Current Patient Billing Statement Request

To request a billing statement, please complete and submit the Billing Statement Request Form below. All requests must be submitted in writing through this form.

Please allow up to 30 days from the date of submission for your request to be processed. Once completed, billing statements will be sent to the email address provided on the form.

Important: Each billing statement request applies only to the specific date(s) or date range indicated on the submitted form. If you require statements for additional dates or time periods, a new request form must be submitted.

If your statement is needed sooner than the standard 30-day processing period, please indicate this on the request form. Expedited requests will be reviewed but cannot be guaranteed.

For Billing Statement Requests Please Fill Out The Form Below

Contact Page Form

Patient Name

Patient Date of Birth

Parent Name Requesting

Parent Email

Reason for Request

Date Range Requested

Do you require your billing statement sooner than the standard 30-day processing period?

Please provide the date needed

Reason for expedited request

Email Consent

Email Consent: By checking this box, I consent to receiving my billing statement via unencrypted email. I understand that unencrypted email is not secure and may pose a risk to the privacy of my information.

Processing Time

Processing Time: By checking this box, I acknowledge that billing statement requests may take up to 30 days to process and deliver from the date of submission.

Additional Statement Requests

Additional Statement Requests: By checking this box, I understand that my billing statement request applies only to the specific date(s) requested. If I need statements for additional dates or time periods, I must submit a new request.

Additional Notes for Billing Department

5458 Town Center Road, Boca Raton, Florida 33486

Current Patient Billing Statement Request

For Billing Statement Requests Please Fill Out The Form Below

Contact Page Form