[Date]
[Patient’s name]
[Address]
[City, State, ZIP]
Account Balance:
Account Number:
Date Last Paid:
$[Dollar value]
[Account number]
[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.
Sincerely,
[Office manager or collection clerk signature block]