pdf

DOCUMENT OVERVIEW : This document may used for patient balances on services rendered more than 60 days from the time of service. It is recommended that this document be used in the early stages of the reimbursement / medical billing cycle.

[date]

[inside address]

Dear [name]:

It has been more than [—] months since we filed your insurance claim with your provider. However, your provider has made no payment.

In addition, we contacted your insurance company for the status of your claim. To date, we have had no response to any of our inquiries. Our policy is to await payment from insurers for [—] days.

Although we have tried to collect payment from your insurance company, you will now have to pursue this matter directly with [name of insurance company].

Please mail us a check today for [$—]. A preaddressed stamped envelope is enclosed for your convenience. Or call us with credit card information and we can transfer the balance to the credit card of your choice.

Please call me at [telephone number] so that we may finalize this matter without delay.

Sincerely,

[name]

Enclosure

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.