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Billing Statement
1 |
Name and Address of responsible party |
2 |
Address for remittance and name to make payment to |
3a |
Account Number (Please place on check) |
3b |
Date services reflected through (Services or payments received
following this statement date appear next month) |
3c |
Total payable from patient and Insurance pending |
4 |
Credit card type (Please fill out completely) |
5 |
Date of Service, payments received or service charges |
6 |
Description of service. (Includes patient and admission number,
patient name, type of visit, detail of payment or interest) |
7 |
Total amount charged and/or interest accumulated. |
8 |
Payment considered, adjustment or write off amount. |
9 |
Amount pending for insurance consideration. |
10 |
Total balance due from patient regardless of insurance pending. |
11 |
Message of the month (Look for a new message each month) |
Payment Options
Teton Valley Hospital & Surgicenter honors most major insurance
carriers including Blue Cross, Blue Shield, Medicare and regional
Medicaid.
Private pay patients should be prepared to pay in full at the
time of service, or make payment arrangements with our Patient
Account Representatives prior to admission.
Insurance coverage is a contract between the patient and their
carrier. Patients are responsible for all hospital charges incurred.
Insurance billing is a courtesy provided by our Billing Office.
Patients in need of financial medical assistance are encouraged
to apply to one of many available federal, state and county programs
before receiving care. If emergency care is required, Medical Assistance
programs may help cover costs.
Remember to contact your insurance company prior to any scheduled
hospital stay. A pre-admission review for hospital stays over 24
hours may be required, and failure to obtain one may affect your
benefit payments.
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