Collection Letter 1

September 11, 2014

Eliminate the need to use multiple patient statements by sending this letter out after the first statement is 30 days stale.

To download this form, click here: Collection Letter 1.doc




[Patient’s name]


[City, State, ZIP]


Account Balance:        $[Dollar value]

Account Number:       [Account number]

Date Last Paid:           [Date]


Dear [Name]:


This is a reminder that your account is now 30 days old and that full payment on your account is now due. Please remit your payment as soon as possible, along with our office’s account statement.

If you have any questions, or may have difficulty making full payment at this time, please call our office as soon as possible.

If your payment has already been sent, please disregard this notice. Thank your for your cooperation.




[Office manager or collection clerk signature block]

To download this form, click here: Collection Letter 1

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