For customer service or to

Froedtert Hospital INVOICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%M R'xt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €1W g $T8ES.exl#V
€ZYe.SdU?j$b&7dwj,+
q1Q1Q1q1Qq1qq1QQ1Q1Q
PRIMARY INSURANCE SECONDARY INSURANCE
ANTHEM NO INSURANCE ON FILE

SERVICE INS PMTS PATIENT BALANCE

DATE PATIENT DESCRIPTION CHARGES & ADJS PMTS DUE
11/19/13 JOHN ACCOUNT # 00000 $2,427.00 -$2,028.97 $0.00 $398.03
SAMPLE CDI MAYFAIR
OUTPATIENT

Important Message:
Only accounts that currently have a patient due balance are shown on this invoice. Please Please Pay This Amount by
call us at the phone number listed above if you would like an itemized statement. This 01/30/14
invoice reflects charges for hospital services only. Physician charges will be billed separately
by the Medical College of Wisconsin. Please see reverse side for additional information. $398.03
PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3202, MILWAUKEE, WI 53201-3202

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

Froedtert Hospital 00001 q q q
P.O. BOX 6545 CARD NUMBER AMOUNT
Madison, WI 53716-0545
SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # INVOICE AMT DUE

00000 3302 01/09/14 00000 $398.03
Please check box if address is incorrect or insurance information has changed,
and indicate change(s) on reverse side.

ƒ„ƒ‚ƒƒ„„ƒ‚‚ƒ„ƒ‚„ƒƒƒƒƒ‚‚„ƒƒ„„„ƒƒ„ƒ„ƒƒ„ƒ„‚‚ƒ‚‚‚‚‚ƒƒ
‚ƒƒ„‚„‚„‚„ƒ‚ƒ„„‚ƒ„ƒ„‚„„ƒ„‚‚„ƒ‚„ƒ„„‚‚ƒ„„‚„„„ƒ‚‚‚„„ƒ„

12345-09A*#2*****************************SINGLE-PIECE
JOHN Q SAMPLE Froedtert Hospital
123 ANY STREET P.O. Box 3202
ANYTOWN US 12345
Milwaukee WI 53201-3202

0000 1000006001055905 0039803 0000000 0000000000 2

1
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
2
 For customer service or to

Froedtert Hospital FINAL NOTICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%M R'xt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €5S g $Q6MyW-s4Gb!V
€ZZd#L@P<bsDpJ;U]' )+
qQqQ1q1Q1Q1qqQQQ1Q
PRIMARY INSURANCE SECONDARY INSURANCE
MEDICARE NO INSURANCE ON FILE

SERVICE INS PMTS PATIENT BALANCE

DATE PATIENT DESCRIPTION CHARGES & ADJS PMTS DUE
09/07/13 - JOHN ACCOUNT # 00000 $112,464.00 -$111,280.00 $0.00 $1,184.00
09/18/13 SAMPLE

TOTAL BALANCE DUE = $1,184.00

After repeated requests for payment on your past due account(s) there continues to be an outstanding balance of $1,184.00. If the balance in full is not
received within 10 days your account(s) will be referred to a collection agency for further collection action.

Mail payment in full today or contact our office toll free at 800-803-8155 to arrange payment over the phone. If you would like to make a payment using
Visa, MasterCard or Discover, please visit us at Froedtert.com. A $25.00 service fee will be charged for any checks returned.

This letter only applies to the balance(s) stated above. You may receive additional letters if you have other outstanding accounts. Please disregard this
notice if the balance in full has been recently mailed.

This notice may not include all outstanding accounts.

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3202, MILWAUKEE, WI 53201-3202

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

Froedtert Hospital 00002 q q q
P.O. BOX 6545 CARD NUMBER AMOUNT
Madison, WI 53716-0545
SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # BALANCE DUE

00000 3310 01/09/14 00000 $1,184.00
Please check box if address is incorrect or insurance information has changed,
and indicate change(s) on reverse side.

ƒ„ƒƒ„„„ƒ‚„„ƒƒ‚ƒƒ‚„‚„„‚‚ƒ‚‚‚ƒƒ„ƒ‚„„„ƒƒ„ƒƒƒƒ‚‚ƒ
‚ƒƒ„‚„‚„‚„ƒ‚ƒ„„‚ƒ„ƒ„‚„„ƒ„‚‚„ƒ‚„ƒ„„‚‚ƒ„„‚„„„ƒ‚‚‚„„ƒ„

12345-09A*2*****************************SINGLE-PIECE
JOHN Q SAMPLE Froedtert Hospital
123 ANY STREET P.O. Box 3202
ANYTOWN US 12345
Milwaukee WI 53201-3202

0000 1000006000882441 0118400 0000000 0000000000 8

3
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
4
 For customer service or to

Froedtert Hospital REMINDER NOTICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%M R'xt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €5W g $R;K~Q+se!wl!V
€Y`b)Q0/gr_n>ETV,+
q1Q1q1qQ1qqQQqQ1Q

