about our services financial assistance patient financial services is … · 2018-10-18 · chc k a...

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Patient Financial Services is here to make the billing process as easy as possible. Your Patient Account You’re here to get better. About Our Services Patient Financial Services is made up of several departments: hospital admitting, outpatient registration, and the patient business office, which is responsible for all billing and collection activity. We have opened a patient account in your name to record all financial transactions related to your care. If you have given us insurance information, we will submit a claim on your behalf and keep you informed of the outcome. Please note that most doctors are independent practitioners and not employees or agents of the hospital. They will bill you and/or your insurance company separately. If you have questions or concerns, please call the Customer Service phone number on your statement and the back of this brochure. We are also happy to provide you with an itemized statement. No cost translation services are available upon request. Financial Assistance Our financial counselors can help you figure out your insurance coverage or make interest free payment arrangements. If you do not have insurance they can help you apply for Medicaid/Medi-Cal, coverage through the state health benefits exchange or other government-sponsored health coverage for which you may qualify. We provide discounts to eligible low to moderate-income patients. Please contact Customer Service if you are unable to pay part of your bill. We will review your financial situation to determine if you are eligible for financial assistance. How To Reach Us If you have questions about your account, please contact Customer Service: Phone: (818) 409-8200 Fax: (818) 956-7613 Patient Financial Services DEPT. No. 2006 Los Angeles, CA 90084-2006

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Page 1: About Our Services Financial Assistance Patient Financial Services is … · 2018-10-18 · CHC K A RDU SIG FO PA T CARD NUMBER TURE TE CODE M M Y Y PA NAME CER-171 TE DUE STA TE

Patient Financial Services is here to make the billing process as easy as possible.

Your Patient AccountYou’re here to get better.

About Our ServicesPatient Financial Services is made up of several departments: hospital admitting, outpatient registration, and the patient business o�ice, which is responsible for all billing and collection activity.

We have opened a patient account in your name to record all financial transactions related to your care. If you have given us insurance information, we will submit a claim on your behalf and keep you informed of the outcome. Please note that most doctors are independent practitioners and not employees or agents of the hospital. They will bill you and/oryour insurance company separately.

If you have questions or concerns, please call the Customer Service phone number on your statement and the back of this brochure.

We are also happy to provide you with an itemized statement.

No cost translation services are available upon request.

Financial AssistanceOur financial counselors can help you figure out your insurance coverage or make interest free payment arrangements. If you do not have insurance they can help you apply for Medicaid/Medi-Cal, coverage through the state health benefits exchange or other government-sponsored health coverage for which you may qualify.

We provide discounts to eligible low to moderate-income patients. Please contact Customer Service if you are unable to pay part of your bill. We will review your financial situation to determine if you are eligible for financial assistance.

How To Reach UsIf you have questions about your account, please contact Customer Service:

Phone: (818) 409-8200Fax: (818) 956-7613Patient Financial ServicesDEPT. No. 2006Los Angeles, CA 90084-2006

Page 2: About Our Services Financial Assistance Patient Financial Services is … · 2018-10-18 · CHC K A RDU SIG FO PA T CARD NUMBER TURE TE CODE M M Y Y PA NAME CER-171 TE DUE STA TE

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PLEASE MAKE CHECKS PAYABLE AND REMIT TO:

ADDRESSEE:

IF PAYING BY CREDIT CARD, FILL OUT BELOW

CHECK CARD USING FOR PAYMENTCARD NUMBER

SIGNATURE

EXP. DATE

SECURITY CODE

M M Y Y

PATIENT NAME

CE

R-171 DATE DUE

STATEMENT NUMBER AMOUNT DUE AMOUNT PAYING

ANY ADVENTIST HOSPITALPO BOX 9900ANY TOWN, CA 99999-9900

JOSEPH PATIENT1234 ANY STREETANYTOWN, USA 12345-6789

Please check box if address is incorrect or insurance

information has changed, and indicate change(s) on reverse side.

ANY ADVENTIST HOSPITAL1234 ANY STREET ANY TOWN, CA 99999-9900

1234567890 $50.00

THANK YOU FOR ALLOWING ANY ADVENTIST HOSPITAL TO PROVIDE

FOR YOUR RECENT HEALTHCARE NEEDS.

Pay Online: adventisthealth.org/pay-your-bill

Access Code: 1234567890 JOSEPH PATIENT 06/01

YOUR STATEMENT 05/10

ANY ADVENTIST HOSPITAL1234 ANY STREET ANY TOWN, CA 99999-9900

u IMPORTANT MESSAGE

Your insurance has processed your claim.

This balance is your responsibility. Please

make your payment today or contact us to

u ENCOUNTER SUMMARY

Patient John Patient

Date(s) of Service 04/17 - 04/20

Statement Number 12345670

Encounter Number 12345678901

Physician John Apex

u INSURANCE INFORMATION

Primary Medicare

Subscriber John Patient

ID Number XXXXX-9999

Secondary Anthem Blue Cross

Subscriber John Patient

ID Number XXXXX-9999

u QUESTIONS? (800) 555-5555

For questions about your statement, call

Customer Service at (800) 555-5555.

Financial Assistance: Adventist Health provides discounts to eligible

low-income patients. If you can’t pay part of

your bill, please contact our Customer Service

situation to determine if you are eligible for

SEPARATE PHYSICIAN BILLING You may receive separate bills from physicians who provided care or who consulted on your case.

u SUMMARY OF SERVICES

Description Amount

Room and Care 1,250.00

Supplies 255.00

Telemedicine 45.00

Therapy Services 950.00

Treatment Room 1,250.00

Total Patient Services $29,981.00

Insurance Payment 04/30/07 -$29,000.00

Insurance Discount 04/30/07 -$931.00

Total Payments & Adjustments -$29,931.00

Current Account Balance $50.00

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PLEASE MAKE CHECKS PAYABLE AND REMIT TO:

ADDRESSEE:

IF PAYING BY CREDIT CARD, FILL OUT BELOWCHECK CARD USING FOR PAYMENTCARD NUMBER

SIGNATURE

EXP. DATE

SECURITY CODE

M M Y Y

PATIENT NAME

CE

R-171

DATE DUE

STATEMENT NUMBER AMOUNT DUE AMOUNT PAYING

ANY ADVENTIST HOSPITALPO BOX 9900ANY TOWN, CA 99999-9900

JOHN PATIENT1234 ANY STREETANYTOWN, USA 12345-6789

Please check box if address is incorrect or insurance information has changed, and indicate change(s) on reverse side.

ANY ADVENTIST HOSPITAL1234 ANY STREET ANY TOWN, CA 99999-9900

1234567890 $50.00

THANK YOU FOR ALLOWING ANY ADVENTIST HOSPITAL TO PROVIDEFOR YOUR RECENT HEALTHCARE NEEDS.

Pay Online: https://myadventisthealth.paymyhealthbill.com/quickpayAccess Code: 1234567890 JOHN PATIENT 06/01/14

YOUR STATEMENT 05/10/2014

ANY ADVENTIST HOSPITAL1234 ANY STREET ANY TOWN, CA 99999-9900

u IMPORTANT MESSAGE

Your insurance has processed your claim. This balance is your responsibility. Please make your payment today or contact us to

u ENCOUNTER SUMMARY Patient John PatientDate(s) of Service 04/17/14 - 04/20/14Statement Number 12345670 Encounter Number 12345678901Physician Mark Smith

u INSURANCE INFORMATION Primary MedicareSubscriber John PatientID Number XXXXX-9999Secondary Anthem Blue CrossSubscriber John PatientID Number XXXXX-9999

u QUESTIONS? (800) 555-5555 For questions about your statement, call Customer Service at (800) 555-5555.Financial Assistance: Adventist Health provides discounts to eligible low-income patients. If you can’t pay part of your bill, please contact our Customer Service situation to determine if you are eligible for

SEPARATE PHYSICIAN BILLING You may receive separate bills from physicians who provided care or who consulted on your case.

u SUMMARY OF SERVICES Description Amount

Pharmacy $45.00Laboratory 223.00Radiology 125.00Supplies 255.00Total Patient Services $648.00Insurance Payment 04/30/14 -$400.00Insurance Discount 04/30/14 -$198.00Total Payments and Adjustments -$598.00Current Account Balance $50.00

SAMP

LEImportant Message: Pay close attention to this important message.

Questions: Call this number if you have any questions about your account.

Insurance Information: These are the insurance plans we have on file for you. If you have di�erent or additional insurance, please call Customer Service.

Understanding Your StatementIf you have insurance, we will send you a statement a�er your insurance has paid its share. If you do not have insurance, we will send you a statement shortly a�er receiving care. Once you receive a statement, payment in full is expected unless other arrangements have been made.

The sample to the right will help you read your statement. Please pay close attention to the Important Message box.

If you need help understanding your statement, please call the Customer Service phone number on your statement and the back of this brochure.

Paying Your BillYou can pay with cash, check or credit card. We accept VISA, MasterCard, Discover and American Express. You can use your credit card either in person or online. See your statement for instructions on how to pay online.