Balance Bill Request - FairPrice

Balance Bill Request

Your Contact Information
Name*
First Last
Your Employer Name*
Phone*
Email*
Enter Email Confirm Email
Provider Billing Information
Healthcare Provider Name*
Healthcare Provider Phone Number*
Account Number*
Date Of Service*
Date Format: YYYY dash MM dash DD
Balance Amount*
Please provide a copy of your balance bill
Please add a PDF file.
Max size: 10MB
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Hidden Fields
SFDCRecordType
SFDCCaseOrigin