This is the statement header which contains the patient’s Clinic account number and the due date for the amount owed.
To indicate an address change, this box should be checked and the updated information provided on the reverse of this page.
The top portion of the statement is to be removed at the dotted line and returned with payment in the enclosed envelope. The bar code allows us to accurately identify the proper account to post the payment.
This statement format begins with a letter from the billing department alerting the patient to the fact that the account is considerably past due. This form of the monthly statement is sent after previous attempts to reach the patient or establish financial arrangements have failed. If there is still no contact from the patient after receipt of this notice, the account is referred on to a collection agency for further action.
This box contains the insurance information the Clinic has on file for the patient’s account. If any of the information appears incorrect, the patient is advised to contact the Clinic with updated information.
This box is provided for the patient to enter updates to name, address or telephone number. If information is being entered here, the small indicator box on the front side of the page should also be marked.
This area contains information regarding making a payment, the Clinic’s financial policies and office hour information
This is the Statement Date which indicates the latest date of account activity included on this statement.
The Clinic account number for the guarantor on the account.
This box contains a line-by-line summary of charges for services provided by Springfield Clinic. Each line provides the amount of the charge, the total of the payments and related insurance adjustments applied, the amount of any payments made through the statement date, and the amount now due. Any letter codes next to the “Insurance Pmt/Adj” column correspond to messages we received from the insurance carrier and are explained below the summary box.
This is the amount that was not paid by insurance and is now due from the patient.
These boxes provide more detailed information about the charges, payments, and adjustments summarized on the front of the statement. As some patients prefer more detail about their charges than others, both formats are provided for our patients’ convenience.