Timely Service Request

Timely Service Request

This form is for people that have ordered a billing service and would like an update. We will let you know if the order was received, and where we are in the process. We will also include information about any next steps you may need to take.
Not for claim follow-up

This form is not for claims follow up (ie, a request for us to take action on your claims like calling your insurance company or help with an appeal). If your claims have been submitted and you want to request follow up, please use the claim follow up request. This form will only give you an update on where we are in the process.
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Email
example@example.com
Midwife
Service Ordered
Please select the order type you are needing an update on
Additional Comments
Any additional information to help us handle your request.
Should be Empty:

Not for claim follow-up