LIFE’S CHECKLISTS · FREE WORKSHEET
Medical bill and EOB comparison
Organize administrative questions and next actions. Keep identity numbers, clinical records and children’s identifying information in the responsible organization’s secure process. This is a planning worksheet, not an official application or authorization.
First read the completed example. Then write your own answers in the blank sections. If you do not know an answer, write what you need to ask. Official applications may require their own forms.
Completed example
This is a fictional practice entry. Write your own details in the blank sections below.
- Service date / reference
- Example visit: October 5
- Provider bill item
- Office visit: $100
- EOB item
- EOB lists patient responsibility $20
- Difference to ask about
- Bill shows $100 instead of $20
- Office response
- Office is checking insurance processing
- Confirmed next step
- Wait for corrected bill; follow up October 30
Date: ____________________
Item 1
Provider bill item
EOB item
Difference to ask about
Office response
Confirmed next step
Item 2
Provider bill item
EOB item
Difference to ask about
Office response
Confirmed next step
Item 3
Provider bill item
EOB item
Difference to ask about
Office response
Confirmed next step
Item 4
Provider bill item
EOB item
Difference to ask about
Office response
Confirmed next step
Notes: