Sample Doctor Bill
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1MidTown
SAMPLE
Orthopedics
123 Midtown Blvd
Patient Name:
Account Number:
Midtown, IL 60610
Julie Smith
0123-4567-89
Responsible Party:
Insurance/Plan Name
Julie Smith
CIGNA
DOCTOR BILL
Bill to:
[Name]
[Street Address]
[City, ST ZIP Code]
For questions or information, please call 1-800-555-5555 or visit
Date of
Type of
Billed
Amount Paid
Patient
Due From
Service
Service
Charges
By Plan
Adjustments
Payments
Patient
Date
3/22/08
Office Visit
New Patient Office Visit
$ 155.00
X-Ray Knee 2 Views
$
79.00
Knee Immosbilizer
$
57.00
CIGNA Payment
4/15/2007
$
113.47
CIGNA Adjustment
4/15/2007
$
104.61
$
72.92
Due from Patient:
Patient Payment
5/1/2007
$
25.00
Balance due from Patient
$
47.92
SUBTOTAL
$ 291.00 $
113.47
$
104.61
$
25.00
$
47.92
TOTALS
$ 291.00 $
113.47 $
104.61 $
25.00 $
47.92
DUE FROM PATIENT:
$
47.92
This Bill represents current activity only. You may receive additional bills from the radiologist, pathologists, etc (This would be hospital
specific). This bill does not include any amount due from the patient that has been referred to a collection agency. For billing inquiries or a
request for a detailed statement, please call 1-800-555-5555, weekdays 9:00 am until 8:00 pm, Saturday 9:00 am until 2:00 pm
Please return bottom portion with your payment (Allow 7-10 days for postal delivery)
Due Date
Account Number
July 1, 2007
0123-4567-89
Fill out below for credit card payments
MidTown Orthopedics
[ ] Master Card
[ ] Visa
[ ] American Express
[ ] Discover
123 Midtown Blvd
Midtown, IL 60610
PRINT NAME ON CARD
CARD NUMBER
EXPIRATION DATE
SIGNATURE
Make all checks payable to Midtown Orthopaedics
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