`NYSCEF DOC. NO. 2
`
`INDEX NO. 2023-00023635
`
`RECEIVED NYSCEF: 10/06/2023
`
`Champlain
`
`.
`
`EMS Inc
`
`Invoice
`Patient Name
`M Ashline
`
`Chad
`
`Statement Date
`02/25/2021
`
`"··- Number
`1 ) 104
`
`Date of Service
`12/1/2020
`
`From
`Resence
`
`Date
`
`Description
`
`12/01/2020
`12/01/2020
`
`BLS Base Rate
`Mileage X 24.0
`
`PO BOX 535
`BALDWINSVILLE NY 13027
`) 806-927-5845
`) 315-635-1789
`£315-635-3289
`
`120,773
`146
`
`aiain Valley Physicians
`
`To
`
`Charge
`
`Payment/Adjustment
`
`$1,000.00
`$648.00
`
`Balance
`
`$1,000.00
`$648.00
`
`Balance
`
`Due
`
`$1,648.00
`
`Your continued
`in your
`failure to respond to our billings will
`result
`account being referred to a collection
`agency. Please contact our
`office to provide insurance
`or discuss
`information
`payment
`arrangements.
`
`with billing questions,
`to pay by credit/debit
`
`card.
`
`PLEASEDETACHANDRETURNTHEPORTIONBELOWWITHYOURPAYMENTENCLOSEDINAN ENVELOPE
`
`CHAMPLAIN
`
`EMS INC
`
`BALDW N VILLE NY 13027-0535
`
`RETURN SERVICE REQUESTED
`
`$
`
`1,648.00
`
`Methods
`
`in the enclosed
`
`envelope.
`
`Payment
`By Mail
`Send your check or money order
`By Phone
`Call 1-800-927-5845
`or 1-866-318-9859
`Online
`Visit https://www.multimedbilling.com/cc/champlain.htmi
`
`