BALANCE DUE 10/25/2007 $ STATEMENT DATE BALANCE DUE $ PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT

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1 R E M I T T O : IF PAYING BY MASTERCARD, DISCOVER, VISA, OR AMERICAN EXPRESS, FILL OUT BELOW: XYZ Orthopaedics STATEMENT DATE BALANCE DUE 10/25/2007 $ BALANCE DUE $ ACCOUNT NUMBER BALANCE $ XYZ Orthopaedics PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT 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 /24/2007 $ $ PATIENT ACCOUNTING CUSTOMER SERVICE Balance Due / Saldo Debido $ Toll-Free / Llamar Gratis a (800) Statement Date / Fecha de Facture 10/25/2007 WE ACCEPT PAYMENTS OVER THE PHONE Account Number / Numero de Cuenta XYZ ORTHOPAEDICS

2 R E M I T T O : IF PAYING BY MASTERCARD, DISCOVER, VISA, OR AMERICAN EXPRESS, FILL OUT BELOW: XYZ Health System STATEMENT DATE BALANCE DUE 10/25/2007 $ BALANCE DUE $ ACCOUNT NUMBER XYZ Health System BALANCE $ PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT 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 /24/2007 $ $ JANE DOE LAB SPECIMEN /24/2007 $ $ JANE DOE VF HEALTH CTR /24/2007 $ $ JANE DOE PA MED CTR /24/2007 $ $ PATIENT ACCOUNTING CUSTOMER SERVICE Balance Due / Saldo Debido $ Toll-Free / Llamar Gratis a (800) Statement Date / Fecha de Facture 10/25/2007 WE ACCEPT PAYMENTS OVER THE PHONE Account Number / Numero de Cuenta XYZ HEALTH SYSTEM

3 IF PAYING BY MASTERCARD, DISCOVER, VISA, OR AMERICAN EXPRESS, FILL OUT BELOW: MAKE CHECKS PAYABLE / REMIT TO: XYZ Hospital CHARGES AND CREDITS MADE AFTER STATEMENT DATE WILL APPREAR ON NEXT STATEMENT. BALANCE DUE $ XYZ Hospital STATEMENT DATE BALANCE DUE ACCOUNT NUMBER 10/10/2007 $ Please check box if above address is incorrect or insurance information has changed, and indicate change(s) on reverse side. PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT IN ENCLOSED ENVELOPE. 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 $ Payment Frequency / Frequencia de Pago MONTHLY Regular Payment Amount / Pago Regular $ Past Due Amount / La Cantidad Vencida $0.00 Payment Due / Pago Debido $ Payment Due Date / Fecha del Pago Debido 10/30/2007 PATIENT ACCOUNTING CUSTOMER SERVICE Statement Date / Fecha de Facture 10/10/2007 Toll-Free / Llamar Gratis a (800) Account Number / Numero de Cuenta WE ACCEPT PAYMENTS OVER THE PHONE Phone Hours: M - F 8:00am - 5:00pm XYZ HOSPITAL SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION

4 IF PAYING BY MASTERCARD, DISCOVER, VISA, OR AMERICAN EXPRESS, FILL OUT BELOW: MAKE CHECKS PAYABLE / REMIT TO: TAX ID: of CHARGES AND CREDITS MADE AFTER STATEMENT DATE WILL APPREAR ON NEXT STATEMENT. BALANCE DUE $ STATEMENT DATE BALANCE DUE ACCOUNT NUMBER 03/01/2001 $ Please check box if above address is incorrect or insurance information has changed, and indicate change(s) on reverse side. PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT IN ENCLOSED ENVELOPE. Date Procedure Code Patient Name Description Diagnosis Charge Credit Balance BALANCE FORWARD $ /15/ John Office/Outpatient Visit, Est $ /17/01 Plan Payment: The Guardian $ $ /27/ John Office/Outpatient Visit, Est $ /01/01 Plan Payment: The Guaridan $ /01/01 Adj: Guardian Write-Off The Guardian $ $ /02/ Jillian Office/Outpatient Visit, Est $ /01/01 Plan Payment: $ /01/ Jillian Puncture Drainage of Lesion $0.00 $9.00 Current Days Days Days Over 120 Days $16.00 $9.00 $0.00 $ $0.00 YOUR INSURANCE HAS PAID ITS PORTION FOR SERVICES. PLEASE REMIT BALANCE PROMPTLY. YOUR ACCOUNT IS SERIOUSLY PAST DUE, PLEASE CALL OUR OFFICE AT (800) Balance Due: $ (800) Tax ID #: Account No.: SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION

5 IF WE DO NOT HAVE YOUR INFORMATION, OR IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE... PATIENT INFORMATION: YOUR NAME (LAST, FIRST, MI) DATE OF BIRTH INSURANCE INFORMATION: YOUR PRIMARY INSURANCE COMPANY S NAME ADDRESS PRIMARY INSURANCE COMPANY S ADDRESS TELEPHONE NUMBER MOBILE HOME OTHER SOCIAL SECURITY # POLICYHOLDER S ID NUMBER GROUP PLAN NUMBER EMPLOYER TELEPHONE YOUR SECONDARY INSURANCE COMPANY S NAME EMPLOYER ADDRESS SECONDARY INSURANCE COMPANY S ADDRESS PLEASE INDICATE IF APPLICABLE: AUTO ACCIDENT WORKER S COMPENSATION DATE OF INJURY POLICYHOLDER S ID NUMBER GROUP PLAN 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.

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