If there is one thing that we can all agree on, it is that medical bills are confusing. Even if you have insurance, the billing process can be convoluted and stressful. To make matters worse, hospital bills are often bloated with unnecessary fees. But now there is a new way to battle these high costs: the Hospital Bill Form. This online tool provides consumers with a breakdown of their bill, making it easy to identify and dispute any unfair charges. It's a user-friendly resource that can help reduce your healthcare expenses.
You can find information about the type of form you need to fill out in the table. It will show you the time it will take to complete hospital bill form, what fields you need to fill in and some further specific details.
Question | Answer |
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Form Name | Hospital Bill Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | doctor format for yahoo, usa hospital bill receipt, sick format for client, hospital billing format for yahoo |
MAKE CHECKS PAYABLE TO:
9200 West Wisconsin Avenue |
Phone: |
Milwaukee, WI |
http://billpay.froedtert.com |
Remit To: P.O. Box 3202 • Milwaukee, WI
1
SUSAN A. PATIENT
123 Main Street
PO Box 1234
Anytown, USA
IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW
CHECK CARD TO BE USED FOR PAYM ENT
CARD NUMBER |
AMOUNT |
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SIGNATURE |
EXP. DATE |
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INVOICE DATE |
PLEASE PAY THIS AMOUNT |
ACCOUNT NUMBER |
09/2/04 |
$100.00 |
123456789 |
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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.
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0000 |
0000000111111111 |
0159275 |
0000000 |
0000000000 |
4 |
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INVOICE |
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT. |
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Thursday, September 2, 2004 |
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Patient: |
Susan A. Patient |
Date of Service : |
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04/24/04 |
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Account: |
123456789 |
Patient Service: |
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ER Arena |
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Amount Due: |
$100.00 |
Primary Insurance Billed: |
WPS |
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Secondary Insurance Billed: |
Blue Cross |
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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
Pharmacy |
$ |
28.40 |
Emergency Room |
$ |
947.00 |
EKG/ECG |
$ |
84.00 |
Total Charges |
$ |
1,059.40 |
Total Payments |
$ |
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Total Adjustments |
$ |
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Please Pay This Amount |
$ |
100.00 |
Please mail payment in full today or contact Patient Financial Services at
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
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Milwaukee, WI |
Patient Financial Services |
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PLEASE UPDATE ANY INFORM ATION THAT HAS CHANGED SINCE YOUR LAST STATEM ENT
ABOUT YOU:
YOUR NAME (Last, First, Middle Initial)
ADDRESS
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ABOUT YOUR INSURANCE:
YOUR PRIMARY INSURANCE COMPANY'S NAME
PRIMARY INSURANCE COMPANY'S ADDRESS
CITY |
STATE |
ZIP |
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POLICYHOLDER'S ID NUMBER |
GROUP PLAN NUMBER |
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YOUR SECONDARY INSURANCE COMPANY'S NAME |
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SECONDARY INSURANCE COMPANY'S ADDRESS |
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CITY |
STATE |
ZIP |
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POLICYHOLDER'S ID NUMBER |
GROUP PLAN NUMBER |
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