Patient Billing Statement Request Form

Patient Billing Statement Request Form
All statements (or "superbills") will be available at the start of each month via your Valant MYIO Patient Portal. These statements include the previous month's appointments and charges. You may submit these to your insurance provider for possible out-of-network benefits.

Please check your emails for alerts regarding your statement uploads.
Which kind of statement are you requesting?*
Who Is Requesting?*
Service Date(s) Requested*
Please specify
Where will this statement be sent to?*
Additional Information

Patient's Name*

First NameLast Name
Preferred Name
If you go by a preferred name such as your middle name, please type that name here.
Patient ID
Found on your monthly statements
Patient DOB*

MonthDayYear
Patient's Date of Birth
Email*

Confirmation Email
Address*

Street Address

Apt/Unit/Room #, P.O. Box, etc.

CityState

Zip Code
Should be Empty: