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 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 includes a reminder to the patient that a monthly payment plan has been established on this account and also provides the monthly payment amount.

This box itemizes the payment plan balance, payments received on the plan, and the amount now due. Any new charges on the account will be included in the payment plan.

This is the agreed upon amount to be paid montly.

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