DOCUMENT OVERVIEW : This document may be used to release a patient from his/her financial obligation.


[inside address]


[-]months have passed since we last heard from you regarding your outstanding medical account balance.

We feel confident that if you could have paid this bill you would have done so. To reduce your financial burden, we are not going to send you any more bills for payment due.

We only ask that when your financial situation improves, you remember us with your payment.



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.