1.

Check made out to and mailing address to send payment and stub

2.

Phone numbers for billing questions

3.

Patient CLH account number

3.

Patient CLH account number

4.

Date bill printed

4.

Date bill printed

5.

Patient name

5.

Patient name

6.

Patient writes in payment amount sent

7.

Responsible party's name and mailing address

8.

Date service provided

9.

CPT code for test performed

10.

Test or service description

11.

Diagnosis code provided by physician

12.

Test cost

13.

Total amount due for tests performed and tax

14.

CLH location where testing performed

15.

Patient's referring physician

16.

Note to patient to call billing office for assistance with bill

1.

Patient CLH account/accession number

1.

Patient CLH account/accession number

2.

Date bill printed

3.

Patient Name

3.

Patient Name

4.

Note to patient to fill out information on back of form for name/address changes or for all credit card payments

5.

Patient writes in payment amount sent

6.

Responsible party's name and mailing address

7.

Mailing address to send payment and stub

8.

Patient's physician

9.

Diagnosis code provided by physician

10.

Date service provided

11.

CPT code for test performed

12.

Test or service description

13.

Test cost

14.

Aging bucket details overdue payment amount

15.

Total amount due for tests performed

16.

Mailing address for billing questions

17.

Phone numbers for billing questions

18.

Day and time billing staff available by phone

19.

Note to patient on overdue interest charged