Sample Bill
STATEMENT OF ACCOUNT
Indicate address corrections below.
JOHN DOE
1234 S. CARTER
ABILENE, TEXAS 79602-11234
***You may pay online here.
Hendrick Medical Center
P.O. Box 3117
Abilene, TX 79604
Business Office located at:
2182 Hickory
325-670-2437 or 1-800-670-0412
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.