MAKE A BILLING INQUIRY

If you have a question or comment regarding your bill, please complete and submit this form.

* indicates required field
* patient first name:
* patient last name:
social security number:
(ex: 123-45-6789)
account number:
bill date:
service from date:
service to date:
question/comment:
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If so, email address:
* I have read and understood the ULH notice of privacy practices. (Click here)  (Initial to agree)