Guarantor Name: Sample

Debtor Master Account:

INS015 AUTOMATED PAYMENT SYSTEM
Statement Date: May 2, 2012 Account Number: INS015
For 24-hour access to account information and to make
If you have any questions about your payment options, payments by check or credit card, please call (503) 581-1747.
financial assistance, health insurance or questions about this
bill, please call our Patient Service Team.

Account Summary
Number Patient Name Svc Date Balance
INS031 INS030
INS034 INS033
INS037 INS036
INS040 INS039
INS043 INS042
INS046 INS045
INS049 INS048
INS052 INS051
INS055 INS054
INS058 INS057

CONTACT INFORMATION
Visit Reason: INS012
Patient Service Team: (503) 581-1747
Telephone Hours: Mon to Thurs 8:00 AM - 6:00 PM
Friday 8:00 AM - 4:00 PM
Patient Financial 3300 State St.
Services Address: Salem, OR 97301
Office Hours: Mon to Friday 8:00 AM - 5:00 PM
Payment Address: PO Box 6990
Portland OR 97228-6990

Total Amount Due: $INS009

0

Make Arrangements Today

Your account(s) remains unpaid. We would appreciate your assistance in helping us resolve the balance
that is due. Please remit your payment upon receipt of this letter.

We are able to accept personal checks, American Express, Visa, Discover and Master Card. If mailing
in your payment, please use the detachable stub and envelope provided and write the account number on
your check.

Thank you for your prompt attention to this matter.

For information about this bill or to submit a payment please see the reverse side
** SEPARATE AND RETURN BOTTOM PORTION WITH YOUR PAYMENT **

REPRINT REQUESTED

Salem
Hospital PO
Box 6990
Portland OR 97228-
6990 RETURN SERVICE
 8-ONHONL10-30
1/06/10
Account Number: INS015
12345678-000000-03-0-AA

-YR1--REPRINT 8

Sample Debtor
1234 Main Salem
Street Hospital PO
Anytown MI Box 6990
48307 Portland OR 97228-6990
 UNDERSTANDING YOUR HOSPITAL BILL
Thank you for choosing Salem Hospital. We are dedicated to providing you with the finest in healthcare services. We
understand that healthcare billing is a complicated process that can leave you with many questions. Therefore, we
want to answer some of the more commonly asked questions.
Health Insurance:
Health insurance helps with many of the financial burdens of illness or injury, but it usually does not cover the entire
bill. Each time you visit Salem Hospital, you will be asked to furnish us with your current insurance information,
including any secondary insurance or Medicare supplemental insurance that you have. We can assist you by filing
your claim with your insurance company, but you are ultimately responsible for your account. So, it is important to
stay involved with your insurance company. You are expected to pay any deductible, co-pay and/or coinsurance
amounts, and any charges not covered under your insurance. If you have additional insurance information that has
not been billed, please contact us at (503) 581-1747.
Payment Options:
Payment for services is due upon receipt of the initial bill for self-pay accounts and upon receipt of the initial bill for
patient responsibility after an insurance company has paid. Payment options include: cash, check, money order, debit
card, American Express, Visa, Discover and Master Card. At any time you feel that you may have difficulty paying your
hospital bill, you are invited to call us. A Patient Service Team representative can discuss payment alternatives that
are available to you, including extended payment arrangements, financial assistance, and charity care
considerations.
Financial Assistance (Charity Care):
Financial assistance (charity care) are a part of the services provided by Salem Hospital. For those unable to pay for
necessary medical services, every effort will be made to assist you in obtaining help from public agencies. Those who do
not qualify for public funding may be considered for charity care. Sources of income and a financial statement may be
required in order to verify need. Any patient may apply. Please contact our Patient Service Team at the number listed
below for assistance. We can only assist you in applying for financial assistance or establishing a payment
arrangement if you contact us.
Billing Cycle:
An account number is assigned for each date of service. Once an account becomes patient responsibility, you will
receive a statement showing the balance due for each date of service. For your convenience, accounts that become the
patient's responsibility within 30 days of one another will automatically combine together and you will receive one
statement for multiple accounts. If another account becomes patient responsibility outside of those 30 days, it will not
automatically combine with the other accounts. However, you can contact our Patient Service Team and request to set
up a payment arrangement, and request that all accounts be combined together.
A representative from our Patient Service Team is available to assist you with any questions concerning your hospital
bill. Please call
(503) 581-1747 between the hours of 8:00AM and 7:00PM, Monday through Thursday and 8:00AM and 5:00PM on Friday,
or visit us in person at 3300 State Street in Salem between the hours of 8:00 am and 5:00 pm, Monday through Friday.

** SEPARATE AND RETURN BOTTOM PORTION WITH YOUR PAYMENT **

PAYMENT FORM
Guarantor Name
Sample Debtor
Apply to Account Number Payment Amount
INS015 $ .
Credit Card or Checking Account Number Expiration Date CCV2
/
Signature Check Payment Card The CCV2 number is
the last 3 or 4 digits on
the back of your
card by your
signature