BayCare HomeCare Medical Bill Nov 2025

--- ## Page 1 **BayCare** **HomeCare** | **Patient Name** | **Account #** | **Statement Date** | **AMOUNT DUE** | |---|---|---|---| | Sophia Jongsma | 01034421 | 11/25/2025 | $631.58 | 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** **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** --- **IF PAYING BY MASTERCARD, DISCOVER, VISA OR AMERICAN EXPRESS, FILL OUT BELOW** | | | | | |---|---|---|---| | CARD NUMBER | | EXP. DATE | MUST INCLUDE SECURITY CODE FROM CREDIT CARD (CVV) | | PRINT NAME | | | | | SIGNATURE | | AMOUNT | | | **STATEMENT DATE** | **AMOUNT DUE** | **PAYMENT DUE DATE** | |---|---|---| | 11/25/2025 | $631.58 | Upon Receipt | **BAYCARE HOMECARE** **PO BOX 741704** **ATLANTA GA 30374-1704** 0000000010344210000631589 141717-BAY-BAI3-637 --- ## Page 2 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** | --- ## Page 3 The user wants me to transcribe all visible text on the page as clean markdown. I need to: 1. Use ### for sections 2. Use **bold** for labels 3. Use markdown tables for tabular data 4. Use - bullets for lists 5. Preserve all numbers, dates, and values exactly as shown 6. Output ONLY the transcribed text — no commentary, no analysis, no preamble Let me go through the document and identify all the text: Top left: BayCare HomeCare logo text Top right section: - Patient Name: Sophia Jongsma - Account #: 01034421 - Statement Date: 11/25/2025 - AMOUNT DUE: $631.58 Main title: STATEMENT OF SERVICES (AS OF November 25, 2025) Black bar text: Any Balance with FINAL NOTICE not paid in 30 days may be forwarded to a collection agency Table headers: DATE, HCPC CODE, QTY, DESCRIPTION, STATUS, BALANCE Table rows: 1. 8/10/2025, E0431, 1, O2 PORT, Final Notice, $5.29 2. 8/10/2025, E0465, 1, VENTILATOR, Final Notice, $331.25 3. 9/10/2025, E0465, 1, VENTILATOR, Final Notice, $287.51 4. 3/31/2025, A7002, 4, TUBING SUCTION 6FT, Final Notice, $2.51 5. 4/29/2025, A7002, 4, TUBING SUCTION 6FT, Final Notice, $2.51 6. 6/5/2025, A7002, 4, TUBING SUCTION 6FT, Final Notice, $2.51 Handwritten text: Called 12/8/25 Bottom left: PAY ONLINE! http://www.personapay.com/bchc Bottom right: BALANCE DUE UPON RECEIPT $631.58 Contact section: CONTACT US FOR QUESTIONS ABOUT YOUR BILL Call 727-394-6401. Monday thru Friday 8:00 am to 4:00pm Small text bottom right: 141717-BAY-BAI3-638 Left side vertical: 2 of 2 Let me format this properly: ### BayCare HomeCare **Patient Name:** Sophia Jongsma **Account #:** 01034421 **Statement Date:** 11/25/2025 **AMOUNT DUE:** $631.58 ### STATEMENT OF SERVICES (AS OF November 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 | |------|-----------|-----|-------------|--------|---------| | 8/10/2025 | E0431 | 1 | O2 PORT | Final Notice | $5.29 | | 8/10/2025 | E0465 | 1 | VENTILATOR | Final Notice | $331.25 | | 9/10/2025 | E0465 | 1 | VENTILATOR | Final Notice | $287.51 | | 3/31/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | | 4/29/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | | 6/5/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | *Called 12/8/25* **PAY ONLINE!** → http://www.personapay.com/bchc **BALANCE DUE UPON RECEIPT:** $631.58 --- **CONTACT US FOR QUESTIONS ABOUT YOUR BILL** - Call 727-394-6401. - Monday thru Friday 8:00 am to 4:00pm 141717-BAY-BAI3-638 I need to make sure I capture everything. The "2 of 2" on the left side - I should include that. Let me check the image again - yes, there's "2 of 2" vertically on the left side. Actually, looking at the layout more carefully: Top section has the BayCare HomeCare logo, then to the right: - Patient Name Sophia Jongsma - Account # 01034421 - Statement Date 11/25/2025 - Amount Due $631.58 I should format the header information clearly. Let me reconstruct: ### BayCare HomeCare **Patient Name:** Sophia Jongsma **Account #:** 01034421 **Statement Date:** 11/25/2025 **AMOUNT DUE:** $631.58 ### STATEMENT OF SERVICES (AS OF November 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 | |------|-----------|-----|-------------|--------|---------| | 8/10/2025 | E0431 | 1 | O2 PORT | Final Notice | $5.29 | | 8/10/2025 | E0465 | 1 | VENTILATOR | Final Notice | $331.25 | | 9/10/2025 | E0465 | 1 | VENTILATOR | Final Notice | $287.51 | | 3/31/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | | 4/29/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | | 6/5/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | *Called 12/8/25* --- **PAY ONLINE!