Please make checks payable and remit to:Addressee
AMOUNT DUE:
APEX-341
$500.00
JON Q DOE
1234 MAIN ST
ALBERT LEA, USA 56007
001234567-1234 Jon Q. Doe 09/02/2017 09/16/2017
Please detach and return top portion with payment.
Page 1
001234567-1234 09/16/2017 $500.00
For Financial Assistance, See Back
Check if address/insurance changes are on back
Primary Insurance: BlueCross Secondary Insurance: Medicare
myEasyMatch Code: AAA-1BB-CCC
MESSAGES
For more information regarding our financial
assistance policies, please refer to the back of
this statement.
Sign up for eStatements
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Enroll today! emory.mysecurebill.com
One-Time Pay: emory.mysecurebill.com
myEasyMatch Code: AAA-1BB-CCC
Need a little more time to pay?
Call 404.686.7041 to arrange one today.
Flexible Payment Plans
Account Number Account Name Statement Date Due Date
EMORY HEALTHCARE
PO BOX 660827
DALLAS, TX 75266
Account Number Due Date Amount Due Amount Paid
$
For help with billing questions, please call:
(404) 686-7041 or (800) 827-7041
Office Hours:
Monday – Friday, 8:30am – 4:30pm
i
Date Service Description Charges
Payments/
Adjustments
Patient
Balance
PATIENT: JON Q. DOE
Encounter #: 001234567-1234 Billed By: John’s Creek Hospital
08/10/2017 PHARMACY GENERAL $100.00
08/10/2017 IV INFUSION HYDRATION ADD $200.00
08/10/2017 LABORATORY CHEMISTRY $200.00
Hospital Balance: $500.00
Your Medicare payer has remitted payment according to the benefits of your
plan. According to our records, there is currently a balance outstanding on your
account. If you have secondary insurance, please contact them regarding payment.
Otherwise, your payment is requested within 30 days. Your prompt payment is
appreciated. If payment has recently been made, please disregard this notice.
Hospital Charges
Messages
SEGMENT 5 – HIGH BALANCE – >9,999.00 – CYCLE 1
Hospital Statement
PO BOX 742436 | ATLANTA, GA 30384-2436
000000000000000000000000000000000000000
Your billing statement
has a new look!
A
myEasyMatch Code
This code is unique to each statement and must be used when making a payment online.
B
C
D
E
F
G
Your Statement
A summary explanation of the statement you’ve received. This section is important because the
message may vary with each statement you receive.
Insurance Information
Displays primary and secondary insurance name
and policy/id number we have for this account.
For Your Information
Provides information about obtaining nancial
assistance.
Contact Us
Explains how to contact the hospital by phone.
About You
How to notify us by mail of changes to patient
name, address, phone number and other
demographic information.
About Your Insurance
How to notify us by mail of changes/additions to
patient insurance information.
Emory Healthcare provides financial assistance for eligible patients who receive emergency or other medically necessary care
at Emory Healthcare and do not have the ability to pay for these services in whole or in part. If you are experiencing financial
hardship, please call 404-686-7041 or 1-800-827-7041 for Emory Hospitals to speak with a representative about the Financial
Assistance Policy for Emory Healthcare, or visit www.emoryhealthcare.org/patients-visitors/financial-assistance.html
Secondary Insurance Updates
Secondary Insured Name
Secondary Insurance Name
Secondary Insurance Street Address
City State ZIP Telephone
Employer Name Group Number
Subscriber ID # Policyholder’s Date of Birth
Primary Insurance Updates
Primary Insured Name
Primary Insurance Name
Primary Insurance Street Address
City State ZIP Telephone
Employer Name Group Number
Subscriber ID # Policyholder’s Date of Birth
Change of Address
Name (Last, First, Middle Initial)
Address
City State ZIP
Telephone
Credit Card Payment Options
Payment by Phone: Call us at 404.686.7041. Option 1
We Oer Interest Free Payment Plans
Call 404.686.7041 to arrange one today.
One-Time Payment Online: emory.mysecurebill.com
We accept the following cards:
Emory Johns Creek Hospital
Emory Rehabilitation Hospital
Emory Saint Joseph’s Hospital
Emory University Hospital
Emory University Hospital
at Wesley Woods
Emory University Hospital Midtown
Emory University Orthopaedics &
Spine Hospital
Appendix A to Part 92—Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Sample
Nondiscrimination Statement: Discrimination is Against the Law
Emory Healthcare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or
sex. [Name of covered entity] does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Emory Healthcare:
Provides free aids and services to people with disabilities to communicate effectivelywith us, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible electronicformats, other formats)
Provides free language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages
If you need these services, contact [Name of Civil Rights Coordinator]
If you believe that [Name of covered entity] has failed to provide these services or discriminated in another way on the basis of race, color, national origin,
age, disability, or sex, you can file a grievance with: [Name and Title of Civil Rights Coordinator], [Mailing Address], [Telephone number ], [TTY number—
if covered entity has one], [Fax], [Email]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, [Name and Title of
Civil Rights Coordinator] is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office
for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
The sample Emory Hospitals billing statement shows where to find important information about your
account. Please note the following features:
Thank you for choosing Emory Healthcare.
A
B
G
F
C
D
E
If you have an active Emory Hospitals account with discharge date before 1 September 2018, you will
continue to receive statements in the old format. Please follow payment instructions printed on the
statement you receive.
