Sample Sentara Itemized Billing Statement

This is an example of an itemized billing statement from Sentara Health.

It lists the patient’s name, admission date, and discharge date.

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 adjustments and discounts applied to the subtotal.

It shows the total insurance payments and adjustments to the bill.

It shows a zero balance on the remaining bill.

VVF needs this document to correctly calculate how much may be paid on a claim, and to distinguish crime-related medical services from non-crime-related medical services.