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Dr Willie Aucamp - Uroloog/Urologist Tel: 011 869 0102/0087

Practice number: 4602072 Fax: 011 869 0147


P O Box 1002, Alberton, 1450 Vat Reg No: 4550150892
Union Hospital, 2nd floor Suite 210
New Redruth,Alberton Email: accounts@drjwaucamp.co.za

Account Number 10920


File Number 12726
Mrs P ZIETSMAN Date Printed 2019-08-01
70 VERMOOTEN STR Medical Scheme NETCARE
BRACKENHURST Option / Plan NETCARE SAVINGS OPTION
1448
Membership Number 559982720
Member ID Number 5405280049087
Member VAT Number
Home Number / Work Number /
Cell Number / Email 0845014886 / zietsman.marcel@gmail.com

Doctor's Banking Details:


Banking Institution Branch Branch Code Account Number Account Name
Please use your File number as referece when making payment. Thank you
Absa The Glen 631205 4054362395 Dr JW Aucamp

ACCOUNT DETAIL STATEMENT


Date Patient Ref Description Patient Funder
Amount Amount
2019-07-22 ZIETSMAN, Mr MARCEL M 00039745 Invoice *Submitted to Scheme 550.00 383.90
2019-07-22 73318 Patient Receipt Allocated [Credit Card] (Payment Completed) -550.00 0.00
Invoice Sub Total 0.00 383.90
Statement Total R 0.00 R 383.90

STATEMENT NOTES
Notes
Please ensure your details are correct and your Medical Aid has received this account. You remain liable for payment. Thank you.

ORIGINAL TAX INVOICE DETAILS


Invoice No Treatment Date Patient Name ID No Dependant Type Date of Birth Gender Claim Ref
00039745 2019-07-22 MARCEL ZIETSMAN, M 5301115024082 01 - Spouse 53-01-11 Male 22076138
Treating / Attending Doctor Referring Doctor Out of Hospital
Dr JW Aucamp (Urology) DR GC RADEMEYER Suit 210 2nd Floor Union Hosp

m
PR Number 4602072 PR Number 1497138 Authorisation No

i
HPCSA Number MP0289779 6542829141
ID Procedure ICD10 NAPPI Modifiers Description Qty Total Patient Liable Fund Liable

la
2 0192 N48.5 New and established patient: Consultation/visit of 1.00 933.90 550.00 383.90
Invoice Total (VAT incl.) R 933.90 R 550.00 R 383.90

AGE ANALYSIS

i C
Current 30 Days 60 Days 90 Days 120 Days + Total
R 383.90 R 0.00 R 0.00 R 0.00 R 0.00 R 383.90

V e r
E. & O.E Generated by VeriClaim 2016.1 VAT No:4550150892 User: Ilze Date/Time: 2019-08-01 11:07:21 AM Page 1 of 1