FINANCIAL STATEMENT DEDUCTIBLE VISIT CHARGES PAYMENT OPTIONS. YOU OWE: $ Due: 8/25/2016 Statement Date: 8/1/2016.

Transcription

1 Visual Composition Easiest Bill to Understand August 8, 2016

2 YOU OWE: $ Due: 8/25/2016 Statement Date: 8/1/2016 FINANCIAL STATEMENT Patient Name: Wendy Smith Person Responsible: Wendy Smith Name of Provider: John Levi, MD Date of Service: 7/25/2016 Single Account Number: Primary Insurance: Hometown Health Secondary Insurance: None Financial Summary: You owe $ On July 25 th, you had an office visit with your heart doctor, Dr. Levi. Upon arrival, you paid a $25 copay with your Visa ending in On 7/25 we billed your insurance $1825. On 7/28 we received a payment of $1725. The total amount you will owe for this visit is $100, minus your copayment of $25. Therefore the total amount owed for this visit is $75. Please note, you have an outstanding balance of $100. You owe $ VISIT CHARGES Code Description Insurance You Owe Flu Shot $ CT-Scan $ $ Lab Work $ Office Visit $ $25.00 TOTAL $ $ /28 Insurance Payment -$ /25 - Copayment -$25.00 You Owe Copay Insurance This Visit Balance $75.00 Previous Balance $ You Owe $ $1,300 Lab DEDUCTIBLE 2016 Spend $5,198 $3,000 $1,056 $1,942 $2,200 Office Visits 2016 Deductible $9,500 $4,000 Hospital PAYMENT OPTIONS Online: Renown.org/PayNow Checks Payable to: Renown Health, PO BOX Los Angeles, CA Credit: Visa MasterCard Disc Amex Amount: Name: Card Number: Exp Date: Signature: CVC: EASY PAYMENT PLAN: Full Amount (10% Discount) Monthly for 3 Months Monthly for 6 Months Monthly for 12 Months Call to Discuss: Paperless Statements: YES NO Billing Questions, Financial Assistance and Payment Plans:

3 HEALTHCARE SUMMARY Patient Name: Wendy Smith Person Responsible: Wendy Smith Name of Provider: John Levi, MD Date of Service: 7/25/2016 Single Account Number: Primary Insurance: Hometown Health Secondary Insurance: None Health Summary: On July 25 th, 2016 you had an office visit with your heart doctor, Dr. Levi. Dr. Levi assessed you in the clinic, performed an echocardiogram and CT-Scan to understand the health of your heart, adjusted your medications, and ordered lab tests to ensure your medications were working as planned. REASON FOR VISIT: Visit Renown.org for interactive map Heart Visit VISIT INFORMATION: Provider: Dr. Levi Dates: 7/25 Location: 75 Pringle Number of Visits Included: 1 CARE PROVIDED: Office Visit (7/25) Flu Shot (7/25) CT-Scan (7/25) Echocardiogram (7/26) Blood Work (7/28) MYCHART VISIT VITALS: Weight: 130 BMI: 22 Blood Pressure: 120/80 Pulse: 80 WELLNESS CHECKLIST: Can we call you to schedule this? Yes No - Mammogram (Due 8/15) Yes No - A1c Lab Test (Due 9/1) Yes No - Colonoscopy (Due 10/1) Yes No - Eye Exam (Due 10/15) YOUR PROVIDER: MyChart.Renown.org HEALTHY LIVING TIPS: BestMedicineNews.org

4 Usted Deve:$ Fecha De Pago: 8/25/2016 Estado Financiero Nombre Del Paciente: Wendy Smith Fecha De Nacimiento: 9/15/1951 Dia de Servicio: 7/25/2016 Numero de Cuenta : RESUMEN FINANCIERO: El 25 de Julio, usted tuvo una visita con su cardiologo el Doctor Levi. A sullegada, usted pago una cuota de $25 dolares con su tarjeta VISA terminando en Le mandamos un bil a su seguransa de $1420. Recibimos un pago de $1350 el dia 7/28. El total restante que usted deve por esta visita es $75.00 dolares. Tome encuenta, que usted tiene un balance de $100 dolares devidos anteriormente. La cantidad que usted debe $ RESPONSABILIDAD POR ESTA VISITA Vacuna de influenza Ecocardiograma, Eco, Tomografia $75.00 Analysis Visita de oficina TOTAL $75.00 Pago de Asegurnasa $ Balanse Anterior $ Esta Visita $75.00 Usted Debe $ PAGO GASTO DE ANO ASTA LA FECHA 2016 Total Gastado $5,198 $1,056 Analysis $1,942 Visitas de Oficina 2016 Maximo $9,500 $2,200 Hospital SEPARACION DEL BIL Resposabilidad del Paciente (Usted Deve): $75 En Linia: Renown.org/PayNow Pago de Checke: Renown Health, PO BOX Los Angeles, CA Credito: Visa MasterCard Disc Amex Numero de Tarjetar: Fecha de Vencimiento: Firma : CVC : El dia 7/28 Su Aseguransa Pago : $250 El dia 7/25 su cuota pagada fue : $25 PREGUNTAS ACERCA DE SU BIL O PLANES DE PAGO:

