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Request for Billing Information and Assistance

The Presbyterian Customer Service Center is here to help you with any inquiries or issues you may have. Please complete the following form so that a representative can assist you.

Fields with an asterisk are required.

Patient's First Name*
Last Name*
Address*
City*
State*
Zip*
Contact Name*
Contact Phone
E-mail Address*
Type of assistance needed* Need Account Balance
Question on Balance
Request for Itemized Bill
Other (Explanation of benefits, financial assistance questions, etc)
Account # or SSN*
Date of Service*
Type of Bill* Hospital
Physician
Ambulance
Reason for Inquiry*

Attach Supporting Documentation:

File 1:
File 2:
File 3: