to ELBA I FRANCO

PROCESSED on Jun 20, 2019 $146.00 $143.00 $0.00
My wife received the services - not me. Please rectify.
EOB posted on Jun 20, 2019

JUN 192019 RAMSHA's visit to ELBA I FRANCO

PROCESSED on Jul 24, 2019 $286.00 $228.80 $57.20 Reference # D191936061910; Issue me the REFUND of the
EOB posted on Jul 24, 2019 NEW amount that I overpaid.

JUN 192019 RAMSHA's visit to ELBA I FRANCO

PROCESSED on Jun 21, 2019 $146.00 $143.00 $0.00
Reference # D191726065380
EOB posted on Jun 21, 2019

JUN 092019 EMAD's visit to ELBA I FRANCO

PROCESSED on Jun 21, 2019 Never visited the dentist office on 06/09/2019. Reported
this to office on 07/11/2019 and being informed that it have
$70.00 $16.00 $54.00
already been reported and rectified. But it still shows up on
EOB posted on Jun 21, 2019 my claims. Please rectify.

JUN 092019 RAMSHA's visit to ELBA I FRANCO

PROCESSED on Jun 22, 2019 Never visited the dentist office on 06/09/2019. Reported
this to office on 07/11/2019 and being informed that it have
$70.00 $16.00 $54.00
already been reported and rectified. But it still shows up on
EOB posted on Jun 22, 2019 my claims. Please rectify.