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Billing Inquiry & Dispute Form

Billing FAQ: Older Visit bills | Unexpected charges | Bill my Insurance | Insurance billed? | Higher bill | Multiple bills | Denied claim | Payment plan | Dispute

PATIENT Name

First Last

PATIENT Date of Birth

MM slash DD slash YYYY

Relationship to Patient(Required)

I AM the Patient

I am Parent/Guardian to the Patient

I am Spouse to the Patient

Other

Describe your relationship to the patient(Required)

YOUR Name (NOT the patient name)(Required)

First Last

Contact Email(Required)

Contact Mobile Phone(Required)

Invoice number (If you have received an invoice)

Visit Date

if multiple dates select most recent date – if visit date is unknown leave it blank

MM slash DD slash YYYY

Clinic You Visited

Reason for Inquiry

I need an itemized receipt from my visit

I am not disputing the bill, but I have questions:

I am disputing some or all of the bill:

Preferred Method of Contacting Me

Text (fastest)

Email (faster)

Phone call (slowest)

Describe your question or dispute

Permission to communicate with me regarding this inquiry(Required)

CommunityMed has my permission to communicate with me about this inquiry using the methods below

Cell phone, email and voicemail