SERVICE INS PMTS PATIENT BALANCE

DATE PATIENT DESCRIPTION CHARGES & ADJS PMTS DUE
02/14/13 JOHN ACCOUNT # 00000 $2,474.00 -$944.00 -$983.52 $546.48
SAMPLE

03/22/13 JOHN ACCOUNT # 00000 $2,474.00 -$2,168.00 $0.00 $306.00

SAMPLE

CURRENT PAYMENT DUE = $109.28

TOTAL BALANCE DUE = $852.48

This is just a friendly reminder of your scheduled payment. Your payment of $109.28 is expected in our office by 01/23/14. For your
convenience, please use the enclosed envelope or call toll-free 800-803-8155 to make payment by phone. If you would like to make a
payment online using Visa, MasterCard or Discover, please visit us at Froedtert.com. A $25.00 service fee will be charged for any checks
returned.

Please be reminded that late or missed payments will result in the cancellation of this agreement and may result in further collection
activity. Additional outstanding accounts not included in this agreement are not reflected in this statement.

This notice may not include all outstanding accounts.

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3202, MILWAUKEE, WI 53201-3202

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

Froedtert Hospital 00003 q q q
P.O. BOX 6545 CARD NUMBER AMOUNT
Madison, WI 53716-0545
SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # PAYMENT DUE

00000 3304 01/09/14 00000 $109.28
Please check box if address is incorrect or insurance information has changed,
and indicate change(s) on reverse side.

ƒ‚ƒƒƒ‚„‚‚‚„ƒ„„„‚ƒ‚ƒƒƒ„ƒƒ‚ƒƒƒƒƒ„ƒ„ƒ‚„„„„ƒ‚ƒ‚‚‚„‚„
‚ƒƒ„‚„‚„‚„ƒ‚ƒ„„‚ƒ„ƒ„‚„„ƒ„‚‚„ƒ‚„ƒ„„‚‚ƒ„„‚„„„ƒ‚‚‚„„ƒ„

12345-09A*2*****************************SINGLE-PIECE
JOHN Q SAMPLE Froedtert Hospital
123 ANY STREET P.O. Box 3202
ANYTOWN US 12345
Milwaukee WI 53201-3202

0000 1000006000430999 0010928 0000000 0000000000 4

5
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
6
 For customer service or to

Froedtert Hospital INVOICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%M R'xt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €5S g $R5B|T)j}NB!V
€YYf:[]Sp}U€,Gk*n ++
qqqqQ11qQQQqqQQ1Q
PRIMARY INSURANCE SECONDARY INSURANCE
NO INSURANCE ON FILE NO INSURANCE ON FILE

SERVICE SELF PAY PMTS & BALANCE

DATE PATIENT DESCRIPTION CHARGES DISCOUNT ADJS DUE
11/19/13 - JOHN ACCOUNT # 00000 $8,482.96 -$1696.59 $0.00 $6,786.37
11/20/13 SAMPLE HOSPITALIST
OUTPATIENT

Important Message:
If you would like an itemized bill, please call us at the number above. This invoice
reflects charges for hospital services only. Physician charges will be billed separately by Please Pay This Amount by
the Medical College of Wisconsin. Please see reverse side for additional information. 01/30/14
$6,786.37
PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3202, MILWAUKEE, WI 53201-3202

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

Froedtert Hospital 00004 q q q
P.O. BOX 6545 CARD NUMBER AMOUNT
Madison, WI 53716-0545
SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # INVOICE AMT DUE

00000 3301 01/09/14 00000 $6,786.37
Please check box if address is incorrect or insurance information has changed,
and indicate change(s) on reverse side.

„‚‚„„ƒƒƒ‚ƒ‚ƒƒ„‚ƒ‚„„ƒ„ƒ‚‚„ƒ‚„ƒ„„‚‚ƒ‚ƒ„„ƒƒ‚„
‚ƒƒ„‚„‚„‚„ƒ‚ƒ„„‚ƒ„ƒ„‚„„ƒ„‚‚„ƒ‚„ƒ„„‚‚ƒ„„‚„„„ƒ‚‚‚„„ƒ„

12345-09A*2*****************************SINGLE-PIECE
JOHN Q SAMPLE Froedtert Hospital
123 ANY STREET P.O. Box 3202
ANYTOWN US 12345
Milwaukee WI 53201-3202

0000 1000006001053025 0678637 0000000 0000000000 8

7
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
8
 NOTICE OF MISSED For customer service or to
make a payment please call
Froedtert Hospital PAYMENT 800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%M R'xt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €5W g $Q<HV/jg~L!V
€Z_h4BM4Ho*Ncn '*+
q1QQ11qQQQqqQqQQQ1Q

SERVICE INS PMTS PATIENT BALANCE

DATE PATIENT DESCRIPTION CHARGES & ADJS PMTS DUE
03/08/13 JOHN ACCOUNT # 00000 $3,486.74 -$2,073.16 -$708.00 $705.58
SAMPLE

CURRENT PAYMENT DUE = $118.00

TOTAL BALANCE DUE = $705.58

We previously agreed to a payment plan with you. We have not received your payment of $118.00 that was due on 12/21/13. Please
mail your payment in the enclosed envelope immediately to prevent cancellation of your payment plan or call toll free at 800-803-8155 to
make payment by phone. If you would like to make a payment online using Visa, MasterCard or Discover, please visit us at Froedtert.com.
A $25.00 service fee will be charged for any checks returned.

As explained when the payment plan was made, late or missed payment will result in the payment plan being cancelled. Please send
payment today.
This notice may not include all outstanding accounts.

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3202, MILWAUKEE, WI 53201-3202

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

Froedtert Hospital 00005 q q q
P.O. BOX 6545 CARD NUMBER AMOUNT
Madison, WI 53716-0545
SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # PAYMENT DUE

00000 3305 01/09/14 00000 $118.00
Please check box if address is incorrect or insurance information has changed,
and indicate change(s) on reverse side.

„ƒ„‚„„‚„„„‚ƒ„„ƒƒƒ‚„ƒ„„ƒ‚ƒ‚‚ƒ‚„ƒ„ƒƒ‚ƒ„„„„ƒƒ„ƒ„ƒ‚‚
‚ƒƒ„‚„‚„‚„ƒ‚ƒ„„‚ƒ„ƒ„‚„„ƒ„‚‚„ƒ‚„ƒ„„‚‚ƒ„„‚„„„ƒ‚‚‚„„ƒ„

12345-09A*2*****************************SINGLE-PIECE
JOHN Q SAMPLE Froedtert Hospital
123 ANY STREET P.O. Box 3202
ANYTOWN US 12345
Milwaukee WI 53201-3202

0000 1000006000478812 0070558 0000000 0000000000 3

9
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
10
 For customer service or to

Froedtert Hospital FINAL NOTICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%N Q'xt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €1[ g $T<F{R.z|F'V
€Y]e2A UigN>yQr,+
qQQQ111Q11q1QQqqQ1Q
PRIMARY INSURANCE SECONDARY INSURANCE
HUMANA MEDICARE NO INSURANCE ON FILE

SERVICE INS PMTS PATIENT BALANCE

DATE PATIENT DESCRIPTION CHARGES & ADJS PMTS DUE
09/16/13 JOHN ACCOUNT # 00000 $2,928.00 -$2,871.23 $0.00 $56.77
SAMPLE
09/20/13 JOHN ACCOUNT # 00000 $3,397.00 -$3,336.55 $0.00 $60.45
SAMPLE

09/25/13 JOHN ACCOUNT # 00000 $2,874.00 -$2,821.65 $0.00 $52.35

SAMPLE

CONTINUED ON NEXT PAGE ---->

After repeated requests for payment on your past due account(s) there continues to be an outstanding balance of $267.54. If the balance in full is not
received within 10 days your account(s) will be referred to a collection agency for further collection action.

Mail payment in full today or contact our office toll free at 800-803-8155 to arrange payment over the phone. If you would like to make a payment using
Visa, MasterCard or Discover, please visit us at Froedtert.com. A $25.00 service fee will be charged for any checks returned.

This letter only applies to the balance(s) stated above. You may receive additional letters if you have other outstanding accounts. Please disregard this
notice if the balance in full has been recently mailed.

This notice may not include all outstanding accounts.

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3202, MILWAUKEE, WI 53201-3202

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

Froedtert Hospital 00006 q q q
P.O. BOX 6545 CARD NUMBER AMOUNT
Madison, WI 53716-0545
SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # BALANCE DUE

00000 3310 01/09/14 00000 $267.54
Please check box if address is incorrect or insurance information has changed,
and indicate change(s) on reverse side.

ƒƒƒ‚ƒ„„ƒ‚ƒƒ„‚„ƒ‚ƒ‚„ƒƒƒ„ƒ„ƒƒƒ„‚‚„‚„„‚„ƒ‚„‚‚ƒ‚„„ƒ
‚ƒƒ„‚„‚„‚„ƒ‚ƒ„„‚ƒ„ƒ„‚„„ƒ„‚‚„ƒ‚„ƒ„„‚‚ƒ„„‚„„„ƒ‚‚‚„„ƒ„

12345-09A*2*****************************SINGLE-PIECE
JOHN Q SAMPLE Froedtert Hospital
123 ANY STREET P.O. Box 3202
ANYTOWN US 12345
Milwaukee WI 53201-3202

Page 1 of 2
0000 1000006000902234 0026754 0000000 0000000000 0
11
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
12
 For customer service or to

