Please submit the form below to be contact by our billing coordinator within 48 business hours!
Patient First Name
Patient Last Name
Email
Phone
Name of Person Inquiring (if different from patient)
State your question or inquiry. Please be as detailed as possible.
Was a Date of Service (DOS) listed in your payment request? Choose an optionYesNo
If a DOS was listed in your payment request, have you reviewed the corresponding EOB from your insurance and/or contacted your insurance for this? Choose an optionYesNoA DOS was not listed in my payment requestI do not have dental insurance
Are you interested in a payment plan for this balance? Choose an optionYesNo
Please enter an answer in digits:
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