Quick Bill Review Intake Form
Submit your information for a non-clinical review of your medical bill by Our Helping Hands (OHH) Health Solutions.
SECTION 1: CLIENT INFORMATION
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (where results will be sent)
*
example@example.com
Are you the patient listed on the bill?
*
Yes
No
Patient’s Full Name
*
First Name
Last Name
Relationship to Patient
*
SECTION 2: BILLING RESPONSIBILITY
Who is financially responsible for this bill?
*
Patient
Family Member
Other (please specify)
Is this bill already paid?
*
Yes
No
Partially
SECTION 3: BILL DETAILS
Provider or Facility Name
*
Date(s) of Service
*
Total Amount Billed
*
Amount the Provider Says You Owe
*
Has the provider contacted you about this bill?
Yes
No
SECTION 4: DOCUMENT UPLOADS
Upload Medical Bill (required) Providing both the bill and EOB allows for a more accurate review.
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload Explanation of Benefits (EOB) if available (optional but encouraged) Providing both the bill and EOB allows for a more accurate review.
Upload a File
Drag and drop files here
Choose a file
Cancel
of
SECTION 5: CLIENT QUESTION & CONTEXT
What is your main concern with this bill?
*
Has this bill been sent to collections?
*
Yes
No
Not sure
Any deadlines or urgency we should know about?
SECTION 6: SERVICE SCOPE & EXPECTATIONS
What This Review Includes:
• Review of the medical bill and EOB
• Identification of possible billing or processing errors
• Plain-language explanation of what the provider billed and why
• An estimate of what you may actually owe, based on available information
• A short action plan if next steps are recommended
What This Review Does Not Include:
• Direct communication with providers or insurance
• Appeals, disputes, or ongoing billing advocacy
• Guarantees of billing outcomes
Please acknowledge the following:
*
I understand this is a one-time bill review
I understand OHH does not contact the provider or insurer as part of this service
I understand this review does not guarantee a reduction or correction
SECTION 7: TURNAROUND TIME & DELIVERY
Turnaround Time:
Reviews are typically completed within X business days after all required documents are received. Results will be delivered by email.
I understand the turnaround time and delivery method
*
I understand the turnaround time and delivery method
SECTION 8: ELECTRONIC SIGNATURE
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: