Contact Form for Patient Billing Issues

 

REQUIRED INFORMATION
Practice or Doctor Name:
 Email:
Patient Last Name:

MI:

First Name:
Date of Birth:

 Account Number:
 
Legal Relationship to Patient:
Self  Spouse Parent Guardian Executor  Other
CORRECT PATIENT MAILING ADDRESS INFORMATION: 
Permanent address or Temporary until: //
Street address:
 		 City:
 State:
  		  Zip:
  
Town:
 Phone:
       
 

COMPLETE THE FOLLOWING IF YOU ARE  PROVIDING INSURANCE INFORMATION:
Medical  Work Comp  Motor Vehicle  Other

Primary Insurance        Secondary Insurance
Primary Insurance Carrier:

Secondary Insurance:
Claim Address:

Claim Address:
City:
 State:
  		 Zip:


City:
 State:
 Zip:
  
Telephone number:
 Telephone number:
If through Employer
Employer Name:
 If through Employer
Employer Name:
Employer Address:
 Employer Address:
Certificate/Policy Number:
 Certificate/Policy Number:
Group Number:
 Group Number:
Case Number: (if applicable)
 Case Number: (if applicable)
Effective Date:
 Effective Date:

Previous Insurance Carrier:
 Referral/Authorization:
Termination Date:
 Name of Insurance:
(Required if Referral/Authorization filled in)
Referral/Authorization #:
Service Date:

(Required if Referral/Authorization filled in)
Condition:

(Required if Referral/Authorization filled in)
Reason for Contact:  

* Notice: Because of HIPAA privacy requirements we can not respond to e-mail.
    If you require a status on an issue please call the number on your statement.

*ALL INFORMATION SUPPLIED WILL BE KEPT CONFIDENTIAL AND WILL NOT BE SOLD TO A THIRD PARTY.  E-MAIL ADDRESSES ARE KEPT CONFIDENTIAL AND ARE NOT SOLD TO A THIRD PARTY.