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Hospital Receipt
St. Mary’s Medical Center Phoenix, AZ Patient: Laura Simmons
Service Date: 03/16/2032 Account No: 44782911
Emergency Room Visit
1,250.00€
Insurance Adjustment
-1,030.00€
Patient Responsibility
220.00€
Total Paid
Total Paid€
Card number
**** **** **** 1234
Card type
Debit
Status
APPROVED

Hospital Receipt

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