This is a letter to a patient who has received a courtesy letting them know that their claim was filed electronically. This is a letter to a patient who has received a professional courtesy that resulted in a reduced fee.
This is a letter to a patient who has received a courtesy letting them know that their claim was filed electronically.
Account # MA 8674
INCLUDE YOUR ACCOUNT # ON ALL CORRESPONDENCE
Jill Bennett, M.D. PC 08/02/2010
P.O. BOX 2759
Islip, NY 11751
800-828-2837 / 631-158-6030 Phone Hrs: Mon-Fri 10 AM To 1 PM
Richard/Marion Hall
35 Dover Lane
Bay Shore, NY 11706
For anesthesia or related services at Good Samaritan Medical Center
1000 Montauk Highway, West Islip, NY 11795
To Marion Hall On 07/06/2010 Amount $1,615.00
Payments received to date $1,502.40
Balance Due $112.60
A claim has been submitted electronically to your carrier for this service and we expect payment to be made shortly.
If you have no other coverage and the primary carrier has paid the claim correctly, the insurance payment will be accepted as payment in full. However, you are responsible for any deductible amount applied against the claim.
If you have secondary insurance coverage, please contact our office with the filing information or send us a completed form assigned to pay the doctor directly.
Should the insurance benefit go to you directly, please send the payment received to our office with a copy of the explanation of benefits.
This is a letter to a patient who has received a professional courtesy that resulted in a reduced fee.
Account # MA 8674
INCLUDE YOUR ACCOUNT # ON ALL CORRESPONDENCE
Jill Bennett, M.D. PC 08/02/2010
P.O. BOX 2759
Islip, NY 11751
800-828-2837 / 631-158-6030 Phone Hrs: Mon-Fri 10 AM To 1 PM
Richard/Marion Hall
35 Dover Lane
Bay Shore, NY 11706
For anesthesia or related services at Good Samaritan Medical Center
1000 Montauk Highway, West Islip, NY 11795
To Marion Hall On 07/06/2010 Amount $1,615.00
Payments received to date $1,502.40
Balance Due $112.60
Please contact our office with the information necessary to file a claim for this service or send us a completed form assigned to pay the doctor directly.
Your insurance company is being billed our usual and customary fee. As a courtesy to you, the doctor will accept $______ as payment in full in the event your insurance carrier does not pay the full fee. However, all insurance proceeds over and above this amount belong to the doctor.
If your insurance carrier pays less than the minimum charge, you will be responsible for the difference between their payment and the balance.
If you have any questions please call our office.
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