Established Patient: Billing Questions Billing Questions Are you the patient?* Yes No Guardian/Parent Name* First Last Client Code (Located on Upper Right Hand Portion of Statement) Patient First Name* Patient Last Name* Patient Date of Birth* How do you want us to contact you?* Email Phone Email* Enter Email Confirm Email If you have chosen email, your email must already be listed on your account. If it is not, billing will call the number on your account to confirm your email, answer your question, and enter your email into your account. If your email is listed on your account, you will receive a secure email that you will have to set up a login for. If you have new inquiries unrelated to the submission of this request and you email billing, you will not receive any details until a new request is made through our website. Phone Number* Describe how we can help you:* Δ
