Update Your Contact Information
Home Medical Equipment and Supply Patients:
Please c
omplete the form below to update your contact information with our billing department in preparation for our transition to eDelivery statements.
Your submission will be processed within 1-2 business days. Changes to your contact information may take 10-14 days to reflect on your account.
If you need immediate assistance, please call 207-480-7011.
Name:
*
First Name
Last Name
Phone:
Please enter a valid phone number
Format: 000-000-0000.
E-mail:
Please enter a valid email address
What would you like to do? Select all that apply:
*
Update the email address on my account.
Opt out of eDelivery statements.
Send a message to the billing department regarding a question or concern.
Would you like your statements to be sent to the email address listed above?
Yes
No
Please enter the email address you would like to use for eDelivery statements:
Has your mailing address changed since you received your last paper statement?
Yes
No
Please enter your updated mailing address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Questions or Concerns:
Please select your preferred method of response:
Email
Phone
Lead Type
eDelivery Contact
Reply Email
example@example.com
Submit
Should be Empty: