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Sample Billing Statement

This statement combines billing charges from both the hospital and the provider. Your bill will come after your hospital and provider services.

We send three statements to provide notification of the balance you owe. After we send the third statement, all accounts may be turned over to collections if you cannot make a payment.

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1. Guarantor ID

This ID is a unique number assigned to the person legally responsible for paying a bill.

2. Account Number (statement pg 2)

The account number is a unique number assigned to each service. There will be a different account number for the facility and the provider.

3. QR Code

This QR code links to MyChart so you can make a payment or set up a payment plan.  If you don’t have a MyChart account, the QR code will send you to a guest pay option.

4. Your Responsibility

This is the current balance you owe. If you’re unable to pay your balance in full you can set up a payment plan using MyChart or contact our billing office.

5. Amount Enclosed

On the bottom portion of your statement, please write in how much you are paying in the “Amount Enclosed” section. This portion must be enclosed with your payment. 

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6. New Visits/Summary of Charges

This section includes details of the charges for your care. The first statement you receive will include these charges.

Financial Hardship 

You can access financial assistance options through MyChart, online, or by calling our office. (Financial aid is subject to approval.)