| SAMPLE LETTER: Patient Statement (2 Sample Letters) |
No More Pain Medical Group
1338 My Street
New York, NY 10012
Today’s Date: __________________
STATEMENT OF ACCOUNT
STATEMENT BALANCE: $ ________________
Date of Service(s):
________________________________________________________________________
________________________________________________________________________
Patient’s Name: ______________________
Address: ______________________
______________________
Our record shows we have not received any payments on your account and is now seriously overdue.
For your questions, please contact your insurance member’s services directly with the telephone number provided
to you at the back of your card. Provide them your member’s ID number and the above date(s) of service.
Otherwise, this statement must be fully paid within 15 days of receipt (prompt payment may avoid collection
procedures).
Kindly make check payable to No More Pain Medical Group. You may disregard this letter if you have settled this
statement.
Thank you.
Medical Billing Department
===========================================================================================
1338 My Street
New York, NY 10012
Today’s Date: __________________
STATEMENT OF ACCOUNT
STATEMENT BALANCE: $ ________________
Date of Service(s):
________________________________________________________________________
________________________________________________________________________
Patient’s Name: ______________________
Address: ______________________
______________________
Our record shows we have not received any payments on your account and is now seriously overdue.
For your questions, please contact your insurance member’s services directly with the telephone number provided
to you at the back of your card. Provide them your member’s ID number and the above date(s) of service.
Otherwise, this statement must be fully paid within 15 days of receipt (prompt payment may avoid collection
procedures).
Kindly make check payable to No More Pain Medical Group. You may disregard this letter if you have settled this
statement.
Thank you.
Medical Billing Department
===========================================================================================
Sample1 Patient Statement (NO Payment Arrangement)
*** useful when the patient is no longer an active patient of your practice
*** useful when the patient is no longer an active patient of your practice
Sample2 Patient Statement (NO Payment Arrangement)
*** useful when the patient is no longer still an active patient of your practice and you may consider payment arrangement
*** useful when the patient is no longer still an active patient of your practice and you may consider payment arrangement
No More Pain Medical Group
1338 My Street
New York, NY 10012
Today’s Date: __________________
STATEMENT OF ACCOUNT
STATEMENT BALANCE: $ ________________
Date of Service(s):
________________________________________________________________________
________________________________________________________________________
Patient’s Name: ______________________
Address: ______________________
______________________
Our record shows we have not received any payments on your account.
For your questions, please contact your insurance member’s services directly with the telephone number provided
to you at the back of your card. Provide them your member’s ID number and the above date(s) of service.
Otherwise, this statement must be fully paid within 15 days of receipt (prompt payment may avoid collection
procedures).
Kindly make check payable to No More Pain Medical Group. You may disregard this letter if you have settled this
statement or had made a payment arrangement with us.
Thank you.
Medical Billing Department
==========================================================================================
1338 My Street
New York, NY 10012
Today’s Date: __________________
STATEMENT OF ACCOUNT
STATEMENT BALANCE: $ ________________
Date of Service(s):
________________________________________________________________________
________________________________________________________________________
Patient’s Name: ______________________
Address: ______________________
______________________
Our record shows we have not received any payments on your account.
For your questions, please contact your insurance member’s services directly with the telephone number provided
to you at the back of your card. Provide them your member’s ID number and the above date(s) of service.
Otherwise, this statement must be fully paid within 15 days of receipt (prompt payment may avoid collection
procedures).
Kindly make check payable to No More Pain Medical Group. You may disregard this letter if you have settled this
statement or had made a payment arrangement with us.
Thank you.
Medical Billing Department
==========================================================================================
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