Start Page 1 of the invoice by noting the name and address of the health care provider that created the bill. Add a section at the top for the statement date, invoice number and the patient's account number.
Skip several lines after the provider's name and write the patient's full name and residence address. Identify by name and address the guarantor that has accepted responsibility to pay the provider's services.
Include the address where the guarantor should send the payment. Explain that the payer should write the invoice and patient's account numbers on the check for the account to receive credit.
Explain how to pay with a credit card. List cards the provider accepts.
Insert a table with four columns for "Date," "Amount," "CPT Code" and "Description." Note the date that treatment was provided under "Date" and the itemized charge for that single treatment under "Amount." Insert the CPT Code, a universal number used by health care providers to identify medical procedures, under the third column. Use everyday language to explain the procedure under the "Description" column, such as "removal of sutures."
Call the next section "Messages." Insert statements explaining the account status. For example, the invoice might alert patients that the current statement is a duplicate that was sent the previous month yet still remains unpaid.
Provide a section for the business office's contact information. Give telephone numbers and addresses for both regular mail and email.
Insert a section notifying patients that they may receive additional billing for the medical conditions covered on the invoice. For example, a hospital might explain that the patient will receive separate bills from emergency room staff that provided initial treatment or the laboratory that performed X-rays.
Make a second page with blank lines for the patient to update personal and billing information. Ask the patient to specify any changes in residence or mailing address, telephone numbers and health insurance providers. Instruct patients to include the page noting these changes when remitting payment.
Finish with a section called "Total Amounts Due." Separate amounts owed by the patient and insurer, if any. Identify previous balances and add them to the current charges under the heading "Please Pay This Amount."