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Each Statement Form contains the same basic information, such as Statement Page Count, Office Address, Statement Account Address, Account Number, Statement Message, and Statement Date. Each statement will also have columns for Procedure Date, Description, Charges, and Payments/Credits. You can read more about these in our Statement Form Fields / Anatomy of a Statement article.
There are a few key differences among the Statement Forms:
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The Statement 2 Column form includes a Charges column and a Payments column along with a Patient total and an Insurance total.
Statement 2 Column is a Finance Charge Information form.
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Statement 2 Column/Installment Amount
The Statement 2 Column/Installment Amount form includes the same information as the Statement the Statement 2 Column formColumn form, but uses a Minimum Amount Due Total in addition to the Patient Portion total and Insurance Portion total.
Statement 2 Column/Installment Amount is a Finance Charge Information form.
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In addition to the information listed on the Statement the Statement 2 Column, Statement 4 Column includes Insurance and Patient Column includes Insurance and Patient Portion columns. The resulting column order is Insurance Portion, Patient Portion, Charges, and Payments.
Statement 4 Column is a Finance Charge Information form.
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The Statement 4 Column/Installment Amount form includes the same information as the Statement the Statement 4 Column formColumn form, but uses a Minimum Amount Due Total in addition to the Patient Portion Total and Insurance Portion Total.
Statement 4 Column/Installment Amount is a Finance Charge Information form.
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Statement 5 Column
In addition to the information listed on the Statement the Statement 4 Column, Statement 5 Column includes a Balance column to add a running total for each statement item. The column order has also been formatted to put the Payments column next to the Balance column. The resulting column order is Charges, Insurance Pending, Patient Portion, and Payments/Credits, and Balance.
Statement 5 Column is a Finance Charge Information form.
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The Statement 5 Column CC form includes the same information as the Statement 5 Column, but replaces the Finance Charge information with Credit Card information.
Statement 5 Column CC is a Credit Card Information form.
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The Statement 5 Column/Installment Amount form includes the same information as the Statement the Statement 5 Column formColumn form, but uses a Minimum Amount Due total in addition to the Patient Portion Total and Insurance Pending Total.
Statement 5 Column/Installment Amount is a Finance Charge Information form.
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Statement 5 Column CC/Installment Amount
The Statement 5 Column CC/Installment Amount form is a combination of the Statement the Statement 5 Column CC and Statement CC and Statement 5 Column/Installment Amount formsAmount forms, including both the Credit Card Information and the Minimum Amount Due total in addition to the Patient Portion Total and Insurance Pending Total.
Statement 5 Column CC/Installment Amount is a Credit Card Information form.
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The Statement CC (Credit Card) form presents a visual and format departure from the previous forms, but offers essentially the same information with the addition of Credit Card Information. The resulting order of the columns is Patient is Patient Name, Provider Provider, Charges, Credits, and Balance.
Statement CC is a Credit Card Information form.
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The Statement CC/Installment Amount form includes the same information as the Statement CC form, but uses a Minimum Due total in addition to the Total Balance.
Statement CC/Installment Amount is a Credit Card Information form.
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The Statement Code and Diagnosis form includes columns for for Code and Diagnosis. Additional columns include Patient include Patient Name, Provider, Charges, Credits, and Balance.
Statement Code and Diagnosis is a Finance Charge Information form.
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The Statement Code and Diagnosis/Installment Amount form includes the same information as the Statement the Statement Code and Diagnosis formDiagnosis form, but uses a Minimum Due total in addition to the Total Balance.
Statement Code and Diagnosis/Installment Amount is a Finance Charge Information form.
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Statement Expected Insurance
The Statement Expected Insurance form adds an Expected Insurance column to the statement along with an Expected Insurance Total in an Expected Insurance Total in the Total box. The Total box also includes totals for the Grand Total and Please Pay This Amount Total.
Statement Expected Insurance is a Finance a Finance Charge Information form.
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Statement Expected Insurance/Installment Amount
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Statement Expected Insurance/Installment Amount is a Finance a Finance Charge Information form.
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Statement FC CC
The Statement FC CC (Finance Charge Credit Card) statement form includes the same information as the Statement CC form: Patient Patient Name, Provider, Charges, Credits, and Balance Columns, with the addition of Finance Charge Information.
Statement FC CC is a Finance a Finance Charge Information form and a Credit Card Information form.
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The Statement FC CC/Installment Amount form includes the same information as the Statement the Statement FC CC formCC form, but uses a Minimum Due total in addition to the Total Balance.
Statement FC CC is a Finance a Finance Charge Information form and a Credit Card Information form.
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The Statement Pending Insurance form adds a Pending Insurance column to the statement along with a Pending Insurance total in the Total box.
Statement Pending Insurance is a Finance a Finance Charge Information form and a Credit Card Information form.
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The Statement Pending Insurance/Installment Amount form includes the same information as the Statement the Statement Pending Insurance formInsurance form, but uses a Minimum Due total in addition to the Total Balance.
Statement Pending Insurance/Installment Amount is a Finance Charge Information form and a Credit Card Information form.
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