Sophia Jongsma Medical Bill

## Header Information **Billing Questions** (904) 240-4555 Monday - Friday; 8:30 - 4:30 EST **Insurance on File** CIGNA **Important Messages** Any insurance provided has been applied, please reference your EOB. The balance shown is your responsibility. A service charge may apply if payments are late. **Date Mailed:** Jan 08, 2026 --- ## Account Information **Account Number:** 11989 **Patient Name:** SOPHIA JONGSMA **Pay Now:** $442.00 **Pay online at:** https://pediatrichomeservicefl.hmebillpay.com/ --- ## Current Due | INVOICE # | DATE | DESCRIPTION | PT. RESP. | PAYMENT | AMOUNT DUE | |-----------|------|-------------|-----------|---------|------------| | 447432 | 12/11/2025 | Cath Sx AirLife Strt w/Ctrl Port 10fr | $442.00 | $0.00 | $442.00 | **Current due by 01/28/2026** → **Total: $442.00** --- ## Billing Notice Your bill has a new look! Starting 3/1 you will receive one statement per month --- ## Payment Section **PLEASE DETACH HERE AND RETURN BOTTOM PORTION** ### Payment Instructions Payments not accepted at this address **All About Pediatrics** PO Box 1259 Dept # 140418 Oaks, PA 19456 ### Patient Address **SOPHIA JONGSMA** 851 BRIGHTWATERS BLVD NE SAINT PETERSBURG FL 33704-3719 ### Payment Slip Details **Account #:** 11989 **Invoice(s):** 447432 **Cards Accepted:** VISA, MasterCard, American Express, Discover **Pay Now:** $442.00 - Card Number: _______________ - Expiration Date: _______________ - Security Code: _______________ - Amount Enclosed: _______________ - Billing Zip Code: _______________ - Name On Card (print): _______________ - Signature: _______________ ### Mail Payment To: **All About Pediatrics** 532 Sample Street Jacksonville FL 32204-2765