Billing Inquiries
Submit your billing-related questions here! Tickets will be responded to within 24-72 business hours
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
/
Month
/
Day
Year
Date
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Your Name (If submitting on behalf of patient)
First Name
Last Name
Your relation to patient:
Parent/Legal Guardian
Other
If "Other", please describe:
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Please select the related service(s)
*
Adult Therapy
Child Therapy
Couples Counseling
Medication Mgmt
Testing/Assessment Services
Speech Therapy
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What is your question in relation to?
*
Invoice received
Unspecified charge(s)
Payment receipt
Balance info/ Account statement
Superbill
Copay/coinsurance amount
Deductible amount
Explanation of benefits/ service eligibility
Request payment plan
Refund request
Other
If "Other", please describe:
Please describe your question(s) in detail:
*
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If applicable, please upload any documents related to your inquiry:
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