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Please use the form below to submit a question to our billing department. Should you need to change insurance information, you can do so by adding it to this form. We require that you provide us with at least one method of contact, either phone or email, so that we can expedite your inquiry. Thank you!  Fields in Red are Required.
 
First Name:
Last Name:
Social Security Number:
Account Number:
Where is my account number?
Insurance Information:
Name:
Address:
City:
State: Zip code:
Insurance Policy Number: Group Number:
Date of Service:
(mm/dd/yyyy)		 Place of Service:
Contact Phone Number: Type of Exam:
Email Address:
Question
Preferred Contact Method: Phone Email
Please click submit to send your question to our billing department.

To Schedule an Exam

Please Call

Centralized Scheduling

(480) 456-9000

Fax (480) 632-1153

  

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