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Guarantor - Patient's name
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Guarantor Address - This is the address our records reflect as the person responsible for paying this bill.
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Location - The medical center location where services were performed.
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Insurance Information - 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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Account Number. - The identification number for this specific period of time the patient received services at the hospital.
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Date of Service - The date(s) when the patient received the services listed on this bill.
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Statement Date - The date this bill was printed.
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Hospital Summary of Charges - A summary of the type of medical services received.
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Amount We Are Billing Your Insurance - The total amount we are billing your insurance company on your behalf.
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What We Billed Insurance(s) - The total amount we are billing your insurance company on your behalf.
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What Insurance(s) Paid - The total amount your insurance company has paid on your behalf including adjustments.
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Other Adjustments – Any other adjustment to your account.
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Patient Payments - This is the total amount you have paid on your account.
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What’s Pending with Insurance #1 - This is the amount that your primary insurance company has neither paid nor denied.
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What’s Pending with Insurance #2 - This is the amount that your secondary insurance company had neither paid nor denied.
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Patient Services Provided - A summary of the type of medical services received.
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What you owe now/Total - The amount you owe at this time.
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Primary Insurance - This is the primary insurance information our records reflect you have including the name of the insurance company, the person holding the policy and the policy number.
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Secondary Insurance - This is the secondary insurance information our records reflect you have including the name of the insurance company, the person holding the policy and the policy number.
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Amount Due - The amount you owe at this time.
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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
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About You - Please fill out this section indicating any change in your name, address, phone number, marital status, employer or employer address.
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About Your Insurance - Please fill out this section indicating any change in your primary or secondary insurance.
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Date Due – This is the date when your payment is due.
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Electronic Billing ID - Used to enroll in electronic billing and payment services.
