Patient Bill Defender
Request for Medical Bill Negotiation
Name
First Name
Last Name
Phone Number:
Format: (000) 000-0000.
E-mail
example@example.com
Contact Number
Format: (000) 000-0000.
Do you consent to Text Messaging and/or Emails from Patient Bill Defender?
Please Select
Yes
No
Only Text
Only Emails
Date of service (If multiple, pick oldest ) If Hospital Stay, pick the discharge date.
-
Month
-
Day
Year
Date Picker Icon
How many bills need to be reviewed?
We’re any of the services rendered as a result of an accident whether automotive or on the job? Explain what happened in the notes
Please Select
Yes
No
Are any of these bills in collections?
Please Select
Yes
No
How much are the medical bill(s) in total?
Whats wrong with your Medical Bill
*
I disagree with the Co-Pay/Co-Insurance/Deductible
I do not believe the service billed was performed
I do not believe the balance is accurate
I believe the claim submitted to insurance was inaccurate
I believe the claim was not processed correctly by insurance
I do not believe all the services rendered were medically necessary
I am self pay and would like a review for fairness
I’m in my deductible and would like to see if I can get a better price than what my insurance has contracted
Other
Feel free to type in any notes that you feel is important.
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Submit
Should be Empty: