                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 1- Helena M Adells                   -------------------------
    279 09/12/03 627.45  STANDARD OFFICE VISIT          55555          50.00
    279 10/01/03 627.45  FLU SHOT DRUG                  FLUSHOT        25.00
    279 10/11/05          PAYMENT                               MC    -52.24CK
    279 10/11/05          *WRTOFF                               MC     -9.70NA
    303 09/17/04     *** BALANCE FROM PRIOR STATEMENT ***              83.60
    314 05/24/05         TEST PROCEEDURE FOR LAB        66666          50.00
    314 05/24/05         NEW TEST OF THE PROCEDURES     11111         100.00
    314 05/24/05         EXTENDED MODIFICATION VISIT    90050          35.00
    314 05/24/05         STANDARD OFFICE VISIT          55555          50.00
    314 05/24/05         NEW PT, OV,MOD.                99203          80.00
    314 05/24/05         STUFF                          99212         160.00
    314 05/24/05         FOLLOW UP CONSULT UNSTABLE     99263          70.00
    314 05/24/05         CRITICAL CARE FIRST HOUR       99291         155.00
    314 05/24/05         NURSING FACILITY SERVICE HIGH  99303         150.00
    314 05/24/05         CONSULT INPAT. L/M             99251          50.00
    314 10/11/05          PAYMENT                               MC   -619.68CK
    314 10/11/05          *WRTOFF                               MC   -125.40NA
    322 10/11/05         SUBSEQ.NURSING FACILITY  X2    99313         140.00
    322 10/12/05          PAYMENT                               MC    -99.20CK
    322 10/12/05          *WRTOFF                               MC    -16.00NA
                                                                    ----------
                                                       BALANCE DUE:   276.38
=>> YOUR AGREED MONTHLY PAYMENT: $    57.45 <<=









     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:    276.38 |  Account    |
    Suite 5                              |  30 Days:           | P       1   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:           | BALANCE DUE |
                                         |  Ins Bal:    164.16 |    276.38   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Ms. Helena M Adells             |    Ms. Helena M Adells             |
  |     556 Shady Grove                 |    556 Shady Grove                 |
  |     Pittsburgh PA 15220             |    Pittsburgh PA 15220             |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 20- Frank L Superman                 -------------------------
    148 12/12/94     *** BALANCE FROM PRIOR STATEMENT ***              22.84
    148 01/12/06         *LATE (1.50% OF 22.84)                          .34
    150 12/12/94     *** BALANCE FROM PRIOR STATEMENT ***              43.10
    150 01/12/06         *LATE (1.50% OF 43.10)                          .65
    151 12/12/94 241.9   TEST PROCEEDURE FOR LAB        66666          50.00
    151 05/12/05          *WRTOFF                               MC     -8.00NA
    151 05/12/05         #1234 PAYMENT                          MC    -33.60CK
    151 08/29/97         TEST1 PAYMENT                          MC    -41.60CK
    151 02/02/03         TAKE BACK *TAKEBK                      MC     40.00TB
    155 12/13/94     *** BALANCE FROM PRIOR STATEMENT ***              21.54
    155 01/12/06         *LATE (1.50% OF 21.54)                          .32
    156 12/13/94     *** BALANCE FROM PRIOR STATEMENT ***              17.41
    156 01/12/06         *LATE (1.50% OF 17.41)                          .26
                                                                    ----------
                                                       BALANCE DUE:   113.26
 THIS BILL IS SERIOUSLY OVERDUE.  CONTACT THIS OFFICE IMMEDIATELY
















     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:      6.80 |  Account    |
    Suite 5                              |  30 Days:           | P      20   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:    106.46 | BALANCE DUE |
                                         |  Ins Bal:    113.40 |    113.26   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Ms. Helena M Adells             |    Frank L Superman                |
  |     556 Shady Grove                 |    558 Senate Drive                |
  |     Pittsburgh PA 15220             |    Pittsburgh PA 15236             |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 6- John M Allentown                  -------------------------
    295 06/11/04 240.0   NEW PATIENT OFFICE VISIT M/H   99204         130.00
    295 07/07/04          PAYMENT                               MC    -68.00CK
    295 07/07/04          *WRTOFF                               MC    -45.00NA
    295 07/07/04         HELP PAYMENT                           PT    -17.00CK
    297 07/07/04     *** BALANCE FROM PRIOR STATEMENT ***              60.90
    297 01/12/06         *LATE (1.50% OF 60.90)                          .91
                                                                    ----------
                                                       BALANCE DUE:    61.81
 THIS BILL IS SERIOUSLY OVERDUE.  CONTACT THIS OFFICE IMMEDIATELY























