1 - Name of Hospital - facility where services were rendered.

2 - Name of Guarantor - name of person responsible for paying the account.

3 - Guarantor Number - Hospital number assigned to person responsible for paying account.

4 - Balance of Account - amount due

5 - Agreement Amount - if payment plan has been setup, this is the agreed amount of monthly payment.

6 - Amount Due - amount due in full if no payment agreement has been set.

7 - Address of Guarantor - current mailing address of Guarantor.

8 - Patient Number & Patient Name - person who received services rendered and account number.

9 - Date of Services - date that patient received services.

10 - Estimated Insurance Due - amount expected from insurance.

11 - Guarantor Number - Hospital number assigned to person responsible for paying account.

12 - Previous Balance - balance from last statement.

13 - New Charges - total amount billed for this visit.

14 - Payments and Other Adjustments - all payments and adjustments made to this account since the last statement.

15 - Current Account Balance - amount due on this statement.

16 - Pay this Amount - amount due at this time.

17 - Discharge / Service Date - date of release from hospital.

18 - Comment Area - messages from the Business Office, phone numbers and website address.