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MIC Htkitt a h"di tS: 'SAP! jilfitKIiN II.IUNIY <br /> ae5 N. San Joaquin Street K( A KAIL?Nti Arlt^Lb <br /> iV P.J BOX 2(M9 <br /> Stockton, _"-' I <br /> (109) 46e-340 <br /> - Jr3i Khanna, ti.G Heait;' L;itce: I <br /> V <br /> I <br /> I C:HtJtiiO I <br /> <br /> RACY, f.q 'l-WE <br /> I <br /> I I <br /> Billing ,titaie*ent For ); j Pumit, Uiueropou'ria io-M rati;ii.+ <br /> I, <br /> 'dtdt£'H!el'+t VJatr tiZ•rii x; 19,31 <br /> Kipwrtt Due Date: 1fty ,i, l?:n <br /> I <br /> 'i-e V!CJ'J5 balanic 'A,4.00- I <br /> I :;mate 5ui':iiar2c i-iii Sb.U� I <br /> '.Art}.alrIertee t.IJUI Illi' 00 <br /> OW2 170.vti I <br /> State sunl?arye 0002 W+00, <br /> ontai iR. tae t1Uii_ ;i(!,lir: <br /> State Su'r myge vow `a• Ot) <br /> n, <br /> ::optairw_r fee :",rJ%: iP.-.'iil <br /> '?tate SurCC,erG. v'04 ck. 00 <br /> WAL ohs Nit SON-0 <br /> N!7tity Muc Health services, -"'—"- <br /> Sen Joa+quirt U-UTA-- Ot ariy <br /> I corrr[t10r+s cc mapm <br /> nete5s6vy. YCdlr pilot. will <br /> be miled won 'receipt of <br /> paywit aril awroval of <br /> facility I <br /> Return p'aywit. ai Vn'! w;th One <br /> >. _:. j } <br /> vuf Oi tt:75 s.,ia 4efNF.'i v I <br /> FSM l - Ct`a <br /> JOAQUCNi3di <br /> ENY,QKNTk HEALIH 'Eii?ii'jiSt„a1i!=:ES I <br /> P.G. Bt]% :00 <br /> f:lOt:CC44, to %210 <br /> Penalties. WE be ackni atter j <br /> ?ate date a5 glcwn: <br /> 10 days - 100% of base fee <br /> I I <br /> I <br /> I <br /> I <br /> I <br />