     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:           |  Account    |
    Suite 5                              |  30 Days:           | P       6   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:     61.81 | BALANCE DUE |
                                         |  Ins Bal:     55.00 |     61.81   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     John M Allentown                |    John M Allentown                |
  |     556 Bettis Rd.                  |    556 Bettis Rd.                  |
  |     Dravosburg PA 15034             |    Dravosburg PA 15034             |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 23- Michael B Byran                  -------------------------
    205 09/12/97     *** BALANCE FROM PRIOR STATEMENT ***             107.73
    205 01/12/06         *LATE (1.50% OF 107.73)                        1.62
                                                                    ----------
                                                       BALANCE DUE:   109.35
 THIS BILL IS SERIOUSLY OVERDUE.  CONTACT THIS OFFICE IMMEDIATELY



























     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:           |  Account    |
    Suite 5                              |  30 Days:           | P      23   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:    109.35 | BALANCE DUE |
                                         |  Ins Bal:       .00 |    109.35   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Michael B Byran                 |    Michael B Byran                 |
  |     555 Arch St                     |    555 Arch St                     |
  |     Greensburg PA 15601             |    Greensburg PA 15601             |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 8- Susan Cuddles                     -------------------------
    286 04/30/04 193.00  HOSPITAL VISIT-HIGH            92334         100.00
    286 10/11/05          PAYMENT                             MCDM    -64.00CK
    286 10/11/05          PAYMENT                               MC     -5.00CK
                                                                    ----------
                                                       BALANCE DUE:    31.00



























     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:     31.00 |  Account    |
    Suite 5                              |  30 Days:           | P       8   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:           | BALANCE DUE |
                                         |  Ins Bal:    996.50 |     31.00   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Ms. Susan Cuddles               |    Ms. Susan Cuddles               |
  |     554 Cypress Avenue              |    554 Cypress Avenue              |
  |     Pittsburgh PA 15236             |    Pittsburgh PA 15236             |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 25- Kathy Garfield                   -------------------------
    231 08/04/98     *** BALANCE FROM PRIOR STATEMENT ***              35.53
    231 01/12/06         *LATE (1.50% OF 35.53)                          .53
                                                                    ----------
                                                       BALANCE DUE:    36.06
 THIS BILL IS SERIOUSLY OVERDUE.  CONTACT THIS OFFICE IMMEDIATELY



























     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:           |  Account    |
    Suite 5                              |  30 Days:           | P      25   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:     36.06 | BALANCE DUE |
                                         |  Ins Bal:     55.00 |     36.06   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Kathy Garfield                  |    Kathy Garfield                  |
  |     553 Meadowfield Lane            |    553 Meadowfield Lane            |
  |     Clairton PA 15025               |    Clairton PA 15025               |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 28- Sue Homecoming                   -------------------------
     34 10/27/99     *** BALANCE FROM PRIOR STATEMENT ***               3.70
     34 01/12/06         *LATE (1.50% OF 3.70)                           .06
                                                                    ----------
                                                       BALANCE DUE:     3.76




























     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:      3.76 |  Account    |
    Suite 5                              |  30 Days:           | P      28   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:           | BALANCE DUE |
                                         |  Ins Bal:       .00 |      3.76   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Sue Homecoming                  |    Sue Homecoming                  |
  |     556 Kendall Street              |    556 Kendall Street              |
  |     Elizabeth PA 15037              |    Elizabeth PA 15037              |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 50- Marianne Jackson                 -------------------------
    132 09/20/94 193.00  NEW PT.OFFICE CONSULT-LOW      99242          80.00
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  NEW PT.OFFICE CONSULT-LOW      99242          80.00
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  NEW PT.OFFICE CONSULT-LOW      99242          80.00
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  LINE 10 FFICE CONSULT-LOW      99242          80.00
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE V X2    99201          60.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  NEW PT.OFFICE CONSULT-LOW      99242          80.00
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  NEW PT.OFFICE CONSULT-LOW      99242          80.00
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  NEW PT.OFFICE CONSULT-LOW      99242          80.00
    132 09/20/94 193.00  LINE 20 LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  NEW PT.OFFICE CONSULT-LOW      99242          80.00
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  LIEN 25 TEST G FACILITY CARE M 99312         100.00
    132 09/20/94 193.00  LINE 26 LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  NEW PT.OFFICE CONSULT-LOW      99242          80.00
                                                                    ----------
                                                      PAGE BALANCE:  1210.00


     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |             |
    123 Main Street                      |  Current:           |  Account    |
    Suite 5                              |  30 Days:           | P      50   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:           |             |
                                         |  Ins Bal:           | CONTINUED   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Marianne Jackson                |    Marianne Jackson                |
  |     5515 Pyramid Ave                |    5515 Pyramid Ave                |
  |     Pittsburgh PA 15227             |    Pittsburgh PA 15227             |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   2
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  NEW PT.OFFICE CONSULT-LO X3    99242         240.00
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  NEW PT.OFFICE CONSULT-LOW      99242          80.00
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  NEW PT.OFFICE CONSULT-LOW      99242          80.00
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  LINE 40  FICE CONSULT-LOW      99242          80.00
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE V X4    99201         120.00
    132 09/20/94 193.00  RANDOM BLOOD GLUCOSE           82947          10.00
    132 09/20/94 193.00  NEW PT.OFFICE CONSULT-LOW      99242          80.00
    132 09/20/94 193.00  NEW PT, LIMITED OFFICE VISIT   99201          30.00
    132 09/20/94 193.00  LINE 45 BLOOD GLUCOSE          82947          10.00
                                                                    ----------
                                                       BALANCE DUE:  2100.00














     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:  2,100.00 |  Account    |
    Suite 5                              |  30 Days:           | P      50   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:           | BALANCE DUE |
                                         |  Ins Bal:           |   2100.00   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Marianne Jackson                |    Marianne Jackson                |
  |     5515 Pyramid Ave                |    5515 Pyramid Ave                |
  |     Pittsburgh PA 15227             |    Pittsburgh PA 15227             |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 29- Lana Kupenhimmer                 -------------------------
    174 04/14/97     *** BALANCE FROM PRIOR STATEMENT ***              28.85
    174 01/12/06         *LATE (1.50% OF 28.85)                          .43
    176 04/15/97     *** BALANCE FROM PRIOR STATEMENT ***              29.05
    176 01/12/06         *LATE (1.50% OF 29.05)                          .44
    177 04/15/97     *** BALANCE FROM PRIOR STATEMENT ***             154.53
    177 01/12/06         *LATE (1.50% OF 154.53)                        2.32
    178 04/15/97     *** BALANCE FROM PRIOR STATEMENT ***              52.55
    178 01/12/06         *LATE (1.50% OF 52.55)                          .79
    181 04/17/97     *** BALANCE FROM PRIOR STATEMENT ***              53.16
    181 01/12/06         *LATE (1.50% OF 53.16)                          .80
    182 04/18/97     *** BALANCE FROM PRIOR STATEMENT ***              30.91
    182 01/12/06         *LATE (1.50% OF 30.91)                          .46
                                                                    ----------
                                                       BALANCE DUE:   354.29
 THIS BILL IS SERIOUSLY OVERDUE.  CONTACT THIS OFFICE IMMEDIATELY

















     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:           |  Account    |
    Suite 5                              |  30 Days:           | P      29   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:    354.29 | BALANCE DUE |
                                         |  Ins Bal:    132.60 |    354.29   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Lana Kupenhimmer                |    Lana Kupenhimmer                |
  |     559 Amelia Street               |    559 Amelia Street               |
  |     Belle Vernon PA 15012           |    Belle Vernon PA 15012           |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 22- Phyllis Manfield                 -------------------------
    102 11/19/93 240.0   NEW PT.OFFICE CONSULT-MODERATE 99243         130.00
    102 08/12/03          PAYMENT                               MD    -76.00CK
                                                                    ----------
                                                       BALANCE DUE:    54.00




























     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:     54.00 |  Account    |
    Suite 5                              |  30 Days:           | P      22   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:           | BALANCE DUE |
                                         |  Ins Bal:     56.67 |     54.00   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Phyllis Manfield                |    Phyllis Manfield                |
  |     550 Brookline Blvd              |    550 Brookline Blvd              |
  |     555 105                         |    555 105                         |
  |     Pittsburgh PA 15226             |    Pittsburgh PA 15226             |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 36- Wanda Newman                     -------------------------
     43 02/09/93     *** BALANCE FROM PRIOR STATEMENT ***              22.94
     43 01/12/06         *LATE (1.50% OF 22.94)                          .34
    213 09/18/97     *** BALANCE FROM PRIOR STATEMENT ***             150.83
    213 01/12/06         *LATE (1.50% OF 150.83)                        2.26
                                                                    ----------
                                                       BALANCE DUE:   176.37
 THIS BILL IS SERIOUSLY OVERDUE.  CONTACT THIS OFFICE IMMEDIATELY

























     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:           |  Account    |
    Suite 5                              |  30 Days:           | P      36   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:    176.37 | BALANCE DUE |
                                         |  Ins Bal:      8.40 |    176.37   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Wanda Newman                    |    Wanda Newman                    |
  |     556 Laurel Drive                |    556 Laurel Drive                |
  |     Irwin PA 15642                  |    Irwin PA 15642                  |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 45- Judy A Polenski                  -------------------------
    211 09/12/97     *** BALANCE FROM PRIOR STATEMENT ***             101.50
    211 01/12/06         *LATE (1.50% OF 101.50)                        1.52
                                                                    ----------
                                                       BALANCE DUE:   103.02
 THIS BILL IS SERIOUSLY OVERDUE.  CONTACT THIS OFFICE IMMEDIATELY



























     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:           |  Account    |
    Suite 5                              |  30 Days:           | P      45   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:    103.02 | BALANCE DUE |
                                         |  Ins Bal:     30.00 |    103.02   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Judy A Polenski                 |    Judy A Polenski                 |
  |     558 Hodgson Street              |    558 Hodgson Street              |
  |     Monongahela PA 15063            |    Monongahela PA 15063            |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 5- Margaret B Rabbini                -------------------------
    223 02/11/98     *** BALANCE FROM PRIOR STATEMENT ***              23.94
    223 01/12/06         *LATE (1.50% OF 23.94)                          .36
    285 04/30/04 250.00  WHEEL CHAIR                    87000         850.00
    285 10/11/05          PAYMENT                             MCDM   -640.00CK
    299 07/19/04 184.50  HOME TO DOCTOR AMBULANCE       99912         150.00
    299 05/12/05         CK #1 PAYMENT                          MC   -104.00CK
    299 05/12/05          *WRTOFF                               MC    -20.00NA
                                                                    ----------
                                                       BALANCE DUE:   260.30
 THIS BILL IS SERIOUSLY OVERDUE.  CONTACT THIS OFFICE IMMEDIATELY






















     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:    236.00 |  Account    |
    Suite 5                              |  30 Days:           | P       5   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:     24.30 | BALANCE DUE |
                                         |  Ins Bal:       .00 |    260.30   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Margaret B Rabbini              |    Margaret B Rabbini              |
  |     554 E. Marrigold Street         |    554 E. Marrigold Street         |
  |     Munhall PA 15120                |    Munhall PA 15120                |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 24- Joseph Ranquick                  -------------------------
     85 01/27/93     *** BALANCE FROM PRIOR STATEMENT ***             202.60
     85 01/12/06         *LATE (1.50% OF 202.60)                        3.04
                                                                    ----------
                                                       BALANCE DUE:   205.64
 THIS BILL IS SERIOUSLY OVERDUE.  CONTACT THIS OFFICE IMMEDIATELY



