5 DUE: 8/25/2016 FINANCIAL STATEMENT Patient Name: Wendy Smith Date of Birth: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: FINANCIAL SUMMARY: On July 25 th, you had an office visit with your heart doctor, Dr. Levi. Upon arrival, you paid a $25 copayment via your Visa ending in We billed your insurance $1420. We received a payment of $1350 on 7/28. The total remaining amount you will owe for this visit is $ Please note, you also have an outstanding balance of $100. Total amount owed is $ RESPONSABILIDAD POR ESTA VISITA Servicio Porcion de Asegursa Usted Deve Vacuna de Influenza $75.00 Ecocardiograma, Echo, CT-Scan $ $75.00 Lab Work $400 Office Visit $ TOTAL $ $ /28 Pago de Aseguransa $ Balance Anterior $ Esta Visita $75.00 Usted Deve $ YEAR-TO-DATE SPENDING 2016 Total Spend $5,198 $1,056 $1,942 PAGO 2016 Maximum $9,500 $2,200 Lab Office Visits Hospital En Linia: Renown.org/Paga Ahora Checks Payable to: Renown Health, PO BOX Los Angeles, CA BILLING QUESTIONS & PAYMENT PLANS:

6 YOU OWE:$ DUE: 8/25/2016 FINANCIAL STATEMENT Patient Name: Wendy Smith Date of Birth: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: FINANCIAL SUMMARY: On July 25 th, you had an office visit with your heart doctor, Dr. Levi. Upon arrival, you paid a $25 copayment via your Visa ending in We billed your insurance $1420. We received a payment of $1350 on 7/28. The total remaining amount you will owe for this visit is $ Please note, you also have an outstanding balance of $100. Total amount owed is $ RESPONSIBILITY FOR THIS VISIT Service Charged Amount Discounted Amount Insurance Portion You Owe Flu Shot $ $75.00 $75.00 EKG, Echo, CT-Scan $ $ $ $75.00 Lab Work $400 Office Visit $ $ $ TOTAL $ $ $ $ /28 - Insurance Payment $ PAYMENT Online: Renown.org/PayNow Checks Payable to: Renown Health, PO BOX Los Angeles, CA Credit: Visa MasterCard Disc Amex Card Number: Exp Date: Signature: CVC Code: Previous Balance $ This Visit $75.00 Your Responsibility $ YEAR-TO-DATE SPENDING Out-of-Pocket at Hometown Health 2016 Total Spend $5, Maximum $9,500 BILLING QUESTIONS & PAYMENT PLANS:

7 PAYMENT INFO Online: Renown.org/PayNow LEVEL 1 - SUMMARY PAYMENT INFO Online: Renown.org/PayNow Checks Payable to: Renown Health, PO BOX Los Angeles, CA Credit: Visa MasterCard Disc Amex Name: Card Number: Exp Date: Signature: CVC Code: LEVEL 2 DETAIL PAYMENT INFO LEVEL 3 FULL INFORMATION EASY PAYMENT PLAN: Full Amount (10% Discount) Monthly for 3 Months Monthly for 6 Months Monthly for 12 Months Call to Discuss: Paperless Statements YES NO Online: Renown.org/PayNow Checks Payable to: Renown Health, PO BOX Los Angeles, CA Credit: Visa MasterCard Disc Amex Name: Card Number: Exp Date: Signature: CVC Code:

