xxxxxxx 
xxx S. Elm
Webster Groves, MO  63119
(314) xxx-1xxx
(800) xxx-xxxx

05/08/2002

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

RE:  Faith Mimstest

This letter summarizes the payment arrangements you recently made with this office.  We expect that you will make your payments to XXXX XXXX on a timely basis.  For your convenience, your payment schedule is shown below. Until this balance is removed, payment in full will be expected at the time service, for all future services are rendered, unless other specific arrangements have been made in advance with the Business Office.

 <~PYMT_PLAN~>

The plan would be auto populate in this area: 
$50.00 due 05/15/02
$50.00 due 06/15/02
$25.00 due 07/15/02

Please call me at (314) 3xx-1xxx  if you have any questions.

Sincerely,

Gwen Ousley 
Collections Department

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