Froedtert Hospital FINAL NOTICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%N U#tt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €1[ g $Q9A~X0}cSJ%V
€Y_b!X'C^%bD`dWs3o++
qqqQ111QqqqQqqQ1Q
PRIMARY INSURANCE SECONDARY INSURANCE
HUMANA MEDICARE NO INSURANCE ON FILE

SERVICE INS PMTS PATIENT BALANCE

DATE PATIENT DESCRIPTION CHARGES & ADJS PMTS DUE
09/26/13 JOHN ACCOUNT # 00000 $2,734.00 -$2,696.48 $0.00 $37.52
SAMPLE

09/27/13 JOHN ACCOUNT # 00000 $3,397.00 -$3,336.55 $0.00 $60.45

SAMPLE

TOTAL BALANCE DUE = $267.54

Please Pay This Amount by

Important Message:
Only accounts that currently have a patient due balance are shown above. Please call us at the
phone number listed above if you would like an itemized statement. $267.54

Page 2 of 2 00023
13
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
14
 For customer service or to

Froedtert Hospital REMINDER NOTICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%N Q'xt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €1_ g $S5D€X,zb 3P'V
€Z[g<\c
€%€A)+
qQq1Q111q1q1QqQQ1Q

SERVICE INS PMTS PATIENT BALANCE

DATE PATIENT DESCRIPTION CHARGES & ADJS PMTS DUE
12/04/12 JOHN ACCOUNT # 00000 $6,567.63 -$6,116.92 -$249.67 $201.04
SAMPLE

01/29/13 JOHN ACCOUNT # 00000 $6,761.01 -$6,295.88 $0.00 $465.13

SAMPLE

06/05/13 JOHN ACCOUNT # 00000 $7,023.92 -$6,549.41 $0.00 $474.51

SAMPLE

04/02/13 JOHN ACCOUNT # 00000 $6,610.42 -$6,143.71 $0.00 $466.71

SAMPLE

07/31/13 JOHN ACCOUNT # 00000 $7,179.04 -$6,702.78 $0.00 $476.26

SAMPLE

CONTINUED ON NEXT PAGE ---->

This is just a friendly reminder of your scheduled payment. Your payment of $215.00 is expected in our office by 01/23/14. For your
convenience, please use the enclosed envelope or call toll-free 800-803-8155 to make payment by phone. If you would like to make a
payment online using Visa, MasterCard or Discover, please visit us at Froedtert.com. A $25.00 service fee will be charged for any checks
returned.

Please be reminded that late or missed payments will result in the cancellation of this agreement and may result in further collection
activity. Additional outstanding accounts not included in this agreement are not reflected in this statement.

This notice may not include all outstanding accounts.

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3202, MILWAUKEE, WI 53201-3202

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

Froedtert Hospital 00007 q q q
P.O. BOX 6545 CARD NUMBER AMOUNT
Madison, WI 53716-0545
SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # PAYMENT DUE

00000 3304 01/09/14 00000 $215.00
Please check box if address is incorrect or insurance information has changed,
and indicate change(s) on reverse side.

ƒƒƒ„ƒ‚„„„‚„ƒƒƒ„ƒ„‚‚‚‚‚‚‚‚ƒ„‚‚‚ƒ‚„‚„‚ƒ„ƒƒ‚ƒ‚„ƒ‚ƒ
‚ƒƒ„‚„‚„‚„ƒ‚ƒ„„‚ƒ„ƒ„‚„„ƒ„‚‚„ƒ‚„ƒ„„‚‚ƒ„„‚„„„ƒ‚‚‚„„ƒ„

12345-09A*2*****************************SINGLE-PIECE
JOHN Q SAMPLE Froedtert Hospital
123 ANY STREET P.O. Box 3202
ANYTOWN US 12345
Milwaukee WI 53201-3202

Page 1 of 2
0000 1000006000275004 0000215 0000000 0000000000 4
15
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
16
 For customer service or to

Froedtert Hospital REMINDER NOTICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%N U#tt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €1_ g $R8GyR*}yB4D%V
€ZYd+M7$
&?nS,Rc>*+
q1QqQ111QqqqQQ1Q1Q

SERVICE INS PMTS PATIENT BALANCE

DATE PATIENT DESCRIPTION CHARGES & ADJS PMTS DUE
09/26/13 JOHN ACCOUNT # 00000 $7,238.62 -$6,764.19 $0.00 $474.43
SAMPLE

CURRENT PAYMENT DUE = $215.00

TOTAL BALANCE DUE = $2,558.08

Please Pay This Amount by

Important Message:
01/23/14
Only accounts that currently have a patient due balance are shown above. Please call us at the
phone number listed above if you would like an itemized statement. $215.00

Page 2 of 2 00025
17
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
18
 NOTICE OF MISSED For customer service or to
make a payment please call
Froedtert Hospital PAYMENT 800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%M R'xt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €1[ g $Q>K}U/vqe l'V
€Y_a9XNmNS> b!gG (*+
qQ1Q1q1Q1QqqQqQQ1Q

SERVICE INS PMTS PATIENT BALANCE

DATE PATIENT DESCRIPTION CHARGES & ADJS PMTS DUE
09/04/13 JOHN ACCOUNT # 00000 $186.50 -$151.68 $0.00 $34.82
SAMPLE

10/16/13 JOHN ACCOUNT # 00000 $186.50 -$151.68 $0.00 $34.82

SAMPLE

10/03/12 JOHN ACCOUNT # 00000 $180.50 -$155.05 $0.00 $25.45

SAMPLE

11/13/13 JOHN ACCOUNT # 00000 $186.50 -$151.68 $0.00 $34.82

SAMPLE

CURRENT PAYMENT DUE = $47.54

TOTAL BALANCE DUE = $129.91

We previously agreed to a payment plan with you. We have not received your payment of $47.54 that was due on 12/23/13. Please mail
your payment in the enclosed envelope immediately to prevent cancellation of your payment plan or call toll free at 800-803-8155 to
make payment by phone. If you would like to make a payment online using Visa, MasterCard or Discover, please visit us at Froedtert.com.
A $25.00 service fee will be charged for any checks returned.

As explained when the payment plan was made, late or missed payment will result in the payment plan being cancelled. Please send
payment today.
This notice may not include all outstanding accounts.

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3202, MILWAUKEE, WI 53201-3202

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

Froedtert Hospital 00008 q q q
P.O. BOX 6545 CARD NUMBER AMOUNT
Madison, WI 53716-0545
SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # PAYMENT DUE

00000 3305 01/09/14 00000 $47.54
Please check box if address is incorrect or insurance information has changed,
and indicate change(s) on reverse side.

‚ƒ‚„„‚ƒƒ„‚„ƒ‚„‚ƒ‚„ƒ„ƒ„„‚„ƒ‚„‚‚ƒ‚ƒ‚„„„ƒ‚‚„„ƒ‚„‚„‚ƒ‚
‚ƒƒ„‚„‚„‚„ƒ‚ƒ„„‚ƒ„ƒ„‚„„ƒ„‚‚„ƒ‚„ƒ„„‚‚ƒ„„‚„„„ƒ‚‚‚„„ƒ„

12345-09A*2*****************************SINGLE-PIECE
JOHN Q SAMPLE Froedtert Hospital
123 ANY STREET P.O. Box 3202
ANYTOWN US 12345
Milwaukee WI 53201-3202

0000 1000006000874259 0012991 0000000 0000000000 4

19
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
20
 For customer service or to

Froedtert Hospital INVOICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%N Q'xt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €1_ g $T6O}S0cd::p'V
€Y\a!K{€)z>Da0pJ++
qq1Q1qqQQq11Q1Q
PRIMARY INSURANCE SECONDARY INSURANCE
UMR UT NO INSURANCE ON FILE

SERVICE INS PMTS PATIENT BALANCE

DATE PATIENT DESCRIPTION CHARGES & ADJS PMTS DUE
11/07/13 JOHN ACCOUNT # 00000 $831.14 -$784.59 $0.00 $46.55
SAMPLE INFUSION FEC
OUTPATIENT

11/14/13 JOHN ACCOUNT # 00000 $664.01 -$626.82 $0.00 $37.19

SAMPLE INFUSION FEC
OUTPATIENT

11/25/13 JOHN ACCOUNT # 00000 $771.14 -$727.95 $0.00 $43.19

SAMPLE INFUSION FEC
OUTPATIENT

CONTINUED ON NEXT PAGE ---->

Important Message:
Only accounts that currently have a patient due balance are shown on this invoice. Please Please Pay This Amount by
call us at the phone number listed above if you would like an itemized statement. This 01/30/14
invoice reflects charges for hospital services only. Physician charges will be billed separately
by the Medical College of Wisconsin. Please see reverse side for additional information. $426.25
PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3202, MILWAUKEE, WI 53201-3202

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

Froedtert Hospital 00009 q q q
P.O. BOX 6545 CARD NUMBER AMOUNT
Madison, WI 53716-0545
SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # INVOICE AMT DUE

00000 3302 01/09/14 00000 $426.25
Please check box if address is incorrect or insurance information has changed,
and indicate change(s) on reverse side.

„‚ƒ„„ƒƒ„„‚„„ƒ‚„ƒ‚‚„ƒƒƒƒƒ‚„ƒƒƒƒ‚„„‚„„ƒ‚„‚„ƒƒ„ƒ
‚ƒƒ„‚„‚„‚„ƒ‚ƒ„„‚ƒ„ƒ„‚„„ƒ„‚‚„ƒ‚„ƒ„„‚‚ƒ„„‚„„„ƒ‚‚‚„„ƒ„

12345-09A*2*****************************SINGLE-PIECE
JOHN Q SAMPLE Froedtert Hospital
123 ANY STREET P.O. Box 3202
ANYTOWN US 12345
Milwaukee WI 53201-3202

