The patient statement summarizes medical services provided to a patient on various dates in January and February 2013. It lists the date of service, description of the service using CPT codes, charges, insurance payments, adjustments, and the remaining balance due of $57.02. The document provides contact information for the medical practice and payment details, including the patient's ID, amounts due by various future dates, and a message to call with billing questions.

1. MAKE CHECKS PAYABLE TO:
Practice Name
Street Address
City, State Zip
STATEMENT DATE
2/19/2013
For Billing Questions, Please Call: (770) 123-4567
Send To:
Patient Name
Street Address
City, State Zip
PAY THIS AMOUNT
$57.02
SHOW AMOUNT
PAID HERE
PATIENT ID
7832
$
Remit To:
Practice Name
Street Address
City, State Zip
PATIENT STATEMENT
Service
Date
1/15/2013
97112 - Therapeutic proc, 1+ areas, each 15 min. Neuromuscular
Reduction
72070 - radiologic exam, spine, thoracic, 2 views
50.00
30.72
Ins.
Payment
16.39
65.00
44.51
17.42
-
3.07
2/1/2013
98940 - Description CPT code
2/6/2013
97112 - Therapeutic proc, 1+ areas, each 15 min. Neuromuscular
Reduction
72070 - radiologic exam, spine, thoracic, 2 views
98940 - Description CPT code
55.00
50.00
20.00
30.72
12.45
16.39
-
22.55
2.89
65.00
55.00
44.51
20.00
17.42
12.45
1/15/2013
2/6/2013
2/13/2013
Currrent
Description
30 Days
60 Days
90 Days
Charges
Adjust.
Patient
Payment
-
-
NOW DUE
120 Days
$57.02
$57.02
For Billing Questions, Please Call: (770) 123-4567
Patient ID: 7832
Statement messages go in this section
Practice Name
Street Address
City, State Zip
Patient
Balance
2.89
3.07
22.55