PHYSICIAN NOTIFICATION FORM

Listed below is a patient that needs your approval for assignment to an outside Collection Agency.

Patient Name	MRN	Guarantor Name	Total Patient Balance	Aging Categories	Doctor	
Faith Mimstest	260541	Theodore A Mimstest	$125.00
	Current

   0.00	30+ Days

   0.00	60+ Days

125.00	90+ Days

   0.00	120+ Days

   0.00	Dr. Collection	

Patient Address	Patient SSN	
123 Main
Bad Debt, TN     37086	124512451	

Please note there has been no response from previous billing statements, and internal collection attempts have been unsuccessful.  This account will be sent to the outside collection agency, unless we hear from you within 14 days.

Sent From:  Gwen Ousley 				Date: 05/08/2002
_____________________________________________________________________________________

Upon physician review, please check the following:

_____  Guarantor Field has been updated

_____  Physician approves to write off charges(indicate amount of write off)

_____  Physician approves the account to go to outside collection agency

Received By:________________________________________	Date:  ______________________

Authorized By:  ______________________________________	Date:  ______________________

Site Comments:

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