Sample Billing Statement

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Item #1Account Number

This number is unique to each patient. Also known as guarantor number. This number is used to look up the account information. It can also be used to log in as a guest to make a payment online. Back to page 1

Item #2Responsible Party

This person is financially responsible for paying the account balance, and may be a different person than the patient. You may also hear this person referred to as a “guarantor”.

Statement Date

You’ll receive a statement once a month. It combines provider and facility charges. Your monthly billing cycle starts shortly after your visit. Back to page 1

Item #3Minimum Amount Due

Look to see that your previous month’s payment was received. Note that your full account balance and due date will always appear on the upper left front of your bill. If you’re unable to pay your balance in full, we provide a minimum amount that will keep your account in good standing. We can extend your payments over 12 months, but require a minimum $75 payment. Back to page 1

Item #4For Questions

On every statement, we give you a way to ask a specific question to a billing representative. You can call from 9 am to 5:30 pm or e-mail us at any time. Back to page 1

Item #5Amount Paid

Be sure to write in how much you are paying when you submit the bottom portion of the statement with your payment. If for some reason you cannot make your minimum payment by the due date, be sure to let us know to avoid defaulting on your balance owed. Financial assistance options are available. Visit us online, or call, to learn more. Back to page 1

Item #6Visit Numbers

Your visit numbers are unique to each date of service and to the University location. This means you will have a different visit number for your provider charges and for your facility charges. For an inpatient stay, the dates you see are when the service was provided. Back to page 2

Item #7Summary of Charges

You’ll see a summary of charges, payments, and amount you owe on the last page of every monthly statement. All of the columns will add up to the charges & payments you see in the detail section. Back to page 2