BayCare HomeCare Medical Bill

--- ## Page 1 ### BayCare HomeCare **Patient Name** Sophia Jongsma **Account #** 01034421 **Statement Date** 12/25/2025 **AMOUNT DUE** $287.51 We have billed your insurance and the remaining balance is your responsibility. One or more of your charges are in **FINAL NOTICE**. Please see next step below. ### Make Payment in Full - To Make a Payment - Pay your bill online at baycare.org/pay-my-bill or call us at (800) 940-5151 (Available 24/7) ### PAYMENT PLANS - If you are unable to pay your amount due in full and would like to establish a monthly payment plan, please contact us at (855) 533-5200 or log onto www.MedMaxFinance.com. ### FINANCIAL ASSISTANCE - If you are unable to pay, you may be eligible for financial assistance. Please call 727-394-6401. ### PAY ONLINE AT personapay.com/bchc --- Detach and return with your payment. Please make checks payable to BayCare HomeCare. Any changes to Address and/or Insurance should be noted on the back of the coupon. **BAYCARE HOMECARE** PO BOX 741704 ATLANTA GA 30374-1704 Pay online at http://www.personapay.com/bchc **SOPHIA JONGSMA** 851 BRIGHTWATERS BLVD NE ST PETERSBURG FL 33704-3719 0000000010344210000287515 **IF PAYING BY MASTERCARD, DISCOVER, VISA OR AMERICAN EXPRESS, FILL OUT BELOW** | | | | | |:---:|:---:|:---:|:---:| | ☐ | ☐ DISCOVER | ☐ VISA | ☐ AMEX | **CARD NUMBER** **EXP. DATE** **MUST INCLUDE SECURITY CODE FROM CREDIT CARD (CVV)** **PRINT NAME** **SIGNATURE** | **AMOUNT** | STATEMENT DATE | AMOUNT DUE | PAYMENT DUE DATE | |:---:|:---:|:---:| | 12/25/2025 | $287.51 | Upon Receipt | **BAYCARE HOMECARE** PO BOX 741704 ATLANTA GA 30374-1704 141717-BAY-BAI3-687 --- ## Page 2 The user wants me to transcribe all visible text from the provided image as clean markdown. Let me analyze the image to extract the text. Looking at the image, I can see a form with the following sections: 1. A header text at the top of the form section 2. "PATIENT INFORMATION" section on the left 3. "INSURANCE INFORMATION" section on the right Let me read the text carefully: Header text: "IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE..." Left side - PATIENT INFORMATION: - Your Name (Last, First, Middle Initial) - Date of Birth - Address - City | State | Zip - Telephone - ( ) [probably for phone number formatting] - Social Security # - Employer's Name | Telephone - ( ) [probably for phone number formatting] - Employer's Address - City | State | Zip - Please Indicate if Applicable: - Date of Injury - AUTO ACCIDENT [with checkbox] - WORKER'S COMPENSATION [with checkbox] Right side - INSURANCE INFORMATION: - Your PRIMARY Insurance Company's Name - Primary Insurance Company's Address - City | State | Zip - Policyholder Name | Date of Birth | Sex - Policyholder's ID Number | Group Plan Number - Your SECONDARY Insurance Company's Name - Secondary Insurance Company's Address - City | State | Zip - Policyholder Name | Date of Birth | Sex - Policyholder's ID Number | Group Plan Number There appears to be some faint text in the top portion of the image (inverted/reversed), but it's not clearly legible and appears to be bleed-through or watermark text. The user asked for "ALL visible text" - but the text in the top portion is very faint and mirrored. However, looking closely, it seems like "PayCash" or something similar, possibly "PayCash" and "HomeCare" backwards. But since the user wants me to preserve all visible text, and if I can make it out, I should include it. Actually, looking more carefully at the top right, there are faint reversed letters. It looks like "PayCash" and "HomeCare" or similar. But this appears to be text from the other side of the paper showing through, and it's mirrored. Actually, wait - the user wants me to transcribe "ALL visible text". The main form is clearly visible at the bottom. The top portion has very faint, possibly reversed text that's hard to read. But I should focus on the clearly legible text first. Let me see if I can make out the reversed text. In the top right, reversed: - "PayCash" (looks like sʜɔɔʎɐԀ) - "HomeCare" (looks like ǝɹɐƆǝɯoH) But since this is reversed/bleed-through and the user wants clean markdown of the document, and the instruction says "Transcribe ALL visible text", I think the main content is the form. The reversed text at the top appears to be from a different page bleeding through, not part of the actual document content that should be transcribed as the main text. Actually, looking at the image again, the reversed text says "PayCash" and "HomeCare" or similar. But it's very faint and appears to be from the back side of the paper or another page. The main document is clearly the patient information form. Let me structure this as clean markdown: ### Header IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE... ### PATIENT INFORMATION | | | | |---|---|---| | **Your Name (Last, First, Middle Initial)** | | **Date of Birth** | | **Address** | | | | **City** | **State** | **Zip** | | **Telephone** | | | | ( ) | | | | **Social Security #** | | | | **Employer's Name** | | **Telephone** | | ( ) | | | | **Employer's Address** | | | | **City** | **State** | **Zip** | | **Please Indicate if Applicable:** | **Date of Injury** | | | ☐ AUTO ACCIDENT | | | | ☐ WORKER'S COMPENSATION | | | ### INSURANCE INFORMATION **Your PRIMARY Insurance Company's Name** | | | | |---|---|---| | **Primary Insurance Company's Address** | | | | **City** | **State** | **Zip** | | **Policyholder Name** | **Date of Birth** | **Sex** | | **Policyholder's ID Number** | | **Group Plan Number** | **Your SECONDARY Insurance Company's Name** | | | | |---|---|---| | **Secondary Insurance Company's Address** | | | | **City** | **State** | **Zip** | | **Policyholder Name** | **Date of Birth** | **Sex** | | **Policyholder's ID Number** | | **Group Plan Number** | Wait, looking at the layout more carefully. The form has two main columns. Let me try to capture the exact field labels and layout. Actually, looking at the "Telephone" field with "( )" below it - this appears to be for area code and number. Let me try to format this more precisely as it appears, using tables to represent the form fields. The text at the top says: "IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE..." Then there's a horizontal line, and below that on the left: "PATIENT INFORMATION" And on the right: "INSURANCE INFORMATION" Let me create a comprehensive transcription: --- IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE... ### PATIENT INFORMATION **Your Name (Last, First, Middle Initial)** | **Date of Birth** ---|--- **Address** | **City** | **State** | **Zip** **Telephone** | ( ) | **Social Security #** | **Employer's Name** | **Telephone** ( ) | **Employer's Address** | **City** | **State** | **Zip** **Please Indicate if Applicable:** | **Date of Injury** ☐ AUTO ACCIDENT | ☐ WORKER'S COMPENSATION | ### INSURANCE INFORMATION **Your PRIMARY Insurance Company's Name** | | | | |:---|:---|:---| | **Primary Insurance Company's Address** | | | | **City** | **State** | **Zip** | | **Policyholder Name** | **Date of Birth** | **Sex** | | **Policyholder's ID Number** | | **Group Plan Number** | **Your SECONDARY Insurance Company's Name** | | | | |:---|:---|:---| | **Secondary Insurance Company's Address** | | | | **City** | **State** | **Zip** | | **Policyholder Name** | **Date of Birth** | **Sex** | | **Policyholder's ID Number** | | **Group Plan Number** | --- Actually, looking at the layout again, the Patient Information section has the fields arranged with lines for input. Let me see if I can represent this more accurately. The Patient Information side has: 1. Your Name (Last, First, Middle Initial) - field - Date of Birth - field 2. Address - long field 3. City - field - State - field - Zip - field 4. Telephone - field 5. ( ) - indicating area code 6. Social Security # - field 7. Employer's Name - field - Telephone - field 8. ( ) - indicating area code 9. Employer's Address - long field 10. City - field - State - field - Zip - field 11. Please Indicate if Applicable: - Date of Injury - field 12. ☐ AUTO ACCIDENT 13. ☐ WORKER'S COMPENSATION The Insurance Information side has: 1. Your PRIMARY Insurance Company's Name - long field 2. Primary Insurance Company's Address - long field 3. City - field - State - field - Zip - field 4. Policyholder Name - field - Date of Birth - field - Sex - field 5. Policyholder's ID Number - field - Group Plan Number - field 6. Your SECONDARY Insurance Company's Name - long field 7. Secondary Insurance Company's Address - long field 8. City - field - State - field - Zip - field 9. Policyholder Name - field - Date of Birth - field - Sex - field 10. Policyholder's ID Number - field - Group Plan Number - field For the markdown representation, I should use a format that captures all the text clearly. Using tables might be the best way to show the field relationships. Let me refine the markdown: IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE... ### PATIENT INFORMATION | | | | |:---|:---|:---| | **Your Name (Last, First, Middle