Document yQkb1E98L1Nv17aaze4rqOV2

The Cleveland Cj 'Nic -- F0UNI3A^)N tjsoo Euclid Avenue, Clcvdnnd, Ohio 44106 OR SERVICES RENDERED TO, MR WILLIAM G PRICE history no 1-2Z4-326-1 STATEMENT OF ACCOUNT OCTOBER 20, 1986 BUSINESS OFFICE USE ONLY ANY CHARGES OR PAYMENTS RECEIVED AFTER THE ABOVE STATEMENT DATE WILL APPEAR ON YOUR NEXT STATEMENT USE PAGES 2 AND 3 FOR INSURANCE OR MEDICARE REPORTS. WP WILLIAM G PRICE 2648 KING RD N KINGSVILLE OH 44068 DETACH THIS STUB AND RETURN WITH YOUR REMITTANCE. MAKE CHECKS PAYABLE TO CLEVELAND CLINIC. The Cleveland Cj "\ic _ Founda^)n " ^ STATEMENT OF ACCOUNT usoo Euclid A\'cnui'. Cleveland, Ohio 44ioo> ^^ERVICES RENDERED TO *R WILL IG PRICE HISTORY NO, 1-224-826-1 SEPTEMBER 8# 1986 BUSINESS OFFICE USE ONLY 1 7 ANY CHARGES OR PAYMENTS RECEIVED AFTER THE ABOVE STATEMENT DATE WILL APPEAR ON YOUR NEXT STATEMENT. USE PAGES 2 AND 3 FOR INSURANCE OR MEDICARE REPORTS BILL TO wst WILLI AM G PRICE ?3 4B <?N3 RD KING5VILLP OH 44068 DETACH THIS STUB AND RETURN WITH YOUR REMITTANCE. MAKE CHECKS PAYABLE TO CLEVELAND CLINIC. THE F0Ll6w1nG>'R0FE"sSI0NAL SERVICES WERE p'rOVIDEd'bY THE NAMED PHYSICIANS AND THEIR ASSOCIATES 9/22/p 3/22/pa 9 mnt G*7A S4LHN VO 3 T Gil 51 36415LU VP FEE PLC 1C 626 80(1210 SPA-12 PROFILE 12T 02599 9CC30CC FOLLOW UP OFFICE VISIT PLEASE PAY THIS AMOUNT --> ll C- -1 'I /f nrji I CO ,:pm< 61937 WORKER'S COMPENSATION DEPT. ]T 1 5 5.2 v*- 03/22/66 CARCINOMA LIVER L SEE REVERSE SIDE FOR IMPORTANT CREDIT INFORMATION HE CLEVELAND CLINIC FOUNDATION n0 EUCLID AVENUE CLEVELAND. OHIO 44106 216)444-5741 1-224-326-1 MR WILLIAM G PRICE 6ENC 00232? * CODES C - CLINIC H HOSPITAL P PROFESSIONAL COMPONENT PAGE 1 RETAIN PAGE 1 FOR INCOME TAX PURPOSES.