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Page 1 of 1 Patient Statement PATIENT : CASE # : 1018 ACCOUNT # : M00001 ACCT TYPE : BC THERAPIST: M Summers REFERRAL: Collins MD, P IN. DATE: Any Physical Therapy 1234 Drive Suite 200 Any town, IL
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Begin by entering your personal information, such as your name, address, and phone number, in the designated fields.
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Indicate the date of service for which you are submitting the statement and provide a brief description of the services received.
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Fill in the amount charged for each service or procedure and calculate the total at the bottom of the statement.
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