Initial)** | | **Date of Birth** | | **Address** | | | | **City** | **State** | **Zip** | | **Telephone** | | | | ( ) | | | | **Social Security #** | | | | **Employer's Name** | | **Telephone** | | ( ) | | | | **Employer's Address** | | | | **City** | **State** | **Zip** | | **Please Indicate if Applicable:** | **Date of Injury** | | | ☐ AUTO ACCIDENT | | | | ☐ WORKER'S COMPENSATION | | | ### INSURANCE INFORMATION **Your PRIMARY Insurance Company's Name** | | | | |:---|:---|:---| | **Primary Insurance Company's Address** | | | | **City** | **State** | **Zip** | | **Policyholder Name** | **Date of Birth** | **Sex** | | **Policyholder's ID Number** | | **Group Plan Number** | **Your SECONDARY Insurance Company's Name** | | | | |:---|:---|:---| | **Secondary Insurance Company's Address** | | | | **City** | **State** | **Zip** | | **Policyholder Name** | **Date of Birth** | **Sex** | | **Policyholder's ID Number** | | **Group Plan Number** | Wait, I need to look at the original image again. The "Telephone" line in Patient Information has "( )" on the line below it, suggesting a format like (___) ____. Similarly for the Employer's Telephone. Also, looking at the Insurance Information, the Primary section: - Your PRIMARY Insurance Company's Name - Primary Insurance Company's Address - City, State, Zip - Policyholder Name, Date of Birth, Sex - Policyholder's ID Number, Group Plan Number And same for Secondary. Actually, looking at the faint text at the top - it appears to be reversed/mirrored. The user said "ALL visible text". But mirrored text that's bleeding through from the other side is technically visible but usually not what is meant in transcription requests. However, if I look closely at the top right, I can see "PayCash" written backwards (sʜɔɐʎɐԀ) and below it "HomeCare" written backwards (ǝɹɐƆǝɯoH). There's also something else very faint. But the main document is the form. I think the user wants the form transcribed. The reversed text at the top is likely just bleed-through from printing on the back side or another document, and not part of the actual content to be transcribed. Let me check if there's any other visible text. The form is the main content. Actually, looking at the very top, there might be some text that's not reversed but very faint. But I think the safe and correct approach is to transcribe the clearly legible form content. One more check: The header text "IF WE DO NOT HAVE YOUR INFORMATION..." is in all caps. The section headers "PATIENT INFORMATION" and "INSURANCE INFORMATION" are in all caps and bold or just caps. In the Patient Information section: - "Your Name (Last, First, Middle Initial)" - "Date of Birth" - "Address" - "City" "State" "Zip" - "Telephone" - "( )" - "Social Security #" - "Employer's Name" - "Telephone" - "( )" - "Employer's Address" - "City" "State" "Zip" - "Please Indicate if Applicable:" - "Date of Injury" - "AUTO ACCIDENT" with a checkbox (square) - "WORKER'S COMPENSATION" with a checkbox (square) In the Insurance Information section: - "Your PRIMARY Insurance Company's Name" - "Primary Insurance Company's Address" - "City" "State" "Zip" - "Policyholder Name" "Date of Birth" "Sex" - "Policyholder's ID Number" "Group Plan Number" - "Your SECONDARY Insurance Company's Name" - "Secondary Insurance Company's Address" - "City" "State" "Zip" - "Policyholder Name" "Date of Birth" "Sex" - "Policyholder's ID Number" "Group Plan Number" Now I'll format this cleanly in markdown. Actually, looking at the layout, it's a two-column form. I could represent it as two separate tables or sections. Let me write it out: IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE... ### PATIENT INFORMATION **Your Name (Last, First, Middle Initial)** **Address** **City** _______________ **State** _______________ **Zip** _______________ **Telephone** ( _______________ ) **Social Security #** _______________ **Employer's Name** _______________ **Telephone** ( _______________ ) **Employer's Address** **City** _______________ **State** _______________ **Zip** _______________ **Please Indicate if Applicable:** **Date of Injury** _______________ ☐ AUTO ACCIDENT ☐ WORKER'S COMPENSATION ### INSURANCE INFORMATION **Your PRIMARY Insurance Company's Name** **Primary Insurance Company's Address** **City** _______________ **State** _______________ **Zip** _______________ **Policyholder Name** _______________ **Date of Birth** _______________ **Sex** _______________ **Policyholder's ID Number** _______________ **Group Plan Number** _______________ **Your