Patient Billing Questions from Email
First Name
*
Last Name
*
Invoice #
*
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Practice Location
*
Please Select
Benton
Little Rock
North Little Rock
Do you want to be enrolled in the patient portal?
*
Yes
No
Billing Question Regarding
*
Please Select
Payment Missing
Deductible Question
Want to Make Payment
Incorrect Balance
Insurance Not Billed
Wrong Insurance Billed
Need Full Statement of All Charges & Payments
Other
Please attach a copy of your insurance card front and back if this is an insurance issue.
Attachment
Browse Files
Drag and drop files here
Choose a file
Please include any attachments (e.g., logo, mission statement, annual report, etc.) that would help us better understand your company's needs.
Cancel
of
Item Attached
*
Please Select
Yes
No
Your Note
Submit
Should be Empty: