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BLUE CROSS [[image]]
Associated Hospital Service of New York 

BLUE SHIELD [[image]]
United Medical Services, Inc.

80 Lexington Avenue • New York, N. Y. 10016 • Telephone: 689 - 2800 

[[note]] Mr. Zammit Ext 7339 [[/note]]

(REGULAR) X (ADJUSTMENT) 
(TYPE OF BILLING)

02 09
M X  Q  SA  A 
(MANNER OF PAYMENT)

2-19-70
(PAYMENT DUE DATE)

14 

GROUP COPY

FOR BLUE CROSS ONLY
RECEIVED
$

CASHIER

CONTROL NO.        DEPOSIT DATE

[[right margin]] PAY - 117(9-69) [[/right margin]]

IN ANY INQUIRY PLEASE REFER TO THIS GROUP NO. 

(GROUP NUMBER) 87378 (DIVISION) 

JACQUES SELIGMANN AND CO INC
5 E 57 ST
NEW YORK 22 N Y 

IMPORTANT please indicate all adjustments or inquiries on the reverse side of this bill. Correction or obliteration of subscribers names and/or certificate numbers delays its reconciliation.

Do not include payment for applications submitted with this remittance—await billing.

PAYMENT OF THE ADDITIONAL CHARGES, IF ANY, AS SHOWN BELOW ARE NECESSARY TO INSURE CONTINUITY OF BENEFITS.

[[10 Columned Table]]

| ARREARS AND CREDITS (EXPLAINED BELOW) |

| NAME OF SUBSCRIBER | BLUE SHIELD RATE | CERTIFICATE NUMBER AND SUFFIX | BLUE CROSS AND BLUE SHIELD RATE | EXTENDED COVERAGE OR MAJOR-MEDICAL CHANGES | * | FROM | TO | AMOUNT | PAY THESE AMOUNTS |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| BAL INGEBORG M | $1.68 | 13905501 C01 | $8.68 |   |   |   |   |   | $8.68 |
| DUESBERRY JOELLY N | $1.68 | 14219962 C01 | $8.68 |   |   |   |   |   |   | $8.68 |
| PORJESZ OTTO | $3.40 | 5364052 S | $19.20 |   |   |   |   |   |   | $19.20 |
| PORJESZ YVONNE R | $1.68 | 13748938 C01 | $8.68 |   |   |   |   |   |   | $8.68 |
| SELIGMAN ETHLYNE | $1.68 | 4254209 C01 | $8.68 |   |   |   |   |   |   | $8.68 |
| *SELIGMAN GERMAIN | $2.15 | 084100052 SC11 | $3.90 |   |   |   |   |   |   | $3.90 |
| 1---A |   |   |   |   |   |   |   |   |   |

[[note]] 11267
2/18/70 [[/note]]

PAGE NO.    1       12 27    6             6           

1. RETURN THE YELLOW COPY WITH YOUR REMITTANCE.
2. USE THE REVERSE SIDE TO DETAIL YOUR ADJUSTMENTSM.
LIST ADDRESSES OF "LEFT-GROUP" EMPLOYEES ON REVERSE SIDE

A - ARREARS ON FORMER STATUS
B - CONTRACT CHANGE
C - CREDIT
D - ARREARS
E - EXTENDED COVERAGE CHARGES ONLY
F - ADDITION TO GROUP

TOTAL AMOUNT DUE -> $ 57.82
SHOW ADJUSTMENTS -> __________
AMOUNT REMITTED -> $ __________

PLEASE MAKE CHECK PAYABLE TO ASSOCIATED HOSPITAL SERVICE OF NEW YORK

Transcription Notes:
---------- Reopened for Editing 2024-03-08 09:29:49 Unsure where to put "ARREARS AND CREDITS (EXPLAINED BELOW)" ---------- Reopened for Editing 2024-03-09 11:28:24 ---------- Reopened for Editing 2024-03-09 11:52:20 ---------- Reopened for Editing 2024-03-13 16:25:42