SECONDARY Insurance Company's Name** **Secondary Insurance Company's Address** **City** _______________ **State** _______________ **Zip** _______________ **Policyholder Name** _______________ **Date of Birth** _______________ **Sex** _______________ **Policyholder's ID Number** _______________ **Group Plan Number** _______________ But the user said to use markdown tables for tabular data. The form uses lines/fields. Tables would be appropriate. Actually, looking at the instruction again: "Use ### for sections, **bold** for labels, markdown tables for tabular data, - bullets for lists." So I should use tables where there are multiple columns in the form. Let me try a table approach for the Patient Information: | **Your Name (Last, First, Middle Initial)** | | **Date of Birth** | |:---|:---|:---| | **Address** | | | | **City** | **State** | **Zip** | | **Telephone** | | | | ( ) | | | | **Social Security #** | | | | **Employer's Name** | | **Telephone** | | ( ) | | | | **Employer's Address** | | | | **City** | **State** | **Zip** | | **Please Indicate if Applicable:** | **Date of Injury** | | | ☐ AUTO ACCIDENT | | | | ☐ WORKER'S COMPENSATION | | | And for Insurance: ### INSURANCE INFORMATION **Your PRIMARY Insurance Company's Name** | **Primary Insurance Company's Address** | | | |:---|:---|:---| | **City** | **State** | **Zip** | | **Policyholder Name** | **Date of Birth** | **Sex** | | **Policyholder's ID Number** | | **Group Plan Number** | **Your SECONDARY Insurance Company's Name** | **Secondary Insurance Company's Address** | | | |:---|:---|:---| | **City** | **State** | **Zip** | | **Policyholder Name** | **Date of Birth** | **Sex** | | **Policyholder's ID Number** | | **Group Plan Number** | Wait, I need to look at the first row of Patient Information again. It says "Your Name (Last, First, Middle Initial)" and "Date of Birth" - these appear to be side by side in the form. Looking at the image more carefully - yes, "Your Name" is on the left and "Date of Birth" is on the right in the same row. Similarly, "Policyholder Name", "Date of Birth", "Sex" are in one row for the insurance sections. For the Employer section in Patient Info: "Employer's Name" is on the left and "Telephone" is on the right. Then "( )" is below the Telephone, or is it below the Employer's Name? Looking at the image, it seems "( )" is for the telephone area code. Actually, looking at the spacing: Row: "Employer's Name" [space] "Telephone" Row: "( )" - this appears to be aligned under the Telephone field. Row: "Employer's Address" [long field] Row: "City" "State" "Zip" And for the checkboxes: "Please Indicate if Applicable:" "Date of Injury" Then checkboxes below that. Actually, looking at the bottom left: "Please Indicate if Applicable:" is on the left. "Date of Injury" is on the right. Below that are the checkboxes for AUTO ACCIDENT and WORKER'S COMPENSATION. Hmm, looking again at the image, it says: "Please Indicate if Applicable:" | "Date of Injury" And below that, spanning the width: ☐ AUTO ACCIDENT ☐ WORKER'S COMPENSATION Or is "Date of Injury" a field next to "Please Indicate if Applicable:"? Looking at the image again - the text "Please Indicate if Applicable:" appears to be on the left side, and "Date of Injury" with a line appears to be to the right of it or nearby. Actually, looking at the table structure, it seems like: Column 1: "Please Indicate if Applicable:" Column 2: "Date of Injury" (with space for entry) But then the checkboxes are below. Let me look one more time at the exact layout of the Patient Information bottom section: There's a row with two fields/columns: Left: "Please Indicate if Applicable:" Right: "Date of Injury" Then below that (spanning or in the left column): "☐ AUTO ACCIDENT" "☐ WORKER'S COMPENSATION" Actually, looking at the vertical spacing, the checkboxes --- ## Page 3 ### BayCare HomeCare **Patient Name:** Sophia Jongsma **Account #:** 01034421 **Statement Date:** 12/25/2025 **AMOUNT DUE:** $287.51 ### STATEMENT OF SERVICES (AS OF December 25, 2025) *Any Balance with **FINAL NOTICE** not paid in 30 days may be forwarded to a collection agency* | DATE | HCPC CODE | QTY | DESCRIPTION | STATUS | BALANCE | |------|-----------|-----|-------------|--------|---------| | 9/10/2025 | E0465 | 1 | VENTILATOR | Final Notice | $287.51 | --- **PAY ONLINE!** → http://www.personapay.com/bchc **BALANCE DUE UPON RECEIPT:** $287.51 --- **CONTACT US FOR QUESTIONS ABOUT YOUR BILL** ☎ **Call 727-394-6401.** Monday thru Friday 8:00 am to 4:00pm 141717-BAY-BAI3-688