If payment in full has been recently made, thank you. Si usted ha mandado pago por complete recientemente, gracias.
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
PAMELA PATIENT
123 MAIN STREET
ANYTOWN, USA 12345
XYZ Orthopaedics
987 Street Road
Anytown, USA 12345
WID: 0000
Toll-Free: (888) 555-5555
Page: 1
REMIT TO:
XYZ Orthopaedics
987 Street Road
Anytown, USA 12345
STATEMENT DATE BALANCE DUE
MASTERCARD DISCOVER VISA AMEX
CARD NUMBER EXPIRATION DATE
SIGNATURE CSV CODE
10/25/2007 $500.00
ACCOUNT NUMBER1111122222
BALANCE
$500.00
BALANCE DUE $500.00
DELINQUENCY NOTICE
It has been at least 45 days from our initial correspondence and the account(s) listed
below is (are) still due. Please remit your payment in full or contact patient accounting
within 15 days of this statement. If no response is received, your account will be
considered for assignment to a collection agency.
NOTIFICACION DE DELINCUENCIA
Han pasado por los menos 45 dias desde nuestra correspondencia inicial en esta(s)
cuenta(s) enunciado(s) abajo. Su pago aun esta pendiente, por favor remita el pago
en su totalidad o comuniquese con nuestro department de servicio a cliente dentro de
los proximos (15) quince dias de la fecha de esta factura. Si no tenemos respuesta,
su cuenta sera considerada asignar a una agencia de cobros.
PATIENT NAME PROVIDER ACCOUNT # SERVICE DATE TOTAL CHARGES PAYMENT(S) ADJUST. BALANCE DUE JANE DOE XYZ ORTHOPAEDICS 1111122222 10/24/2007 $1500.00 -500.00 -500.00 $500.00
PATIENT ACCOUNTING CUSTOMER SERVICE Balance Due / Saldo Debido $500.00
Toll-Free / Llamar Gratis a (800) 555-5555 Statement Date / Fecha de Facture 10/25/2007
WE ACCEPT PAYMENTS OVER THE PHONE Account Number / Numero de Cuenta 1111122222
XYZ ORTHOPAEDICS 987 STREET ROAD ANYTOWN, USA 12345
Make checks payable to / Favor de meitir cheques a:
If payment in full has been recently made, thank you. Si usted ha mandado pago por complete recientemente, gracias.
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
PAMELA PATIENT
123 MAIN STREET
ANYTOWN, USA 12345
XYZ Health System
987 Street Road
Anytown, USA 12345
WID: 0000
Toll-Free: (888) 555-5555
Page: 1
REMIT TO:
XYZ Health System
987 Street Road
Anytown, USA 12345
STATEMENT DATE BALANCE DUE
1111122222
1111122223
1111122224
1111122225
IF PAYING BY MASTERCARD, DISCOVER, VISA, OR AMERICAN EXPRESS, FILL OUT BELOW:
MASTERCARD DISCOVER VISA AMEX
CARD NUMBER EXPIRATION DATE
SIGNATURE CSV CODE
10/25/2007 $2000.00
ACCOUNT NUMBER BALANCE$2000.00
BALANCE DUE $2000.00
BALANCE DUE NOTICE
Thank you for choosing our facility for your medical needs. This statement represents
charges that are due from you, as our systems shows no medical insurance is
outstanding for payment. Please remit your payment in full or contact patient
accounting for any assistance we can provide. If you have a question about how your
insurance benefits or co-insurance amounts were determined, please contact your
insurance company directly.
AVISO DE SALDO PENDIENTE
Gracias por utilizar nuestros servicios para sus necesidades de salud. Esta cuenta
representa su saldo pendiente de pago. Por cuanto nuestro sistema presenta pagos
de seguro medico pendientes. Por favor remita el pago en su totalidad o llame
nuestro Departamento de Servicio al Cliente para cualquier asistencia que podemos
proveer. Si tiene alguna pregunta sobre como sus beneficios o las cantidades de su
co-seguro fueron distribuidas, por favor llame a su compania de seguros directamente.
PATIENT NAME PROVIDER ACCOUNT # SERVICE DATE TOTAL CHARGES PAYMENT(S) ADJUST. BALANCE DUE JANE DOE XYZ PEDIATRICS 1111122222 10/24/2007 $1500.00 -500.00 -500.00 $500.00 JANE DOE LAB SPECIMEN 1111122223 10/24/2007 $1500.00 -500.00 -500.00 $500.00 JANE DOE VF HEALTH CTR 1111122224 10/24/2007 $1500.00 -500.00 -500.00 $500.00 JANE DOE PA MED CTR 1111122225 10/24/2007 $1500.00 -500.00 -500.00 $500.00
PATIENT ACCOUNTING CUSTOMER SERVICE Balance Due / Saldo Debido $2000.00
Toll-Free / Llamar Gratis a (800) 555-5555 Statement Date / Fecha de Facture 10/25/2007
WE ACCEPT PAYMENTS OVER THE PHONE Account Number / Numero de Cuenta 1111122222
XYZ HEALTH SYSTEM 987 STREET ROAD ANYTOWN, USA 12345
Make checks payable to / Favor de meitir cheques a:
CHARGES AND CREDITS MADE AFTER STATEMENT
DATE WILL APPREAR ON NEXT STATEMENT. BALANCE DUE
$175.00
S T A T E M E N T PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT IN ENCLOSED ENVELOPE.
Please check box if above address is incorrect or insurance information has changed, and indicate change(s) on reverse side.
PAMELA PATIENT
123 MAIN STREET
ANYTOWN, USA 12345
WID: 0000
Toll-Free: (888) 555-5555
Page: 1
XYZ Hospital
987 Street Road
Anytown, USA 12345
MASTERCARD DISCOVER VISA AMEX
CARD NUMBER EXPIRATION DATE
SIGNATURE CSV CODE
STATEMENT DATE BALANCE DUE ACCOUNT NUMBER
10/10/2007 $175.00 1234567890
PAYMENT PLAN REMINDER NOTICE
This notice is to remind you of your agreement to make payments according to the
terms below. If you encounter difficulty meeting this arrangement, please contact us
for assistance. Thank you.
AVISO PARA RECORDARLE SU PLAN DE PAGO
Esta nota es un recuerdo para hacer los pagos segun los terminus de abajo. Si usted
encuentra dificultad con esta acuerdo, por favor de ponerse en contacto con la oficina
de contabilidad. Gracias.
Total Balance Owing / Total de Balance Debido
$699.90Payment Frequency / Frequencia de Pago
MONTHLYRegular Payment Amount / Pago Regular
$175.00Past Due Amount / La Cantidad Vencida
$0.00Payment Due / Pago Debido
$175.00Payment Due Date / Fecha del Pago Debido
10/30/2007If payment in full has been recently made, thank you. Si usted ha mandado pago por complete recientemente, gracias.
S T A T E M E N T
SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION
PATIENT ACCOUNTING CUSTOMER SERVICE Statement Date / Fecha de Facture 10/10/2007
Toll-Free / Llamar Gratis a (800) 555-5555 Account Number / Numero de Cuenta 1234567890
WE ACCEPT PAYMENTS OVER THE PHONE Phone Hours: M - F 8:00am - 5:00pm
Make checks payable to / Favor de meitir cheques a:
XYZ HOSPITAL 987 STREET ROAD ANYTOWN, USA 12345 MAKE CHECKS PAYABLE / REMIT TO:XYZ Hospital
987 Street Road
Anytown, USA 12345
CHARGES AND CREDITS MADE AFTER STATEMENT
DATE WILL APPREAR ON NEXT STATEMENT. BALANCE DUE
$131.00
MAKE CHECKS PAYABLE / REMIT TO:
S T A T E M E N T PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT IN ENCLOSED ENVELOPE.
Please check box if above address is incorrect or insurance information has changed, and indicate change(s) on reverse side.
