JWC Billing Contact Submission Form

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 NameLast Name
Date of Birth:*

MonthDayYear
Date of birth:
Address*

Street Address

Street Address Line 2

CityState / 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 onlyVIA Email onlyVIA phone or EmailNo return contact authorized
Primary Organization

MonroevilleSouthsideWexfordUnspecified
Submission Purpose*

New Insurance InformationRequesting a Statement for Balance DueRequesting a Statement of services (HRA/HSA/FSA)Insurance Benefit InquiryPayment InquiryRefund Request (must have received refund letter from organziation)Other
Insurance Carrier
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:

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If applicable: Upload back of insurance card.
Back of insurance card:

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Statement/Benefit information:
How would you like to receive your statement or benefit information?

Physical MailEmailPick up in Office
Specify date requested for pick up:

MonthDayYear
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:

MonthDayYear
Date
Service End Date:

MonthDayYear
Date
Payment Inquiry:
Payment Amount
Payment Date:

MonthDayYear
Date
Inquiry information:
Refund Request Inquiry:
Refund Amount
Refund letter date:

MonthDayYear
Date
How would you like your refund to be delivered to you:

By Mail:Refund to Credit CardHold for use towards future services
Name on Credit Card

First NameLast 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.*

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Signature

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Billing Contact Submission Form

If you are submitting new insurance information please provide photo of insurance card

If applicable: Upload front of insurance card.

If applicable: Upload back of insurance card.

Statement/Benefit information:

If requesting Statement information please select date range of services below:

Payment Inquiry:

Refund Request Inquiry: