DATE: 03/17/20 PAGE 1 MAIL TO: INVOICE ... - Hometown Health
BUZZ LIGHTYEAR
DISNEY INC ACT PRM HMO
1234 DISNEYLAND WAY
SPARKS
NV 89431
MAIL TO: HOMETOWN HEALTH PREMIUM BILLING 10315 PROFESSIONAL CIRCLE
RENO, NV 89521
DATE: 03/17/20 PAGE 1
INVOICE
20009955-00001
GROUP
999955
DISNEY INC ACT PRM HMO
ACCOUNT
9995P
BILL PERIOD 20/04
INVOICE DUE DATE 04/01/20
COMPNO: 01
MEMBER # REL NAME
SSN
DOB
AGE M/F TIER MM/YY CURRENT
RETRO TOTAL COMMENT
-----------------------------------------------------------------------------------------------------------------------
9911223333 1 DUCK, DONALD
*****1111 09/09/88 31 M AB 04/20 357.67
0.00 357.67 _______
9911223334 2 DUCK, DAISY
*****2222 04/04/90 30 F AB 04/20 334.16
0.00 334.16 _______
1122339999 1 MOUSE, MICKEY
*****9999 05/05/55 64 M AB 04/20 664.85
0.00 664.85 _______
** GROUP 999955 TOTAL **
1356.68
0.00 1356.68
** COMPANY 01 TOTAL **
1356.68
0.00 1356.68
................
................
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