Billing Contact Submission Form
Please complete the questionaire and an associate will get back to you within 3 business days.
Full Name of Client:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date of birth:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
I authorize a JADE Wellness Center staff to contact me:
*
VIA phone only
VIA Email only
VIA phone or Email
No return contact authorized
Primary Organization
Monroeville
Southside
Wexford
Unspecified
Submission Purpose
*
New Insurance Information
Requesting a Statement for Balance Due
Requesting a Statement of services (HRA/HSA/FSA)
Insurance Benefit Inquiry
Payment Inquiry
Refund Request (must have received refund letter from organziation)
Other
Insurance Carrier
Please Select
Aetna
Cigna
Highmark
UPMC
United Healthcare/Optum
Meritain
Other
If other Specify:
If you selected "Other" we may not be in network with your specified plan.
Member ID Number:
Group Number
If you are submitting new insurance information please provide photo of insurance card
If applicable: Upload front of insurance card.
Front of insurance card:
Browse Files
Drag and drop files here
Choose a file
Add image.
Cancel
of
If applicable: Upload back of insurance card.
Back of insurance card:
Browse Files
Drag and drop files here
Choose a file
Add image.
Cancel
of
Statement/Benefit information:
How would you like to receive your statement or benefit information?
Physical Mail
Email
Pick up in Office
Specify date requested for pick up:
-
Month
-
Day
Year
Please specify the date you'd like to pick up your statement. Please note that you must call and confirm pick up date with front office.
If requesting Statement information please select date range of services below:
Service Begin Date:
-
Month
-
Day
Year
Date
Service End Date:
-
Month
-
Day
Year
Date
Payment Inquiry:
Payment Amount
Payment Date:
-
Month
-
Day
Year
Date
Inquiry information:
Refund Request Inquiry:
Refund Amount
Refund letter date:
-
Month
-
Day
Year
Date
How would you like your refund to be delivered to you:
By Mail:
Refund to Credit Card
Hold for use towards future services
Name on Credit Card
First Name
Last Name
Credit Card Number
Expiration Date:
CVV
Comments:
By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold JADE Wellness Center harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.
*
Yes
Signature
Clear
Submit
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