PiF

Date:

To:

Certified Mail No: ________________________________________

RE: _____________________

Account/Chart No:

Check No:

Dear ______________________

I am sending the enclosed check, referenced above, as payment in full for my account, also referenced above, concluding with a final payment on the date referenced above.

The services you have rendered as referenced above may include services given by you, your company, your contractors, subcontractors, agents, heirs and assigns. The latter expressly include laboratories, hospitalists, technical and utility operators. This letter serves notice to you that I consider all such parties completely paid in full, including credits from applicable insurance and related benefit payments.

If you dispute or deny my assertion above that this account is paid in full, please inform me in writing within thirty (30) days from the date of this letter.

In absence of your timely written dispute as above, any bills, invoices or other demands for payment that I receive from you after this thirty day period for services/activities referenced above will not be honored, and may be cause for estoppel or other legal action.

Sincerely yours,

(This document is for information only and is not legal advice. Please consult your legal professional before using.)