Secure Payments
GLUPKER ORTHODONTICS
203 RILEY ST, HOLLAND, MI 49424
RETURN SERVICE REQUESTED
To Pay Online, go to
www.GoPatientco.com
Statement Date: 06/13/2025
Then enter this
SecureHealthCode YD5-AWU-D8A
To Pay by Phone
Available 24/7
EVELYN ORELLANA 877-256-5080
13054 RILEY ST
Then enter this
HOLLAND MI 49424 935-298-382
SecureHealthCode
Summary at a Glance
DUE BY JUN 25, 2025
PAYMENTS &
$2,175.00
SERVICES &
CHARGES ADJUSTMENTS
$5,427.00 -$5,277.00
Please see reverse side for details.
Patient Information A Message From VCU Medical Center
Patient Name Evelyn Orellana Glupker Orthodontics is moving to a new billing system
MRN 5295053 December 4, 2021! You may receive a statement like this,
or you may receive the new billing statement. Statements
are dependent upon your date of service. More
Thank you for choosing Glupker information will be available at glupkeror.org, Billing and
Orthodontics for your health care Insurance, December 1.
needs!
COVID 19 is affecting many families and causing financial
This statement reflects charges for non-provider services at hardship. To help offset, we are offering extended
Glupker Orthodontics and may reflect inpatient and/or payment plans/terms. We also provide financial
outpatient care. If you have physician services, they will be assistance to our patients - see reverse for contact
billed separately. information.
If you have any questions regarding your account, please Following CDC guidelines, we have stopped all face-to-
contact us at (888) 803-0082
face discussions regarding billing, financial application,
Hours: 8:30am - 4:00pm
Or email us at Glupkerorthopedic@.org and payments. Please call us to discuss payment
arrangements.
Prompt payment of the balance is appreciated.
YD5-AWU-D8A
Name EVELYN ORELLANA If paying by check, make payable to:
MRN 5295053 Glupker orthodontics
203 Riley St
Holland MI 49424
BALANCE DUE $2,175.00
Payment Included $
0969480147247301 0000150003
Details Services provided to Evelyn ORELLANA (Outpatient)
Date Description Amount
05/19/25 Mri Brain Wo/w Contrast $7,427.00
05/25/25 Anthem Billed
06/13/25 Anthem Payment -$1,727.00
06/13/25 Insurance -$3,525.00
Visit # 180893891 Balance $2,175.00
Insurance: ANTHEM BCBS
Need help with your medical bills?
If you do not have health insurance and worry that you may not be able to pay in full for your care, VCU Health Financial
Counseling may be able to help. We provide financial assistance to patients based on their income, assets and needs. In
addition, we may be able to help you get free or low-cost health care.
If you have any questions or would like more information, please call (804) 828-0966, Monday through Friday, 9 a.m. to 4 p.m. or visit
vcuhealth.org.
Form 405-A (elf. 1/2021)
BALANCE BILLING PROTECTION FOR OUT-OF-NETWORK
SERVICES
Starting January 1, 2021, Virginia state law may protect you from “balance billing” when you get:
• EMERGENCY SERVICES from an out-of-network hospital, or an out-of-network doctor or other medical provider
at a hospital; or
• NON-EMERGENCYSURGICALORANCILLARY SERVICES from an out-of-network lab or health care
professional at an in-network hospital, ambulatory surgical center or other health care facility.
What is balance billing?
• An “IN-NETWORK” health care provider has signed a contract with your health insurance plan. Providers
who haven't signed a contract with your health plan are called “OUT-OF-NETWORK” providers.
• In-network providers have agreed to accept the amounts paid by your health plan after you, the patient, has paid for
all required cost sharing (copayments, coinsurance and deductibles for covered services).
• But, if you get all or part of your care from out-of-network providers, you could be billed for the difference
between what your plan pays to the provider and theamount the provider bills you. This is called “balance billing.”
• The new Virginia law prevents certain balance billing, but it does not apply to all health plans.
Applies May Apply Does Not Apply
o Fully insured managed care plans, a Employer-based coverage a Health plans issued to an
including those bought through a Health plans issued to an employer association outside Virginia
HealthCare.gov outside Virginia o Health plans that do not use a
o The state employee health plan a a Short-term limited duration plans network of providers
Group health plans that opt-in a Limited benefit plans
How can I find out if I am protected?
Be sure to check your plan documents or contact your health plan to find out if you are protected by this law. When
you schedule a medical service, ask your health care provider if they are in-network. Insurers are required to tell you (on
their websites or on request) which providers are in their networks. Hospitals and other health care providers also must tell
you (on their websites or on request) which insurance plans they contract with as in-network providers. Whenever
possible, you should use in-network providers for your health care to avoid paying more.
After you receive medical services, your health plan will send you an “Explanation of Benefits” (EOB) that will tell you what
you must pay the provider. Save the EOB and check that any bills you receive are not more than the amount listed.
When you cannot be balance billed:
If the new law applies to your health plan, an out-of-network provider can no longer balance bill or collect more than your
plan's in-network cost-sharing amounts for either (1) emergency care or (2) when you receive lab or professional services
(like surgery, anesthesiology, pathology, radiology, and hospitalist services) at an in-network facility.
What should I know about these situations?
Your cost-sharing amount will be based on what your plan usually pays an in-network provider in your area. These
payments must count toward your in-network deductible and out-of-pocket limit. If the out-of-network provider collects
more than this from you, the provider must refund the excess with interest.
Exception: \l you have a high deductible health plan with a Health Savings Account (HSA) or a catastrophic health plan,
you must pay any additional amounts your plan is required to pay to the provider, up to the amount of your deductible.
What if I am billed too much?
If you are billed an amount more than your payment responsibility shown on your EOB, or you believe you've been
wrongly billed, you can file a complaint with the State Corporation Commission's (SCC) Bureau of Insurance.
To contact the SCC for questions about this notice visit: scc.virginia.gov or call: 1-877-310-6560.
Page 3 of 3 VCU Medical Center (Nov 30, 2021 - YD5-AWU-D8A)