** → http://www.personapay.com/bchc **BALANCE DUE UPON RECEIPT:** $631.58 --- **CONTACT US FOR QUESTIONS ABOUT YOUR BILL** ☎ Call 727-394-6401. Monday thru Friday 8:00 am to 4:00pm --- 141717-BAY-BAI3-638 Wait, I need to check if there's a phone icon. The document shows a phone icon before "Call". I should represent that or just include the text. The user says "Transcribe ALL visible text". The icon might not be text, but "Call" is. There's also a small "2 of 2" on the left margin. Let me look one more time at the exact formatting. The "Any Balance with FINAL NOTICE..." is in a black bar. In markdown, I can use a blockquote or just bold text. The user wants clean markdown. Actually, looking at the prompt again: "Use ### for sections, **bold** for labels, markdown tables for tabular data, - bullets for lists." So I need to identify sections and use ### for them. Sections I see: 1. Header with patient info 2. Statement of Services title 3. The table 4. Payment info 5. Contact info But the user says "Output ONLY the transcribed text — no commentary, no analysis, no preamble, no 'The document is...' sentences. Start directly with the content." So I should just output the markdown directly. Let me be very precise with the text: BayCare HomeCare Patient Name Sophia Jongsma Account # 01034421 Statement Date 11/25/2025 AMOUNT DUE $631.58 STATEMENT OF SERVICES (AS OF November 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 8/10/2025 E0431 1 O2 PORT Final Notice $5.29 8/10/2025 E0465 1 VENTILATOR Final Notice $331.25 9/10/2025 E0465 1 VENTILATOR Final Notice $287.51 3/31/2025 A7002 4 TUBING SUCTION 6FT Final Notice $2.51 4/29/2025 A7002 4 TUBING SUCTION 6FT Final Notice $2.51 6/5/2025 A7002 4 TUBING SUCTION 6FT Final Notice $2.51 Called 12/8/25 PAY ONLINE! http://www.personapay.com/bchc BALANCE DUE UPON RECEIPT $631.58 CONTACT US FOR QUESTIONS ABOUT YOUR BILL Call 727-394-6401. Monday thru Friday 8:00 am to 4:00pm 141717-BAY-BAI3-638 And on the left side: "2 of 2" Now formatting: ### BayCare HomeCare | | | | | |:---|:---|:---|:---| | **Patient Name** | Sophia Jongsma | **AMOUNT DUE** | $631.58 | | **Account #** | 01034421 | | | | **Statement Date** | 11/25/2025 | | | Actually, looking at the original, the Amount Due is in a shaded box on the top right. I can just list the fields. Let me try: **BayCare HomeCare** **Patient Name:** Sophia Jongsma **Account #:** 01034421 **Statement Date:** 11/25/2025 **AMOUNT DUE:** $631.58 ### STATEMENT OF SERVICES (AS OF November 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 | |------|-----------|-----|-------------|--------|---------| | 8/10/2025 | E0431 | 1 | O2 PORT | Final Notice | $5.29 | | 8/10/2025 | E0465 | 1 | VENTILATOR | Final Notice | $331.25 | | 9/10/2025 | E0465 | 1 | VENTILATOR | Final Notice | $287.51 | | 3/31/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | | 4/29/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | | 6/5/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | *Called 12/8/25* --- **PAY ONLINE!** → http://www.personapay.com/bchc | **BALANCE DUE UPON RECEIPT** | $631.58 | |:----------------------------|--------:| --- **CONTACT US FOR QUESTIONS ABOUT YOUR BILL** ☎ Call 727-394-6401. Monday thru Friday 8:00 am to 4:00pm --- 141717-BAY-BAI3-638 I need to decide how to handle the "2 of 2" on the left. It's page numbering. I could include it at the bottom or just omit it since it's not really part of the content, but the user said "ALL visible text". Let me add it. Actually, looking at the image, there's a barcode on the left side with "2 of 2" below it. I should probably include that. Let me format the contact section properly. The phone icon is visible, but in markdown text, I can just write "Call" or use a phone emoji or just the text. Since the user wants text transcription, I'll use the text. Actually, the instruction says "Preserve all numbers, dates, and values exactly as shown." It doesn't say I need to preserve icons exactly, but I should transcribe the text. Let me do one final pass: 1. Top left: BayCare (with logo) HomeCare 2. Top right labels and values: - Patient Name: Sophia Jongsma - Account #: 01034421 - Statement Date: 11/25/2025 - AMOUNT DUE: $631.58 3. Title: STATEMENT OF SERVICES (AS OF November 25, 2025) 4. Black bar text: Any Balance with FINAL NOTICE not paid in 30 days may be forwarded to a collection agency 5. Table with 6 rows 6. Handwritten: Called 12/8/25 7. Bottom: PAY ONLINE! http://www.personapay.com/bchc BALANCE DUE UPON RECEIPT $631.58 8. Contact: CONTACT US FOR QUESTIONS ABOUT YOUR BILL [Phone icon] Call 727-394-6401. Monday thru Friday 8:00 am to 4:00pm 9. Bottom right: 141717-BAY-BAI3-638 10. Left side: 2 of 2 (vertical) I think for the vertical "2 of 2", I can just put it at the bottom left or note it. Since it's a page indicator, I'll include it. Final markdown: ``` ### BayCare HomeCare **Patient Name:** Sophia Jongsma **Account #:** 01034421 **Statement Date:** 11/25/2025 **AMOUNT DUE:** $631.58 ### STATEMENT OF SERVICES (AS OF November 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 | |------|-----------|-----|-------------|--------|---------| | 8/10/2025 | E0431 | 1 | O2 PORT | Final Notice | $5.29 | | 8/10/2025 | E0465 | 1 | VENTILATOR | Final Notice | $331.25 | | 9/10/2025 | E0465 | 1 | VENTILATOR | Final Notice | $287.51 | | 3/31/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | | 4/29/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | | 6/5/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | Called 12/8/25 --- **PAY ONLINE!** → http://www.personapay.com/bchc | **BALANCE DUE UPON RECEIPT** | **$631.58** | |:----------------------------|------------:| --- **CONTACT US FOR QUESTIONS ABOUT YOUR BILL** Call 727-394-6401. Monday thru Friday 8:00 am to 4:00pm 141717-BAY-BAI3-638 2 of 2 ``` Wait, I see in the original that "BALANCE DUE UPON RECEIPT" is in a shaded box. And the amount is $631.58. In my table above I had it formatted differently. Let me check the image again. Actually, looking at the bottom of the image: - Left side: "PAY ONLINE! http://www.personapay.com/bchc" - Right side: Box with "BALANCE DUE UPON RECEIPT" and "$631.58" These are side by side. I can format this as a table or just as two separate lines. Since it's tabular in appearance, I'll use a table or bold text. Actually, looking more carefully, it says: "PAY ONLINE! ➡ http://www.personapay.com/bchc" on the left And on the right: "BALANCE DUE UPON RECEIPT $631.58" in a box. I could format: **PAY ONLINE!** → http://www.personapay.com/bchc **BALANCE DUE UPON RECEIPT:** $631.58 Or use a table to show them side by side. But simple is better. Also, I notice the handwritten text is "Called 12/8/25" which appears to be in cursive. One more thing: The black bar at the top says "Any Balance with FINAL NOTICE not paid in 30 days may be forwarded to a collection agency". This is important. Let me finalize the transcription: ``` **BayCare HomeCare** **Patient Name:** Sophia Jongsma **Account #:** 01034421 **Statement Date:** 11/25/2025 **AMOUNT DUE:** $631.58 ### STATEMENT OF SERVICES (AS OF November 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 | |------|-----------|-----|-------------|--------|---------| | 8/10/2025 | E0431 | 1 | O2 PORT | Final Notice | $5.29 | | 8/10/2025 | E0465 | 1 | VENTILATOR | Final Notice | $331.25 | | 9/10/2025 | E0465 | 1 | VENTILATOR | Final Notice | $287.51 | | 3/31/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | | 4/29/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | | 6/5/2025 | A7002 | 4 | TUBING SUCTION 6FT | Final Notice | $2.51 | Called 12/8/25 --- **PAY ONLINE!** → http://www.personapay.com/bchc **BALANCE DUE UPON RECEIPT:** $631.58 --- **CONTACT US FOR QUESTIONS ABOUT YOUR BILL** Call 727-394-6401. Monday thru Friday 8:00 am to 4:00pm 141717-BAY-BAI3-638 2 of 2 ``` I should include the "2 of 2" which is visible on the left side. And the small code at the bottom right. Actually, looking at the contact section again, there's a phone icon (