8 BILLING BREAKDOWN PATIENT RESPONSIBILITY (YOU OWE): $75 LEVEL 1 - SUMMARY ON 7/28 YOUR INSURANCE COMPANY PAID: $250 ON 7/25 YOUR COPAY PAID: $25 BILLING BREAKDOWN LEVEL 2 DETAIL You Owe Insurance Copay LEVEL 3 FULL INFORMATION BILLING BREAKDOWN INSURANCE PAID: $250 YOU PREVIOUSLY PAID: $25 YOU OWE: $75

9 YEAR-TO-DATE SPENDING Out-of-Pocket at Hometown Health 2016 Total Spend $5, Maximum $9,500 LEVEL 1 - SUMMARY YEAR-TO-DATE SPENDING 2016 Total Spend $5,198 $1, Maximum $9,500 $2,200 LEVEL 2 DETAIL $1,056 Lab Office Visits Hospital YEAR-TO-DATE SPENDING 2016 Total Spend $5, Maximum $9,500 $1,300 $3,000 $1,942 $4,000 $2,200 LEVEL 3 FULL INFORMATION $1,056 Lab Office Visits Hospital

10 RESPONSIBILITY FOR THIS VISIT Flu Shot EKG, Echo, CT-Scan $75.00 Lab Work Office Visit TOTAL $75.00 Insurance Payment $ Previous Balance $ This Visit $75.00 You Owe $ LEVEL 1 SUMMARY LEVEL 2 DETAIL LEVEL 3 FULL INFO RESPONSIBILITY FOR THIS VISIT Service Insurance Portion You Owe Flu Shot $75.00 EKG, Echo, CT-Scan $ $75.00 Lab Work $400 Office Visit $ TOTAL $ $ /28 Insurance Payment $ Previous Balance $ This Visit $75.00 You Owe $ RESPONSIBILITY FOR THIS VISIT Service Charged Amount Discounted Amount Insurance Portion You Owe Flu Shot $ $75.00 $75.00 EKG, Echo, CT-Scan $ $ $ $75.00 Lab Work $400 Office Visit $ $ $ TOTAL $ $ $ $ /28 - Insurance Payment $ Previous Balance $ This Visit $75.00 Your Responsibility $75.00

11 HEALTH SUMMARY Patient Name: Wendy Smith Date of Birth: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: HEALTH SUMMARY: On July 25 th, 2016 you had an office visit with your heart doctor, Dr. Levi. Dr. Levi assessed you in the clinic, performed an EKG, echocardiogram, and CT Scan to understand the health of your heart, adjusted your medications, and ordered lab tests to ensure your medications were working as planned. Heart Visit VISIT INFORMATION: Provider: Dr. Levi Dates: 7/25 Location: 75 Pringle Number of Visits Included: 1 CARE PROVIDED: Physical Exam (7/25) Flu Shot (7/25) EKG (7/25) and CT-Scan (7/25) Echocardiogram (7/26) Blood Work (7/28) MYCHART VISIT VITALS: Weight: 130 BMI: 22 Blood Pressure: 120/80 Pulse: 80 REASON FOR VISIT: Visit Renown.org for interactive map Heart Checkup WELLNESS CHECKLIST: Mammogram (Done 4/1) Pneumonia Shot (Due 9/1) Colonoscopy (Due 10/1) Eye Exam (Due 10/15) YOUR PROVIDER: MyChart.Renown.org HEALTHY LIVING TIPS: BestMedicineNews.org

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13 Subject: Hi Wendy, your healthcare statement is ready for review Wendy, you received services at Renown Health

14 PAY BY: August 25, 2016 WHO: Wendy Smith WHAT: Visit to Dr Levi and tests ordered WHEN: July 25, 2016 WHERE: 75 Pringle Use different payment method

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16 FINANCIAL STATEMENT This is your bill Patient Name: Wendy Smith Date of Birth: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: FINANCIAL SUMMARY: On July 25 th, you had an office visit with your heart doctor, Dr. Levi. Upon arrival, you paid a $25 copayment via your Visa ending in We billed your insurance $1420. We received a payment of $1350 on 7/28. The total remaining amount you will owe for this visit is $ Please note, you also have an outstanding balance of $100. Total amount owed is $ RESPONSIBILITY FOR THIS VISIT Service EKG, Echo, CT-scan Charged Amount Flu Shot $75.00 $ Lab Work Insurance Responsibility $75.00 $ You Owe $75.00 STATEMENTS DATE NOTES PAID AMOUNT 6/8 Prev Balance NO $ /25 New Balance NO $75.00 Office Visit $ TOTAL $ $ $ $75.00 YOU OWE:$ DUE: 8/25/2016 PAYMENT Online: Renown.org/PayNow Checks Payable to: Renown Health, PO BOX Los Angeles, CA Credit: Visa MasterCard Disc Amex Card Number: Exp Date: Signature: CVC Code: YEAR-TO-DATE SPENDING 2016 Out of Pocket Renown Spend $5,198 $1,056 $1,942 $2,200 Lab Office Visits Hospital BILLING QUESTIONS & PAYMENT PLANS:

