STATEMENT OF ACCOUNT Page 1 Creekside Orthopaedics Account Number: 0011001111 123 fake street Statement Date: 01/11/2012 Orem, UT 84058 Payment Enclosed:____________ JANET P SMITH 123 FAKE STREET Orem, UT 84058 Date For Description Ref. Charges Credits -------- ------------- ------------------------- ------- ----------- ----------- 08112011 JANET DESCRIPTION LINE 1 654321 0.00 DESCRIPTION LINE 2 08112011 JANET DESCRIPTION LINE 1 654321 84.08 DESCRIPTION LINE 2 09192011 JANET DESCRIPTION LINE 1 654321 -30.18 DESCRIPTION LINE 2 09192011 JANET DESCRIPTION LINE 1 654321 -46.36 DESCRIPTION LINE 2 09272011 JANET DESCRIPTION LINE 1 654321 0.00 DESCRIPTION LINE 2 09272011 JANET DESCRIPTION LINE 1 654321 -7.54 DESCRIPTION LINE 2 01092012 JANET DESCRIPTION LINE 1 654321 30.72 DESCRIPTION LINE 2 01092012 JANET DESCRIPTION LINE 1 654321 -0.54 DESCRIPTION LINE 2 -------------------------------------------------------------------------------- PATIENT TOTAL BALANCE PENDING AT INSURANCE PATIENT BALANCE DUE $30.18 $0.00 $30.18 IF YOU CAN'T PAY THE BALANCE IN FULL, PLEASE CONTACT OUR OFFICE. Current Past Due Past Due Past Due Past Due 0 - 30 31 - 60 61 - 90 91 - 120 > 121 Balance Due ----------- ----------- ----------- ----------- ----------- ----------- $30.18 $0.00 $0.00 $0.00 $0.00 $30.18 =========== =========== =========== =========== =========== =========== STATEMENT OF ACCOUNT Page 1 Creekside Orthopaedics Account Number: 0111111000 123 fake street Statement Date: 01/11/2012 OREM, UT 84058 Payment Enclosed:____________ JOHN DOE JR. 123 Fake Dr. OREM, UT 84058 Date For Description Ref. Charges Credits -------- ------------- ------------------------- ------- ----------- ----------- 01092012 JOHN REVERSE ADJUSTMENT 123456 998.85 DESCRIPTION $$$ 01092012 JOHN REVERSE ADJUSTMENT 123456 577.58 DESCRIPTION $$$ -------------------------------------------------------------------------------- PATIENT TOTAL BALANCE PENDING AT INSURANCE PATIENT BALANCE DUE $1576.43 $0.00 $1576.43 IF YOU CAN'T PAY THE BALANCE IN FULL, PLEASE CONTACT OUR OFFICE. YOUR ACCOUNT IS AT RISK FOR COLLECTIONS Current Past Due Past Due Past Due Past Due 0 - 30 31 - 60 61 - 90 91 - 120 > 121 Balance Due ----------- ----------- ----------- ----------- ----------- ----------- $0.00 $0.00 $0.00 $0.00 $1576.43 $1576.43 =========== =========== =========== =========== =========== ===========