Free Printable Medical Billing Statement Template
Printable Medical Billing Statement
[YOUR COMPANY NAME] BILLING STATEMENT
Date: January 15, 2050
Statement Number: 12345
Patient Name: Lester Nolan
Patient Address: Orlando, FL 32801
Patient Contact: lester@you.mail
Services Rendered
|
Date of Service |
Description of Service |
Amount |
Insurance Coverage |
Balance Due |
|---|---|---|---|---|
|
January 5, 2050 |
Consultation Fee |
$150.00 |
$120.00 |
$30.00 |
|
January 6, 2050 |
Lab Tests |
$200.00 |
$180.00 |
$20.00 |
|
January 7, 2050 |
X-Ray Imaging |
$300.00 |
$250.00 |
$50.00 |
|
January 8, 2050 |
Follow-up Visit |
$100.00 |
$100.00 |
$0.00 |
Summary of Charges
|
Total Charges |
$750.00 |
|---|---|
|
Total Payments |
$650.00 |
|
Balance Due |
$100.00 |
Payment Instructions
Please make your payment by February 15, 2050 to avoid any late fees. You can pay by check, credit card, or online through our payment portal.
For assistance, contact [YOUR COMPANY NAME] at [YOUR COMPANY EMAIL] or [YOUR COMPANY NUMBER].
Call to Action
Act Now to Pay Your Bill: Ensure your payment is received before the due date to maintain uninterrupted service. If you have any questions or concerns regarding your bill, feel free to reach out to us at [YOUR COMPANY EMAIL].
We are happy to assist you!
