Request a Free Major Medical Bill Evaluation
First Name
Last Name
Email
Phone
Street Address
City
State
Zip Code
DOB
Insurance
Best Time to contact?
Best Method to contact?
Email
Phone
What is the general reason for requesting a Free Major Medical Bill Evaluation?
What is the Major Medical procedure?
When was the major medical procedure?
Was it an emergency? or Health Reasons?
Emergency
Health Reasons
Was your insurance approved for this type of procedure?
Yes
No
Other
Was pre-authorization required?
Yes
No
Other
What was the costs of the major medical procedure?
Did Insurance pay for the procedure?
Yes
No
If so, How much?
What are your out of pocket expenses for the Major Medical Procedure?
Do you have an itemized bill?
Yes
No
Other
Has your account been turned over to collections for this procedure?
Yes
No
I don't know
Have you discussed concerns with the billing office where this procedure occurred?
Yes
No
Generally describe the feedback received.:
Any other concerns or comments.
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