Patient Billing Information

The form below has been created to better serve you regarding inquiries with your patient account. Please complete as many of the text fields as possible and please clearly state your questions in the comment box.

Contact the Financial Service Department

The Patient Financial Service Department
Monday – Friday, 8:30 a.m. – 4:30 p.m.
866-772-6309 Toll-free
561-798-8678 Local
561-798-8615 Fax

Patient First Name *

Patient Last Name *

Address *

City *

State *

Patient Account Number

Date of Service *

Year

Month

Day

Insurance Provider 1 *

Insurance ID # *

Subscriber Group # *

Insurance Phone *

Insurance Provider 2

Insurance ID #

Subscriber Group #

Insurance Phone

Questions/Comments

ZIP Code *

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Patient Billing Information

Contact the Financial Service Department