17 FINANCIAL STATEMENT This is your bill Patient Name: Wendy Smith Date of Birth: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: FINANCIAL SUMMARY: On July 25 th, you had an office visit with your heart doctor, Dr. Levi. Upon arrival, you paid a $25 copayment via your Visa ending in We billed your insurance $1420. We received a payment of $1350 on 7/28. The total remaining amount you will owe for this visit is $ Please note, you also have an outstanding balance of $100. Total amount owed is $ RESPONSIBILITY FOR THIS VISIT YEAR-TO-DATE SPENDING Out-of-Pocket at Hometown Health Service EKG, Echo, CT-scan TOTAL Charged Amount Flu Shot $75.00 $ Lab Work Office Visit $ $ Insurance Responsibility $75.00 $ $ You Owe $75.00 $ $ Total Spend $5,198 STATEMENTS DATE NOTES PAID AMOUNT 6/8 Prev Balance NO 2016 Maximum $9,500 $ /25 New Balance NO $75.00 PAYMENT Online: Renown.org/PayNow Checks Payable to: Renown Health, PO BOX Los Angeles, CA Credit: Visa MasterCard Disc Amex Card Number: Exp Date: Signature: CVC Code: 7/25 Charged $ YES 7/25 Copayment YES Insurance 7/31 Payment YES $ Your 7/31 Responsibility NO $75.00 YOU OWE:$ DUE: 8/25/2016 $25.00 BILLING QUESTIONS & PAYMENT PLANS:

18 HEALTH SUMMARY Patient Name: Wendy Smith Date of Birth: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: HEALTH SUMMARY: On July 25 th, 2016 you had an office visit with your heart doctor, Dr. Levi. Dr. Levi assessed you in the clinic, performed an EKG, echocardiogram, and CT Scan to understand the health of your heart, adjusted your medications, and ordered lab tests to ensure your medications were working as planned. Heart Visit VISIT INFORMATION: Provider: Dr. Levi Dates: 7/25 Location: 75 Pringle Number of Visits Included: 1 CARE PROVIDED: Physical Exam (7/25) Flu Shot (7/25) EKG (7/25) and CT-Scan (7/25) Echocardiogram (7/26) Blood Work (7/28) MYCHART VISIT VITALS: Weight: 130 BMI: 22 Blood Pressure: 120/80 Pulse: 80 REASON FOR VISIT: Visit Renown.org for interactive map Heart Checkup WELLNESS CHECKLIST: Mammogram (Done 4/1) Pneumonia Shot (Due 9/1) Colonoscopy (Due 10/1) Eye Exam (Due 10/15) YOUR PROVIDER: MyChart.Renown.org HEALTHY LIVING TIPS: BestMedicineNews.org

19 FINANCIAL SUMMARY Yes Wendy, this is your bill. Patient Name: Wendy Smith Date of Birth: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: FINANCIAL SUMMARY: On July 25 th, you had an office visit with your heart doctor, Dr. Levi. Upon arrival, you paid a $25 copayment via your Visa ending in We billed your insurance $1420 and received a payment of $1350 on 7/28. The total remaining amount you will owe for this visit is $ Please note, you also have an outstanding balance of $100. Total amount owed is $ PATIENT RESPONSIBILITY YEAR-TO-DATE SPENDING Out-of-Pocket at Hometown Health Services Total Fee Flu Shot $75.00 Insurance Responsibility $75.00 You Owe 2016 Total Spend $5,198 EKG, Echo, CT-scan $ $ $75.00 BALANCE Lab Work Office Visit $ $ /14 YOU PAID $25.00 TOTAL $ $ $ /1 INSURANCE $ PAYMENT Online: Renown.org/PayNow Checks Payable to: Renown Health, PO BOX Los Angeles, CA Credit: Visa MasterCard Disc Amex Card Number: Exp Date: Signature: CVC Code: 6/15 $ PREVIOUS BALANCE CURRENT 7/25 $75.00 DUE YOU OWE:$ DUE: 8/25/2016 BILLING QUESTIONS & PAYMENT PLANS:

20 HEALTH SUMMARY Patient Name: Wendy Smith Date of Birth: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: HEALTH SUMMARY: On July 25 th, 2016 you had an office visit with your heart doctor, Dr. Levi. Dr. Levi assessed you in the clinic, performed an EKG, echocardiogram, and CT Scan to understand the health of your heart, adjusted your medications, and ordered lab tests to ensure your medications were working as planned. Heart Visit VISIT INFORMATION: Provider: Dr. Levi Dates: 7/25 Location: 75 Pringle Number of Visits Included: 1 CARE PROVIDED: Physical Exam (7/25) Flu Shot (7/25) EKG (7/25) and CT-Scan (7/25) Echocardiogram (7/26) Blood Work (7/28) MYCHART VISIT VITALS: Weight: 130 BMI: 22 Blood Pressure: 120/80 Pulse: 80 REASON FOR VISIT: Visit Renown.org for interactive map Heart Checkup WELLNESS CHECKLIST: Mammogram (Done 4/1) Pneumonia Shot (Due 9/1) Colonoscopy (Due 10/1) Eye Exam (Due 10/15) YOUR PROVIDER: MyChart.Renown.org HEALTHY LIVING TIPS: BestMedicineNews.org

21 FINANCIAL SUMMARY Patient Name: Wendy Smith Date of Birth: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: Hi Wendy! On July 25 th, 2016 you had an office visit with your heart doctor, Dr. Levi. Upon arrival, you paid your $25 copayment via your Visa card ending in We billed your insurance $350 and received a payment of $250 on 7/28. The total remaining amount you will owe is $ PATIENT RESPONSIBILITY YEAR-TO-DATE SPENDING Out-of-Pocket at Renown Services Total Fee Flu Shot Insurance Responsibility You Owe 2016 Total Spend $5,198 $2,200 EKG & X-Ray $ $25.00 $75.00 $1,942 Lab Work $1,056 Office Visit $ TOTAL $ $ ($25.00) $ $75.00 Lab Office Visits Hospital BILLING BREAKDOWN PATIENT RESPONSIBILITY (YOU OWE): $75 PAYMENTS 7/25 YOU PAID $ /25 INSURANCE $ ON 7/28 YOUR INSURANCE COMPANY PAID: $250 ON 7/25 YOUR COPAY PAID: $25 YOU OWE: DUE: 8/25/2016 $75.00 PAY ONLINE: Renown.org PAY BY CHECK: 1155 Mill St Reno, NV CUSTOMER SERVICE:

22 HEALTH SUMMARY Patient Name: Wendy Smith Date of Birth: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: Hi Wendy! On July 25 th, 2016 you had an office visit with your heart doctor, Dr. Levi. Dr. Levi assessed you in the clinic, performed an EKG to understand the health of your heart, adjusted your medications, and ordered lab tests to ensure your medications were working as planned. VISIT INFORMATION: Provider: Dr. Levi Dates: 7/25 Location: 75 Pringle Number of Visits Included: 1 CARE PROVIDED: Physical Exam Flu Shot EKG and X-Ray Blood Work TRACK MY VITALS: Weight: 130 BMI: 22 Blood Pressure: 120/80 Pulse: 80 REASON FOR VISIT: Visit Renown.org for interactive map Heart Checkup MYCHART.RENOWN.ORG WELLNESS CHECKLIST: Mammogram (Done 4/1) Pnemonia Shot (Due 9/1) Colonoscopy (Due 10/1) Eye Exam (Due 10/15) BESTMEDICINENEWS.ORG

23 FINANCIAL SUMMARY Patient Name: Wendy Smith Date of Birth: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: BILLING BREAKDOWN PATIENT RESPONSIBILITY PATIENT RESPONSIBILITY (YOU OWE): $75 Medication Flu Shot ON 7/28 YOUR INSURANCE COMPANY PAID: $250 ON 7/25 YOUR COPAY PAID: $25 EKG & X-Ray $ Lab Work Office Visit $ TOTAL $ YEAR-TO-DATE SPENDING PAYMENTS 2016 Total Spend $5,198 7/25 COPAY $25.00 $2,200 $1,942 7/25 INSURANCE $ $1,056 Lab Office Visits Hospital YOU OWE: $75.00 PAY ONLINE: Renown.org CHECK: 1155 Mill St Reno, NV CUSTOMER SERVICE:

