Itemized Statement Request

Itemized Statement Request

First Name*

Last Name*

Date of Birth*

Statement type

Select

Date of Service(s)*

Address statements should be mailed to*

Contact number*

Email address*

Release Authorization*

Due to HIPPA Laws, Hendrick Health may only release requested statements to the parties who received services at one of our facilities. By checking this box, you are acknowledging that you are the patient and accept any responsibility with the release of this information.

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