This is an example of an itemized billing statement from Riverside Health System.

It lists each service provided, the date of each service, the cost of each service, and has a total amount of costs for all services.

It shows the insurance/Medicaid payments applied to the total charges.

It shows the insurance Medicaid adjustments applied to the total charges.

It shows the total payment and adjustments applied to the bill.

It shows the current hospital account balance as zero.

VVF needs this document to correctly calculate how much may be paid on a claim. On this sample, there is no payment needed due to the zero balance.