Ledger 19754 y
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32
J �
COPY OF BILLING
SENT TO DIV. OF
Summary of Balser Act xuc-nditures
MENTAL HEALTH for Period Fndin-
;� r•r� ���
----^-'--
District Board # '`
��Dame Submitted��=�
r
ra of Provider of Servi.cc:: p�,rf�y� n.* ,�a�, �s Provider
_
#
Paid From
Net Amount
State
Amount
Case Number
Due
Funds
Paid From �
Written y
b Off
Social Security
-Provider
Gross Amount
I
hoca l
Provider
Number
Less any 'Chird
75R/ of
Funds
i
Party Payments
Column 2
Tax
Private
Supported
Hospital or
jjI
j
Tospital
j Physician
\
(1�
(2)
i r(3)
;
(5) e6y
-I
}
7q GG s act-1—S
4
$ 76,f�� 7
�$I �
S
DANNY KOLHAGE,
Finance Office
County of Monro
Check #04 in the amoun of $ 1 02. . 9 6 dated June 13,975
was written in fafror of the Guidanc Clinic of the Middle
rendered b .L. Dodge H s ital Mi i Fla. to the client
identified above by case number. T e county's hhare of
this office in accordanCE with the erms of the funding
agreement currently in e istance between_a ounEy o onr
__Elnd the Fle-E-jda Keys Men a] UQ
Sincerely,-,
a
'�F}�l��a�. Keys Mental
r • �i
alth Board
0
5
33 I I
3737 r�
38 - TOTAL. $ !0:z te $ /r ,7- $
--�+ .
x
xx
y The total of column 3,4,5,6 should equal column 2.
xx Amount of c:leck paid Provider by State Funds. Doi-PA-99A