Collection Letter 3

September 11, 2014

If patient has already been send the Collection Letter 1 and Collection Letter 2 and no payment was received, send this letter out after the first statement is 90 days stale and provide them with their FINAL NOTICE of the account.

To download this form, click here: Collection Letter 3.doc




[Patient’s Name]


[City, State, ZIP]


Account Balance:        $[Dollar value]

Account Number:       [Account number]

Date Last Paid:           [Date]



Dear [Name]:

We have sent a number of previous notices advising you that you account is seriously delinquent. We have not received any response to these letters.

A payment must be made within ten (10) days from the date of this letter to prevent severe collection action.

Please indicate your desired form of settlement and return a copy of this letter to our office within the 10-day period:

☐     I prefer to settle the account. Please find full payment enclosed.

☐     I prefer to make monthly payments of $        until this balance is paid in full. I understand that no interest will be charged for this delayed payment schedule.

Patient’s Signature:     _________________________________________________


It is our sincere wish to avoid collection action. Please contact us immediately. If your payment has already been sent, please disregard this notice.




[Office manager or collection clerk signature block]

To download this form, click here: Collection Letter 3

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