| Invoice Number: | 142658 |
| Billing Period: | 01/01/2007 - 01/31/2007 |
| Vision Group Number: | 40001-000-00000-00000 |
| Group Name: | VISION |
| Master Number: | 40001 |
| Description: | |
| Phone Number: | (999) 999-0000 |
| VISION |
| GILLIAN MYERS |
| VP SECRETARY |
| 2245 BLUE JAY WAY |
| ANYWHERE, USA 55555-0000 |
| SUBSCRIBER ADJUSTMENTS |
|---|
The following changes have been made to our eligibility records.
*Action Code: 1=Addition, 2=Termination, 3=Eff Date Change, 4=Cov Type Change |
| Member Number | Member Last Name | Member First Name | Coverage Type | Effective Date | *Action Code | Amount Due |
|---|
| 231524089 | ADAMS | SARAH | Single | 01/01/2007 | 1 | $ | 9.72 | |
| |
| | | | | Total Adjustments: | $ | 9.72 | |
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