Medical Office Guest Bill Third-Party Payment Approval
Patient Name
Patient ID/Record Number
Date of Service
Service(s) Provided
Total Bill Amount
Amount to be Paid by Third Party
Reason for Third-Party Payment
Third-Party Payer Details
Name / Organization
Contact Person
Phone / Email
Additional Notes
Patient / Guest Signature
Date
Third-Party Payer Signature
Date
Medical Office Approval
Date