Outpatient Statement -- Description of Parts

Patient - Patient's name

Medical Record Number - A unique, patient specific number that does not change. This number provides a common link for the Medical Center and the Health Services Foundation to all the patient's dates of service within the UVA Health System.

Statement Date - The date the statement printed.
Account Number - The identification number for a specific patient visit. You will see an account number on this statement for each visit that has a balance due by the patient. The patient may have other accounts with the Medical Center that are still pending with insurance. These accounts will not be on this statement because the balance has not yet been determined.

If you would like to review a summary of the services received for each account listed on a statement, refer to the Summary Bill received approximately 20 days after the services were received.

Service/Activity Date - The first line is the date services were received for the specific account number listed. The other dates are when the activity listed in under the "Description" column occurred.

Description - "Previous Balance" is the total of all the charges for this account that were billed to your insurance carrier or billed to you. "Current Balance" is the amount you owe on this account at this time. You will also see a description for any insurance payments or adjustments made on the account as well as any previous payments made by the patient.

Account Total - The amount for each item listed in "Description."

Insurance - The amount of any insurance payments, contractual adjustments, or payment reversals will be listed in this column.

Patient - The amount of any patient payment and the patient balance will be listed in this column. The last line in each account number section, listed in the "Current Balance" row, is the amount you currently owe for the specific account.
Please Pay This Amount - The total amount you owe at this time for the account(s) listed.
Address - The name and address our records reflect as the person responsible for paying this bill.
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.