Sample Billing Statement

Below is a sample PSA Billing Statement.

Front of Billing Statement

Move your mouse over each number for an explanation of that item.

Your Pathology or Laboratory Service Provider
 Patient Name
JANE DOE
Account # Statement Date
CHR - 0000000-00 3/3/2015
Please contact our billing agent, PSA, to submit payment, update information, or speak with a billing representative. Due Date Amount Due
3/13/2015 52.08
IMPORTANT MESSAGE
FIRST NOTICE, PLEASE REMIT PROMPTLY.
The amount shown is your responsibility, please pay by due date. Thank You.
www.psabilling.com
email: psabilling@psapath.com

Servicio en español, por favor llame.
TOLL FREE: 1-877-268-1012
TOLL FREE FAX: 1-877-268-1254
Our records indicate the following insurance:
         Primary Ins: ABC Health Insurance
         Secondary Ins: XYZ Health Insurance 		Referring Physician
         JOHN SMITH MD 		Office hours:
         Mon-Thur 8am-9pm ET
         Fri 8am-8pm

DATE PROC. CODE DESCRIPTION QUANTITY AMOUNT






These charges are not included in any other hospital, laboratory or physician statement. For more information or to update insurance information, see the back of this statement or visit www.psabilling.com.

BILLING OFFICE ADDRESS:
STATEMENT DATE
3/3/2015 		DUE DATE
3/13/2015 		ACCOUNT #
CHR-0000000-00
Check # _________ (Please do not staple) 		AMOUNT DUE
$52.08
ABC PATHOLOGY
PO BOX 1070
CHARLOTTE NC 28201
AMOUNT
ENCLOSED $
Patient Name: JANE DOE
Please check box if address or insurance information is incorrect and indicate change(s) on reverse side.
 Do Not Mail Credit Card Information.
To pay by Credit Card, visit us at: www.psabilling.com
or call: 1-877-268-1012
ADDRESSEE: MAKE CHECKS PAYABLE TO & REMIT TO:



JANE Q DOE
128 TALBERT RD STE J
MOORESVILLE NC 28117-9123
YOUR PATHOLOGY OR LABORATORY SERVICE PROVIDER
PO BOX 1070
CHARLOTTE NC 28201-1070


0000 00000000 000000000000000 0 00000000 00000000 0




Back of Billing Statement

PAYMENT METHODS
Please mail all payments with the bottom portion of this statement and return to the address shown on the reverse side. We accept
personal checks, money orders, cashier’s checks and major credit cards for the payment of balances due. If you are unable to pay
your bill in full or on time, please contact us to discuss payment arrangements. A service charge may be applied on returned checks.
REQUEST FOR TEST RESULTS
As a billing agent, we are not legally permitted to discuss test results.

WHY DID I RECEIVE THIS BILL?
This statement is for services rendered for diagnostic testing and results requested by your doctor which were performed at the
physician’s office and/or hospital. These charges are not included in any other hospital, laboratory or physician statement. PSA will file your insurance with the information supplied from the requesting facility and you will receive a statement for the amount you are required to pay after insurance has paid its portion of the bill or denied payment. By providing the most current insurance information, you can help expedite this process.

Please submit new or updated insurance information below, for the date that services were provided.
If your address or phone number has changed since your last statement, please indicate below.

Your Name_____________________________ Home Phone #_______________ Work Phone #_______________
Street________________________________________________________________________________________
City____________________________________ State_______________________ Zip_______________________
PRIMARY INSURANCE Insured Name Insured Birth Date Effective Date Employer Name
Group Number or Plan Number Policy ID Number Relationship
Self         Child
Spouse   Other
Insurance Name Insurance Address City      State      Zip
SECONDARY INSURANCE Insured Name Insured Birth Date Effective Date Employer Name
Group Number or Plan Number Policy ID Number Relationship
Self         Child
Spouse   Other
Insurance Name Insurance Address City      State      Zip
MEDICARE Medicare Part B Number
MEDICAID Medicaid Number For State: