Billing Inquiry Form
Have some questions or concerns for the billing department? Fill out the form below or contact us at billing@creeksidecounselingllc.com, and one of our billing specialists will follow up within 48 business hours.
Your Name
*
First Name
Last Name
Pt Name (if different from submitter name)
First Name
Last Name
Pt Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Service (if applicable)
-
Month
-
Day
Year
Date
Please provide details regarding your billing questions or concerns.
*
Submit
Should be Empty: