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Itemized Bill Request

To request an itemized bill, fill out the required fields below and click the "SUBMIT INFORMATION" button. The itemized bill will be mailed to you via regular US Mail within seven business days.

Patient Information

Date of Birth (required)*

Select your birth month from the dropdown, then enter your birth day, followed by your birth year.
E.g. January 1, 1990
Guarantor Information

Date of Birth (required)*

Select your birth month from the dropdown, then enter your birth day, followed by your birth year.
E.g. January 1, 1990
Send Itemized Bill To
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