Billing Statement Sample
Content
Providence Hospital - Billing Services Billing Statement
Below is a sample billing statement. This statement identifies only the balance due for the specified
account and visit. The statement is mailed to patients at 30-day intervals. This statement does not include
physician fees. The number in red is referred to at bottom of statement for explanation of each area.
FRONT OF STATEMENT
1 Statement Date: The date the statement was actually printed.
2 Patient Name: The name of the patient that received the services.
3 Account #H: The account number assigned to this visit.
4 Please Pay this Amount:The amount the patient is being billed.
5 Insurance Type: The primary insurance that is listed on this account.
6 Name/Address: The name and address of the person responsible for payment of the bill for this
patient.
7 Date: The beginning date of services provided during this visit.
8 Description: The summary of all charge, payment, and adjustment activity on this account.
9 Information: Information explaining why the balance is being billed to the person responsible for
payment.
10 Statement Message: requesting payment.
11 Diagnosis Code: The national code provided by your physician or medical record, identifying the
medical reason for this visit.
12 Please Pay this Amount: The amount due from you for this visit.
13 Detachable Portion: Detachable portion of the statement to include with the payment to assure your
payment is posted to the correct account.
14 Patient Name: Same as above, to assure accurate posting of your payment.
15 Check Box: To notify us that your information needs to be updated. If you check this box please
complete the applicable section on the back of the statement.
16 Date of Service: First and last date of service billed in this statement.
17 Due Date: All balances are due upon receipt of the statement.
18 Account Balance: The total unpaid balance due for this visit, including balances due from your
insurance carrier.
19 Estimated Insurance Due: The estimated amount that we still expect from your insurance carrier.
20 Credit Card Information: Please complete this portion of the statement if you would like to pay by
Visa, MasterCard, or Discover.
21 Payment Amount: Amount that is being paid.
22 Number H: The account number where the payment will be applied.
------------------------BACK OF STATEMENT
1 Other Providers: A list of other billing agents that you may receive statements from for professional
fees.
2 HELP Financial Corporation: HELP Financial Corp. - the telephone number to HELP to apply for a
revolving credit loan to assist you in paying your hospital bill.
3 Question/Answer: Answers to questions often asked about our bills.
4 Insurance Changes: Space to provide us with insurance coverage to cover the charges from this visit.
5 Address Changes: The address that future statements should be sent to.
Below is a sample billing statement. This statement identifies only the balance due for the specified
account and visit. The statement is mailed to patients at 30-day intervals. This statement does not include
physician fees. The number in red is referred to at bottom of statement for explanation of each area.
FRONT OF STATEMENT
1 Statement Date: The date the statement was actually printed.
2 Patient Name: The name of the patient that received the services.
3 Account #H: The account number assigned to this visit.
4 Please Pay this Amount:The amount the patient is being billed.
5 Insurance Type: The primary insurance that is listed on this account.
6 Name/Address: The name and address of the person responsible for payment of the bill for this
patient.
7 Date: The beginning date of services provided during this visit.
8 Description: The summary of all charge, payment, and adjustment activity on this account.
9 Information: Information explaining why the balance is being billed to the person responsible for
payment.
10 Statement Message: requesting payment.
11 Diagnosis Code: The national code provided by your physician or medical record, identifying the
medical reason for this visit.
12 Please Pay this Amount: The amount due from you for this visit.
13 Detachable Portion: Detachable portion of the statement to include with the payment to assure your
payment is posted to the correct account.
14 Patient Name: Same as above, to assure accurate posting of your payment.
15 Check Box: To notify us that your information needs to be updated. If you check this box please
complete the applicable section on the back of the statement.
16 Date of Service: First and last date of service billed in this statement.
17 Due Date: All balances are due upon receipt of the statement.
18 Account Balance: The total unpaid balance due for this visit, including balances due from your
insurance carrier.
19 Estimated Insurance Due: The estimated amount that we still expect from your insurance carrier.
20 Credit Card Information: Please complete this portion of the statement if you would like to pay by
Visa, MasterCard, or Discover.
21 Payment Amount: Amount that is being paid.
22 Number H: The account number where the payment will be applied.
------------------------BACK OF STATEMENT
1 Other Providers: A list of other billing agents that you may receive statements from for professional
fees.
2 HELP Financial Corporation: HELP Financial Corp. - the telephone number to HELP to apply for a
revolving credit loan to assist you in paying your hospital bill.
3 Question/Answer: Answers to questions often asked about our bills.
4 Insurance Changes: Space to provide us with insurance coverage to cover the charges from this visit.
5 Address Changes: The address that future statements should be sent to.