Page 1 of 2
0000 1000006001026672 0042625 0000000 0000000000 4
21
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
22
 For customer service or to

Froedtert Hospital INVOICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%N U#tt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €1_ g $Q7L|U.h{r9d%V
€YZf2^V?"]R%.IW ,+
q1qQ1qqQ1qqqqQQqQ1Q
PRIMARY INSURANCE SECONDARY INSURANCE
UMR UT NO INSURANCE ON FILE

SERVICE INS PMTS PATIENT BALANCE

DATE PATIENT DESCRIPTION CHARGES & ADJS PMTS DUE
11/26/13 - JOHN ACCOUNT # 00000 $2,689.02 -$2,538.44 $0.00 $150.58
11/27/13 SAMPLE GYNECOLOGY
OUTPATIENT

12/02/13 JOHN ACCOUNT # 00000 $602.14 -$568.41 $0.00 $33.73

SAMPLE INFUSION FEC
OUTPATIENT

12/05/13 JOHN ACCOUNT # 00000 $679.60 -$641.54 $0.00 $38.06

SAMPLE INFUSION FEC
OUTPATIENT

12/10/13 JOHN ACCOUNT # 00000 $542.80 -$512.40 $0.00 $30.40

SAMPLE INFUSION MOORLAND
OUTPATIENT

12/12/13 JOHN ACCOUNT # 00000 $831.14 -$784.59 $0.00 $46.55

SAMPLE INFUSION FEC
OUTPATIENT

Important Message: Please Pay This Amount by

Only accounts that currently have a patient due balance are shown on this invoice. Please call
01/30/14
us at the phone number listed above if you would like an itemized statement. This invoice
reflects charges for hospital services only. Physician charges will be billed separately by the
Medical College of Wisconsin. Please see reverse side for additional information.
$426.25

Page 2 of 2 00028
23
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
24
 For customer service or to

Froedtert Hospital INVOICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%N R'xt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €5[ g $R:AyW+mqGZN%V
€Z^f)P ?}Zodm,z8 Q*+
qqQQQ1qqQqq1qqQQQ1Q
PRIMARY INSURANCE SECONDARY INSURANCE
NO INSURANCE ON FILE NO INSURANCE ON FILE

SERVICE SELF PAY PMTS & BALANCE

DATE PATIENT DESCRIPTION CHARGES DISCOUNT ADJS DUE
10/21/13 JOHN ACCOUNT # 00000 $996.48 -$199.30 $0.00 $797.18
SAMPLE LAB CC
OUTPATIENT

10/23/13 JOHN ACCOUNT # 00000 $521.99 -$104.40 $0.00 $417.59

SAMPLE LAB CC
OUTPATIENT

10/25/13 JOHN ACCOUNT # 00000 $611.48 -$122.30 $0.00 $489.18

SAMPLE LAB CC
OUTPATIENT

10/28/13 JOHN ACCOUNT # 00000 $932.48 -$186.50 $0.00 $745.98

SAMPLE LAB CC
OUTPATIENT

CONTINUED ON NEXT PAGE ---->

Important Message:
**You will receive an additional 10% discount on the balance due if we receive the
payment in full within 10 days of this invoice date. If you would like an itemized bill, Please Pay This Amount by
please call us at the number above. This invoice reflects charges for hospital services 01/30/14
only. Physician charges will be billed separately by the Medical College of Wisconsin.
Please see reverse side for additional information.
$63,662.14
PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3202, MILWAUKEE, WI 53201-3202

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

Froedtert Hospital 00010 q q q
P.O. BOX 6545 CARD NUMBER AMOUNT
Madison, WI 53716-0545
SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # INVOICE AMT DUE

00000 3301 01/09/14 00000 $63,662.14
Please check box if address is incorrect or insurance information has changed,
and indicate change(s) on reverse side.

ƒ‚ƒ„ƒ‚‚‚‚ƒ„„ƒ‚‚„ƒ‚„„‚ƒƒƒ‚‚„„‚„ƒƒƒƒƒ„‚‚ƒƒ„‚ƒ„
‚ƒƒ„‚„‚„‚„ƒ‚ƒ„„‚ƒ„ƒ„‚„„ƒ„‚‚„ƒ‚„ƒ„„‚‚ƒ„„‚„„„ƒ‚‚‚„„ƒ„

12345-09A*2*****************************SINGLE-PIECE
JOHN Q SAMPLE Froedtert Hospital
123 ANY STREET P.O. Box 3202
ANYTOWN US 12345
Milwaukee WI 53201-3202

Page 1 of 5
0000 1000006000982795 6366214 0000000 0000000000 1
25
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
26
 For customer service or to

Froedtert Hospital INVOICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%N V#tt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €5[ g $S;F€Q)jjYB'V
€Z`a:Y%€v}hGpX9P )+
qqQ1qqQQq1QqqQ1Q
PRIMARY INSURANCE SECONDARY INSURANCE
NO INSURANCE ON FILE NO INSURANCE ON FILE

