Your Billing Statement

Front of Statement

A. Customer Number

B. Responsible party’s name and address

C. Summary of the account (This shows all charges, payments and balances on the statement)

D. Personal message will change based on the content of the statement

E. myChart authorization number (An authorization number is generated only if you do not have an active myChart account)

F. Payment options myChart, mail or phone

G. Information needed for paying with credit card (Complete only if paying with credit card by mail)

H. Amount due with this statement

I. Address to mail payments (check, money order, or credit card information)

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Back of Statement

J. Lakeland Health offers short term payment plan options. (Long term payment options are offered through a loan program)

K. Accounts on a Payment Plan (This shows all accounts on a Lakeland Health payment plan. Each additional account needs to be added by calling the business office. New accounts will not be
automatically added.)

L. Account balances, monthly payment, and number of payments left on the arrangement

M. Current amount due for the payment plans

N. Final Notice on past due accounts (These accounts have been on previous statements)

O. Location and name of the Provider

P. Charge per service

Q. Insurance payments and adjustments

R. Patient payments/adjustments (Payments made by the patient and any patient adjustments are listed here)

S. Balance due from patient for this visit

T. Description of services and insurance payments (Detailed description of office visits, or procedures may be listed here. Charges for reading images may be a separate charge, as well as visits from specialist while in the hospital)

U. Insurance balances (Balances still at insurance for processing at the time of the statement’s release will be listed here)

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