SAINT BRIGID REGIONAL MEDICAL CENTER
Patient Financial Services, 400 Harbor Road, Lantern Hollow

STATEMENT
Statement date: August 28, 2026
Patient: Jordan Reyes
Guarantor: Jordan Reyes
Account number: 4471-20983

Date of service   Description                         Charges
08/14/2026        Emergency department visit, level 4   $2,960.00
08/14/2026        CT scan, abdomen                      $1,410.00
08/14/2026        Laboratory panel                        $442.50

Insurance payments                                        $0.00
Adjustments                                               $0.00
AMOUNT DUE                                            $4,812.50
Please pay by: September 27, 2026

Unpaid balances may be referred to an outside collection agency 120 days
after the first statement.

Financial assistance is available. Ask for our Financial Assistance Policy
and application, or see the copy included with this statement.