Please complete this form for any billing inquiries or if you would like a Customer Service Representative to contact you to assist you in resolving your account. To serve you better, please be sure to provide as much information as possible when completing the fields below.

According to HIPAA privacy regulations, we will be unable to send any protected health information to anyone other than the patient or their legal guardian when appropriate. Should we have questions regarding the information submitted, you will be contacted by one of our representatives. Please provide your best contact number when completing this form.

If you are enrolled in MyChart, please visit the MyChart portal to request an itemized bill.