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DISCLOSURE: BY ACCESSING OUR SITE AND COMMUNICATING WITH US, YOU HEREBY GRANT US PERMISSION TO COMMUNICATE BACK TO YOU AT THE EMAIL ADDRESS INDICATED.

PLEASE BE SURE TO INCLUDE IN YOUR EMAIL, THE PATIENT'S NAME AND HOSPITAL ACCOUNT NUMBER FROM THE STATEMENT YOU RECEIVED.

If you wish to contact the business office by phone please call us at 888-214-4065.

Patient Name	*
Date of Birth (mm/dd/yy)	*
Hospital Account No.	*
Facility Name	*
Your Name	*
Your relationship to patient	*
Your Email Address	*
	* Yes, I certify that I am the owner of the email account and am the patient, the legally responsible party for the patient's account, or I am authorized to act on behalf of the patient.
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