Providence PHYSICIAN - Billing Statement

Billing Statement
Below is an example of a Physician Billing Services Statement. The number in red is referred to at bottom of statement for explanation of each area.  

FRONT of STATEMENT



1 Business Hours/LocalTelephone Numbers : Contact information for billing inquiries.
2 Statement History : Including current statement date and last statement date.
3 Outstanding Patient Balance : Amount to be paid.
4 Name/Address : Guarantor name and address.
5 Account Number : Patient Account Number - refer to this number when making inquiries, also print number on all payments.
6 Providence Hospital Tax Identification Number
7 Out-of-State Telephone Number : Use our toll-free telephone number when calling from out-of-state.
8 Patient Name : To assure accurate posting of your payment.
9 Provider Name : Name of person who performed services.
10 Date of Service
11 Procedure Code : National code which identifies procedure.
12 Diagnosis Code : The national code provided by your physician or medical record, identifying the medical reason for this visit.
13 Procedure Description
14 Procedure Charge
15 Payment Date
16 Source of Payment
17 Payment/Adjusted Amount
18 Dunning Message : Special message regarding inquiries.
19 Payment Due Date : Date payment is due.
20 Charge Payment Information : Complete this information if paying by MasterCard, Discover or Visa.
21 Amount Enclosed : Indicate amount of payment enclosed.
22 Checks Payable to and Mailing Address : Indicates who checks to be payable and where payment is mailed to.


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BACK of STATEMENT



24  Additional Provider Information: Affiliated providers billing office telephone numbers.
25  Update Information: Area to update information since last statement.