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000uSign Envelope ID:euoeos5e-5euo4uoA-85os4FAuFEse1Fa5 <br /> NE E) <br /> Electronic Remittance Advice <br /> Electronic Remittance Adxice -De|iveryand View <br /> Subscription includes 1.00OERAs. $OO5 per additional $5000 $BBOO <br /> ERA. <br /> Total $BBOO <br /> Patient Financial Services <br /> Credit Card Processing <br /> $25 per Merchant ID. Subscribed for 1 Meruhont |D(s) $2500 $BBOO <br /> See Merchant Agreement for transaction fee pricing. <br /> Total $BBOO <br /> Patient Statements <br /> Print Services <br /> $O72 each for the first page printed, $O12each $OOO $BBOO <br /> additional page. <br /> Total $BBOO <br /> The information contained in this document is intended for the recipient and is considered confidential information. ~�r�N�� �=�� <br /> a��� �`�������.�°�/ <br /> 3 <br />