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Click here for Electronic Billing and Payment Services!!!

One Insurance

One Insurance Page 1 Date of Service Guarantor Guarantor Guaranto Address Location Account Number For Credit Card Payment Statement Date Primary Insurance Secondary Insurance Amount we are billing your insurance

One Insurance Page 2

 

With Insurance

 

Two Insurances Page 1 Date of Service Guarantor Guarantor Guarantor Address Location Account Number For Credit Card Payment Statement Date Primary Insurance Secondary Insurance Amount we are billing insurance

Two Insurances Page 2

 

Self Pay (No Insurance)

  What you owe now Date of Service Location About your insurance About you Hospital Summary of Charges Account Number

No Insurance Page 1 Date of Service Guarantor Guarantor Guarantor Address Location Account Number For Credit Card Payment Statement Date Amount Due

No Insurance page 2

 

Pharmacy

  What you owe now Date of Service Location About your insurance About you Hospital summary of charges Account Number

Pharmacy Page 1 Date of Service Guarantor Guarantor Guarantor address Location Acoount number For credit card payment Statement Date Amount Due

Pharmacy Page 2 What you owe now Date of service Location About your insurance About you Hospital summary of charges Account Number

What You Owe Now Date of Service Location About your insurance About you Hospital Summary of Charges Account Number

Last modified on: July 2, 2004

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Patient Financial Services

PO Box 800750

Charlottesville, VA 22908

1-800-523-4398

tdd: 434-982-HEAR

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