Billing Query Form

For general feedback, please use the Contact Us page.

If you have a billing related question please fill out the form below and click the Submit button.

We endeavour to protect your privacy and provide you with superior customer service. Accordingly, we are unable at this time to respond to your request via an email without prior verification. We will call you at the telephone number you enter below within approximately three (3) business days.

Please note that depending on your relationship to the patient, we may or may not be able to discuss the full financial details pertaining to the patient's bill(s). Written authorization is often necessary for us to disclose this information to a third party.

Thank you!

Patient's Name: *

Type of Query *

Patient Account Number(s); *

Separate multiple numbers by comma ","

My Name: *

Relationship to Patient: *

Daytime Phone Number *

Email Address:

Question/Comments *

By clicking the Submit button below, I represent that the information I provided is accurate and that I have the authority to discuss the status of the bill pertaining to the account number(s) I listed above.

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Math question * 1 + 1 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

Billing Query Form

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