2This is the first page of a multi-page bill.
3This provides your original statement date, information about the prompt pay discount, and the way payments are applied to accounts.
4If eligible, prompt pay discounts may be listed here.
5This amount reflects charges for all the children in the family receiving care.
6Payment arrangements and customer service.
7As of November 2012, CHOP patient families can pay their bills online. Go to www.chop.edu/billpay for instructions.
8If personal information is incorrect (name, address, telephone number, or insurance coverage), check this box and fill out the back of this coupon.
9On the payment coupon, indicate the amount you are sending. If paying by credit or debit card, please complete all sections.
10The signature code is on the back of your card, on the right-hand side of the signature area.
12Send Hospital Bill payments to this address, and include the completed coupon.
11If paying Hospital Bill by check, please make payable to CHOP.