TruChoice Diagnostics Billing Inquiries 2

TruChoice Diagnostics Billing Inquiries

Patient Information:
Patient Name:*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
MM/DD/YYYY
Account Number *NR:
What is your relationship to patient account you are inquiring about:

SelfLegal GuardianSpouseOther
If other than self, please provide your information:
Your Name:

First Name Last Name
Your Date of Birth:

MonthDayYear
MM/DD/YYYY
How would you like to be contacted?

Phone CallEmailMail
Phone Number:
Please enter a valid phone number.
E-Mail:
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Lab Service *NR:

MonthDayYear
Date
Insurance Plan Name:

Billing Inquiries - Blue Cross Blue Shield

TruChoice Diagnostics
Frequent Questions:
If none of the options above match your question please type your question below:

Billing Inquiry

TruChoice Diagnostics
Frequent Questions:
If none of the options above match your question please type your question below:

You have indicated the bill you received has already been paid

Please provide some additional information about the payment:
Date Bill was paid:

MonthDayYear
Date
Payment Method:
Additional Payment Information (Check Number, Last 4 Digits of Credit Card, etc.)

You have indicated you received payment from your insurance

See More Information & Remittance Instructions Below
REMITTANCE INSTRUCTIONS:

If you receive/received a check, please endorse it to “Pay to the order of TruChoice Diagnostics” and return the check in person or by mail to:

TruChoice Diagnostics

135 Midway Drive, Suite A

Dubois, PA 15801

If you already received a check and cashed it, you can pay the check amount by cash, credit card, or personal check.

Please note, if you do not submit the check you may be billed for services rendered at our facility.

If you are a member of Highmark Blue Cross Blue Shield (or affiliates) you may receive a check by mail for laboratory services rendered at our facility. Unfortunately, some Highmark plans follow this protocol for out-of-network medical facilities such as TruChoice Diagnostics.

We know this can be an inconvenience and appreciate your help in making TruChoice Diagnostics a success in our area!
Would you like to pay your outstanding bill now via credit card?

YesNo
NAME AS IT APPEARS ON CARD:

First NameLast Name
CARD NUMBER:
CARD EXPIRATION:
CVV SECURITY CODE:
HOW WOULD YOU LIKE YOUR RECEIPT?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
I hereby authorize TruChoice Diagnostics, LLC to deduct payment for my outstanding account balance from the provided debit/credit card account.

Clear
Your card will be charged and applied to your account balance within 7 business days of your submission.

You have indicated you do not know how to pay your bill

See More Information & Remittance Instructions Below
REMITTANCE INSTRUCTIONS:

You can pay your outstanding bill with a check, credit card, or cash. Payment can be remitted by mail to the address below:

TruChoice Diagnostics

135 Midway Drive, Suite A

Dubois, PA 15801
Would you like to pay your outstanding bill now via credit card?

YesNo
NAME AS IT APPEARS ON CARD:

First NameLast Name
CARD NUMBER:
CARD EXPIRATION:
CVV SECURITY CODE:
HOW WOULD YOU LIKE YOUR RECEIPT?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
I hereby authorize TruChoice Diagnostics, LLC to deduct payment for my outstanding account balance from the provided debit/credit card account.

Clear
Your card will be charged and applied to your account balance within 7 business days of your submission.

Additional Questions, Comments, or Information
Please type any additional comments or information below:
Should be Empty:

TruChoice Diagnostics Billing Inquiries

If other than self, please provide your information:

Billing Inquiries - Blue Cross Blue Shield

Billing Inquiry

You have indicated the bill you received has already been paid

You have indicated you received payment from your insurance

You have indicated you do not know how to pay your bill

Additional Questions, Comments, or Information