Itemized Bill Request

Itemized Bill Request

Please utilize this form to submit any requests for Itemized Bills to be mailed to your desired address. We ask that you submit a new form for each individual request.

Patient's Full Legal Name*

Patient's Date of Birth*

Are you requesting for multiple service encounters?

Yes

Encounter Number

This is usually a 10-digit number that begins with a 20, 21, or 22. This can also be found in the top left hand side of your statement under the Account Summary.

Date of Treatment*

Encounter Number #2

Date of Treatment #2

Encounter Number #3

Date of Treatment #3

Street Address*

City, State*

Zip Code*

Contact Phone Number*

Please provide the best number for us to reach you at if we have any questions.

Phone

Other Information

If there is anything else you would like to communicate to our team, please include that information here.

Contact Email Address

Please provide an email if you would like to receive confirmation updates .

Consent Obtainted*

I consent that the provided information is accurate and truthful, and will be utilized for personal purposes.

Send me a copy of my responses

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