Patient Refund Request Form
Please complete this form to request a refund review. Submission does not guarantee approval. All requests are reviewed within 7-10 business days. Refunds will be issued within 15-30 days from time of approval.
Patient Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Service or Payment
*
-
Month
-
Day
Year
Date
Reason for Refund Request
*
Please Select
Overpayment
Duplicate Payment
Service Not Rendered
Insurance Adjustment
Other
Please provide details about your refund request
Amount Requested for Refund (if known)
Upload Supporting Documents (e.g., receipts, proof of payment)
Upload a File
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Choose a file
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of
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