Upon Receipt

							                                                                                                                                               Date bill was
                                                                                                                                                    printed.

                                                                                               02/11/2002       $610.00         123456
                                                                                                                                          Amount you owe.

                                                                                                Upon Receipt                               Date payment is
                                    Altru Clinic - A part of Altru Hospital
                                                                                                                                               due at Altru.
                                      John Doe, Jr.
                                      106 Acorn Trail                                                                                     Send payment to
                                      Anytown, USA 01010
                                                                                                                                             this address.
Guarantor is the
person responsible
for payment of bill.
                                                                                                                                             Individual staff
                                                                                                                                               numbers are
Each visit to the           123456                              John Doe, Jr.                      02/11/2002       Phone list on back
                                                                                                                                         printed on back of
clinic is assigned a
                                                                                                                                                     the bill.
“visit number.”        Services for John Doe, Jr.
Charges and                                           Previous balance forwarded                                  $325.00
                       01/5/2002       9876543        Dr. Good Guy        Office Visit                             $45.00                      Balance from
payments are linked
                       01/5/2002       9876543        Dr. Good Guy        Strep Screen                             $35.00                previous statement.
to this number.        01/5/2002       9876543                            Co-payment received                                  $10.00
                       01/16/2002      9876543                            Payment received Blue Cross                          $50.00
                                                                          Balance this visit     **                $20.00                  Amount charged
Dates of service
                                                                                                                                              for services
provided to            01/13/2002      123456         Dr. Do Right            Office Visit                         $55.00
                       01/13/2002      123456                                 Co-payment received                              $10.00            provided.
John Doe, Jr.
                       01/23/2002                                             Insurance in process
                                                                              Balance this visit       **          $45.00                 Amount received
                       01/13/2002      5432100        Dr. Do Right            Chest x-ray                          $75.00                  on an account,
                       01/13/2002      5432100        Dr. Radd                Chest x-ray interpretation           $90.00                   including any
                       01/23/2002                                             Insurance in process
                                                                              Balance this visit        **        $165.00                  adjustments or
                                                                                                                                               discounts.
Dates of service       Services for Jane Doe
provided to                                           Previous balance forwarded                                  $245.00
Jane Doe.              01/7/2002       1230044        Dr. Good Guy        Office Visit                             $45.00
                                       1230044                            Co-payment received                                  $10.00
                       01/18/2002      1230044                            Payment received Blue Cross                          $15.00
                                                                          Balance this visit     **                $20.00
                                                                                                                                          Total charges for
                                                                                                                                         services provided.

                                                                                                                             $820.00       Charges sent to
Where patient
                              Altru Clinic - Main                                                                            $210.00        your insurance
received services.            1000 S. Columbia Rd.                                                                                                  carrier.
                              Grand Forks, ND 58206                                                                          $610.00
                                                                                                                                          Amount you owe.
                                             The medical provider                     Explanation of medical services,
                                               of your services.                    charges, payments, or adjustments.