Draft Billing Forms - Heritage Valley Health System

Billing Inquiry

"*" indicates required fields

Contact Information

Contact Name*

First Middle Last

Contact Phone Number*

Contact Email Address*

Patient Information

Patient Name*

First Middle Last

Patient Date of Birth*

Date of Service

Patient Insurance Coverage

Subscriber of Insurance

Insurance Policy ID Number

Ordering Physician

Physician Phone Number

Physician Procedure Code

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Pricing Transparency Request

"*" indicates required fields

Name*

First Middle Last

Date of Birth*

Email Address*

Phone Number*

Account Number*

Date of Service*

Contact Name

First Last

How Can We Help You?

Please send me an Itemized bill

Please indicate specific dates of service or time span.

Please provide me with additional insurance or authorization information

Please provide a description of the information you are seeking.

Please provide me with a payment receipt

Please provide when payment was sent and include account number if possible.

Please provide me with pricing for an upcoming service

Please include the following details below: Patient Name, Patient Insurance Coverage, Subscriber of insurance, Policy ID Number, Ordering Physician, Physician phone number, Procedure Code(s), Contact information for response.

Please assist me with a billing question

Please include Patient Account Number from billing, Patient Name and Date of Birth.

Other

Please provide any details that may help us assist you.

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This field is for validation purposes and should be left unchanged.