24 HEALTH SUMMARY Patient Name: Wendy Smith Date of Birth: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: Hi Wendy! On July 25 th, 2016 you had an office visit with your heart doctor, Dr. Levi. Dr. Levi assessed you in the clinic, performed an EKG to understand the health of your heart, adjusted your medications, and ordered lab tests to ensure your medications were working as planned. VISIT INFORMATION Provider: Dr. Levi Dates: 7/25 Location: 75 Pringle Number of Visits Included: 1 CARE PROVIDED: Physical Exam Flu Shot EKG and X-Ray Blood Work TRACK MY VITALS: Weight: 130 BMI: 22 Blood Pressure: 120/80 Pulse: 80 REASON FOR VISIT: Visit Renown.org for interactive map Heart Checkup MYCHART.RENOWN.ORG WELLNESS CHECKLIST: Mammogram (Done 4/1) Flu Shot (Due 9/1) Colonoscopy (Due 10/1) Eye Exam (Due 10/15) BESTMEDICINENEWS.ORG

25 FINANCIAL SUMMARY NAME: John Smith DOB: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: BILLING BREAKDOWN: YOU OWE: $75 PATIENT RESPONSIBILITY: Based Upon Hometown Health Insurance: Medication Reconciliation Flu Shot YOU PREVIOUSLY PAID: $25 EKG and X-Ray Blood Work Office Visit $ ($25.00) -Paid YOUR INSURANCE COMPANY HAS PAID: $250 AMOUNT OWED FOR THIS SERVICE $75.00 ANNUAL SUMMARY: What You ve Actually Paid Renown PREVIOUS BALANCE: YOU OWE: $ $ DUE DATE: Aug 25 th, 2016 Lab Services: $1,500 Hospital: $1,800 Office Visits: $2,500 PAY NOW: Online: Renown.org/PayNow Check: 1155 Mill St Reno, NV RENOWN CUSTOMER SERVICE:

26 HEALTH SUMMARY NAME: John Smith DOB: 9/15/1951 Date of Service: 7/25/2016 SINGLE Account Number: Hi Wendy! On July 25 th, 2016 you had an office visit with your heart doctor, Dr. Levi. Dr. Levi assessed you in the clinic, performed an EKG to understand the health of your heart, adjusted your medications, and ordered lab tests to ensure your medications were working as planned. REASON FOR VISIT: Visit Renown.org for interactive map Heart Visit CARE PROVIDED: Medication Reconciliation (7/25) Flu Shot (7/25) Vitals, EKG, Chest X-Ray (7/26) Blood Work (7/26) Physical Exam (7/25) WENDY S Series WELLNESS 2LIST: 2016 Mammogram (Done 4/1) Flu Shot (Due 9/1) Colonoscopy (Due 10/1) Eye Exam (Due 10/15) ACCOUNT SUMMARY: Turn Page for Additional Detail PREVIOUS BALANCE: YOU OWE: AMOUNT OWED FOR THIS SERVICE $75.00 $ $ DUE DATE: Aug 25 th, 2016

27 Information, Layout and Aesthetic of Patient Bill Front Page Balance, Due Date and Statement Date are at the top, clear and prominent Patient Information and what was done is at the top, in bullets, and is easily understood A summary narrative, written in common language, explains exactly what has been billed, paid and is still owed Visit Charges, Patient Balance, and Account Status, detailing only absolutely necessary information, is displayed. Insurance payment, copayment, previous balance, and current patient balance are detailed, with most important numbers highlighted Patient Deductible, based upon insurance benefits, and current annual healthcare spend YTD, are outlined giving the patient up-to-date information as to the status of out-of-pocket spend. Visuals make the information easy to understand Payment Options, with easy to follow instructions and payment plans, clearly outline actions needed Prominent Contact Us information is outlined in the event of billing questions, financial assistance needs, and payment arrangements

28 Information, Layout and Aesthetic of Patient Bill Back Page An outline of the human body, with the area of focus for the patient s visit, is clearly and visually outlined. Patient Information and what was done is at the top, in bullets, and is easily understood A summary narrative, written in common language, explains exactly the care that was provided and the tests that were performed Visit Information, outlined in bullet points, defines the episode of care that the patient received Because patients receive care from many providers, Care Provided, lists all care that the patient received MyChart Visit Vitals are detailed For patient tracking, and for a reminder to log into Renown s Patient Portal Prominent Contact Us information is outlined in the event of nonurgent medical questions, or the desire for healthy living tips. Wellness Checklist, outlining all of the patients overdue health maintenance gaps in care, is listed and will be sent in with payment. Requests can be made for Renown Patient Outreach to contact the patient for scheduling.

