CONFIDENTIAL (1) CONFIDENTIAL FOR AUTHORIZED PERSONNEL ONLY (1) DIABETIC (1) FINAL NOTICE *THIS IS THE LAST STATEMENT THAT WILL BE SENT TO YOU. *REMIT PAYMENT IN FULL TODAY! *WE ACCEPT VISA & M (1) FINAL NOTICE IF WE DO NOT RECEIVE YOUR PAYMENT BY ___ WE WILL BE FORCED TO TURN YOUR ACCOUNT OVER FOR COLLECTION. (1) FINAL NOTICE IF WE DO NOT HEAR FROM YOU WITHIN 10 DAYS, THIS ACCOUNT WILL BE TURNED OVER TO OUR COLLECTION AGENCY. (1) FINAL NOTICE! (2) FOR YOUR CONVENIENCE, YOU MAY TRANSFER THIS BALANCE TO YOUR CREDIT CARD ACCOUNT. TO PAY WITH YOUR CREDIT CARD, PLEASE C (1) FRIENDLY REMINDER THIS ACCOUNT IS PAST DUE. YOUR PROMPT ATTENTION IS COURTEOUSLY REQUESTED. (1) HIPAA (1) HIPAA REQUIREMENTS PRIVACY NOTICE:GIVEN TO PATIENT__ ACKNOWLEDGEMENT RECEIVED__AUTHORIZATION/OTHER: DISCLOSURE AUTHORIZ (1) IF YOU ARE UNABLE TO PAY IN FULL PLEASE SEND A PARTIAL PAYMENT (1) JUST A FRIENDLY REMINDER THAT YOUR ACCOUNT IS OVERDUE. WON'T YOU PLEASE MAIL YOUR REMITTANCE? (1) MAY WE HELP YOU? WE ARE WILLING TO MAKE ARRANGEMENTS FOR REGULAR PAYMENTS TO CLEAR UP THIS BALANCE. PLEASE CALL OR STO (1) MEDICAL ALERT (1) MISSED APPOINTMENT ON (1) PAST DUE PROMPT PAYMENT OF THIS BALANCE DUE WILL PRESERVE YOUR GOOD CREDIT RATING. MAIL YOUR CHECK TODAY. (1) PAST DUE WE ACCEPT VISA AND MASTERCARD. CALL OUR OFFICE WITH YOUR CARD NUMBER. (1) PAST DUE PLEASE CONTACT US AT ONCE REGARDING YOUR OVERDUE ACCOUNT (1) PAST DUE PLEASE REMIT TODAY! (1) PATIENT RECORD CONFIDENTIAL (1) PAYMENT HAS NOT BEEN RECEIVED FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW DUE FROM YOU. PLEASE REMIT OR CONTACT US (1) PLEASE CONTACT OUR OFFICE REGARDING YOUR OVERDUE BALANCE. WE'D LIKE TO WORK WITH YOU TO DEVELOP A REASONABLE PAYMENT P (1) PLEASE NOTE THIS ACCOUNT IS PAST DUE. YOUR PROMPT ATTENTION IS COURTEOUSLY REQUESTED. (1) PLEASE… HAVING TO ASK A GOOD PATIENT FOR PAYMENT IS NOT A PLEASANT TASK: HOWEVER, YOUR REMITTANCE WOULD BE GREATLY APP (1) PRE-MEDICATE (1) REGULAR MONTHLY PAYMENTS ARE NECESSARY TO KEEP THIS ACCOUNT CURRENT (1) REGULAR PAYMENTS MUST BE MADE EVERY MONTH IN ORDER TO MAINTAIN GOOD CREDIT. (1) RUSH (1) SECOND NOTICE THIS ACCOUNT IS PAST DUE. PLEASE REMIT PAYMENT TODAY. IF PAYMENT HAS BEEN MADE, PLEASE DISREGARD THIS NO (1) SELF PAY (1) SIGN HERE - With Arrow (1) THANK YOU FOR YOUR RECENT PAYMENT ON YOUR ACCOUNT. WE TRUST YOU WILL CONTINUE THESE REMITTANCES UNTIL THE ACCOUNT IS PA (1) THANK YOU! (1) THIS BALANCE IS OVERDUE! PROMPT PAYMENT WILL AVOID COLLECTION PROCEDURES. (1) THIS BALANCE MAY BE TRANSFERRED TO YOUR VISA OR MASTERCARD JUST CALL US (1) YOUR ACCOUNT IS PAST DUE. WE WOULD APPRECIATE YOUR PAYMENT TODAY! (1)

FLUORESCENT YELLOW (1) GREEN (1) LIGHT BLUE (1) RED (1)

3-1/4"W x 1-3/4"H (1) 4"W x 2"H (1) 4"W x 2-1/2"H (1) 6-1/2"W x 1"H (1)