PAMELA PATIENT
123 MAIN STREET
ANYTOWN, USA 12345
TAX ID: 23-1234567 Toll-Free: (888) 555-5555 Page: 1 of 1
XYZ Pediatrics
987 Street Road
Anytown, USA 12345
IF PAYING BY MASTERCARD, DISCOVER, VISA, OR AMERICAN EXPRESS, FILL OUT BELOW:
MASTERCARD DISCOVER VISA AMEX
CARD NUMBER EXPIRATION DATE
SIGNATURE CSV CODE
STATEMENT DATE BALANCE DUE ACCOUNT NUMBER
03/01/2001 $131.00 000123-00
YOUR INSURANCE HAS PAID ITS PORTION FOR SERVICES.
PLEASE REMIT BALANCE PROMPTLY.
YOUR ACCOUNT IS SERIOUSLY PAST DUE, PLEASE CALL OUR OFFICE AT (800) 555-5555.
S T A T E M E N T
SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 09504 137510 02 1 3 016065
Balance Due:
$131.00
Current 31-60 Days 61-90 Days 91-120 Days Over 120 Days
$16.00 $9.00 $0.00 $106.00 $0.00
Date
Procedure
Code
Patient
Name Description Diagnosis Charge Credit Balance
BALANCE FORWARD $106.00
12/15/00 99212 John Office/Outpatient Visit, Est 465.9 $45.00
01/17/01 Plan Payment: 00711723150 The Guardian $-36.00
$9.00
12/27/00 99212 John Office/Outpatient Visit, Est 461.9 $45.00
02/01/01 Plan Payment: 0075687757 The Guaridan $-28.00
02/01/01 Adj: Guardian Write-Off The Guardian $-10.00
$7.00 01/02/01 99212 Jillian Office/Outpatient Visit, Est 915.2 $45.00
02/01/01 Plan Payment: 0071723149 $-36.00
02/01/01 10160 Jillian Puncture Drainage of Lesion 915.2 $0.00
$9.00
XYZ Pediatrics 987 Street Road Anytown, USA 12345 (800) 555-5555 Tax ID #: 23-1234567 Account No.: 000123-00
XYZ Pediatrics
987 Street Road
Anytown, USA 12345
IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED
SINCE YOUR LAST STATEMENT, PLEASE INDICATE...
DATE OF INJURY PLEASE INDICATE IF APPLICABLE:
_____ AUTO ACCIDENT _____ WORKER’S COMPENSATION
PATIENT INFORMATION:
YOUR NAME (LAST, FIRST, MI) DATE OF BIRTH
ADDRESS
CITY STATE ZIP
TELEPHONE NUMBER _____ MOBILE _____ HOME _____ OTHER
SOCIAL SECURITY #
EMPLOYER TELEPHONE
EMPLOYER ADDRESS
CITY STATE ZIP
INSURANCE INFORMATION:
YOUR PRIMARY INSURANCE COMPANY’S NAME
PRIMARY INSURANCE COMPANY’S ADDRESS
CITY STATE ZIP
POLICYHOLDER’S ID NUMBER GROUP PLAN NUMBER
YOUR SECONDARY INSURANCE COMPANY’S NAME
SECONDARY INSURANCE COMPANY’S ADDRESS
CITY STATE ZIP
GROUP PLAN NUMBER POLICYHOLDER’S ID NUMBER
DETACH HERE AND RETURN ABOVE STUB
FOR HOSPITAL OR OTHER FACILITY PATIENTS
YOU COULD RECEIVE 2 OR MORE BILLS FOR SERVICES PROVIDED
TOTAL DIAGNOSTIC OR TREATMENT COSTS
PHYSICIAN OR
PROVIDER’S FEE
HOSPITAL CHARGES
OR OTHER FACILITY
This statement is not a duplicate charge, but a separation of
the facility and physician or provider’s fees.
These services were provided while you were under our care, or at the
request of your other physicians or providers.
Your bill from the facility may include a separate charge
for use of its equipment, supplies, and technical personnel.
You may also receive bills from other physicians or providers who
were involved with your care if you were a patient in a hospital or
other facility.
If you have any questions concerning your bill, please call
our office and we will be happy to assist you.
IF YOU REQUIRE ASSISTANCE, YOU MAY CONTACT OUR OFFICE AT THE PHONE NUMBER ON THE REVERSE SIDE.
