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 1.
Patient - Patient's name
2. Type Service - Inpatient means the
patient was admitted to the hospital. Outpatient usually means
services you receive in one day/24 hours (e.g. clinic visits,
lab tests, trip to emergency room). There may be times when
a patient stays in the hospital more than 24 hours for observation;
this is still considered outpatient.
3. Insurance(s) - This is the type of
insurance coverage our records reflect for this patient. We
will submit a claim for payment to this insurance company.
If our information is incorrect, please notify Patient Financial
Services immediately at 924-5377 or 1-800-523-4398.
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 4.
Account No.: The identification number for this specific
period of time the patient stayed in the hospital.
5. Service Date(s): -The date(s) when the patient
received the services listed on this bill.
Bill Date - The date this bill was printed.
6. "S" means this is a follow-up notice.
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 7.
Summary of Charges, Payments, and Adjustments: A summary
of the type of medical services received. For example, all lab
tests will be summarized under, "CLINICAL LAB". All
payments and adjustments will also be summarized here. |
 8.
Charges/Payments: The charge amount for the type of service
listed. |
|
 Estimated
Insurance Coverage1 -
This column is usually blank.
Estimated Insurance Coverage2
-
This column is usually blank.
|
 Estimated
Amount You Owe - The amount you owe at this time. If you
have insurance, your insurance company determines your benefits.
Therefore, this amount could change after insurance payment. |
9. Balance Due
Now - The amount you owe at this time.
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 13
The name and address our records reflect as the person
responsible for paying this bill. |
 15.
For credit card payment: You may pay this bill by credit
card by either checking this box and filling out the form on
the back of the page, or by calling our Customer Service Department
at 924-5377 or 1-800-523-4398. |
