Download IPRS Estimate

NewYork-Presbyterian/Columbia
177 Fort Washington Avenue
Milstein 9th Floor
New York, NY 10032 USA
TEL +1-212-305-4900
FAX +1-212-342-5393
May 24, 2016
Dear ALISSA POPOVA,
Re: POPOVA, ALISSA
On behalf of Global Services thank you for inquiring about receiving care at New York-Presbyterian Hospital. We
would like to take this opportunity to provide you with an estimate of charges for the care and treatment
recommended by your physician (page 2). This estimate includes hospital charges only, excluding any
professional fees for the physicians associated with your care.
This letter represents the 'technical' component of your bill and may include items such as: hospital rooms,
laboratory tests, operating rooms, medications, radiology, and other diagnostic procedures. You will also note a
New York State Surcharge line item. This is a tax based on 9.63% of your total hospital bill and is required by
law.
Hospital policy requires that we collect the entire amount of $20,000 requested on this estimate prior to services
being rendered. Payments can be made by wire transfer, credit card, cash, or check (instructions on page 3).
After your care at the hospital is complete, your bill will be finalized within 4-6 weeks and an Executive Summary
will be sent to you at that time. The total bill may vary from the Estimate of Charges and will depend upon your
actual charges. If actual charges exceed the estimate, payment for the balance is expected within two weeks of
receiving the final invoice. If the estimate exceeds the actual charges, any overpayment will be refunded to you
promptly.
Please submit payment as follows:
1. One payment to 'NewYork-Presbyterian Hospital' for $20,000
Global Services is open Monday through Friday from 9:00 a.m. to 5:00 p.m. (Eastern Time). You can contact us
by telephone, fax, or e-mail (see top right for contact information).
Again, thank you for selecting NewYork-Presbyterian for your medical care needs. Should you have any
questions or comments, please don’t hesitate to contact us.
Sincerely,
Kristen Harleston
Financial Representative
[email protected]
ALISSA POPOVA - 7762193
Limey Monsanto
Referral Liaison
[email protected]
NewYork-Presbyterian/Columbia
177 Fort Washington Avenue
Milstein 9th Floor
New York, NY 10032 USA
TEL +1-212-305-4900
FAX +1-212-342-5393
Estimate of Charges
Patient: ALISSA POPOVA
Procedure: Visa Letter Deposit
Prepared: 5/24/2016
Length of Stay:
Charge Description
________________
Actual
_____________
Charges
Hospital Charges
Visa Letter Deposit
$20,000
Total Hospital Charges
Discount
_______
Amount
$20,000
Total Balance Due:
This is only an estimate and does not include costs associated with any professional fees, complications, need
for additional hospitalization, tests, or radiology procedures. The estimates are a guideline of expected cost and
can vary according to the actual treatment provided.
ALISSA POPOVA - 7762193
___________
Balance Due
$20,000
$20,000
NewYork-Presbyterian/Columbia
177 Fort Washington Avenue
Milstein 9th Floor
New York, NY 10032 USA
TEL +1-212-305-4900
FAX +1-212-305-5393
PAYMENT OPTIONS AND INSTRUCTIONS
1. Wire Transfer:
Account
Name
Bank
Account
Name
Bank
The Trustees of Columbia
University
JP Morgan Chase Bank
Branch #: 692
Account No.
ABA No.
"Chase Operating for
New York Hospital"
The Chase Manhattan
Bank
Branch #: 692
0052400207
021000021
Account No.
ABA No.
590165046
021000021
Swift No.
Patient Name
Amount
CHASUS33
__________________
USD_____________
Swift No.
Patient Name
Amount
CHASUS33
____________________
USD_______________
Please fax confirmation of wire transfer with date of transfer and amount transferred to +1-212-746-4777
2. Credit Card:
o Visa
o MasterCard
o American Express
__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__
Card number
____________________________________________________
USD _____________
Expiration Date
mm / yy
Amount
____________________________________________________ _________________________________
Cardholder name (Print)
Patient’s Name (please print)
____________________________________________________
Cardholder signature
I hereby authorize The New York and Presbyterian Hospital and/or ColumbiaDoctors to charge my credit
card for the amount indicated above.
ALISSA POPOVA - 7762193
NewYork-Presbyterian/Columbia
177 Fort Washington Avenue
Milstein 9th Floor
New York, NY 10032 USA
TEL +1-212-305-4900
FAX +1-212-305-5393
3. Check:
Payment via check must be a US certified bank check or traveler’s check. Please provide checks payable
as shown below:
a. Hospital Charges: One check payable to NewYork-Presbyterian Hospital for USD _______ to the
following address:
NewYork-Presbyterian/Columbia
177 Fort Washington Avenue
Milstein 9th Floor
New York, NY 10032 USA
b. Professional Charges: One check payable to The Trustees of Columbia University for USD ________
to the following address:
Columbia Presbyterian Physician Network Global
General Post Office
PO Box 27572
New York, NY 10087-7572
ALISSA POPOVA - 7762193