Account Inquiry

Account Inquiry
Today's Date:*

MonthDayYear
Patient Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Email Address:*
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Providers Name or Office Name:*
Who do you see for services?
Account BalanceInsuranceOther
Comments/Questions:*
Attach Files (if needed):

If updating insurance please send a picture of the front and back of your insurance card. Please indicate the start date of the new insurance in the comment box above.
Cancelof
Submitted By:*
SelfParentOther (if other please state relationship in the comment box below).
Relationship
Thank you for reaching out. We will review the information you have provided and get back to you with an answer within 24-48 hours, Monday through Thursday.

Please note that our response time may vary based on the complexity of your inquiry. We appreciate your patience and will respond as soon as possible.

Best regards,

Michigan Medical Billing Services
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