To view an explanation of your bill, move your pointer over the numbered red boxes.
The University of Pennsylvania Health System
bills the professional fees for the physicians
and practitioners who are faculty members of
the University of Pennsylvania Medical School
and Clinical Care Associates. A sample bill is
If you received services from a private practice
physician who maintains medical staff privileges
at a University of Pennsylvania Health System
hospital but is not employed by UPHS, you will
receive a bill directly from that physician's
office which will be different than the bill
presented below. Questions about those bills
should be directed to your doctor's office.
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- 1. Return Address
- 1. Return Address –
This is where the bill payment should be sent.
- 2. Guarantor Name and Address
- 2. Guarantor Name and Address –
The name and mailing address of the individual responsible for payment.
- 3. Statement Date
- 3. Statement Date –
This is the date your bill was produced by our system.
- 4. Account Number
- 4. Account Number –
A unique number that is assigned to each patient.
- 5. Amount You Owe
- 5. Amount You Owe –
The amount that you owe as of the date the statement was produced.
- 6. Insurance Information
- 6. Insurance Information –
This section tells us the priority of your insurance companies and the order in which we bill them. Please note, if dental or vision insurance is listed, the insurance is only billed for applicable services.
- 7. Patient Name
- 7. Patient Name –
The name of the individual receiving treatment.
- 8. Amount Enclosed
- 8. Amount Enclosed –
Fill in the amount of money that you are enclosing when you pay this bill.
- 9. Credit Card Payment Field
- 9. Credit Card Payment Field –
Use this area if you wish to pay by credit card.
- 10. Department Name and Mailing Address
- 10. Department Name and Mailing Address –
The name and address of the department rendering service.
- 11. Date of Service
- 11. Date of Service –
The date the service was provided.
- 12. Posting Date
- 12. Posting Date –
The date a payment/adjustment was posted to the account.
- 13. CPT (Current Procedural Terminology) Code
- 13.CPT (Current Procedural Terminology) Code –
The numeric code assigned to medical tests and services.
- 14. Department
- 14. Department –
The name of the department rendering the service.
- 15. CPT Code Description
- 15. CPT Code Description –
The explanation of medical tests and services.
- 16. Provider of Service
- 16. Provider of Service –
This is your physician of record.
- 17. Charges
- 17. Charges –
The fee for each test and service.
- 18. Payments or Adjustments
- 18. Payments or Adjustments –
The amount of payment or adjustment for procedure charges.
- 19. Amount You Owe
- 19. Amount You Owe –
The amount you owe for each test and service.
- 20. Statement Message Field
- 20. Statement Message Field –
This field will contain important information regarding your bill.
- 21. Total Charges
- 21. Total Charges –
The total fee for tests and services as of this billing.
- 22. Total Amount You Owe
- 22. Total Amount You Owe –
The total amount you owe the physician(s) as of this billing.
- 23. Change of Address Field
- 23. Change of Address Field –
Please indicate any change in your address in this area.
- 24. New Insurance Information
- 24. New Insurance Information –
Please use this area to inform us of any changes in your insurance coverage.