Hospital Bill Form PDF Details

The Hospital Bill form serves as a crucial link between healthcare providers and patients, guiding the process of financial transactions for medical services. Issued after the provision of healthcare services, it outlines the charges incurred, method of payment, and pertinent patient information. Specifically tailored to streamline the payment process, the form includes details such as the payee information for the hospital, with Froedtert Hospital in Milwaukee, WI, being the example here, along with various payment options including online and credit card payments. Patient details, including address and account number, alongside the total amount due after adjustments and payments are summarily provided. The form also delineates instructions for payment, insurance information updating procedures, and additional notes on separate billing for physician charges. Crucially, it stands not just as a request for payment, but as a document designed for clarity and convenience in settling healthcare expenses, supporting patients through relevant information on due dates, service fees for returned checks, and contact details for further assistance. This comprehensive approach aims to demystify the billing process, encouraging timely and informed payments while reinforcing the hospital’s commitment to patient care.

QuestionAnswer
Form Name Hospital Bill Form
Form Length 2 pages
Fillable? Yes
Fillable fields 27
Avg. time to fill out 5 min 54 sec
Other names sickness billing format, hospital bill receipt in usa, hospital bill template, hospital billing format for yahoo

Form Preview Example

MAKE CHECKS PAYABLE TO:

9200 West Wisconsin Avenue

Phone: 800-803-8155

Milwaukee, WI 53226-3596

http://billpay.froedtert.com

Remit To: P.O. Box 3202 • Milwaukee, WI 53201-3202

1 1*****AUTO**5-DIGIT 12345

SUSAN A. PATIENT

123 Main Street

PO Box 1234

Anytown, USA 12345-5678

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

CHECK CARD TO BE USED FOR PAYM ENT

CARD NUMBER

AMOUNT

 

 

SIGNATURE

EXP. DATE

 

 

INVOICE DATE

PLEASE PAY THIS AMOUNT

ACCOUNT NUMBER

09/2/04

$100.00

123456789

 

 

 

PATIENT NAME

Susan A. Patient

PAYMENT IS DUE UPON RECEIPT.

Please check box if address is incorrect or insurance information 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 INFORM ATION THAT HAS CHANGED SINCE YOUR LAST STATEM ENT

ABOUT YOU:

YOUR NAME (Last, First, Middle Initial)

ADDRESS

CITY

 

 

 

 

 

 

 

 

 

 

STATE

 

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE

 

 

 

 

 

 

 

 

 

MARITAL STATUS

 

 

 

 

Separated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

 

 

 

 

Divorced

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Married

 

 

 

 

Widowed

 

EMPLOYER'S NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER'S ADDRESS

 

 

 

 

 

 

 

CITY

STATE

 

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ABOUT YOUR INSURANCE:

YOUR PRIMARY INSURANCE COMPANY'S NAME

PRIMARY INSURANCE COMPANY'S ADDRESS

CITY

STATE

ZIP

 

 

 

 

 

POLICYHOLDER'S ID NUMBER

GROUP PLAN NUMBER

 

 

 

 

 

 

 

YOUR SECONDARY INSURANCE COMPANY'S NAME

 

 

 

 

 

 

 

 

SECONDARY INSURANCE COMPANY'S ADDRESS

 

 

 

 

 

 

 

 

CITY

STATE

ZIP

 

 

 

 

 

POLICYHOLDER'S ID NUMBER

GROUP PLAN NUMBER

 

 

 

 

 

 

 

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part 1 to completing medical billing form template

Provide the requested information in ABOUT, YOU YOUR, NAME, Last, First, Middle, Initial YOUR, PRIMARY, INSURANCE, COMPANY, S, NAME PRIMARY, INSURANCE, COMPANY, S, ADDRESS ADDRESS, CITY, TELEPHONE, EMPLOYERS, NAME CITY, STATE, ZIP, STATE, ZIP, POLICYHOLDERS, ID, NUMBER and GROUP, PLAN, NUMBER segment.

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