Free Medical Bill Review Request Form

First Name

Last Name

Email

Phone

Street Address

City

State

Zip Code

DOB

Insurance

Best Time to contact?

Best Method to contact?

Email Phone

What is the general reason for requesting a Free Medical Bill Review?

What bill / procedure would you like reviewed?

When were the services rendered?

Where were the services rendered?

Do you have a copy of the bill?

Yes No

If Yes: Is it an itemized bill?

Was Pre-Authorization required?

Yes No

Has insurance paid? or denied?

Paid Denied Other

Have you discussed billing concern with provider?

Yes No

Are you receiving collection letters or calls?

Yes No

Other questions, comments or concerns:

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