Billing Department Inquiry

DISCLAIMER:

All accounts must be in good standing with no deliquencies prior to requesting a hold / termination. In the event where there is a negative balance/declined payment on the account, the balance must be cleared to qualify for a hold / termination.


All account hold requests must be
medically related and verified by a physician. A doctor's note specifying the exact time frame you will be able to return is required.


All billing requests must be sent in
30-days prior
to the upcoming billing cycle. No exceptions & No refunds will apply.

PLEASE DO NOT - SUBMIT THIS FORM MULTIPLE TIMES. You have been placed in a queue and submitting multiple requests will move your place to the bottom of the incoming requests.

Please make sure you select the correct location when submitting your form and all information is as detailed as possible.

PLEASE SELECT ONE OF THE FOLLOWING OPTIONS: