PATIENT STATEMENT LETTER
[Your Company Name]
[Your Company Address]
December 4, 2051
Adelia Harber
Mesa, AZ 85201
Dear Adelia Harber,
We are writing to provide you with a statement of your account as of December 4, 2051. Below is a summary of the charges and payments recorded for your account:
Account Summary
Description | Amount ($) |
|---|
Outstanding Balance | $150.00 |
Charges | $200.00 |
Payments Received | $100.00 |
Adjustments | -$50.00 |
Total Amount Due | $200.00 |
Charges Detail
Date | Description | Amount ($) |
|---|
November 15, 2051 | Office Visit | $100.00 |
November 20, 2051 | Lab Tests | $80.00 |
November 22, 2051 | Consultation Fee | $20.00 |
Payments Received
Date | Amount ($) |
|---|
November 5, 2051 | $100.00 |
Adjustments
Description | Amount ($) |
|---|
Insurance Adjustment | -$50.00 |
Please review the statement and ensure that all information is correct. If you have any questions or need further clarification, do not hesitate to contact us at [Your Company Number] or [Your Company Email].
Thank you for your attention to this matter.
Sincerely,
[Your Name]
Billing Manager
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