PAYMENT IS DUE AND PAYABLE WITHIN 30 DAYS OF THIS BILLING. Please enclose a copy of this statement with payment.
Salem Psychiatric Associates
821 Saginaw St South
Salem, Oregon 97302
Federal Tax ID: 93-0789808
$5.00 – Fax fee
$25.00 for first ten (10) pages
$.15/pp - # of pages___________
Total Amount Due: $___________