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Bon secours doctors note

150 kingsley lane bon secours hampton roads health system form 2025

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The document is a billing statement from Bon Secours Health System addressed to John Doe, regarding an outstanding balance of $7,961.95 for services rendered to Jane Doe on October 7, 2007. It includes details about payment options, a community service adjustment applied to the account, and a prompt pay discount of 10% if paid within 30 days. The document also provides contact information for customer service and instructions for payment.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your payment information. Fill in the card type (Check, Visa, MC, or Discover) and provide the card number, CID number, and expiration date.
In the 'Payment Amount' field, specify the amount you wish to pay. Remember to deduct 10% if paying within 30 days.
Print your name clearly in the designated area and ensure that your billing address matches the address where your credit card statements are sent.
Sign the form in the 'Signature' section to authorize the payment.
Review all entered information for accuracy before submitting. If you have questions, contact customer service using the provided numbers.

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