SERVICE SELF PAY PMTS & BALANCE

DATE PATIENT DESCRIPTION CHARGES DISCOUNT ADJS DUE
10/24/13 JOHN ACCOUNT # 00000 $84.50 -$16.90 $0.00 $67.60
SAMPLE OPHTHALMOLOGY EI
OUTPATIENT

10/30/13 JOHN ACCOUNT # 00000 $277.99 -$55.60 $0.00 $222.39

SAMPLE LAB CC
OUTPATIENT

11/04/13 JOHN ACCOUNT # 00000 $220.00 -$44.00 $0.00 $176.00

SAMPLE DIABETES CARE FEC
OUTPATIENT

11/07/13 JOHN ACCOUNT # 00000 $3,744.19 -$748.84 $0.00 $2,995.35

SAMPLE LAB CC
OUTPATIENT

11/18/13 JOHN ACCOUNT # 00000 $932.48 -$186.50 $0.00 $745.98

SAMPLE HEMONC BMT CC
OUTPATIENT

11/20/13 JOHN ACCOUNT # 00000 $5,777.24 -$1155.45 $0.00 $4,621.79

SAMPLE HEMONC BMT CC
OUTPATIENT

11/21/13 JOHN ACCOUNT # 00000 $5,266.07 -$1053.21 $0.00 $4,212.86

SAMPLE DAY HOSPITAL CC
OUTPATIENT

11/22/13 JOHN ACCOUNT # 00000 $5,450.06 -$1090.01 $0.00 $4,360.05

SAMPLE LAB CC
OUTPATIENT

CONTINUED ON NEXT PAGE ---->

Important Message: Please Pay This Amount by
**You will receive an additional 10% discount on the balance due if we receive the payment in
01/30/14
full within 10 days of this invoice date. If you would like an itemized bill, please call us at the
number above. This invoice reflects charges for hospital services only. Physician charges will
be billed separately by the Medical College of Wisconsin. Please see reverse side for
$63,662.14

Page 2 of 5 00029
27
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
28
 For customer service or to

Froedtert Hospital INVOICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%N V#xt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €5[ g $T4N~U,|wGvX#V
€Y\h!MK`ab;!E4!@6 *+
qqqqQ11111qq1QQQ1Q
PRIMARY INSURANCE SECONDARY INSURANCE
NO INSURANCE ON FILE NO INSURANCE ON FILE

SERVICE SELF PAY PMTS & BALANCE

DATE PATIENT DESCRIPTION CHARGES DISCOUNT ADJS DUE
11/06/13 JOHN ACCOUNT # 00000 $902.98 -$180.60 $0.00 $722.38
SAMPLE HEMONC BMT CC
OUTPATIENT

11/23/13 JOHN ACCOUNT # 00000 $5,219.45 -$1043.89 $0.00 $4,175.56

SAMPLE DAY HOSPITAL CC
OUTPATIENT

11/24/13 JOHN ACCOUNT # 00000 $5,219.45 -$1043.89 $0.00 $4,175.56

SAMPLE DAY HOSPITAL CC
OUTPATIENT

11/25/13 JOHN ACCOUNT # 00000 $5,834.05 -$1166.81 $0.00 $4,667.24

SAMPLE LAB CC
OUTPATIENT

11/26/13 JOHN ACCOUNT # 00000 $5,129.89 -$1025.98 $0.00 $4,103.91

SAMPLE DAY HOSPITAL CC
OUTPATIENT

11/27/13 JOHN ACCOUNT # 00000 $5,677.55 -$1135.51 $0.00 $4,542.04

SAMPLE HEMONC BMT CC
OUTPATIENT

11/28/13 JOHN ACCOUNT # 00000 $5,219.45 -$1043.89 $0.00 $4,175.56

SAMPLE DAY HOSPITAL CC
OUTPATIENT

11/29/13 JOHN ACCOUNT # 00000 $5,677.55 -$1135.51 $0.00 $4,542.04

SAMPLE HEMONC BMT CC
OUTPATIENT

CONTINUED ON NEXT PAGE ---->

Important Message: Please Pay This Amount by
**You will receive an additional 10% discount on the balance due if we receive the payment in
01/30/14
full within 10 days of this invoice date. If you would like an itemized bill, please call us at the
number above. This invoice reflects charges for hospital services only. Physician charges will
be billed separately by the Medical College of Wisconsin. Please see reverse side for
$63,662.14

Page 3 of 5 00029
29
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
30
 For customer service or to

Froedtert Hospital INVOICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%N V'tt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €5[ g $R6HyQ+{aJ~!V
€Y\b#G9+
&u5G#[A)+
qQQ111Qq1qqQQQQ1Q
PRIMARY INSURANCE SECONDARY INSURANCE
NO INSURANCE ON FILE NO INSURANCE ON FILE

