Preview
51-CO-24-11
Filed in District Court
State of Minnesota
2/1/2024 1:28 PM
Dr. Jon A Heezen D5
212 3'd St
Tracy MN 56175
Phone: 507-212-0002 888-817-6392 Fax; 5o7-212oozo
Email:
'J
Certfied Mail #70180360000070067030
Brittani Skillings
'331 'lSt St E
Hadley MN 56133
Date: October 25, 2023
-
RE: Dental Chares
Dear Ms. Skillings
URGENT: PLEASE RECTII'7Y THIS MATTER IMMEDIATELY
Despite our previous reminders the above amount due remains unpaid. As such,
'
we wouId appreciate you making this payment as soon as possible. The charge
detail Is attached. ,
AMOUNT DUE: $2222.10E
PLEASE REMIT PAYMENT TO: 212 3rd St Tracy MN 56175 or online at
https:"pay. balancecolIect. com/mlprairieiakesfamilydentistry
We regret to advise that unIess payment'Is received by November 7, 2023 this
collection will be passed over to our debt collection agency/lawyer. This could
seriously affect your credit rating and therefore urge you contact us immediately
to make payment or arrange an alternative before this date.
You haVe the right to dispute this debt by submitting written notice within thirty
.
(30) days of receiving this letter. If this letter'Is not disputed within the thirty (30) ,
day time-frame then the colIection will be considered accepted by the debtor.
Sincerely,
Dr. Jonl4
eezen/
51-CO-24-11
Filed in District Court
State of Minnesota
2/1/2024 1:28 PM
'
PO Box 1174'
, 212 3rdStreet, Suite 5
Tracy; Minnesota156175
LA
'
Dr'Jon A'Hmen 3'93 507-212-0002
»
888-817-6392
DENTIaTQY
.
mmpraifialafebsj'izmz'bzdentz'saycom .
Fax 507.212.0020 ,
'
Treating youiike family
7
Brittany Skiliings
'
,
.
Ceflified Mail #9589071052700592840098'
331 E 1st St , .
Hadiey MN 56133
'
Date: December 12, 2023
RE: Dental Charges Account #6205
Dear Ms Skillings,
URGENT: PLEASERECTIFY THIS MATTER IMMEDIATELY
You have been given ample time to rectIfy the past due balance of $2,222.10 due
to Prairie Lakes Family Dentistry.
No further services will be pr'pvided until this account is cleared. Your immediate
attention IS needed regarding this account.
This"Is your FINAL NOTICEgi' Within the next 30 days, contact our office to pay
this account In full or setup a mutually acceptable payment arrangement. We
accept castt cheek or credit card as payment forms After 30 days, your account
will be filed In Conciliation Court.
AMOUNT DUE: $2,222 10
PLEASE REMIT PAYMENT TO: 212 3rd St Tracy MN 56175 or online at
https:I/pay balancecoliectcomlm/pratnelakesfamtlydentrstly
/
l
Sincere
fit
Dr. Jon Heezen
51-CO-24-11
Filed in District Court
State of Minnesota
2/1/2024 1:28 PM
'SENDER: COfifPLEY'E TH£S SECT§ON CQfiJ?PLETE YHIS SECTt'ON 0N [DELIVERY
IPfint nameamlwdressonmemerse
sommoanremmthecardtom 5.5x
IAMmhmwmwfi$flmUmkmflmnmmmw,"*'B'%WM"WVWW"MWQ "
GIMMdDwww
fl 6" Y
7
~7 "Em BAddresses'
,1
04)"?3
'
wonmefiontrfmpermlts. ,
1cmG1°Wmdm D susmmmmmmre ffi'ves
*7
EYBaenmrdelweryaddressbelow BNO
3.; E
if
CH5.36""
AN mtg} 'jrassaq'o'e.Type 7
WWW
Wm!
"1::
amateur Delivery :1 mmmm
Signfi
9590 9402 5680 9346 4496 99 mu"?
Wggémflmm
D rMerchandlse
2. Article Number {Transfer from sen/ice Jabs!)
"155"! 073.0 SE78 135512
2003??
511813 '15 mm
011 9911119131 "9311131113 99171"?
g mmfi'
WWW
1:3!!!
