xxxxxx 
xxx S. Elm
Webster Groves, MO  63119
(314) 3xx-1xxx
(800) 4xx-xxxx

05/08/2002

Theodore A Mimstest					Account # 260541
123 Main						Patient Balance:  $125.00
La Vergne, TN  37086

RE:  Faith Mimstest	

Your insurance company has advised this office that payment for services provided by Esse Health 
has been: 	
		
		_______ (1) paid directly to you.

		_______(2) applied to your deductible

		_______(3) denied for no dependent coverage

                        	_______(4) denied because the carrier needs additional information from you	

                       		_______(5) denied because the plan was not in effect at the time of service

                      		_______(6) denied because service was not a covered benefit

                		_______(7) other ______________________________________________

Consequently, we now  look to you for payment of the remaining balance of your account, $ __________.  

A self-addressed return envelope has been enclosed to assist you in making prompt payment.  Please be sure to indicate your account number, provided above, on your check, or you may return this notice with your payment to assure the prompt application of your payment to your account.

Sincerely, 

Gwen Ousley 
Collections Department

 This document has been entered into the patient's chart without prior review