Sample Billing Statement

STATEMENT OF ACCOUNT     INDICATE ANY ADDRESS CORRECTIONS BELOW          JOHN DOE     1234 S. CARTER     ABILENE, TEXAS 79602-1234

Check Card Using for Payment   M/C Visa   Discover Am Exp Card Number Exp Date Signature Page: 1 Acct# 00000 Due Date 01/01/2010 Pay this Amount 0.00 Enter Amount Enclosed

Acct #

Number assigned to the guarantor, which will always remain the same

Due Date

Date your payment is due, if you owe a balance

Pay This Amount

The patient portion due for all visits listed on this statement

Guarantor Name and Address

Name and address of the guarantor held responsible for all hospital visits listed on the statement, multiple patient names may appear

Date of Service

Reflects the date the medical service(s) were provided

Description

Reflects the patient seen, visit number and type of service provided

Charges

Total Charges posted to visit 

Total Adjustments

Reflects any adjustments posted to the visit including any insurance contractual adjustments

Total Insurance Payments

Reflects any and all insurance payments posted to the visit

Pending Insurance

An estimate of the expected payment from your insurance company

Total Patient Payments

Reflects all personal payments made on the visit

Patient Balance

Reflects the amount you owe for the visit

Statement Date

Date the statement was printed

Patient Payments Since Last Statement

Reflects any personal payment you have made since your last statement was printed

Current Pending Insurance

Reflects any and all pending insurance payments on any visit listed on this statement

Current Patient Balance

Reflects the patient portion of all listed visits on this statement. 

Pending Insurance is an estimate of the amount we expect to be reimbursed by the insurance company based on the information we have.  How the insurance actually reimburses has a direct effect on the patient portion.  Once we have a response from the insurance company, either in the form of a payment or denial, we move the outstanding amount from the Pending Insurance to Patient Balance.   The guarantor becomes responsible for the balance once insurance has paid or denied.