Free Patient Statement Letter Template
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
