| This sample statement explains at a glance the components of your bill
For your convenience you can also pay your bill online.
- Name and Address of facility where services were rendered.
- Person responsible for paying the bill
- Date of statement
- Name of patient
- Number identifying patient
- Date of services
- Total amount owed on this account
- Amount due at this time
- This area may contain important information regarding your statement.
- Description of services for which are billed
- To pay by credit card, fill in this box with proper information
- The address that you need to send your payment to. Please detach and remit the bottom part of the statement with your payment to ensure proper credit to your account.