Itemized Statement/bill Description
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1Forensic Interview
Itemized Statement/Bill Description
an itemized statement/bill. To proceed with the verification process, the bill MUST BE ITEMIZED.
Therefore, please send a bill that provides the following information:
2. Patient
1. Provider(s) name, address and phone number
Name/Acct.
1. Provider
Number
Information
2. Victim’s Name
3. Date of Service (actual date of interview)
Patient Name:
ABC Hospital, LLC
Jane Doe
1234 Your Street
4. Description of the service provided (e.g. Forensic
Account Number:
Anywhere, Georgia 30005
Interview)
123
(404) 555-4455 phone
(404) 555-5544 fax
5. Usual and Customary Charge for interview.
Date of Service
Description/Code
Amount
07/01/2011
Forensic Interview
$ 200.00
6. Total charges
3. Dates of
Service
4. Description of
Service
Total Charges $200.00
5. Cost per
Service
6. Total Charge
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