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DOCUMENT OVERVIEW : This document may be used internally by medical staff to help determine the financial viability of a patient. Effective patient financial viability assessment can facilitate enhanced medical billing.

_______________________________________    ___________________________

Name of patient

Balance due

____________

Date of last patient visit

Reason for nonpayment or for lack of contact:

Patient is deceased

Patient refused to pay

Post returned

Payment is late or not paid in ___ months

Patient’s telephone is disconnected or number changed

Patient moved out-of-state

Other:

Telephone contact: Yes No

Dates of telephone contact:__________________________________________________

Discussed a payment plan with patient: Yes No Highlights of discussion:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Which collection letters were sent? ___________________________________________

Have all payments from insurance company been received?

Yes No

Amount outstanding ______________

How old is bill? ______________

Staff recommendation:

 

 

 

Write off

Settle for partial payment

Send to collection

Physician’s recommendation:

 

 

 

Write off

Settle for partial payment

Send to collection

Terminate care?

Yes

No

 

 

__________________________________________

________________________

Signature of physician

 

 

Date

This document is provided to you as a courtesy by PGM Billing, a full service medical billing company.

This document is free to use it for personal or office use; however, may not be reproduced, transferred, sold, used for financial gain, or circulated in the public domain, without prior written authorization from

PGM Billing.