ABC Pediatric Urgent Care

ABC Pediatric Urgent Care

Patient Billing Inquiry
Our billing team will respond to your inquiry as soon as possible (usually within 1 business day, unless research with your insurance company is needed)

Please provide as many details as possible below. Thank you.
My inquiry is related to*

There is an error on the billThe charges should have been paid by my insurerI need to set up a payment planI'd like to pay my billOther
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
More than one patient? If so, indicate below but provide only one child's name and date of birth*

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Details of Person Completing this form*

First NameLast Name
Relationship to Patient

ParentGuardianRepresentativeSurrogate
Please provide details about your issue:*
Date of Service (if more than one, please provide the first date of service)

MonthDayYear
Date
THANK YOU FOR YOUR INQUIRY

The Billing Team
Should be Empty:

Our billing team will respond to your inquiry as soon as possible (usually within 1 business day, unless research with your insurance company is needed)