This is the address for payment remittal.

Please write the amount enclosed for payment on this line.

Please remove the bottom portion of this bill and keep for your own records. Please
return the top half along with your payment.

This is the date that activity occurred and was added to your statement.

This is the name of the Provider that activity was scheduled with.

A detailed explanation of the activity that occurred during your visit.

This is the name of the Patient who received the listed activity.

Amounts of charges and debts that have been charged to the account.

Amounts of payments and credits that have been credited to your account.

This is the closing date of your statement.

If you have any questions, please send inquiries to this address.

Sample Statement: