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  For Patients Overview › On - Line Patient Billing Center

On - Line Patient Billing Center

 

Fill out the information below so we can better assist you with:

  • Updates to your billing and insurance information.
  • Questions concerning your Dynacare invoice.
  • Insurance questions or concerns.
After you complete this form, your information will be sent to the Patient Billing Department. Please feel free to add more information in the "Comments and Questions" box (step 5) regarding your account.


*Required information is indicated by an asterisk (*) to update your account.

Step 1:
Patient Information
Accession/Account Number (Invoice Number)*
Account Number on your Bill
Patient Name *
Name as it appears on your Insurance card
First
Last

Patient Address * Street Address:
  City:
 
  Zip Code:
Patient Date of Birth*
(MM/DD/YYYY)
Patient Gender*
Patient Telephone Number
Patient e-mail Address*
Confirm e-mail Address*


Step 2:
Doctor's Name First

Last
Doctor's Address Street Address:
  City:

 
  Zip Code:


Step 3:
Patient's Relationship to Insured (ie. Self, Spouse)
Insured's Name
(if different from the patient)
First

Last


Step 4:
Insurance Company Name*
Effective Date
Insurance Address Street Address:
  City:
 
  Zip Code:
Insurance Telephone Number
Insured SSN#
Insured Employer
Insurance Number
Group Number
Medicare Number
Medicaid Number


Step 5:
Comments or Questions
 

 

 

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