29 Notification A very simple and inviting body makes it clear as to what the is requesting. The Visit Charges section outlines a very basic summary of their current and past due balance The Pay Now button allows the patient to pay their bill immediately without requesting additional information. The View Statement button allows the patient to view a detailed version of their Healthcare Statement

30 Design A Bill YOU Can Understand at Renown Health PAYMENT OPTIONS Summary Detail Full Information DEDUCTIBLE Summary Detail Full Information BILLING BREAKDOWN Summary Detail Full Information VISIT CHARGES Summary Detail Full Information

31 PAYMENTS Online: Renown.org/PayNow Phone: LEVEL 1 - SUMMARY LEVEL 2 DETAIL PAYMENT OPTIONS Online: Renown.org/PayNow Checks Payable to: Renown Health, PO BOX Los Angeles, CA Credit: Visa MasterCard Disc Amex Amount: Name: Card Number: Exp Date: Signature: CVC: Billing Questions and Payment Plans: LEVEL 3 FULL INFORMATION PAYMENT OPTIONS Online: Renown.org/PayNow Checks Payable to: Renown Health, PO BOX Los Angeles, CA Credit: Visa MasterCard Disc Amex Amount: Name: Card Number: Exp Date: Signature: CVC: EASY PAYMENT PLAN: Billing Questions and Payment Plans: Full Amount (10% Discount) Monthly for 3 Months Monthly for 6 Months Monthly for 12 Months Call to Discuss: Paperless Statements: YES NO

32 BILLING BREAKDOWN Insurance You Owe Copay LEVEL 1 - SUMMARY BILLING BREAKDOWN INSURANCE PAID: $1725 COPAYMENT PAID: $25 PREVIOUS BALANCE: $100 YOU OWE: $175 LEVEL 2 DETAIL BILLING BREAKDOWN PATIENT RESPONSIBILITY (YOU OWE): $75 LEVEL 3 FULL INFORMATION ON 7/28 YOUR INSURANCE COMPANY PAID: $1725 ON 7/25 YOUR COPAY PAID: $25

33 DEDUCTIBLE 2016 Total Spend $5, Deductible $9,500 LEVEL 1 - SUMMARY DEDUCTIBLE 2016 Total Spend $5,198 $1,300 Lab $3,000 Office Visits 2016 Deductible $9,500 $4,000 $1,056 $1,942 $2,200 Hospital LEVEL 2 DETAIL DEDUCTIBLE 2016 Total Spend $5, Deductible $9,500 $3,000 $4,000 LEVEL 3 FULL INFORMATION $1,300 $1,056 $1,942 $2,200 Lab Offic e Visits Hospital

34 LEVEL 1 SUMMARY VISIT CHARGES Flu Shot CT-Scan $ Lab Work Office Visit $25.00 TOTAL $ /25 Copayment -$25.00 This Visit Balance $75.00 Previous Balance $ You Owe $ Code Description Insurance You Owe Flu Shot $ CT-Scan $ $ Lab Work $ Office Visit $ $25.00 TOTAL $ $ /28 Insurance Payment -$ /25 - Copayment -$25.00 You Owe Copay Insurance VISIT CHARGES This Visit Balance $75.00 Previous Balance $ You Owe $ LEVEL 3 FULL INFO VISIT CHARGES LEVEL 2 DETAIL Service Code Service Description Charged Amount Discounted Amount Insurance Portion You Owe Flu Shot $ $75.00 $ CT-Scan $ $ $ $ Lab Work $ $ $ Office Visit $ $ $ $25.00 TOTAL $ $ $ $ YOU OWE: $75 7/28 - Insurance Payment -$ /25 - Copayment -$25.00 COPAY PAID PAID: $25 This Visit Balance $75.00 Previous Balance $ INSURANCE PAID: $1725 You Owe $175.00