1. MAKE CHECKS PAYABLE TO:
Practice Name
Street Address
City, State Zip
STATEMENT DATE
2/19/2013
For Billing Questions, Please Call: (770) 123-4567
Send To:
Patient Name
Street Address
City, State Zip
PAY THIS AMOUNT
$57.02
SHOW AMOUNT
PAID HERE
PATIENT ID
7832
$
Remit To:
Practice Name
Street Address
City, State Zip
PATIENT STATEMENT
Service
Date
1/15/2013
97112 - Therapeutic proc, 1+ areas, each 15 min. Neuromuscular
Reduction
72070 - radiologic exam, spine, thoracic, 2 views
50.00
30.72
Ins.
Payment
16.39
65.00
44.51
17.42
-
3.07
2/1/2013
98940 - Description CPT code
2/6/2013
97112 - Therapeutic proc, 1+ areas, each 15 min. Neuromuscular
Reduction
72070 - radiologic exam, spine, thoracic, 2 views
98940 - Description CPT code
55.00
50.00
20.00
30.72
12.45
16.39
-
22.55
2.89
65.00
55.00
44.51
20.00
17.42
12.45
1/15/2013
2/6/2013
2/13/2013
Currrent
Description
30 Days
60 Days
90 Days
Charges
Adjust.
Patient
Payment
-
-
NOW DUE
120 Days
$57.02
$57.02
For Billing Questions, Please Call: (770) 123-4567
Patient ID: 7832
Statement messages go in this section
Practice Name
Street Address
City, State Zip
Patient
Balance
2.89
3.07
22.55