Draft Billing Forms

Billing Inquiry Form

We would like to help you with your billing inquiry. Please fill out the form below and someone from our staff will be in touch within 2 business days. Thank you!

Patient Name

First

Middle

Last

Patient Date of Birth

E-mail Address

Phone Number

Account Number

Date of Service

Contact Name

First

Middle

Last

How Can We Help You?

Please send me an Itemized billPlease indicate specific dates of service or time span

Please provide me with additional insurance or authorization informationPlease provide a description of the information you are seeking

Please provide me with a payment receiptPlease provide when payment was sent and include account number if possible

Please provide me with pricing for an upcoming servicePlease 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 questionPlease include Patient Account Number from billing, Patient Name and Date of Birth

OtherPlease provide any details that may help us assist you

If you are a human, ignore this field

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Draft Billing Forms

Billing Inquiry Form

We would like to help you with your billing inquiry. Please fill out the form below and someone from our staff will be in touch within 2 business days. Thank you!

How Can We Help You?

Pricing Transparency Request