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 $500.00 BALANCE DUE $500.00 ACCOUNT NUMBER 1111122222 BALANCE $500.00 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 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
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 $2000.00 BALANCE DUE $2000.00 ACCOUNT NUMBER 1111122222 1111122223 1111122224 1111122225 XYZ Health System BALANCE $2000.00 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 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
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 $175.00 XYZ Hospital STATEMENT DATE BALANCE DUE ACCOUNT NUMBER 10/10/2007 $175.00 1234567890 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 $699.90 Payment Frequency / Frequencia de Pago MONTHLY Regular Payment Amount / Pago Regular $175.00 Past Due Amount / La Cantidad Vencida $0.00 Payment Due / Pago Debido $175.00 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) 555-5555 Account Number / Numero de Cuenta 1234567890 WE ACCEPT PAYMENTS OVER THE PHONE Phone Hours: M - F 8:00am - 5:00pm XYZ HOSPITAL SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION
IF PAYING BY MASTERCARD, DISCOVER, VISA, OR AMERICAN EXPRESS, FILL OUT BELOW: MAKE CHECKS PAYABLE / REMIT TO: TAX ID: 23-1234567 of 1 09504 137510 02 1 3 016065 CHARGES AND CREDITS MADE AFTER STATEMENT DATE WILL APPREAR ON NEXT STATEMENT. BALANCE DUE $131.00 STATEMENT DATE BALANCE DUE ACCOUNT NUMBER 03/01/2001 $131.00 000123-00 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 $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 Current 31-60 Days 61-90 Days 91-120 Days Over 120 Days $16.00 $9.00 $0.00 $106.00 $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) 555-5555. Balance Due: $131.00 (800) 555-5555 Tax ID #: 23-1234567 Account No.: 000123-00 SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION
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.