Planned Parenthood Receipt Generator

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Organization Name: Planned Parenthood Organization Tagline: Care. No matter what. Address Line 1: 123 Health Services Way Address Line 2: — City, State, Zip: New York, NY 10001 Phone: 1-800-230-7526 Website: www.plannedparenthood.org Email: [email protected]

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Transaction Type: Healthcare Services Visit Reference ID: PP-VIS-20251112-004981 Receipt ID: PP-REC-20251112-004981 Payment Status: Completed Service Date & Time: 11/12/2025 10:37:25 AM Payment Method: Debit Card Card: Visa ending 4922 Authorization Code: PP-AUTH-6H72F9 Reference Number: PP20251112R004981 Currency: USD

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Patient Name:

Samantha Lee

Clinic Location:

Planned Parenthood Health Center

Patient Email:

[email protected]

Provider:

Planned Parenthood

Billing Address:

742 Evergreen Terrace, Apt 9C, Springfield, IL 62704, United States

Visit Type:

In-Clinic Appointment

Service Date:

11/12/2025

Visit Reference ID:

PP-VIS-20251112-004981

30/06/2026, 09:28:36 PM

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Clinical Consultation & Evaluation

$120.00

Preventive Health Services

$85.00

Laboratory & Screening Services

$62.50

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Subtotal$267.50

Discount(10%)$26.75

Tax(9%)$21.67

Total

$262.42

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Card Number**** **** **** 4922

Card TypeDebit

Card EntryChip

Date/Time11/20/2019 11:09 AM

Reference #62845289260246240685C

StatusAPPROVED

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Receipt Number: PP-2025-1112-009 Patient Support: 1-800-230-7526 Help Center: www.plannedparenthood.org/learn Thank you for trusting Planned Parenthood with your care. Privacy Notice: Your health information is protected under applicable privacy laws. Footer: Planned Parenthood

Planned Parenthood Receipt

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