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    Hospital Bill Form

    Uploaded by

    Meena Verma
    The document is an invoice from Froedtert Hospital billing a patient $100 for medical services. It provides the patient's account information, date of service, amounts billed and payments received, and leaves a balance due of $100. It directs the patient to mail payment in full or call to set up a payment plan, and offers online payment options. Physician charges will be billed separately.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Hospital Bill Form

    Uploaded by

    Meena Verma
    799 views2 pages
    The document is an invoice from Froedtert Hospital billing a patient $100 for medical services. It provides the patient's account information, date of service, amounts billed and payments received, and leaves a balance due of $100. It directs the patient to mail payment in full or call to set up a payment plan, and offers online payment options. Physician charges will be billed separately.

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    Hbill

    Original Title

    hospital-bill-form

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    The document is an invoice from Froedtert Hospital billing a patient $100 for medical services. It provides the patient's account information, date of service, amounts billed and payments received, and leaves a balance due of $100. It directs the patient to mail payment in full or call to set up a payment plan, and offers online payment options. Physician charges will be billed separately.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    799 views2 pages

    Hospital Bill Form

    Uploaded by

    Meena Verma
    The document is an invoice from Froedtert Hospital billing a patient $100 for medical services. It provides the patient's account information, date of service, amounts billed and payments received, and leaves a balance due of $100. It directs the patient to mail payment in full or call to set up a payment plan, and offers online payment options. Physician charges will be billed separately.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    MAKE CHECKS PAYABLE TO: IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

    CHECK CARD TO BE USED FOR PAYMENT


    9200 West Wisconsin Avenue Phone: 800-803-8155 CARD NUMBER AMOUNT
    Milwaukee, WI 53226-3596 http://billpay.froedtert.com
    SIGNATURE EXP. DATE
    Remit To: P.O. Box 3202 • Milwaukee, WI 53201-3202

    INVOICE DATE PLEASE PAY THIS AMOUNT ACCOUNT NUMBER

    09/2/04 $100.00 123456789


    PATIENT NAME
    1 1*****AUTO**5-DIGIT 12345
    SUSAN A. PATIENT Susan A. Patient
    123 Main Street
    PAYMENT IS DUE UPON RECEIPT.
    PO Box 1234
    Please check box if address is incorrect or insurance information
    Anytown, USA 12345-5678 has changed, indicate change(s) on reverse side.

    0000 0000000111111111 0159275 0000000 0000000000 4

    INVOICE PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT.

    Thursday, September 2, 2004


    Patient: Susan A. Patient Date of Service : 04/24/04
    Account: 123456789 Patient Service: ER Arena
    Amount Due: $100.00 Primary Insurance Billed: WPS
    Secondary Insurance Billed: Blue Cross
    Dear Susan:

    Thank you for selecting Froedtert Hospital for your health care services. For your records, below is a
    summary of the charges for this account. If you would like an itemized statement, please call Patient Financial
    Services at 800-803-8155.

    Pharmacy $ 28.40
    Emergency Room $ 947.00
    EKG/ECG $ 84.00

    Total Charges $ 1,059.40


    Total Payments $ -815.74
    Total Adjustments $ -143.66
    Please Pay This Amount $ 100.00

    Please mail payment in full today or contact Patient Financial Services at 800-803-8155 to arrange
    payment. Please visit us at http://billpay.froedtert.com if you would like to make a payment online using
    MasterCard, Visa or Discover or if you would like to view a list of Frequently Asked Questions. A $25
    service fee will be charged for any checks returned.

    Physician charges will be billed separately by the Medical College of Wisconsin.

    Our commitment is to your health. We appreciate your confidence in Froedtert Hospital.

    Sincerely,
    9200 West Wisconsin Avenue
    Milwaukee, WI 53226-3596
    Patient Financial Services Page 1 of 1
    PLEASE UPDATE ANY INFORMATION THAT HAS CHANGED SINCE YOUR LAST STATEMENT ABOUT YOUR INSURANCE:
    ABOUT YOU: YOUR PRIMARY INSURANCE COMPANY'S NAME

    YOUR NAME (Last, First, Middle Initial)


    PRIMARY INSURANCE COMPANY'S ADDRESS

    ADDRESS CITY STATE ZIP

    CITY STATE ZIP POLICYHOLDER'S ID NUMBER GROUP PLAN NUMBER

    YOUR SECONDARY INSURANCE COMPANY'S NAME


    TELEPHONE MARITAL STATUS Separated
    Single Divorced
    Married Widowed SECONDARY INSURANCE COMPANY'S ADDRESS
    EMPLOYER'S NAME TELEPHONE
    CITY STATE ZIP

    EMPLOYER'S ADDRESS CITY STATE ZIP


    POLICYHOLDER'S ID NUMBER GROUP PLAN NUMBER

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