Submit Billing Complaint/Grievance
Contact Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to patient
Preferred method of communication
Email
Mail
Patient Information
Patient's name
First Name
Last Name
Patient's date of birth
Date of visit
Details of your complaint/grievance
Amount/item disputing
Describe your complaint/grievance (include specific details)
Describe desired outcome
Submit
Should be Empty: