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 [QR Code] BayCare --- 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 `0000000010344210000287515` --- **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 | |----------------|------------|------------------| | 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 on the page. Let me look at the document carefully. The document has two main sections: PATIENT INFORMATION and INSURANCE INFORMATION. At the top, there's a header: "IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE..." Then there are two columns: - Left: PATIENT INFORMATION - Right: INSURANCE INFORMATION Let me transcribe each field: **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 (checkbox) - WORKER'S COMPENSATION (checkbox) **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 I need to format this cleanly with markdown. Let me structure it properly. Actually, looking at the layout, it's a form with two main columns. I should represent this as a structured markdown document with the header, then the two sections. Let me transcribe exactly what I see: Header: 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 - Social Security # - Employer's Name | Telephone ( ) - Employer's Address - City | State | Zip - Please Indicate if Applicable: | Date of Injury - [ ] AUTO ACCIDENT - [ ] WORKER'S COMPENSATION 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 I'll format this using markdown tables or sections. The user wants clean markdown with ### for sections, **bold** for labels, etc. Let me structure it: ### 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** | | Actually, looking more carefully at the layout, it's two main columns side by side. Let me see if I can represent this better. Actually, the user says "Use ### for sections, **bold** for labels, markdown tables for tabular data". Let me look at the form structure again. It's a two-column form. Let me try to capture it as two separate sections. But looking at the image, it seems like the Insurance Information section is separate from Patient Information. Let me format this properly. Actually, I think the best way is to present it as two main sections, and use tables for the form fields that are laid out in table format. Let me be precise about the text: Top banner: "IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE..." Then two headers: "PATIENT INFORMATION" and "INSURANCE INFORMATION" Let me transcribe each field exactly as it appears: **PATIENT INFORMATION fields:** - 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 fields:** - 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. Since it's a form with a grid layout, I'll use tables to represent the structure. Actually, looking at the layout again - the form has a header spanning both columns, then two column headers: "PATIENT INFORMATION" and "INSURANCE INFORMATION". Let me format it as: ### 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** | |:---:|:---:| Wait, that's not right. Let me look at the table structure more carefully. The Patient Information section appears to have: - Row 1: Your Name (Last, First, Middle Initial) | Date of Birth - Row 2: Address (spanning) - Row 3: City | State | Zip - Row 4: Telephone - Row 5: Social Security # - Row 6: Employer's Name | Telephone - Row 7: empty with ( ) - Row 8: Employer's Address - Row 9: City | State | Zip - Row 10: Please Indicate if Applicable: | Date of Injury - Row 11: AUTO ACCIDENT checkbox - Row 12: WORKER'S COMPENSATION checkbox And Insurance Information: - Row 1: Your PRIMARY Insurance Company's Name - Row 2: Primary Insurance Company's Address - Row 3: City | State | Zip - Row 4: Policyholder Name | Date of Birth | Sex - Row 5: Policyholder's ID Number | Group Plan Number - Row 6: Your SECONDARY Insurance Company's Name - Row 7: Secondary Insurance Company's Address - Row 8: City | State | Zip - Row 9: Policyholder Name | Date of Birth | Sex - Row 10: Policyholder's ID Number | Group Plan Number I need to format this cleanly. Since the user wants markdown tables for tabular data, I'll create two separate tables or one combined table. Actually, looking at the image, these are two separate forms side by side. But in markdown, I can present them as two separate sections with their own tables. Let me create 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, the tables with City/State/Zip - these are three columns. And for the Insurance section, the first two rows are single column (full width), then City/State/Zip are three columns, then Policyholder Name/Date of Birth/Sex are three columns, then Policyholder's ID Number/Group Plan Number are two columns. Let me be more precise: For Insurance Information section: 1. "Your PRIMARY Insurance Company's Name" - this looks like a full width field 2. "Primary Insurance Company's Address" - full width 3. City | State | Zip - three fields 4. Policyholder Name | Date of Birth | Sex - three fields 5. Policyholder's ID Number | Group Plan Number - two fields 6. "Your SECONDARY Insurance Company's Name" - full width 7. "Secondary Insurance Company's Address" - full width 8. City | State | Zip - three fields 9. Policyholder Name | Date of Birth | Sex - three fields 10. Policyholder's ID Number | Group Plan Number - two fields Actually looking at the lines, it seems like there are divider lines. Let me try to capture the table structure as accurately as possible. Actually, I think the best approach is to present two separate tables side by side conceptually, but in markdown I'll present them sequentially or as separate sections. Wait, I should look at the actual image again. The user provided an image that shows two distinct sections: PATIENT INFORMATION on the left and INSURANCE INFORMATION on the right. Let me format this as two sections with tables that represent the form fields. Actually, I want to be careful about the "Telephone" field in the Patient section. There's a line with "Telephone" and then a line below with "( )" which suggests a blank for the phone number. Let me try again with a cleaner format: ``` ### 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:** ☐ **AUTO ACCIDENT** ☐ **WORKER'S COMPENSATION** **Date of Injury** _______________ ``` But the user specifically asked for markdown tables for tabular data. So I should use tables. Let me try with tables: ``` ### 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** | | ``` Hmm, that gets messy. Let me look at the actual layout again and try to match it. Actually, looking at standard medical forms, the layout is usually: Patient Info table with merged cells for the address fields. Let me try a different approach. I'll use a single markdown table for each section where the columns align with the form structure. For Patient Information: - Row 1: Name (spans 2 cols) | DOB (1 col) - Wait, looking at the image, the Patient Info section has the name and DOB side by side, then address full width, then City/State/Zip in three columns. Actually, the Patient Information section has these rows: 1. Your Name (Last, First, Middle Initial) | Date of Birth 2. Address (spanning) 3. City | State | Zip 4. Telephone (spanning or left) 5. Social Security # (spanning or left) 6. Employer's Name | Telephone 7. ( ) [empty line for phone number parentheses] 8. Employer's Address 9. City | State | Zip 10. Please Indicate if Applicable: | Date of Injury 11. AUTO ACCIDENT (checkbox) 12. WORKER'S COMPENSATION (checkbox) And Insurance Information: 1. Your PRIMARY Insurance Company's Name 2. Primary Insurance Company's Address 3. City | State | Zip 4. Policyholder Name | Date of Birth | Sex 5. Policyholder's ID Number | Group Plan Number 6. Your SECONDARY Insurance Company's Name 7. Secondary Insurance Company's Address 8. City | State | Zip 9. Policyholder Name | Date of Birth | Sex 10. Policyholder's ID Number | Group Plan Number I think the most accurate transcription is to capture the text labels as they appear, using tables to show the structure. Let me format the Insurance Information table. It looks like: - Primary Insurance Company Name (full width) - Primary Insurance Company Address (full width) - City | State | Zip (three columns) - Policyholder Name | Date of Birth | Sex (three columns) - Policyholder ID Number | Group Plan Number (two columns) - Secondary Insurance Company Name (full width) - Secondary Insurance Company Address (full width) - City | State | Zip (three columns) - Policyholder Name | Date of Birth | Sex (three columns) - Policyholder ID Number | Group Plan Number (two columns) Wait, looking more carefully at the insurance section - there are horizontal lines dividing the rows. Let me count the rows in the Insurance Information table. Actually, looking at the image, the Insurance Information section appears to have a table structure with the following fields in order: Row 1: Your PRIMARY Insurance Company's Name (full width) Row 2: Primary Insurance Company's Address (full width) Row 3: City | State | Zip Row 4: Policyholder Name | Date of Birth | Sex Row 5: Policyholder's ID Number | Group Plan Number Row 6: Your SECONDARY Insurance Company's Name (full width) Row 7: Secondary Insurance Company's Address (full width) Row 8: City | State | Zip Row 9: Policyholder Name | Date of Birth | Sex Row 10: Policyholder's ID Number | Group Plan Number Yes, that looks right. The secondary section mirrors the primary section. For the Patient Information, the structure is: Row 1: Your Name (Last, First, Middle Initial) | Date of Birth Row 2: Address (full width) Row 3: City | State | Zip Row 4: Telephone Row 5: Social Security # Row 6: Employer's Name | Telephone Row 7: ( ) [This is just the parentheses for the phone number format] Row 8: Employer's Address Row 9: City | State | Zip Row 10: Please Indicate if Applicable: | Date of Injury Row 11: [Checkbox] AUTO ACCIDENT Row 12: [Checkbox] WORKER'S COMPENSATION Actually, looking at the checkbox area - "Please Indicate if Applicable:" is on the left, "Date of Injury" is on the right. Then below that are the two checkboxes stacked on the left side. Let me create 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** | | ``` Wait, the "Please Indicate if Applicable:" and "Date of Injury" seem to be side by side in the same row, and then the checkboxes are below in the left column. Let me look one more time. The form shows: - A row with "Please Indicate if Applicable:" on the left and "Date of Injury" on the right - Below that, on the left: checkbox AUTO ACCIDENT - Below that, on the left: checkbox WORKER'S COMPENSATION So the table might be: | **Please Indicate if Applicable:** | **Date of Injury** | |:---|:---| | ☐ **AUTO ACCIDENT** | | | ☐ **WORKER'S COMPENSATION** | | Or it could be that the Date of Injury is a field to the right of the label, and the checkboxes are on the left side only. Actually, looking at typical medical form layouts and the image, "Date of Injury" probably has a line or box next to it for entering the date, and it's positioned to the right of "Please Indicate if Applicable:". Then the checkboxes are stacked below "Please Indicate if Applicable:". Let me format it as: ``` | **Please Indicate if Applicable:**