For customer service or tomake a payment please call866-223-6836 or visit our

website.

0 100004000161476 00000 0000804526 00000000009

SERVICEDATE PATIENT DESCRIPTION CHARGES

SELF PAYDISCOUNT

PMTS &ADJS

BALANCEDUE

12/30/13 -12/31/13

JOHNSAMPLE

ACCOUNT # 00000HOSPITALISTOUTPATIENT**10% prompt pay discount if paid by 1/22/14

$10,056.58 -$2011.32 $0.00 $8,045.26

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3106, MILWAUKEE, WI 53201-3106

P.O. BOX 6545Madison, WI 53716-0545

12345-09A*#1*****************************SINGLE-PIECE

JOHN Q SAMPLE123 ANY STREETANYTOWN US 12345

Please Pay This Amount by

01/30/14

$8,045.26

Please check box if address is incorrect or insurance information has changed,and indicate change(s) on reverse side.

Important Message:**You will receive an additional 10% discount on the balance due if we receive thepayment in full within 10 days of this invoice date. If you would like an itemized bill,please call us at the number above. Please see reverse side for additionalinformation.

GUARANTOR NAME INVOICE DATE

JOHN SAMPLE 01/09/14

PRIMARY INSURANCE SECONDARY INSURANCE

NO INSURANCE ON FILE NO INSURANCE ON FILE

INVOICE

00000 4401

00001

Community Memorial HospitalPO Box 3106Milwaukee WI 53201-3106

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

q q qCARD NUMBER AMOUNT

SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # INVOICE AMT DUE

01/09/14 00000 $8,045.26

Community MemorialHospital

Communitymemorial.com

Community MemorialHospital

1

Community Memorial Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In HoursMonday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pmFriday 8:00 am – 5:00 pm Located in the Froedtert Health CorporateSaturday 9:00 am – 1:00 pm Center in Menomonee Falls

Account InformationTo make a payment or review your account information after our normal business hours, please call 866-223-6836to access our interactive voice response system.

Insurance InformationCommunity Memorial Hospital will bill your insurance company on your behalf if you have provided us with yourinsurance information at the time of registration. If you did not have your insurance information with you, please faxa copy of your insurance card to us at 262-257-2578.

Physician BillingServices provided by your physician are not included on your hospital bill. Questions about your physician billingshould be directed to:● Emergency Room Physicians – 414-290-6720 (Infinity Healthcare)● Advanced Healthcare – 262-532-6700● Froedtert Health Medical Group – 414-777-1630● Radiologists – 888-989-2289 (Wisconsin Radiology Specialists)● Anesthesiologist – 262-787-4050 (Falls Anesthesia)● Pathologists – 800-242-1649 (Medical College of Wisconsin)● Oncology Alliance – 414-906-4400

Financial AssistanceFinancial Assistance is available for those who qualify. If you would like a Financial Assistance application or havequestions about the Financial Assistance Program, please contact our office. Completed applications and otherinformation can also be faxed to 414-777-1503.

Payment Plans and Billing PracticesFroedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receiptof this invoice, please contact our office to make payment arrangements. Failure to set up a formal paymentarrangement that meets the guidelines of Froedtert Health will result in the account being referred for furthercollection activity.

P.O. Box 3106 • Milwaukee, WI 53201-3106

Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone( ) ( )

Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE

Communitymemorial.com

Community MemorialHospital

2

For customer service or tomake a payment please call866-223-6836 or visit our

website.

P.O. BOX 6545Madison, WI 53716-0545

SERVICEDATE PATIENT DESCRIPTION CHARGES

INS PMTS& ADJS

PATIENTPMTS

BALANCEDUE

12/21/13 JOHNSAMPLE

ACCOUNT # 00000EMERGENCY

$928.26 -$388.11 $0.00 $540.15

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3106, MILWAUKEE, WI 53201-3106

12345-09A*1*****************************SINGLE-PIECE

JOHN Q SAMPLE123 ANY STREETANYTOWN US 12345

Please Pay This Amount by

01/30/14

$540.15

Important Message:Only accounts that currently have a patient due balance are shown on this invoice. Pleasecall us at the phone number listed above if you would like an itemized statement. Please seereverse side for additional information.

GUARANTOR NAME INVOICE DATE

JOHN SAMPLE 01/09/14

PRIMARY INSURANCE SECONDARY INSURANCE

ANTHEM NO INSURANCE ON FILE

INVOICE

Please check box if address is incorrect or insurance information has changed,and indicate change(s) on reverse side.

00000 4402

0 100004000159660 00000 0000054015 00000000001

Community Memorial HospitalPO Box 3106Milwaukee WI 53201-3106

00002

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

q q qCARD NUMBER AMOUNT

SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # INVOICE AMT DUE

01/09/14 00000 $540.15

Community MemorialHospital

Communitymemorial.com

Community MemorialHospital

3

Community Memorial Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In HoursMonday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pmFriday 8:00 am – 5:00 pm Located in the Froedtert Health CorporateSaturday 9:00 am – 1:00 pm Center in Menomonee Falls

Account InformationTo make a payment or review your account information after our normal business hours, please call 866-223-6836to access our interactive voice response system.

Insurance InformationCommunity Memorial Hospital will bill your insurance company on your behalf if you have provided us with yourinsurance information at the time of registration. If you did not have your insurance information with you, please faxa copy of your insurance card to us at 262-257-2578.

Physician BillingServices provided by your physician are not included on your hospital bill. Questions about your physician billingshould be directed to:● Emergency Room Physicians – 414-290-6720 (Infinity Healthcare)● Advanced Healthcare – 262-532-6700● Froedtert Health Medical Group – 414-777-1630● Radiologists – 888-989-2289 (Wisconsin Radiology Specialists)● Anesthesiologist – 262-787-4050 (Falls Anesthesia)● Pathologists – 800-242-1649 (Medical College of Wisconsin)● Oncology Alliance – 414-906-4400

Financial AssistanceFinancial Assistance is available for those who qualify. If you would like a Financial Assistance application or havequestions about the Financial Assistance Program, please contact our office. Completed applications and otherinformation can also be faxed to 414-777-1503.

Payment Plans and Billing PracticesFroedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receiptof this invoice, please contact our office to make payment arrangements. Failure to set up a formal paymentarrangement that meets the guidelines of Froedtert Health will result in the account being referred for furthercollection activity.

P.O. Box 3106 • Milwaukee, WI 53201-3106

Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone( ) ( )

Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE

Communitymemorial.com

Community MemorialHospital

4

For customer service or tomake a payment please call866-223-6836 or visit our

website.

This is just a friendly reminder of your scheduled payment. Your payment of $77.13 is expected in our office by 01/23/14. For yourconvenience, please use the enclosed envelope or call toll-free 866-223-6836 to make payment by phone. If you would like to make apayment online using Visa, MasterCard or Discover, please visit us at Communitymemorial.com. A $25.00 service fee will be charged forany checks returned.

Please be reminded that late or missed payments will result in the cancellation of this agreement and may result in further collectionactivity. Additional outstanding accounts not included in this agreement are not reflected in this statement.

This notice may not include all outstanding accounts.

SERVICEDATE PATIENT DESCRIPTION CHARGES

INS PMTS& ADJS

PATIENTPMTS

BALANCEDUE

08/17/13 -08/18/13

JOHNSAMPLE

ACCOUNT # 00000 $22,804.92 -$21,879.41 -$254.26 $671.25

CURRENT PAYMENT DUE = $77.13TOTAL BALANCE DUE = $671.25

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3106, MILWAUKEE, WI 53201-3106

Community Memorial HospitalPO Box 3106Milwaukee WI 53201-3106

12345-09A*1*****************************SINGLE-PIECE

JOHN Q SAMPLE123 ANY STREETANYTOWN US 12345

Please Pay This Amount by

01/30/14

$671.25

GUARANTOR NAME INVOICE DATE

JOHN SAMPLE 01/09/14

REMINDER NOTICE

Please check box if address is incorrect or insurance information has changed,and indicate change(s) on reverse side.

00000 4404

2 100004000124257 14023 0000067125 00000077135

P.O. BOX 6545Madison, WI 53716-0545

00003

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

q q qCARD NUMBER AMOUNT

SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # PAYMENT DUE

01/09/14 00000 $77.13

Community MemorialHospital

Communitymemorial.com

Community MemorialHospital

5

Community Memorial Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In HoursMonday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pmFriday 8:00 am – 5:00 pm Located in the Froedtert Health CorporateSaturday 9:00 am – 1:00 pm Center in Menomonee Falls

Account InformationTo make a payment or review your account information after our normal business hours, please call 866-223-6836to access our interactive voice response system.

Insurance InformationCommunity Memorial Hospital will bill your insurance company on your behalf if you have provided us with yourinsurance information at the time of registration. If you did not have your insurance information with you, please faxa copy of your insurance card to us at 262-257-2578.

Physician BillingServices provided by your physician are not included on your hospital bill. Questions about your physician billingshould be directed to:● Emergency Room Physicians – 414-290-6720 (Infinity Healthcare)● Advanced Healthcare – 262-532-6700● Froedtert Health Medical Group – 414-777-1630● Radiologists – 888-989-2289 (Wisconsin Radiology Specialists)● Anesthesiologist – 262-787-4050 (Falls Anesthesia)● Pathologists – 800-242-1649 (Medical College of Wisconsin)● Oncology Alliance – 414-906-4400

Financial AssistanceFinancial Assistance is available for those who qualify. If you would like a Financial Assistance application or havequestions about the Financial Assistance Program, please contact our office. Completed applications and otherinformation can also be faxed to 414-777-1503.

Payment Plans and Billing PracticesFroedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receiptof this invoice, please contact our office to make payment arrangements. Failure to set up a formal paymentarrangement that meets the guidelines of Froedtert Health will result in the account being referred for furthercollection activity.

P.O. Box 3106 • Milwaukee, WI 53201-3106

Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone( ) ( )

Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE

Communitymemorial.com

Community MemorialHospital

6

For customer service or tomake a payment please call866-223-6836 or visit our

website.

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3106, MILWAUKEE, WI 53201-3106

After repeated requests for payment on your past due account(s) there continues to be an outstanding balance of $65.00. If the balance in full is notreceived within 10 days your account(s) will be referred to a collection agency for further collection action.

Mail payment in full today or contact our office toll free at 866-223-6836 to arrange payment over the phone. If you would like to make a payment usingVisa, MasterCard or Discover, please visit us at CommunityMemorial.com. A $25.00 service fee will be charged for any checks returned.

This letter only applies to the balance(s) stated above. You may receive additional letters if you have other outstanding accounts. Please disregard thisnotice if the balance in full has been recently mailed.

This notice may not include all outstanding accounts.

SERVICEDATE PATIENT DESCRIPTION CHARGES

INS PMTS& ADJS

PATIENTPMTS

BALANCEDUE

09/14/13 JOHNSAMPLE

ACCOUNT # 00000 $830.00 -$765.00 $0.00 $65.00

TOTAL BALANCE DUE = $65.00

12345-09A*1*****************************SINGLE-PIECE

JOHN Q SAMPLE123 ANY STREETANYTOWN US 12345

GUARANTOR NAME INVOICE DATE

JOHN SAMPLE 01/09/14

PRIMARY INSURANCE SECONDARY INSURANCE

UHC MEDICARE NO INSURANCE ON FILE

FINAL NOTICE

Please check box if address is incorrect or insurance information has changed,and indicate change(s) on reverse side.

00000 4410

0 100004000132103 00000 0000006500 00000000006

P.O. BOX 6545Madison, WI 53716-0545

Community Memorial HospitalPO Box 3106Milwaukee WI 53201-3106

00004

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

q q qCARD NUMBER AMOUNT

SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # BALANCE DUE

01/09/14 00000 $65.00

Community MemorialHospital

Communitymemorial.com

Community MemorialHospital

7

Community Memorial Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In HoursMonday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pmFriday 8:00 am – 5:00 pm Located in the Froedtert Health CorporateSaturday 9:00 am – 1:00 pm Center in Menomonee Falls

Account InformationTo make a payment or review your account information after our normal business hours, please call 866-223-6836to access our interactive voice response system.

Insurance InformationCommunity Memorial Hospital will bill your insurance company on your behalf if you have provided us with yourinsurance information at the time of registration. If you did not have your insurance information with you, please faxa copy of your insurance card to us at 262-257-2578.

Physician BillingServices provided by your physician are not included on your hospital bill. Questions about your physician billingshould be directed to:● Emergency Room Physicians – 414-290-6720 (Infinity Healthcare)● Advanced Healthcare – 262-532-6700● Froedtert Health Medical Group – 414-777-1630● Radiologists – 888-989-2289 (Wisconsin Radiology Specialists)● Anesthesiologist – 262-787-4050 (Falls Anesthesia)● Pathologists – 800-242-1649 (Medical College of Wisconsin)● Oncology Alliance – 414-906-4400

Financial AssistanceFinancial Assistance is available for those who qualify. If you would like a Financial Assistance application or havequestions about the Financial Assistance Program, please contact our office. Completed applications and otherinformation can also be faxed to 414-777-1503.

Payment Plans and Billing PracticesFroedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receiptof this invoice, please contact our office to make payment arrangements. Failure to set up a formal paymentarrangement that meets the guidelines of Froedtert Health will result in the account being referred for furthercollection activity.

P.O. Box 3106 • Milwaukee, WI 53201-3106

Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone( ) ( )

Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE

Communitymemorial.com

Community MemorialHospital

8

For customer service or tomake a payment please call866-223-6836 or visit our

website.

P.O. BOX 6545Madison, WI 53716-0545

Page 1 of 2

SERVICEDATE PATIENT DESCRIPTION CHARGES

INS PMTS& ADJS

PATIENTPMTS

BALANCEDUE

01/03/13 JOHNSAMPLE

ACCOUNT # 00000ADT GENERAL SURGERYOUTPATIENT

$2,209.80 -$1,996.98 -$111.00 IN PAYMENTPLAN

02/28/13 JOHNSAMPLE

ACCOUNT # 00000ADT GENERAL SURGERYOUTPATIENT

$2,084.60 -$1,981.47 $0.00 IN PAYMENTPLAN

04/04/13 JOHNSAMPLE

ACCOUNT # 00000ADT GENERAL SURGERYOUTPATIENT

$2,179.08 -$2,083.86 $0.00 IN PAYMENTPLAN

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3106, MILWAUKEE, WI 53201-3106

12345-09A*1*****************************SINGLE-PIECE

JOHN Q SAMPLE123 ANY STREETANYTOWN US 12345

Please Pay This Amount by

01/30/14

$0.00

Important Message:Only accounts that currently have a patient due balance are shown on this invoice. Pleasecall us at the phone number listed above if you would like an itemized statement. Please seereverse side for additional information.

GUARANTOR NAME INVOICE DATE

JOHN SAMPLE 01/09/14

PRIMARY INSURANCE SECONDARY INSURANCE

MEDICARE MEDICAID WI BADGERCARE

CONTINUED ON NEXT PAGE ---->

INVOICE

Please check box if address is incorrect or insurance information has changed,and indicate change(s) on reverse side.

00000 4402

0 100004000062011 14015 0000067157 00000061009

Community Memorial HospitalPO Box 3106Milwaukee WI 53201-3106

00005

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

q q qCARD NUMBER AMOUNT

SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # INVOICE AMT DUE

01/09/14 00000 $0.00

Community MemorialHospital

Communitymemorial.com

Community MemorialHospital

9

Community Memorial Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In HoursMonday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pmFriday 8:00 am – 5:00 pm Located in the Froedtert Health CorporateSaturday 9:00 am – 1:00 pm Center in Menomonee Falls

Account InformationTo make a payment or review your account information after our normal business hours, please call 866-223-6836to access our interactive voice response system.

Insurance InformationCommunity Memorial Hospital will bill your insurance company on your behalf if you have provided us with yourinsurance information at the time of registration. If you did not have your insurance information with you, please faxa copy of your insurance card to us at 262-257-2578.

Physician BillingServices provided by your physician are not included on your hospital bill. Questions about your physician billingshould be directed to:● Emergency Room Physicians – 414-290-6720 (Infinity Healthcare)● Advanced Healthcare – 262-532-6700● Froedtert Health Medical Group – 414-777-1630● Radiologists – 888-989-2289 (Wisconsin Radiology Specialists)● Anesthesiologist – 262-787-4050 (Falls Anesthesia)● Pathologists – 800-242-1649 (Medical College of Wisconsin)● Oncology Alliance – 414-906-4400

Financial AssistanceFinancial Assistance is available for those who qualify. If you would like a Financial Assistance application or havequestions about the Financial Assistance Program, please contact our office. Completed applications and otherinformation can also be faxed to 414-777-1503.

Payment Plans and Billing PracticesFroedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receiptof this invoice, please contact our office to make payment arrangements. Failure to set up a formal paymentarrangement that meets the guidelines of Froedtert Health will result in the account being referred for furthercollection activity.

P.O. Box 3106 • Milwaukee, WI 53201-3106

Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone( ) ( )

Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE

Communitymemorial.com

Community MemorialHospital

10

For customer service or tomake a payment please call866-223-6836 or visit our

website.

Please Pay This Amount by

01/30/14

$0.00

GUARANTOR NAME INVOICE DATE

JOHN SAMPLE 01/09/14

PRIMARY INSURANCE SECONDARY INSURANCE

MEDICARE MEDICAID WI BADGERCARE

Important Message:Only accounts that currently have a patient due balance are shown on this invoice. Please callus at the phone number listed above if you would like an itemized statement. Please seereverse side for additional information.

INVOICE

05/06/13 JOHNSAMPLE

ACCOUNT # 00000ADT GENERAL SURGERYOUTPATIENT

$2,180.53 -$2,083.67 $0.00 IN PAYMENTPLAN

06/05/13 JOHNSAMPLE

ACCOUNT # 00000ADT GENERAL SURGERYOUTPATIENT

$2,275.11 -$2,179.87 $0.00 IN PAYMENTPLAN

08/05/13 JOHNSAMPLE

ACCOUNT # 00000ADT GENERAL SURGERYOUTPATIENT

$2,261.51 -$2,152.77 -$25.00 IN PAYMENTPLAN

07/03/13 JOHNSAMPLE

ACCOUNT # 00000GENERAL SURGERYOUTPATIENT

$2,360.15 -$2,264.59 $0.00 IN PAYMENTPLAN

SERVICEDATE PATIENT DESCRIPTION CHARGES

INS PMTS& ADJS

PATIENTPMTS

BALANCEDUE

00005Page 2 of 2

Communitymemorial.com

Community MemorialHospital

11

Community Memorial Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In HoursMonday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pmFriday 8:00 am – 5:00 pm Located in the Froedtert Health CorporateSaturday 9:00 am – 1:00 pm Center in Menomonee Falls

Account InformationTo make a payment or review your account information after our normal business hours, please call 866-223-6836to access our interactive voice response system.

Insurance InformationCommunity Memorial Hospital will bill your insurance company on your behalf if you have provided us with yourinsurance information at the time of registration. If you did not have your insurance information with you, please faxa copy of your insurance card to us at 262-257-2578.

Physician BillingServices provided by your physician are not included on your hospital bill. Questions about your physician billingshould be directed to:● Emergency Room Physicians – 414-290-6720 (Infinity Healthcare)● Advanced Healthcare – 262-532-6700● Froedtert Health Medical Group – 414-777-1630● Radiologists – 888-989-2289 (Wisconsin Radiology Specialists)● Anesthesiologist – 262-787-4050 (Falls Anesthesia)● Pathologists – 800-242-1649 (Medical College of Wisconsin)● Oncology Alliance – 414-906-4400

Financial AssistanceFinancial Assistance is available for those who qualify. If you would like a Financial Assistance application or havequestions about the Financial Assistance Program, please contact our office. Completed applications and otherinformation can also be faxed to 414-777-1503.

Payment Plans and Billing PracticesFroedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receiptof this invoice, please contact our office to make payment arrangements. Failure to set up a formal paymentarrangement that meets the guidelines of Froedtert Health will result in the account being referred for furthercollection activity.

P.O. Box 3106 • Milwaukee, WI 53201-3106

Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone( ) ( )

Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE

Communitymemorial.com

Community MemorialHospital

12

For customer service or tomake a payment please call866-223-6836 or visit our

website.

We previously agreed to a payment plan with you. We have not received your payment of $25.00 that was due on 12/23/13. Please mailyour payment in the enclosed envelope immediately to prevent cancellation of your payment plan or call toll free at 866-223-6836 tomake payment by phone. If you would like to make a payment online using Visa, MasterCard or Discover, please visit us atCommunitymemorial.com. A $25.00 service fee will be charged for any checks returned.

As explained when the payment plan was made, late or missed payment will result in the payment plan being cancelled. Please sendpayment today.

This notice may not include all outstanding accounts.

SERVICEDATE PATIENT DESCRIPTION CHARGES

INS PMTS& ADJS

PATIENTPMTS

BALANCEDUE

05/24/13 JOHNSAMPLE

ACCOUNT # 00000 $347.50 -$97.50 -$150.00 $100.00

CURRENT PAYMENT DUE = $25.00TOTAL BALANCE DUE = $100.00

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3106, MILWAUKEE, WI 53201-3106

12345-09A*1*****************************SINGLE-PIECE

JOHN Q SAMPLE123 ANY STREETANYTOWN US 12345

Please Pay This Amount by

01/30/14

$100.00

GUARANTOR NAME INVOICE DATE

JOHN SAMPLE 01/09/14

NOTICE OF MISSEDPAYMENT

Please check box if address is incorrect or insurance information has changed,and indicate change(s) on reverse side.

