Sample Bill

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Finance Assistance - Options for requesting Financial Assistance on account balancesGuarantor – Name and address of the person who is financially responsible for the bill

MyChart allows you to connect with your doctor and manage your health information online, anytime. You can also access your information without signing up for MyChart using the QR code to the right.


If you have a current payment plan, you will find the payment plan detail in this space.

Payment Plan Details
Self Pay Balance: $1,948.31
Payment Plan Balance: $1,948.31
Payment Plan Monthly Amount: $162.36
Number of Remaining Payments: 12
Next Payment Due: 10/30/21

This page of the statement will provide the detail for the Amount Due/Pay This Amount for this statement. The patient name, payments/adjustments, as well as any remaining patient balance(s) are listed for each account.


If a payment plan has been set up, the payment plan summary for these accounts will be listed.