xxxxxxxx
xxx x. Elm
Webster Groves, MO 63119
(314) 3xxx-1xxx

05/08/2002

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

RE:  Faith Mimstest

A recent audit of your account shows that your insurance has not responded on past billed charges, therefore the balance becomes your responsibility. Should you have additional questions concerning the delay in claims processing contact your employer, and/or insurance carrier to adjudicate your claims within a timely manner or pay the balance in full.  For your convenience we have enclosed a copy of your claim form and proof of filing that was billed to your insurance. 

Please respond within 14 days upon receipt of this notice. Failure to respond will result in further collection actions. 

If you are having a problem paying on your account, please contact our office and we will be happy to work out a payment plan for you.

Thank you for your prompt attention to this matter.

Sincerely,

Gwen Ousley 
Collections Department

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PLEASE CHARGE MY CREDIT CARD

_______ VISA  _______ MASTERCARD _______DISCOVER

Amount Authorized ____________ Account # ____________________

Expiration Date ___/___/____

Signature _________________________________________________DATE____________________

Acct #   260541

  

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