00000 4405

0 100004000102032 13357 0000010000 00000025008

P.O. BOX 6545Madison, WI 53716-0545

Community Memorial HospitalPO Box 3106Milwaukee WI 53201-3106

00006

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

q q qCARD NUMBER AMOUNT

SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # PAYMENT DUE

01/09/14 00000 $25.00

Community MemorialHospital

Communitymemorial.com

Community MemorialHospital

13

Community Memorial Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In HoursMonday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pmFriday 8:00 am – 5:00 pm Located in the Froedtert Health CorporateSaturday 9:00 am – 1:00 pm Center in Menomonee Falls

Account InformationTo make a payment or review your account information after our normal business hours, please call 866-223-6836to access our interactive voice response system.

Insurance InformationCommunity Memorial Hospital will bill your insurance company on your behalf if you have provided us with yourinsurance information at the time of registration. If you did not have your insurance information with you, please faxa copy of your insurance card to us at 262-257-2578.

Physician BillingServices provided by your physician are not included on your hospital bill. Questions about your physician billingshould be directed to:● Emergency Room Physicians – 414-290-6720 (Infinity Healthcare)● Advanced Healthcare – 262-532-6700● Froedtert Health Medical Group – 414-777-1630● Radiologists – 888-989-2289 (Wisconsin Radiology Specialists)● Anesthesiologist – 262-787-4050 (Falls Anesthesia)● Pathologists – 800-242-1649 (Medical College of Wisconsin)● Oncology Alliance – 414-906-4400

Financial AssistanceFinancial Assistance is available for those who qualify. If you would like a Financial Assistance application or havequestions about the Financial Assistance Program, please contact our office. Completed applications and otherinformation can also be faxed to 414-777-1503.

Payment Plans and Billing PracticesFroedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receiptof this invoice, please contact our office to make payment arrangements. Failure to set up a formal paymentarrangement that meets the guidelines of Froedtert Health will result in the account being referred for furthercollection activity.

P.O. Box 3106 • Milwaukee, WI 53201-3106

Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone( ) ( )

Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE

Communitymemorial.com

Community MemorialHospital

14

For customer service or tomake a payment please call866-223-6836 or visit our

website.

This is just a friendly reminder of your scheduled payment. Your payment of $95.13 is expected in our office by 01/22/14. For yourconvenience, please use the enclosed envelope or call toll-free 866-223-6836 to make payment by phone. If you would like to make apayment online using Visa, MasterCard or Discover, please visit us at Communitymemorial.com. A $25.00 service fee will be charged forany checks returned.

Please be reminded that late or missed payments will result in the cancellation of this agreement and may result in further collectionactivity. Additional outstanding accounts not included in this agreement are not reflected in this statement.

This notice may not include all outstanding accounts.

SERVICEDATE PATIENT DESCRIPTION CHARGES

INS PMTS& ADJS

PATIENTPMTS

BALANCEDUE

09/17/13 JOHNSAMPLE

ACCOUNT # 00000 $2,626.50 -$2,326.63 -$150.00 $149.87

09/27/13 JOHNSAMPLE

ACCOUNT # 00000 $329.00 -$29.13 $0.00 $299.87

10/21/13 JOHNSAMPLE

ACCOUNT # 00000 $685.50 -$422.48 $0.00 $263.02

11/27/13 -11/30/13

JOHNSAMPLE

ACCOUNT # 00000 $43,643.91 -$43,215.11 $0.00 $428.80

CURRENT PAYMENT DUE = $95.13TOTAL BALANCE DUE = $1,141.56

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3106, MILWAUKEE, WI 53201-3106

Community Memorial HospitalPO Box 3106Milwaukee WI 53201-3106

12345-09A*1*****************************SINGLE-PIECE

JOHN Q SAMPLE123 ANY STREETANYTOWN US 12345

Please Pay This Amount by

01/30/14

$1,141.56

GUARANTOR NAME INVOICE DATE

JOHN SAMPLE 01/09/14

REMINDER NOTICE

Please check box if address is incorrect or insurance information has changed,and indicate change(s) on reverse side.

00000 4404

0 100004000132636 14022 0000114156 00000095133

P.O. BOX 6545Madison, WI 53716-0545

00007

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

q q qCARD NUMBER AMOUNT

SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # PAYMENT DUE

01/09/14 00000 $95.13

Community MemorialHospital

Communitymemorial.com

Community MemorialHospital

15

Community Memorial Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In HoursMonday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pmFriday 8:00 am – 5:00 pm Located in the Froedtert Health CorporateSaturday 9:00 am – 1:00 pm Center in Menomonee Falls

Account InformationTo make a payment or review your account information after our normal business hours, please call 866-223-6836to access our interactive voice response system.

Insurance InformationCommunity Memorial Hospital will bill your insurance company on your behalf if you have provided us with yourinsurance information at the time of registration. If you did not have your insurance information with you, please faxa copy of your insurance card to us at 262-257-2578.

Physician BillingServices provided by your physician are not included on your hospital bill. Questions about your physician billingshould be directed to:● Emergency Room Physicians – 414-290-6720 (Infinity Healthcare)● Advanced Healthcare – 262-532-6700● Froedtert Health Medical Group – 414-777-1630● Radiologists – 888-989-2289 (Wisconsin Radiology Specialists)● Anesthesiologist – 262-787-4050 (Falls Anesthesia)● Pathologists – 800-242-1649 (Medical College of Wisconsin)● Oncology Alliance – 414-906-4400

Financial AssistanceFinancial Assistance is available for those who qualify. If you would like a Financial Assistance application or havequestions about the Financial Assistance Program, please contact our office. Completed applications and otherinformation can also be faxed to 414-777-1503.

Payment Plans and Billing PracticesFroedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receiptof this invoice, please contact our office to make payment arrangements. Failure to set up a formal paymentarrangement that meets the guidelines of Froedtert Health will result in the account being referred for furthercollection activity.

P.O. Box 3106 • Milwaukee, WI 53201-3106

Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone( ) ( )

Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE

Communitymemorial.com

Community MemorialHospital

16

For customer service or tomake a payment please call866-223-6836 or visit our

website.

0 100004000153965 00000 0000261680 00000000003

CONTINUED ON NEXT PAGE ---->

SERVICEDATE PATIENT DESCRIPTION CHARGES

SELF PAYDISCOUNT

PMTS &ADJS

BALANCEDUE

12/02/13 JOHNSAMPLE

ACCOUNT # 00000COMMUNITY RECOVERY CMHOUTPATIENT

$156.50 -$31.30 $0.00 $125.20

12/05/13 JOHNSAMPLE

ACCOUNT # 00000COMMUNITY RECOVERY CMHOUTPATIENT

$342.00 -$68.40 $0.00 $273.60

12/12/13 JOHNSAMPLE

ACCOUNT # 00000LAB CMHOUTPATIENT

$378.50 -$75.70 $0.00 $302.80

12/09/13 JOHNSAMPLE

ACCOUNT # 00000COMMUNITY RECOVERY CMHOUTPATIENT

$342.00 -$68.40 $0.00 $273.60

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3106, MILWAUKEE, WI 53201-3106

P.O. BOX 6545Madison, WI 53716-0545

12345-09A*1*****************************SINGLE-PIECE

JOHN Q SAMPLE123 ANY STREETANYTOWN US 12345

Please Pay This Amount by

01/30/14

$2,616.80

Please check box if address is incorrect or insurance information has changed,and indicate change(s) on reverse side.

Important Message:**You will receive an additional 10% discount on the balance due if we receive thepayment in full within 10 days of this invoice date. If you would like an itemized bill,please call us at the number above. Please see reverse side for additionalinformation.

GUARANTOR NAME INVOICE DATE

JOHN SAMPLE 01/09/14

PRIMARY INSURANCE SECONDARY INSURANCE

NO INSURANCE ON FILE NO INSURANCE ON FILE

INVOICE

00000 4401

00008

Page 1 of 2

Community Memorial HospitalPO Box 3106Milwaukee WI 53201-3106

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

q q qCARD NUMBER AMOUNT

SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # INVOICE AMT DUE

01/09/14 00000 $2,616.80

Community MemorialHospital

Communitymemorial.com

Community MemorialHospital

17

Community Memorial Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In HoursMonday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pmFriday 8:00 am – 5:00 pm Located in the Froedtert Health CorporateSaturday 9:00 am – 1:00 pm Center in Menomonee Falls

Account InformationTo make a payment or review your account information after our normal business hours, please call 866-223-6836to access our interactive voice response system.

Insurance InformationCommunity Memorial Hospital will bill your insurance company on your behalf if you have provided us with yourinsurance information at the time of registration. If you did not have your insurance information with you, please faxa copy of your insurance card to us at 262-257-2578.

Physician BillingServices provided by your physician are not included on your hospital bill. Questions about your physician billingshould be directed to:● Emergency Room Physicians – 414-290-6720 (Infinity Healthcare)● Advanced Healthcare – 262-532-6700● Froedtert Health Medical Group – 414-777-1630● Radiologists – 888-989-2289 (Wisconsin Radiology Specialists)● Anesthesiologist – 262-787-4050 (Falls Anesthesia)● Pathologists – 800-242-1649 (Medical College of Wisconsin)● Oncology Alliance – 414-906-4400

Financial AssistanceFinancial Assistance is available for those who qualify. If you would like a Financial Assistance application or havequestions about the Financial Assistance Program, please contact our office. Completed applications and otherinformation can also be faxed to 414-777-1503.

Payment Plans and Billing PracticesFroedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receiptof this invoice, please contact our office to make payment arrangements. Failure to set up a formal paymentarrangement that meets the guidelines of Froedtert Health will result in the account being referred for furthercollection activity.

P.O. Box 3106 • Milwaukee, WI 53201-3106

Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone( ) ( )

Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE

Communitymemorial.com

Community MemorialHospital

18

For customer service or tomake a payment please call866-223-6836 or visit our

website.

00008

Please Pay This Amount by

01/30/14

$2,616.80

GUARANTOR NAME INVOICE DATE

JOHN SAMPLE 01/09/14

PRIMARY INSURANCE SECONDARY INSURANCE

NO INSURANCE ON FILE NO INSURANCE ON FILE

Important Message:**You will receive an additional 10% discount on the balance due if we receive the payment infull within 10 days of this invoice date. If you would like an itemized bill, please call us at thenumber above.Please see reverse side for additional information.

INVOICE

12/10/13 JOHNSAMPLE

ACCOUNT # 00000COMMUNITY RECOVERY CMHOUTPATIENT

$342.00 -$68.40 $0.00 $273.60

12/12/13 JOHNSAMPLE

ACCOUNT # 00000COMMUNITY RECOVERY CMHOUTPATIENT

$342.00 -$68.40 $0.00 $273.60

12/14/13 JOHNSAMPLE

ACCOUNT # 00000COMMUNITY RECOVERY CMHOUTPATIENT

$342.00 -$68.40 $0.00 $273.60

12/17/13 JOHNSAMPLE

ACCOUNT # 00000COMMUNITY RECOVERY CMHOUTPATIENT**10% prompt pay discount if paid by 1/22/14

$342.00 -$68.40 $0.00 $273.60

12/19/13 JOHNSAMPLE

ACCOUNT # 00000COMMUNITY RECOVERY CMHOUTPATIENT**10% prompt pay discount if paid by 1/22/14

$342.00 -$68.40 $0.00 $273.60

12/23/13 JOHNSAMPLE

ACCOUNT # 00000COMMUNITY RECOVERY CMHOUTPATIENT**10% prompt pay discount if paid by 1/22/14

$342.00 -$68.40 $0.00 $273.60

SERVICEDATE PATIENT DESCRIPTION CHARGES

SELF PAYDISCOUNT

PMTS &ADJS

BALANCEDUE

Page 2 of 2

Communitymemorial.com

Community MemorialHospital

19

Community Memorial Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In HoursMonday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pmFriday 8:00 am – 5:00 pm Located in the Froedtert Health CorporateSaturday 9:00 am – 1:00 pm Center in Menomonee Falls

Account InformationTo make a payment or review your account information after our normal business hours, please call 866-223-6836to access our interactive voice response system.

Insurance InformationCommunity Memorial Hospital will bill your insurance company on your behalf if you have provided us with yourinsurance information at the time of registration. If you did not have your insurance information with you, please faxa copy of your insurance card to us at 262-257-2578.

Physician BillingServices provided by your physician are not included on your hospital bill. Questions about your physician billingshould be directed to:● Emergency Room Physicians – 414-290-6720 (Infinity Healthcare)● Advanced Healthcare – 262-532-6700● Froedtert Health Medical Group – 414-777-1630● Radiologists – 888-989-2289 (Wisconsin Radiology Specialists)● Anesthesiologist – 262-787-4050 (Falls Anesthesia)● Pathologists – 800-242-1649 (Medical College of Wisconsin)● Oncology Alliance – 414-906-4400

Financial AssistanceFinancial Assistance is available for those who qualify. If you would like a Financial Assistance application or havequestions about the Financial Assistance Program, please contact our office. Completed applications and otherinformation can also be faxed to 414-777-1503.

Payment Plans and Billing PracticesFroedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receiptof this invoice, please contact our office to make payment arrangements. Failure to set up a formal paymentarrangement that meets the guidelines of Froedtert Health will result in the account being referred for furthercollection activity.

P.O. Box 3106 • Milwaukee, WI 53201-3106

Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone( ) ( )

Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE

Communitymemorial.com

Community MemorialHospital

20

For customer service or tomake a payment please call866-223-6836 or visit our

website.

We previously agreed to a payment plan with you. We have not received your payment of $150.00 that was due on 12/10/13. Pleasemail your payment in the enclosed envelope immediately to prevent cancellation of your payment plan or call toll free at 866-223-6836 tomake payment by phone. If you would like to make a payment online using Visa, MasterCard or Discover, please visit us atCommunitymemorial.com. A $25.00 service fee will be charged for any checks returned.

As explained when the payment plan was made, late or missed payment will result in the payment plan being cancelled. Please sendpayment today.

This notice may not include all outstanding accounts.

SERVICEDATE PATIENT DESCRIPTION CHARGES

INS PMTS& ADJS

PATIENTPMTS

BALANCEDUE

01/29/13 JOHNSAMPLE

ACCOUNT # 00000 $6,059.45 -$5,939.02 $0.00 $120.43

09/05/13 JOHNSAMPLE

ACCOUNT # 00000 $7,534.57 -$7,324.35 $0.00 $210.22

09/10/13 JOHNSAMPLE

ACCOUNT # 00000 $550.50 -$522.50 $0.00 $28.00

09/18/13 JOHNSAMPLE

ACCOUNT # 00000 $5,928.24 -$5,484.75 $0.00 $443.49

09/24/13 JOHNSAMPLE

ACCOUNT # 00000 $5,257.59 -$5,033.29 $0.00 $224.30

PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT TO PO BOX 3106, MILWAUKEE, WI 53201-3106

12345-09A*#1*****************************SINGLE-PIECE

JOHN Q SAMPLE123 ANY STREETANYTOWN US 12345

Please Pay This Amount by

01/30/14

$2,384.24

GUARANTOR NAME INVOICE DATE

JOHN SAMPLE 01/09/14

CONTINUED ON NEXT PAGE ---->

NOTICE OF MISSEDPAYMENT

Please check box if address is incorrect or insurance information has changed,and indicate change(s) on reverse side.

