                                             Your Practice Name
                                                                                    Printed: 02/24/03


    Patient's Name              Frm-Date  Amt Due                      Providing Physician        Insurance Policy Holder
    Group          Policy       Ins-Subm  Allowed ---Diagnosis---      Referring Physician
+------------------------------ -------- -------- ------- ------- ------------------------------ ---------------------------+
|Fountin Rose                   02/12/02  1045.00 242.10          Vicki G Henry M.D.             Rose M Fountin             |
|              174-18-7037A     02/12/02  1045.00                                                Auto N  Accidt N  Emrgy N  |
| Acct 1234567 Inv     251 DOB 10/14/1921 Bill  1                 Where LEWIS RUN ROAD OFFICE    Work N  Similr N  Famil N  |
+---------------------------------------------------------------------------------------------------------------------------+
+---------------------------------------------------------------------------------------------------------------------------+
|AFL  AMER FAMILY LIFE                                Records Selected:        1                                            |
|                                                            Total Due:  1045.00 Allowance:  1045.00                        |
+---------------------------------------------------------------------------------------------------------------------------+
+------------------------------ -------- -------- ------- ------- ------------------------------ ---------------------------+
|Adells Helena                  07/26/98    77.40 240.0   244.9   Vicki G Henry M.D.             Helena M Adells            |
|6609000       183385467B                   77.40 250.90  193     MELVIN PERKS MD                Auto N  Accidt N  Emrgy    |
| Acct 1234567 Inv     227 DOB 10/04/1912 Bill  0 252.0   ABC1234 Where Jefferson Hos. Chgo, Il  Work N  Similr N  Famil N  |
+---------------------------------------------------------------------------------------------------------------------------+
+---------------------------------------------------------------------------------------------------------------------------+
|BS   BLUE SHIELD Of Kentucky                         Records Selected:        1                                            |
|                                                            Total Due:    77.40 Allowance:    77.40                        |
+---------------------------------------------------------------------------------------------------------------------------+
+------------------------------ -------- -------- ------- ------- ------------------------------ ---------------------------+
|Adells Helena                  03/07/02   110.00 240.0   TESST   Vicki G Henry M.D.             Adam L Kuczma              |
|              123456789A                  151.00                                                Auto N  Accidt N  Emrgy N  |
| Acct 1234567 Inv     252 DOB 10/04/1912 Bill  0                 Where LEWIS RUN ROAD OFFICE    Work N  Similr N  Famil N  |
+---------------------------------------------------------------------------------------------------------------------------+
|Allentown John                 12/08/94     8.40 240.0           John R Candy M.D.              John M Allentown           |
|              187200810A       05/26/99     8.40                 VICKI L HERBERT                Auto N  Accidt N  Emrgy N  |
| Acct 1234567 Inv     138 DOB 01/18/1927 Bill  1                 Where LEWIS RUN ROAD OFFICE    Work N  Similr N  Famil N  |
+---------------------------------------------------------------------------------------------------------------------------+
|Allentown John                 12/08/94    12.80 240.0           Vicki G Henry M.D.             John M Allentown           |
|              187200810A       05/26/99    12.80                 VICKI L HERBERT                Auto N  Accidt N  Emrgy N  |
| Acct 1234567 Inv     141 DOB 01/18/1927 Bill  1                 Where LEWIS RUN ROAD OFFICE    Work N  Similr N  Famil N  |
+---------------------------------------------------------------------------------------------------------------------------+
|Amellia Julia                  02/10/93    50.00 244.9           Vicki G Henry M.D.             Julia Amellia              |
|              203127329A       05/26/99    36.80                                                Auto N  Accidt N  Emrgy N  |
| Acct 1234567 Inv      65 DOB 05/14/1923 Bill  1                 Where LEWIS RUN ROAD OFFICE    Work N  Similr N  Famil N  |
+---------------------------------------------------------------------------------------------------------------------------+
|Clementime Alma                02/10/93    55.00 244.9           Vicki G Henry M.D.             Alma Clementime            |
|              178262466B       05/26/99    44.00                                                Auto N  Accidt N  Emrgy N  |
| Acct 1234567 Inv      70 DOB 02/22/1924 Bill  1                 Where LEWIS RUN ROAD OFFICE    Work N  Similr N  Famil N  |
+---------------------------------------------------------------------------------------------------------------------------+
|Cucumber Lewis                 02/10/93    55.00 ABC1234         Vicki G Henry M.D.             Lewis Cucumber             |
|              192102712A       05/26/99    14.40                                                Auto N  Accidt N  Emrgy N  |
| Acct 1234567 Inv      71 DOB 08/19/1911 Bill  1                 Where Jefferson Hos. Chgo, Il  Work N  Similr N  Famil N  |
+---------------------------------------------------------------------------------------------------------------------------+
|Dragonski Louis                01/20/93   374.69 BALFOR          Vicki G Henry M.D.             Louis L Dragonski          |
|              174143124A       05/26/99                                                         Auto N  Accidt N  Emrgy N  |
| Acct 1234567 Inv      93 DOB 06/07/1921 Bill  1                 Where LEWIS RUN ROAD OFFICE    Work N  Similr N  Famil N  |
+---------------------------------------------------------------------------------------------------------------------------+
|Handsome Homer                 10/28/97    43.00 ABC1234         Vicki G Henry M.D.             Homer G Handsome           |
|              211096590A       05/26/99   288.00                                                Auto N  Accidt N  Emrgy N  |
| Acct 1234567 Inv     217 DOB 04/19/1918 Bill  1                 Where LEWIS RUN ROAD OFFICE    Work N  Similr N  Famil N  |
+---------------------------------------------------------------------------------------------------------------------------+
