Patient Form

This form can be used to answer simple billing questions. Please complete the form entirely. A representative will answer your question via email within 2 business days. If your question is deemed complex, the representative will not email you back, however we will telephone you within 2 business days after researching your account.

By submitting this form you agree that personal health information may be sent over the internet which is NOT HIPAA Compliant.

Patient Name:

First Name

Last Name

Email:

Healthcare Provider or Clinic you are being seen at:

Date of Birth MM/DD/YYYY:

YYYY

Phone:

(###)

###

####

Question for Billing Department: