Patient Billing Statement Template with Examples
What is a Patient Billing Statement?
A patient billing statement template is a standardized document used by healthcare providers to communicate patient financial responsibility and billing information. It itemizes services rendered, insurance payments, and patient balance due.
A well-structured patient billing statement typically includes:
- Patient Information: Name, date of birth, account number, and contact details
- Service Information: Dates of service, services rendered, and procedure codes
- Charge Details: Itemized charges for each service with amounts
- Insurance Information: Insurance company name, policy number, and payments received
- Payment Application: Insurance payments, patient payments, and adjustments
- Patient Balance: Amount due from patient and payment due date
- Payment Instructions: Payment methods accepted and where to send payment
Why Patient Billing Statements are Essential
Patient billing statements improve payment compliance, ensure accurate billing, support patient communication, and enable revenue cycle management. Clear, professional statements help patients understand what they owe and increase payment rates.
Key Benefits:
- Improves patient understanding of charges
- Increases payment compliance
- Reduces billing inquiries and disputes
- Accelerates cash collection
- Supports regulatory compliance
Key Components of a Billing Statement
1. Header Section
- Practice name and logo
- Practice address, phone, and website
- Statement date and period
2. Patient Information Section
- Patient name, date of birth, account number
- Patient address, phone, and email
3. Statement Summary Section
- Previous balance, charges this period
- Payments received, adjustments
- Current balance due and due date
4. Service Details Section
- Date of service, service description
- Procedure code (CPT), quantity, charge amount
5. Insurance Information Section
- Insurance company name, policy number
- Insurance payment received and date
- Insurance write-offs or adjustments
6. Payment Application Section
- Insurance payments applied
- Patient payments applied
- Adjustments applied, remaining balance
7. Payment Instructions Section
- Payment methods accepted
- Payment address, online portal, phone payment
- Payment due date
8. Aging Information Section
- Current (0-30 days), 31-60 days
- 61-90 days, over 90 days
Complete Patient Billing Statement Template
[PRACTICE LOGO]
PATIENT BILLING STATEMENT
[PRACTICE NAME]
[PRACTICE ADDRESS] | [PHONE] | [EMAIL] | [WEBSITE]
---
STATEMENT INFORMATION:
Statement Date: ___/___/_____ Statement Period: ___/___/_____ to ___/___/_____
Account Number: _________________________
PATIENT INFORMATION:
Patient Name: _________________________________ Date of Birth: ___/___/_____
Address: ________________________________________________________________
Phone: _________________________ Email: __________________________________
STATEMENT SUMMARY:
Previous Balance: $______________
Charges This Period: $______________
Insurance Payments: $______________
Patient Payments: $______________
Adjustments/Write-offs: $______________
_______________
CURRENT BALANCE DUE: $______________
Due Date: ___/___/_____
---
SERVICE DETAILS:
Date of Service | Service Description | CPT Code | Qty | Charge Amount
_______________|_____________________|__________|_____|_______________
___/___/_____ | __________________ | ________ | ___ | $____________
___/___/_____ | __________________ | ________ | ___ | $____________
___/___/_____ | __________________ | ________ | ___ | $____________
Total Charges This Period: $______________
---
INSURANCE INFORMATION:
Insurance Company: ______________________________________________________
Policy Number: _________________________ Group Number: ___________________
Insurance Payment Received:
Date Received: ___/___/_____ Amount: $_____________ Reference #: __________
Insurance Adjustment/Write-off:
Amount: $_____________ Reason: ___________________________________________
---
BALANCE SUMMARY:
Total Charges: $______________
Less: Insurance Payment: ($______________)
Less: Patient Payment: ($______________)
Less: Adjustments: ($______________)
_______________
BALANCE DUE: $______________
---
AGING ANALYSIS:
Current (0-30 days): $______________
31-60 days: $______________
61-90 days: $______________
Over 90 days: $______________
_______________
TOTAL BALANCE DUE: $______________
---
PAYMENT INSTRUCTIONS:
Payment Methods Accepted:
☐ Credit Card (Visa, Mastercard, American Express)
☐ Debit Card ☐ Check or Money Order ☐ Bank Transfer/ACH ☐ Online Portal
Pay Online:
Visit [WEBSITE] and log in with your credentials. Select "Make a Payment."
Pay by Phone:
Call [PHONE] to make a payment over the phone.
Hours: [HOURS]
Pay by Mail:
Send your check to:
[PRACTICE NAME]
[BILLING ADDRESS]
[CITY, STATE ZIP]
---
QUESTIONS ABOUT THIS STATEMENT?
Phone: [PHONE]
Email: [EMAIL]
Hours: [HOURS]
---
IMPORTANT INFORMATION:
• This statement reflects charges for services rendered during the statement period.
• Insurance payments are based on the insurance company's determination of covered services.
• Patient responsibility includes copays, coinsurance, deductibles, and non-covered services.
• Payment is due by the due date shown above.
---
PATIENT ACKNOWLEDGMENT:
I acknowledge receipt of this billing statement. I understand the charges and my financial responsibility.
Patient Signature: _________________________ Date: ___/___/_____Automating Patient Billing Statements with HealOS
Modern healthcare organizations are automating patient billing statements to generate, send, and manage statements efficiently.
1. Patient Statements Agent
Patient Statements Agent: Automatically generates and sends professional billing statements to patients through email, mail, or patient portal.
2. Billing Management Agent
Billing Management Agent: Manages the complete billing workflow including charge posting, insurance billing, and patient statement generation.
3. Payment Posting Agent
Payment Posting Agent: Automatically posts insurance and patient payments to patient accounts and updates balances.
4. Credit Posting Agent
Credit Posting Agent: Automatically posts insurance adjustments, contractual write-offs, and other credits to patient accounts.
5. Collections Automation Agent
Collections Automation Agent: Automates collections activities for outstanding patient balances with collection letters and payment plans.
6. Payment Reminder Agent
Payment Reminder Agent: Automatically sends payment reminders to patients with outstanding balances on a scheduled basis.
7. Claim Status Tracking Agent
Claim Status Tracking Agent: Tracks claim status and updates patient statements based on claim activity and insurance payments.
8. Patient Data Management Agent
Patient Data Management Agent: Maintains accurate patient demographic and contact information used for billing statement delivery.
9. EHR Interoperability Agent
EHR Interoperability Agent: Syncs billing information from the billing system to the EHR, ensuring clinical staff can see current patient balance information.
10. Accounts Receivable Management Agent
Accounts Receivable Management Agent: Tracks all patient balances, monitors aging, and prioritizes follow-up activities.
Automated Patient Billing Statement Workflow
STEP 1: Charge Capture & Posting
├─ Services rendered
├─ Billing Management Agent captures charges
└─ Charges posted to patient account
STEP 2: Insurance Billing & Payment
├─ Billing Management Agent bills insurance
├─ Claim Status Tracking Agent monitors claim
└─ Insurance payment received
STEP 3: Payment Posting & Adjustments
├─ Payment Posting Agent posts insurance payment
├─ Credit Posting Agent posts adjustments
└─ Patient balance updated
STEP 4: Statement Generation & Delivery
├─ Patient Statements Agent generates statement
├─ Patient Data Management Agent ensures accurate contact info
└─ Statement delivered via email/mail/portal
STEP 5: Collections & Follow-up
├─ Accounts Receivable Management Agent monitors aging
├─ Payment Reminder Agent sends reminders
├─ Collections Automation Agent manages collections
└─ Payments tracked and posted
RESULT: Complete patient billing statement workflow automatedFAQs
Q: How often should I send patient billing statements?
Most practices send statements monthly. Automated statements can be sent on any schedule that works for your practice.
Q: What should I include in a patient billing statement?
Include patient information, statement summary, itemized service details, insurance information, payment application, balance due, payment instructions, and aging information.
Q: How do I handle statements for patients with zero balance?
You can choose not to send statements for zero-balance accounts or send a statement showing the account is paid in full.
Q: Should I send statements to patients with insurance coverage?
Yes. Even if insurance pays most of the bill, patients may have copays, coinsurance, or deductible responsibility.
Q: How do I handle disputed charges on a patient statement?
If a patient disputes a charge, investigate, verify it's accurate, and explain it to the patient. If incorrect, correct it and send an updated statement.
Q: Can I send statements electronically instead of by mail?
Yes. Electronic delivery via email or patient portal is faster and more cost-effective. Offer patients the choice of delivery method.
Q: How do I ensure patient privacy when sending statements?
Use secure email or patient portal for electronic delivery. If mailing, use a closed envelope.
Q: What payment methods should I accept?
Accept multiple payment methods including credit cards, debit cards, checks, money orders, bank transfers, and online payments.
Q: How do I handle patient payment plans?
The Collections Automation Agent can manage payment plans, sending reminders for each payment due and tracking payments received.
Q: What should I do if a patient doesn't pay their statement?
Send payment reminders, offer payment plans, and escalate to collections if necessary. The Payment Reminder Agent and Collections Automation Agent automate these activities.
Example Letter Template