4P8 Form 3811, July 2015 PSN 7530.02-000-9053 '
Domestic Return Receipt
51-CO-24-11
Filed in District Court
State of Minnesota
2/1/2024 1:28 PM
STATEMENT
Remit To of
Page 1 1
Prairie Lakes Family Dentistry
212 3rd St SteS POBX 1174 IF PAYING BY CREDIT CARD, FILL OUT BELOW.
Tracy, MN 56175 NAME(As it appears on card) TYPE OF CARD
CARD NUMBER AMOUNT
SIGNATURE EXP. DATE
Statement Date: Balance Due Now: Acct#:
Brittany Skillings
7/25/2023 $2,422.1 0 6205
331 E1st
Hadley, MN 56133-0 DUE DATE: Amount
8/24/2023 Enclosed:
if address has changed, please correct.
For Billing Questions, call: (507)212-0002
TO ENSURE PROPER CREDIT, PLEASE DETACH AND RETURN THIS PORTION OF THE STATEMENT WITH YOUR PAYMENT
PLEASE RETAIN THIS PORTION OF THE STATEMENT FOR YOUR RECORDS
ate Patient Code Description Debits Credits Baiance'
BaIanc Forward >>>>>>> $0.00
7/14/2023 Brittany D0367 CONE BEAM CT CAPTURE AND INTBOTH JA 306.34 306.34
7/14/2023 Brittany D0220 INTRAORALPERIAPICAL FIRST FILM Tooth 37.10 343 .44
19
7/14/2023 Brittany D0140 LIMITED ORAL EVALUATION-PROBLEM 97.52 440.96
FOCU
7/14/2023 Brittany D2740 CROWNBruxZ/PORC/CERAM Tooth 19 1,363.16 1,804.12
7/14/2023 Brittany D2950 CORE BUILDUP, INCLUDING ANY PINS Tooth 328.60 2,132 72
19
7/14/2023 Brittany D3221 GROSS PULPAL DEBRIDEMENT, PRIM. & 289.38 2,422.10
PERM. Tooth 19
Banae
ta Due
$2,422.10
s.
'3cw . .
wafirwowemwetmimmame
'
$2,422.10 $0 00 $0 00 $0 00 $0.00 $0.00
We appreciate your prompt payment.
Prairie Lakes Family Dentistry
PLEASE PAY
THIS AMOUNT .5 $2,422.10
212 3rd St SteS POBX 1174 , Tracy , MN 56175 Q grrgnt antgl Terminology (gQT) ©Amencan Dental Assooiation (ADA) All nghts reserved 1
51-CO-24-11
Filed in District Court
State of Minnesota
2/1/2024 1:28 PM
STATEMENT
Remit To: of
Page 1 1
Prairie Lakes Family Dentistry
212 3rd St SteS POBX 1174 IF PAYING BY CREDIT CARD, FILL OUT BELOW.
Tracy, MN 56175 NAME(As it appears on card) TYPE OF CARD
CARD NUMBER AMOUNT
SIGNATURE EXP. DATE
Statement Date: Balance Due Now: Acct#:
Brittany Skillings
0/17/2023 $2,222.10 6205
331 E1st
1
Hadley, MN 561330 DUE DATE: Amount
11l16l2023 Enclosed:
If address has changed, please correct.
For Billing Questions, call: (507)212-0002
TO ENSURE PROPER CREDIT, PLEASE DETACH AND RETURN THIS FOR'HON OF THE STATEMENT WITH YOUR PAYMENT.
PLEASE RETAIN THIS PORTION OF THE STATEMENT FOR YOUR RECORDS
Date Patient Code Description Debits Credits Baiance
Balanc Forward >>>>>>> $2,222.10
Balance Due:
$2,222.10
Current 30 Days 60 Days 90 Days On Contract Est. Insurance
$0.00 $0.00 ($200.00) $2,422.1 0 $0.00 $0.00
Your Account is Now 90 days Overdue. Finance charges will be applied
Prairie Lakes Family Dentistry
PLEASE PAY
THIS AMOUNT .p $2,222.10
212 3rd St Ste5 POBX 1174 , Tracy , MN 56175 Qgrrgnj ganja [am no 991 (912T) ©Amencan Dental Association (ADA). All rights reserved I
Preview
51-CO-24-11 Filed in District Court State of Minnesota 2/1/2024 1:28 PM Dr. Jon A Heezen D5 212 3'd St Tracy MN 56175 Phone: 507-212-0002 888-817-6392 Fax; 5o7-212oozo Email: 'J Certfied Mail #70180360000070067030 Brittani Skillings '331 'lSt St E Hadley MN 56133 Date: October 25, 2023 - RE: Dental Chares Dear Ms. Skillings URGENT: PLEASE RECTII'7Y THIS MATTER IMMEDIATELY Despite our previous reminders the above amount due remains unpaid. As such, ' we wouId appreciate you making this payment as soon as possible. The charge detail Is attached. , AMOUNT DUE: $2222.10E PLEASE REMIT PAYMENT TO: 212 3rd St Tracy MN 56175 or online at https:"pay. balancecolIect. com/mlprairieiakesfamilydentistry We regret to advise that unIess payment'Is received by November 7, 2023 this collection will be passed over to our debt collection agency/lawyer. This could seriously affect your credit rating and therefore urge you contact us immediately to make payment or arrange an alternative before this date. You haVe the right to dispute this debt by submitting written notice within thirty . (30) days of receiving this letter. If this letter'Is not disputed within the thirty (30) , day time-frame then the colIection will be considered accepted by the debtor. Sincerely, Dr. Jonl4 eezen/ 51-CO-24-11 Filed in District Court State of Minnesota 2/1/2024 1:28 PM ' PO Box 1174' , 212 3rdStreet, Suite 5 Tracy; Minnesota156175 LA ' Dr'Jon A'Hmen 3'93 507-212-0002 » 888-817-6392 DENTIaTQY . mmpraifialafebsj'izmz'bzdentz'saycom . Fax 507.212.0020 , ' Treating youiike family 7 Brittany Skiliings ' , . Ceflified Mail #9589071052700592840098' 331 E 1st St , . Hadiey MN 56133 ' Date: December 12, 2023 RE: Dental Charges Account #6205 Dear Ms Skillings, URGENT: PLEASERECTIFY THIS MATTER IMMEDIATELY You have been given ample time to rectIfy the past due balance of $2,222.10 due to Prairie Lakes Family Dentistry. No further services will be pr'pvided until this account is cleared. Your immediate attention IS needed regarding this account. This"Is your FINAL NOTICEgi' Within the next 30 days, contact our office to pay this account In full or setup a mutually acceptable payment arrangement. We accept castt cheek or credit card as payment forms After 30 days, your account will be filed In Conciliation Court. AMOUNT DUE: $2,222 10 PLEASE REMIT PAYMENT TO: 212 3rd St Tracy MN 56175 or online at https:I/pay balancecoliectcomlm/pratnelakesfamtlydentrstly / l Sincere fit Dr. Jon Heezen 51-CO-24-11 Filed in District Court State of Minnesota 2/1/2024 1:28 PM 'SENDER: COfifPLEY'E TH£S SECT§ON CQfiJ?PLETE YHIS SECTt'ON 0N [DELIVERY IPfint nameamlwdressonmemerse sommoanremmthecardtom 5.5x IAMmhmwmwfi$flmUmkmflmnmmmw,"*'B'%WM"WVWW"MWQ " GIMMdDwww fl 6" Y 7 ~7 "Em BAddresses' ,1 04)"?3 ' wonmefiontrfmpermlts. , 1cmG1°Wmdm D susmmmmmmre ffi'ves *7 EYBaenmrdelweryaddressbelow BNO 3.; E if CH5.36"" AN mtg} 'jrassaq'o'e.Type 7 WWW Wm! "1:: amateur Delivery :1 mmmm Signfi 9590 9402 5680 9346 4496 99 mu"? Wggémflmm D rMerchandlse 2. Article Number {Transfer from sen/ice Jabs!) "155"! 073.0 SE78 135512 2003?? 511813 '15 mm 011 9911119131 "9311131113 99171"? g mmfi' WWW 1:3!!! 4P8 Form 3811, July 2015 PSN 7530.02-000-9053 ' Domestic Return Receipt 51-CO-24-11 Filed in District Court State of Minnesota 2/1/2024 1:28 PM STATEMENT Remit To of Page 1 1 Prairie Lakes Family Dentistry 212 3rd St SteS POBX 1174 IF PAYING BY CREDIT CARD, FILL OUT BELOW. Tracy, MN 56175 NAME(As it appears on card) TYPE OF CARD CARD NUMBER AMOUNT SIGNATURE EXP. DATE Statement Date: Balance Due Now: Acct#: Brittany Skillings 7/25/2023 $2,422.1 0 6205 331 E1st Hadley, MN 56133-0 DUE DATE: Amount 8/24/2023 Enclosed: if address has changed, please correct. For Billing Questions, call: (507)212-0002 TO ENSURE PROPER CREDIT, PLEASE DETACH AND RETURN THIS PORTION OF THE STATEMENT WITH YOUR PAYMENT PLEASE RETAIN THIS PORTION OF THE STATEMENT FOR YOUR RECORDS ate Patient Code Description Debits Credits Baiance' BaIanc Forward >>>>>>> $0.00 7/14/2023 Brittany D0367 CONE BEAM CT CAPTURE AND INTBOTH JA 306.34 306.34 7/14/2023 Brittany D0220 INTRAORALPERIAPICAL FIRST FILM Tooth 37.10 343 .44 19 7/14/2023 Brittany D0140 LIMITED ORAL EVALUATION-PROBLEM 97.52 440.96 FOCU 7/14/2023 Brittany D2740 CROWNBruxZ/PORC/CERAM Tooth 19 1,363.16 1,804.12 7/14/2023 Brittany D2950 CORE BUILDUP, INCLUDING ANY PINS Tooth 328.60 2,132 72 19 7/14/2023 Brittany D3221 GROSS PULPAL DEBRIDEMENT, PRIM. & 289.38 2,422.10 PERM. Tooth 19 Banae ta Due $2,422.10 s. '3cw . . wafirwowemwetmimmame ' $2,422.10 $0 00 $0 00 $0 00 $0.00 $0.00 We appreciate your prompt payment. Prairie Lakes Family Dentistry PLEASE PAY THIS AMOUNT .5 $2,422.10 212 3rd St SteS POBX 1174 , Tracy , MN 56175 Q grrgnt antgl Terminology (gQT) ©Amencan Dental Assooiation (ADA) All nghts reserved 1 51-CO-24-11 Filed in District Court State of Minnesota 2/1/2024 1:28 PM STATEMENT Remit To: of Page 1 1 Prairie Lakes Family Dentistry 212 3rd St SteS POBX 1174 IF PAYING BY CREDIT CARD, FILL OUT BELOW. Tracy, MN 56175 NAME(As it appears on card) TYPE OF CARD CARD NUMBER AMOUNT SIGNATURE EXP. DATE Statement Date: Balance Due Now: Acct#: Brittany Skillings 0/17/2023 $2,222.10 6205 331 E1st 1 Hadley, MN 561330 DUE DATE: Amount 11l16l2023 Enclosed: If address has changed, please correct. For Billing Questions, call: (507)212-0002 TO ENSURE PROPER CREDIT, PLEASE DETACH AND RETURN THIS FOR'HON OF THE STATEMENT WITH YOUR PAYMENT. PLEASE RETAIN THIS PORTION OF THE STATEMENT FOR YOUR RECORDS Date Patient Code Description Debits Credits Baiance Balanc Forward >>>>>>> $2,222.10 Balance Due: $2,222.10 Current 30 Days 60 Days 90 Days On Contract Est. Insurance $0.00 $0.00 ($200.00) $2,422.1 0 $0.00 $0.00 Your Account is Now 90 days Overdue. Finance charges will be applied Prairie Lakes Family Dentistry PLEASE PAY THIS AMOUNT .p $2,222.10 212 3rd St Ste5 POBX 1174 , Tracy , MN 56175 Qgrrgnj ganja [am no 991 (912T) ©Amencan Dental Association (ADA). All rights reserved I