Sample Bill Legend - CHKD Medical Group/Surgical Group

To help you better understand your bill, we have created a sample bill and legend to explain each item listed.   

Front of the Bill

1. Provider Name and Address - Where services were rendered.

2. Patient/Guarantor Name - Person responsible for the bill.

3. Remittance Address - Mail payment to this address.

4. Address/Insurance Information Update - Check here if there has been a change in address, insurance information or if making a payment by credit card. Then include that information on the back of the bill.

5. Account Information - Here you'll find your account number (tracking number assigned within the practice to identify the patient), statement date (the date the statement was generated by our patient accounting system), due date and total amount due.

6. Remittance Section - This is the remittance portion of your bill. Please fill in the amount paid, detach and return with a mailed-in payment. 

7. Statement Messages - Statement messages may include concerns about a delinquent account.

8. Date of Service - The date the service was provided.

9. Procedure Code - Procedure codes vary depending on services rendered.

10. Description - Summary of procedure/services rendered.

11. Charges - Summary of charges.

12. Credits - This column shows payments made, including private and insurance payments.

13. Insurance Balance - Balance still owed by insurance.

14. Patient Balance - Balance still owed by patient/guarantor.

15. Amount Due/Pay this Amount - This is the patient/guarantor responsibility portion, which could be your copay, deductible or any amount your insurance company states is the patient's responsibility. 

16. Balance Due/Aging Category - This section details both patient and insurance balance information, including any past due amount. 

Back of the Bill 

17. Change of Address and Phone Number - If you have moved and/or your phone number has changed, please update that information here. 

18. Change of Insurance Information - If the insurance information listed on the front of your bill is incorrect or missing, please update that information here.

19. Pay by Credit Card - If you're paying with a credit card, please include credit card information here.

20. About This Bill - In this section you'll find helpful information about paying your bill.

21. Email Billing Questions -  To email billing questions to the practice.

22. Financial Assistance - Here you'll find information about how to apply for financial assistance.

23. Paperless Billing - Here you'll find information about signing up for electronic billing and where to make payments online.

24. Billing Phone Number - To call the practice with billing questions.