Patient Statements Print Sample

The Patient Statements prints statements showing the charges, payments and adjustments for the services the patients received.

Tips:

• To see instructions for running the report shown below, see the Patient Statements Print Instructions.

• The statement can have a variety of information printed on the back as well.  Often practices will have remittance information, credit card payment information and perhaps the practice's collection policies printed on the back.

• To see descriptions of the report fields, click More.

   

  Patient Statements Print Fields Tip:  To see more information about a field, click the hyperlink for the field name.
  ACCOUNT NO.	Patient Account Number
  Guarantor Billing Name	Patient's guarantor First and Last name
  Guarantor Billing Address	Patient's guarantor address, city, state and zip code
  STATEMENT DATE	Statement Date
  DIAG CODE	Diagnosis Code associated with the patient charge
  SERVICE DATE	Date of service
  PROCEDURE REFERENCE	Procedure Code or payment reference for patient charge
  PATIENT NAME	Name of patient associated with the charge
  LOC	Location Code for location where charge incurred
  DESCRIPTION	Procedure description
  CHARGES/PAYMENTS/ADJ.
  PATIENT	Dollar amount of charge, payment or adjustment that is the patients responsibility
  INSURANCE	Dollar amount of charge, payment or adjustment that is the insurance company's responsibility
  AMOUNT DUE
  CURRENT	Total dollar amount due for the account that is current
  OVER 30 DAYS	Total dollar amount due for the account that is over 30 days old
  OVER 60 DAYS	Total dollar amount due for the account that is over 60 days old
  OVER 90 DAYS	Total dollar amount due for the account that is over 90 days old
  PATIENT	Total dollar amount due that is the patient's responsibility
  INSURANCE	Totals dollar amount due that is the insurance company's responsibility
  STATEMENT DATE	Date of the statement
  PATIENT PAY YTD	Total dollar amount of payments the patient has made so far this year
  ACCOUNT NUMBER	Patient Account Number