Note: Patient co-payments and deductible payments made at the time of a visit should be reported on the Billing Log Form in parentheses next to the date of service.

Office Name

Patient 1 Name

Patient 1 Payment Date

Patient 1 Payment Method

Check Cash Credit Card Money Order

Patient 1 Check Number

Patient 1 Payment Amount

Patient 2 Name

Patient 2 Payment Date

Patient 2 Payment Method

Check Cash Credit Card Money Order

Patient 2 Check Number

Patient 2 Payment Amount

Patient 3 Name

Patient 3 Payment Date

Patient 3 Payment Method

Check Cash Credit Card Money Order

Patient 3 Check Number

Patient 3 Payment Amount

Patient 4 Name

Patient 4 Payment Date

Patient 4 Payment Method

Check Cash Credit Card Money Order

Patient 4 Payment Amount

Patient 5 Name

Patient 5 Payment Date

Patient 5 Payment Method

Check Cash Credit Card Money Order

Patient 5 Check Number

Patient 5 Payment Amount