Patient Services

Sample Billing Statement

Below is a sample Change Healthcare Billing Statement.

Front of Billing Statement

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

Your Pathology or Laboratory Service Provider
Name of Pathology Practice or Laboratory-This is your provider who rendered diagnostic testing and results requested by your doctor.

Name of Pathology Practice or Laboratory-This is your provider who rendered diagnostic testing and results requested by your doctor.

Patient Name

JANE DOE

Account #

Statement Date

CHR - 0000000-00

Statement Date-Date this Statement was generated.

12/13/2019

Please contact our billing agent, Change Healthcare, to submit payment, update information, or speak with a billing representative.

Due Date

Amount Due

12/23/2019

52.08

IMPORTANT MESSAGE

FIRST NOTICE, PLEASE REMIT PROMPTLY.
The amount shown is your responsibility, please pay by due date. Thank You.
Important Messages-Important message pertaining to the Statement.

	www.psabilling.com
	email: psrbilling@changehealthcare.com
	Servicio en español, por favor llame.
	TOLL FREE: 1-877-268-1012
	TOLL FREE FAX: 1-877-268-1254

Insurance Filed-Please update on website if incorrect.

Our records indicate the following insurance:
Primary Ins: ABC Health Insurance
Secondary Ins: XYZ Health Insurance

Referring Physician-The name of the referring physician.

Referring Physician
JOHN SMITH MD

Office Hours-Patient Service Center office hours.

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
12/13/2019

DUE DATE
12/23/2019

ACCOUNT #
CHR-0000000-00

Payment by Check-Required information if submitting payment by check.

Check # _________ (Please do not staple)

AMOUNT DUE
$52.08

ABC PATHOLOGY
PO BOX 1070
CHARLOTTE NC 28201

AMOUNT
ENCLOSED $

Check Box-Check Box for incorrect address or insurance information (please correct on reverse side of statement or on website).

Credit Cards Accepted-We accept the following credit cards: Visa, Mastercard, American Express and Discover.

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:

Addressee-Responsible party name and billing address.

JANE Q DOE
128 TALBERT RD STE J
MOORESVILLE NC 28117-9123

Remit to Address-Checks should be made payable to this party and sent to this address.

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. Change Healthcare 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: