STATEMENT EXPLANATION





1. Your name and address information

2. Our phone number

3. Your statement number

4. Date that statement was printed

5. Mailing address to send coupon with payment

6. Your CNT account number

7. Amount you are paying

8. Amount you owe

9. Date that you received your service

10. Physician/Healthcare provider who provided the service

11. Description of service rendered and/or account activity with patient or insurance

12. Date that charge or payment posted to your account

13. Amount charged for service

14. Amount paid or adjusted by your insurance

15. Payments or Co-pays you have made on your account

16. Amount you owe after insurance & patient payments

17. Aging of your account balance


  Wednesday, 3/10/2010                        Clinics of North Texas, LLP                         Notice of Privacy Practices