Have A Question For The Medical Billing Department?

If you have a question about a bill you received, an insurance denial, or a request for a ledger please use this form or call the office at (904) 249-6307.

NOTE: This form is not for questions about a lab bill or a medical condition. Please call your physician's office for these types of questions.

Practice Name:
Doctor Name:
Patient's full name:
Contact person's name:
	(Please note privacy laws prohibit us from speaking with anyone other than the patient unless the patient signed a HIPAA form in the office allowing communication with another person or persons. If this information is not at the office and you are not the patient, we will not be able to speak with you regarding the account without the patient's permission.)
Daytime phone number:
Account number on statement (or last 4 of patient's SSN):
Patient's Date of Birth:
	Please enter your question or request below:
	Other Comments:
	Someone will contact you at your daytime phone number within 24 hours to resolve your questions or concerns.
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