The medical billing statement is a statement that is created by the health institutions for billing the service(s) provided to their respective patients. This is done so as to ensure and keep an account of the cash flow within the institution. This also serves as a record for all medical services provided and accounted for. Thus, because of its usefulness for future referenced, it is important that all details are filled in carefully. This statement is created towards the end when the patient is discharged. The medical billing statement should be constructed in a simple and easy-to-understand manner.

Sample Medical Billing Statement:

Name of Hospital: St. John’s Mercy Hospital

Patient’s Name: Ryan Panofsky

Patient’s Day of Discharge: 22/3/2011

Bank Account No.: 12456786

Bill to be paid within: 3/4/2011

Patient’s Insurance Information:

Policy Number: 23455667

Alternative Payment Method: Cash

Billing Done for:

The patient had been suffering from acute stomach ache and had been admitted to St. John’s Mercy Hospital on 1/3/2012. The x-ray and USG tests were done to reveal appendicitis and, Mr. Panofsky was operated on immediately. After surgery, the patient was given XYC medications and kept under strict observations till Dr. Matthews discharged him on 22/3/2011

The Medical billing statement shows additional expenses borne for cleaning, catering and other non-medical staff labor.

X Rays: $120

USG: $345

XYC Medications: $1200

Other medical charges: $400

The patient is requested to contact the Insurance Company for his preferred choice of payment.

Thank you for choosing St John’s Mercy for your medical needs.

Signature of Patient: _____________________