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Credit Card Payment: If paying by credit card, use this area to complete the information including type of credit card, card number, expiration date, amortized paying and signature. We accept Master Card, Discover and Visa. |
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Statement Date: Date your statement was created. Any payments posted after this date will not be reflected in the current Amount Due. |
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Amount Due: This is the amount that you are responsible for paying. |
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Account Number: This is the account number created for the services billed on this statement. |
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Due Date: Please remit your payment by this date. |
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Show Amount Paid Here: Write the amount you are paying toward this bill. |
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Addressee: The guarantor name and address appears here. |
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Remit To: The address where you should mail your payment. Please detach the top portion of your statement to ensure proper credit to your account. |
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Prompt payment discount Information: If you are able to pay your entire bill within 30 days of receiving your first balance statement, we will give you a 10 percent discount. |
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Patient Name: Name of the person who received service. |
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Comment Area: Read this area for important information and notices regarding your account. |
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Charges: Amounts charged for services during this visit. |
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Credits: Payments from insurance and self-payments. |
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Dates of service: Dates of service and action for this account. |
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Total Account Balance: Total amount outstanding for this account. |