Guarantor Name: Sample Debtor

Master Account: INS015

Statement Date: May 2, 2012 AUTOMATED PAYMENT SYSTEM
Account Number: INS015
If you have any questions about your payment options, financial
assistance, health insurance or questions about this bill, please call our For 24-hour access to account information and to make payments by
check or credit card, please call (503) 581-1747.
Patient Service Team.

Account Summary CONTACT INFORMATION

Number Patient Name Svc Date Balance Visit Reason: INS012
INS031 INS030 Patient Service Team: (503) 581-1747
INS034 INS033
Telephone Hours: Mon to Thurs 8:00 AM - 6:00 PM
INS037 INS036
INS040 INS039
Friday 8:00 AM - 4:00 PM
INS043 INS042 Patient Financial 3300 State St.
INS046 INS045 Services Address: Salem, OR 97301
INS049 INS048
Office Hours: Mon to Friday 8:00 AM - 5:00 PM
INS052 INS051
INS055 INS054 Payment Address: PO Box 6990
INS058 INS057 Portland OR 97228-6990

Total Amount Due: $INS009

0

Make Arrangements Today

Your account(s) remains unpaid. We would appreciate your assistance in helping us resolve the balance that
is due. Please remit your payment upon receipt of this letter.
We are able to accept personal checks, American Express, Visa, Discover and Master Card. If mailing in your
payment, please use the detachable stub and envelope provided and write the account number on your
check.
Thank you for your prompt attention to this matter.

For information about this bill or to submit a payment please see the reverse side
** SEPARATE AND RETURN BOTTOM PORTION WITH YOUR PAYMENT **

8-ONHONL10-3032-1/06/10
REPRINT

Salem Hospital
PO Box 6990
Portland OR 97228-6990
RETURN SERVICE REQUESTED
Account Number: INS015
12345678-000000-03-0-AA

-YR1--REPRINT 8

Sample Debtor
1234 Main Street Salem Hospital
Anytown MI 48307 PO Box 6990
Portland OR 97228-6990
 UNDERSTANDING YOUR HOSPITAL BILL
Thank you for choosing Salem Hospital. We are dedicated to providing you with the finest in healthcare services. We understand that
healthcare billing is a complicated process that can leave you with many questions. Therefore, we want to answer some of the more
commonly asked questions.
Health Insurance:
Health insurance helps with many of the financial burdens of illness or injury, but it usually does not cover the entire bill. Each time you
visit Salem Hospital, you will be asked to furnish us with your current insurance information, including any secondary insurance or
Medicare supplemental insurance that you have. We can assist you by filing your claim with your insurance company, but you are
ultimately responsible for your account. So, it is important to stay involved with your insurance company. You are expected to pay any
deductible, co-pay and/or coinsurance amounts, and any charges not covered under your insurance. If you have additional insurance
information that has not been billed, please contact us at (503) 581-1747.
Payment Options:
Payment for services is due upon receipt of the initial bill for self-pay accounts and upon receipt of the initial bill for patient responsibility
after an insurance company has paid. Payment options include: cash, check, money order, debit card, American Express, Visa, Discover
and Master Card. At any time you feel that you may have difficulty paying your hospital bill, you are invited to call us. A Patient Service
Team representative can discuss payment alternatives that are available to you, including extended payment arrangements, financial
assistance, and charity care considerations.
Financial Assistance (Charity Care):
Financial assistance (charity care) are a part of the services provided by Salem Hospital. For those unable to pay for necessary medical
services, every effort will be made to assist you in obtaining help from public agencies. Those who do not qualify for public funding may be
considered for charity care. Sources of income and a financial statement may be required in order to verify need. Any patient may apply.
Please contact our Patient Service Team at the number listed below for assistance. We can only assist you in applying for financial
assistance or establishing a payment arrangement if you contact us.
Billing Cycle:
An account number is assigned for each date of service. Once an account becomes patient responsibility, you will receive a statement
showing the balance due for each date of service. For your convenience, accounts that become the patient's responsibility within 30 days
of one another will automatically combine together and you will receive one statement for multiple accounts. If another account becomes
patient responsibility outside of those 30 days, it will not automatically combine with the other accounts. However, you can contact our
Patient Service Team and request to set up a payment arrangement, and request that all accounts be combined together.
A representative from our Patient Service Team is available to assist you with any questions concerning your hospital bill. Please call
(503) 581-1747 between the hours of 8:00AM and 7:00PM, Monday through Thursday and 8:00AM and 5:00PM on Friday, or visit us in
person at 3300 State Street in Salem between the hours of 8:00 am and 5:00 pm, Monday through Friday.

** SEPARATE AND RETURN BOTTOM PORTION WITH YOUR PAYMENT **

PAYMENT FORM
Guarantor Name
Sample Debtor
Apply to Account Number Payment Amount
INS015 $ .
Credit Card or Checking Account Number Expiration Date CCV2
/
Signature Check Payment Card The CCV2 number is
the last 3 or 4 digits on
the back of your card
by your signature