Your Bill Fields

  1. Name of Hospital-Facility where services were rendered.
  2. Return Address-Return address of facility where services were rendered. 
  3. Addressee-Guarantor’s address.
  4. Statement Date-Date the statement was created.
  5. Account #-Financial number assigned to the account being billed.
  6. Patient Name-Name of person that received services.
  7. Date of Service-Date services began for this account/visit.
  8. Type of Service-Type of service being billed.
  9. Health Plan 1-Primary insurance plan on account.
  10. Health Plan 2-Secondary insurance plan on account.
  11. Balance-Current balance on account, less any payments you or your insurance company has made since the “Statement Date”. Any payments and/or adjustments made past the “Statement Date” will not be reflected in this balance.
  12. Message Area-Read this area for important information regarding the account. The message text will change from statement to statement depending on the account status, payments received and number of statements sent.
  13. Customer Service Information-Customer Service Contact information, including hours of operation, Local and/or Toll Free phone numbers and the facility Fax number.
  14. Return Address of Guarantor-In case of lost mail, your payment will be returned to you.
  15. Name/Address of Hospital-Facility payment is being sent to.
  16. Credit Card Payment-When paying by credit card, use this area to provide the following information: Charge Amount, Type of Credit Card, Expiration Date and Credit Card number. We accept Visa, Master Card, American Express or Discover.
  17. Previous Balance-Balance on last statement.
  18. Service- This area will reflect services/charges rendered, total payments received and total adjustments for which the account qualified since the last statement.