GUIDE FOR CARE AND SUPPORT DURING SERIOUS ILLNESS

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Chapter 4: The Health Care System: Piecing it all together

Record of Payments

Bill from: _________________________________________________

Address: _________________________________________________

Account number: ________________ Date of service: ___________

Service provided: _________________________________________

Medicare/Medicaid Paid: __________________ Date: ____________

Claim number: ______________________ Other I.D: _____________

Questions/Concerns/Correspondence: _________________________

Contact with: _____________________________________________

Regarding: ________________________ Date: __________________

Response: _________________________ Date: _________________

Insurance Company: _______________________________________

Paid: ______________________ Date: ________________________

Claim number: ______________________ Other I.D: _____________

Questions/Concerns/Correspondence: _________________________

Contact with: _____________________________________________

Regarding: ________________________ Date: __________________

Response: _________________________ Date: _________________

Amount paid by self: __________ Date: _______ Check #: _______

Bill from: _________________________________________________

Address: _________________________________________________

Account number: ________________ Date of service: ___________

Service provided: _________________________________________

Medicare/Medicaid Paid: __________________ Date: ____________

Claim number: ______________________ Other I.D: _____________

Questions/Concerns/Correspondence: _________________________

Contact with: _____________________________________________

Regarding: ________________________ Date: __________________

Response: _________________________ Date: _________________

Insurance Company: _______________________________________

Paid: ______________________ Date: ________________________

Claim number: ______________________ Other I.D: _____________

Questions/Concerns/Correspondence: _________________________

Contact with: _____________________________________________

Regarding: ________________________ Date: __________________

Response: _________________________ Date: _________________

Amount paid by self: __________ Date: _______ Check #: _______

Created by Compassionate Choices.

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Next page: Chapter 5: Essential Conversations: Family matters: An Introduction to Essential Conversations: The Prelude and the Music