00000 4405

0 100004000071721 13344 0000238424 00000150005Page 1 of 2

P.O. BOX 6545Madison, WI 53716-0545

Community Memorial HospitalPO Box 3106Milwaukee WI 53201-3106

00009

IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW

q q qCARD NUMBER AMOUNT

SIGNATURE EXP. DATE

INVOICE DATE ACCOUNT # PAYMENT DUE

01/09/14 00000 $150.00

Community MemorialHospital

Communitymemorial.com

Community MemorialHospital

21

Community Memorial Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In HoursMonday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pmFriday 8:00 am – 5:00 pm Located in the Froedtert Health CorporateSaturday 9:00 am – 1:00 pm Center in Menomonee Falls

Account InformationTo make a payment or review your account information after our normal business hours, please call 866-223-6836to access our interactive voice response system.

Insurance InformationCommunity Memorial Hospital will bill your insurance company on your behalf if you have provided us with yourinsurance information at the time of registration. If you did not have your insurance information with you, please faxa copy of your insurance card to us at 262-257-2578.

Physician BillingServices provided by your physician are not included on your hospital bill. Questions about your physician billingshould be directed to:● Emergency Room Physicians – 414-290-6720 (Infinity Healthcare)● Advanced Healthcare – 262-532-6700● Froedtert Health Medical Group – 414-777-1630● Radiologists – 888-989-2289 (Wisconsin Radiology Specialists)● Anesthesiologist – 262-787-4050 (Falls Anesthesia)● Pathologists – 800-242-1649 (Medical College of Wisconsin)● Oncology Alliance – 414-906-4400

Financial AssistanceFinancial Assistance is available for those who qualify. If you would like a Financial Assistance application or havequestions about the Financial Assistance Program, please contact our office. Completed applications and otherinformation can also be faxed to 414-777-1503.

Payment Plans and Billing PracticesFroedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receiptof this invoice, please contact our office to make payment arrangements. Failure to set up a formal paymentarrangement that meets the guidelines of Froedtert Health will result in the account being referred for furthercollection activity.

P.O. Box 3106 • Milwaukee, WI 53201-3106

Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone( ) ( )

Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE

Communitymemorial.com

Community MemorialHospital

22

For customer service or tomake a payment please call866-223-6836 or visit our

website.

Please Pay This Amount by

12/10/13

$150.00

GUARANTOR NAME INVOICE DATE

JOHN SAMPLE 01/09/14

Important Message:Only accounts that currently have a patient due balance are shown above. Please call us at thephone number listed above if you would like an itemized statement.

NOTICE OF MISSEDPAYMENT

09/25/13 JOHNSAMPLE

ACCOUNT # 00000 $10,603.25 -$9,869.50 $0.00 $733.75

10/16/13 JOHNSAMPLE

ACCOUNT # 00000 $10,867.62 -$10,243.57 $0.00 $624.05

CURRENT PAYMENT DUE = $150.00TOTAL BALANCE DUE = $2,384.24

SERVICEDATE PATIENT DESCRIPTION CHARGES

INS PMTS& ADJS

PATIENTPMTS

BALANCEDUE

00009Page 2 of 2

Communitymemorial.com

Community MemorialHospital

23

Community Memorial Hospital - Patient Financial Services

Telephone Hours ● 800-803-8155 Walk-In HoursMonday through Thursday 8:00 am – 8:00 pm Monday through Friday 8:00 am – 4:30 pmFriday 8:00 am – 5:00 pm Located in the Froedtert Health CorporateSaturday 9:00 am – 1:00 pm Center in Menomonee Falls

Account InformationTo make a payment or review your account information after our normal business hours, please call 866-223-6836to access our interactive voice response system.

Insurance InformationCommunity Memorial Hospital will bill your insurance company on your behalf if you have provided us with yourinsurance information at the time of registration. If you did not have your insurance information with you, please faxa copy of your insurance card to us at 262-257-2578.

Physician BillingServices provided by your physician are not included on your hospital bill. Questions about your physician billingshould be directed to:● Emergency Room Physicians – 414-290-6720 (Infinity Healthcare)● Advanced Healthcare – 262-532-6700● Froedtert Health Medical Group – 414-777-1630● Radiologists – 888-989-2289 (Wisconsin Radiology Specialists)● Anesthesiologist – 262-787-4050 (Falls Anesthesia)● Pathologists – 800-242-1649 (Medical College of Wisconsin)● Oncology Alliance – 414-906-4400

Financial AssistanceFinancial Assistance is available for those who qualify. If you would like a Financial Assistance application or havequestions about the Financial Assistance Program, please contact our office. Completed applications and otherinformation can also be faxed to 414-777-1503.

Payment Plans and Billing PracticesFroedtert Health Patient Financial Services will try to collect any unpaid balances from the patient for approximately120 days before we refer an account for further collection activity. If you cannot pay the balance in full upon receiptof this invoice, please contact our office to make payment arrangements. Failure to set up a formal paymentarrangement that meets the guidelines of Froedtert Health will result in the account being referred for furthercollection activity.

P.O. Box 3106 • Milwaukee, WI 53201-3106

Responsible Party Name Address, City, State, Zip Day me Phone Evening Phone( ) ( )

Primary Insurance Company Name Primary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

Secondary Insurance Company Name Secondary Insurance Address, City, State, Zip Phone( )

Policyholder Name Pa ent Rela onship to Policyholder Policyholder Date of Birth

Iden fica on Number Group Number Effec ve Date of Coverage

Employer Name Employer Address, City, State, Zip Phone( )

PLEASE UPDATE ANY AND ALL INFORMATION THAT HAS CHANGED SINCE YOUR LAST INVOICE

Communitymemorial.com

Community MemorialHospital

24