SERVICE SELF PAY PMTS & BALANCE

DATE PATIENT DESCRIPTION CHARGES DISCOUNT ADJS DUE
11/27/13 JOHN ACCOUNT # 00000 $116.50 -$23.30 $0.00 $93.20
SAMPLE ENDOCRINE FEC
OUTPATIENT

12/04/13 JOHN ACCOUNT # 00000 $3,524.10 -$704.82 $0.00 $2,819.28

SAMPLE HEMONC BMT CC
OUTPATIENT

12/06/13 JOHN ACCOUNT # 00000 $794.50 -$158.90 $0.00 $635.60

SAMPLE HEMONC BMT CC
OUTPATIENT

12/09/13 JOHN ACCOUNT # 00000 $2,360.10 -$472.02 $0.00 $1,888.08

SAMPLE HEMONC BMT CC
OUTPATIENT

12/13/13 JOHN ACCOUNT # 00000 $3,088.17 -$617.63 $0.00 $2,470.54

SAMPLE HEMONC BMT CC
OUTPATIENT

12/11/13 JOHN ACCOUNT # 00000 $752.48 -$150.50 $0.00 $601.98

SAMPLE HEMONC BMT CC
OUTPATIENT

12/16/13 JOHN ACCOUNT # 00000 $368.50 -$73.70 $0.00 $294.80

SAMPLE HEMONC BMT CC
OUTPATIENT
**10% prompt pay discount if paid by 1/22/14

12/18/13 JOHN ACCOUNT # 00000 $851.48 -$170.30 $0.00 $681.18

SAMPLE HEMONC BMT CC
OUTPATIENT
**10% prompt pay discount if paid by 1/22/14

CONTINUED ON NEXT PAGE ---->

Important Message: Please Pay This Amount by
**You will receive an additional 10% discount on the balance due if we receive the payment in
01/30/14
full within 10 days of this invoice date. If you would like an itemized bill, please call us at the
number above. This invoice reflects charges for hospital services only. Physician charges will
be billed separately by the Medical College of Wisconsin. Please see reverse side for
$63,662.14

Page 4 of 5 00029
31
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
32
 For customer service or to

Froedtert Hospital INVOICE make a payment please call

800-803-8155 or visit our
website.
Froedtert.com

GUARANTOR NAME INVOICE DATE

€%N V'xt#W;m'n&W%E {;d+
JOHN SAMPLE 01/09/14 €5[ g $Q=P{U*i€Zel%V
€Z`g<SW 9`:HmxpHv*+
qq1Q1qqqQQqqQQqqQ1Q
PRIMARY INSURANCE SECONDARY INSURANCE
NO INSURANCE ON FILE NO INSURANCE ON FILE

SERVICE SELF PAY PMTS & BALANCE

DATE PATIENT DESCRIPTION CHARGES DISCOUNT ADJS DUE
12/27/13 JOHN ACCOUNT # 00000 $3,707.58 -$741.52 $0.00 $2,966.06
SAMPLE LAB CC
OUTPATIENT
**10% prompt pay discount if paid by 1/22/14

12/23/13 JOHN ACCOUNT # 00000 $318.98 -$63.80 $0.00 $255.18

SAMPLE LAB CC
OUTPATIENT
**10% prompt pay discount if paid by 1/22/14

Important Message: Please Pay This Amount by

**You will receive an additional 10% discount on the balance due if we receive the payment in
01/30/14
full within 10 days of this invoice date. If you would like an itemized bill, please call us at the
number above. This invoice reflects charges for hospital services only. Physician charges will
be billed separately by the Medical College of Wisconsin. Please see reverse side for
$63,662.14

Page 5 of 5 00029
33
 Froedtert Hospital
Froedtert.com

Froedtert Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In Hours

Monday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pm
Friday 8:00 am – 5:00 pm Located in the Froedtert Health Corporate
Saturday 9:00 am – 1:00 pm Center building in Menomonee Falls

Account Information
To make a payment or review your account information after our normal business hours, please call 800-803-8155
to access our interactive voice response system

Insurance Information
Froedtert Hospital will bill your insurance company on your behalf if you have provided us with your insurance
information at the time of registration. If you did not have your insurance information with you, please fax a copy of
your insurance card to us at 414-805-8500.

Physician Billing
Services provided by your physician are not included on your hospital bill. Questions about your physician billing
should be directed to the Medical College of Wisconsin at 800-242-1649.

Financial Assistance
Financial Assistance is available for those who qualify. If you would like a Financial Assistance application or have
questions about the Financial Assistance Program, please contact our office. Completed applications and other
information can also be faxed to 414-777-1503.

Payment Plans and Billing Practices

Froedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately
120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receipt
of this invoice, please contact our office to make payment arrangements. Failure to set up a formal payment
arrangement that meets the guidelines of Froedtert Health will result in the account being referred for further
collection activity.

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE
Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone
( ) ( )
Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone
( )
Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone

( )
P.O. Box 3202 • Milwaukee, WI 53201-3202
34