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- This is the information the hospital uses to identify each patient and his or her visit. A new account number is generated for each visit to the hospital.
- The activity date is for the hospital's internal use only.
- Billing address for hospital, where payment is to be mailed.
- The patient's address that the hospital has on file. Please notify the hospital if your address should be changed.
- The first statement will include a summary of services received and any payments that have been made, such as co-pays. The second and third statements will show the balance from the previous statement (balance forward), minus payments sent to the hospital, and the new balance due.
- Indicates which statement this is (in a three-statement cycle) and how to contact customer service.
- Please include the bottom portion of the statement with payment. Fill in the amount of the check in the "Amount paid" box. Also write the account number (shown in area 1 above) on the check so that the account is credited correctly.
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