Billing Inquiry Form

Use this form to submit billing inquiries. A Patient Accounts team member will respond to your inquiry through a secure e-mail or through a phone call. Please allow up to two business days for a response.

Please note the patient’s financial responsibility for a visit to Patient First is determined by the patient’s health insurance company. If you have a question regarding the amount you owe after insurance payment, please contact your insurance company.

New or updated portal activation codes must be requested in person at any Patient First location, with a valid photo ID.

"*" indicates required fields

Patient's First Name*

Patient's Last Name*

Patient's Date of Birth*

Account Number

Mailing Address

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Service

Center Visited*

Contact Name*

Contact Phone Number*

Contact E-mail Address*

How can we assist you*

Insurance

Primary Insurance

Secondary Insurance

Primary Insurance - Insurance Card Entry

Upload images of insurance card (please include the front and back of the card)

Type insurance card

Add Files

Drop files here or

Max. file size: 2 GB.

ID/Policy Number

Group Number

Policy Holder Name

Policy Holder Address

Patient's relationship to policy holder

Insurance contact phone number

Claims mailing address

Secondary Insurance - Insurance Card Entry