Medicare Summary Notice
for Part B (Medical Insurance)
The Official Summary of Your Medicare Claims
MARGARET ELLIS
1420 Oak Grove Ln Apt 3B
Sacramento, CA 95816
Medicare Number: XXXXX-XX7A
Date: October 15, 2026
THIS IS NOT A BILL
This notice shows claims processed for services you received from July 1 – September 30, 2026. You may have to pay your provider the "Maximum You May Be Billed" amount. If you get a bill, compare it to this notice.
Your Deductible Status
Your deductible is what you must pay each year for most health services before Medicare begins to pay.
Part B Deductible: You have now met $257.00 of your $257.00 deductible for 2026.
Total You May Be Billed
$48.36
Did Medicare approve all services?
YESNumber of services Medicare denied:
0
| Service date | Provider & service | Amount provider charged | Medicare-approved amount | Medicare paid provider | Maximum you may be billed |
|---|
| 07/22/26 | Sutter Medical Group, Dr. A. Patel
Office visit, established patient (99214) | $215.00 | $128.40 | $102.72 | $25.68 |
| 08/14/26 | Quest Diagnostics
Blood test, lipid panel (80061) | $94.00 | $18.39 | $18.39 | $0.00 |
| 09/03/26 | Capitol Eye Associates
Eye exam, glaucoma screening (92014) | $180.00 | $113.40 | $90.72 | $22.68 |
| Total for this period | $489.00 | $260.19 | $211.83 | $48.36 |
Need help? If you have questions, call Medicare customer service at 1-800-555-0123 (TTY 1-877-555-0148). Be ready to give your Medicare Number. Medicare will never call you to ask for your Medicare Number or bank information.
How to report fraud: If you think a provider billed Medicare for services you didn't get, call 1-800-555-0123.
Appeals: If you disagree with a decision, you have until February 12, 2027 to file an appeal. See page 3.