Medical Billing Statement Example Medical Billing Statement Example Hartleyville Pathology Group Patient Name

							                               Medical Billing Statement Example


Hartleyville Pathology Group                 Patient Name                      Account Number
299 Littleton Road                            Jerry Jones                         X00458987
Hartleyville, Ak 06733             Primary insurance Name & Policy               Closing Date
                                               Number:                             1/30/98
Inquiries 999-8233                                                             Amount Enclosed

Jerry Jones                        Make checks payable to:                   We accept: VISA,
9 Edgewater Drive                  Hartleyville Pathology Group              MasterCard, American
Hartleyville, AK 06733                                                       Express

This statement reflects charges, payments and adjustments for Hartleyville Pathology Group

Date      CPT     ICD.9.       Description         Charges        Payments     Amount billed   Amount
                  CM                                              Adjust       to insurance    due from
                                                                                               patient.

1/2/98    88305   787.1        Pathology           340.00                                      340.00
                               analysis

1/2/98    88312   787.1        Pathology               90.00                                     90.00
                               analysis



Amount     Now           Due               Insurance           Account          Now due
                                           Pending             total                       $430.00
Current    30 to 60      Over 60      +                  =                      On or
           days          days              00.00               430.00           before
430.00     overdue       overdue                                                2/2/98
           00.00         00.00

Important Message Regarding Your Account : Payment due on receipt.




Thank you for choosing Hartleyville Pathology Group