Doctor Contact Request | Medical Billing Experts

Doctor Contact Request

Your Name*

Billed or unbilled query*
- Billed
- Unbilled
Invoice Number*
Billing File Number*
Provider
Name
First Last
Group or Personal*
- Group
- Personal
Group*
Patient
Name*
First Last
Date of Birth*

Day
Month
Year
Billing
Hospital
Check this box if date of service is unknown
- Yes
Date of Service*
DD slash MM slash YYYY

Query
Query Type*
- Referral
- Item Number/s
- Fees
Enquiry*
Please word your query as though you are writing an email.
Comments
This field is for validation purposes and should be left unchanged.