This sample statement explains at a glance the components of your bill
- 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.
For your convenience you can also pay your bill online. |