     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:           |  Account    |
    Suite 5                              |  30 Days:           | P      24   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:    205.64 | BALANCE DUE |
                                         |  Ins Bal:    560.00 |    205.64   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Joseph Ranquick                 |    Joseph Ranquick                 |
  |     552 Third Street                |    552 Third Street                |
  |     Clairton PA 15025               |    Clairton PA 15025               |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 26- Mary Skelly                      -------------------------
    214 09/18/97     *** BALANCE FROM PRIOR STATEMENT ***             142.30
    214 01/12/06         *LATE (1.50% OF 142.30)                        2.13
    215 09/18/97     *** BALANCE FROM PRIOR STATEMENT ***               8.53
    215 01/12/06         *LATE (1.50% OF 8.53)                           .13
                                                                    ----------
                                                       BALANCE DUE:   153.09
 THIS BILL IS SERIOUSLY OVERDUE.  CONTACT THIS OFFICE IMMEDIATELY

























     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:           |  Account    |
    Suite 5                              |  30 Days:           | P      26   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:    153.09 | BALANCE DUE |
                                         |  Ins Bal:       .00 |    153.09   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Mary Skelly                     |    Mary Skelly                     |
  |     5548 Gates Drive                |    5548 Gates Drive                |
  |     Munhall PA 15120                |    Munhall PA 15120                |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 21- Mary Vase                        -------------------------
    100 10/27/99     *** BALANCE FROM PRIOR STATEMENT ***              41.80
    100 01/12/06         *LATE (1.50% OF 41.80)                          .63
                                                                    ----------
                                                       BALANCE DUE:    42.43
 THIS BILL IS SERIOUSLY OVERDUE.  CONTACT THIS OFFICE IMMEDIATELY



























     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:           |  Account    |
    Suite 5                              |  30 Days:           | P      21   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:     42.43 | BALANCE DUE |
                                         |  Ins Bal:    160.00 |     42.43   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Mary Vase                       |    Mary Vase                       |
  |     RTE 5, Box 262                  |    RTE 5, Box 262                  |
  |     Carmichaels PA 15320            |    Carmichaels PA 15320            |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
                              STATEMENT 
  Your Practice Name                            Statement Date: 01/12/06
  123 Main Street
  Suite 5                                       Page:   1
  Yourcity, PA 12345

INVOICE  DATE     DIAG     DESCRIPTION                 PROC ID  FROM  AMOUNT BY
-------------------------------------------------------------------------------------
******* PATIENT: 42- Mary Wilson                      -------------------------
    316 05/24/05 250.90  RETURN OFFICE VISIT-M/H  X2    99214         110.00
    316 05/24/05 250.90  NEW PT.OFFICE CONSULT-LOW      99242          80.00
    316 05/24/05 250.90  NEW TEST OF THE PROCEDURES     11111         100.00
    316 05/24/05 250.90  RANDOM BLOOD GLUCOSE           82947          10.00
                                                                    ----------
                                                       BALANCE DUE:   300.00


























     THIS IS A SAMPLE OF STATEMENT WITH COUPON FOR LASER PRINTERS
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
   Please detach and return this portion with your payment to the address below.  
                                         +---------------------+-------------+
    Your Practice Name                   |    Aging Status     |  Patient    |
    123 Main Street                      |  Current:    300.00 |  Account    |
    Suite 5                              |  30 Days:           | P      42   |
    Yourcity PA 12345                    |  60 Days:           +-------------+
                                         | 90+ Days:           | BALANCE DUE |
                                         |  Ins Bal:       .00 |    300.00   |
        (412) 835-9417                   +---------------+-----+-------------+
                                                         | Amount Enclosed   |
      Bill To:       Date: 01/12/06        Patient:      | $                 |
  +-------------------------------------+----------------+-------------------+
  |     Mary Wilson                     |    Mary Wilson                     |
  |                                     |                                    |
  |                                     |                                    |
  |                                     |                                    |
  +-------------------------------------+------------------------------------+
