Sample Blank Billing Statement

Mailing Address:
Premium Summary Billing Statement
Group Name:
Group Number:
SAMPLE BILL C
099030003
700 BISHOP ST # 300
Billing Summary:
Statement Date:
Payment is due by:
12/10/2014
Billing Period:
01/01/2014
01/01/2014 to 01/31/2014
HONOLULU, HI 96813
SAMPLE C
Amounts outstanding from the prior month:
Less: Payments received: $2,700.00
Adjustments: $0.00
Total Unpaid amount from prior periods:
Total Current Month and Retroactive Charges $900.00
Total Amount Due:
$915.75
$2,700.00
$0.00
(see detail statement)
Other Fees: $0.00
$31.50
($15.75)
*Total Current Monthly ACA Fee
Total Retro Monthly ACA Fee
For changes in status, such as (1) new subscriber; (2) addition of dependents; (3) deletion of subscribers or dependents, please send
Member Enrollment Form or Member Termination Form to UHA Employer Services, 700 Bishop St., Suite 300, Honolulu, HI, 96813, or fax it to
(877) 222-3198. Enrollments and changes are effective on the first of the month after our receipt of notice. Enrollments and changes received after
the 1st of the month may not be reflected in this billing.
Late payments may result in termination of your policy. Premiums are still due and payable for that period.
For questions regarding payments, call Billing at (808) 532-4000 ext. 353 from Oahu, or (800) 458-4600, ext. 353 from the neighbor islands.
The Monthly ACA Fee includes a reinsurance fee of $5.25 per member per month to be paid to the Department of Health and Human Services
(HHS) reinsurance program. Additional fees such as PCORI and/or Health Insurance Industry Tax are included in your medical premium.
Important!
Group Number:
099030003
Payment is due by:
01/01/2014
BILLING STATEMENT
To ensure proper credit to your account, please indicate Group Number on check.
Make check payable to:
UHA
P.O. Box 29590
Honolulu, HI 96820-1990
TOTAL AMOUNT DUE:
$915.75
AMOUNT ENCLOSED:
For information and forms, see our web site:
www.uhahealth.com
+
+
*
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EMP_PBC-0070-101613
201412100099030003295900000915751
- - - - - - - - - - - - - - - - - - - - - - - - - - - Detach here and return bottom portion with your payment - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
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Sample Blank Billing Statement PDF

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