Electronic Document Submission

Billing

To utilize the Electronic Document Submission feature, please fill out the fields below and select the files you would like to attach. Please ensure that all electronic and scanned files are clear and legible before submitting them.

If you are a physician, please ensure any medical documentation you are providing (including diagnosis code) is signed and dated. All submissions using this form are secure and meet the requirements for HIPAA compliance.

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Phone *

Attn

Message Please do not include credit card information in this form.

Attachment(s)

Acceptable file types include: pdf, xps, jpg, png, svg, tiff. Sum of all attachments not to exceed 25MB.

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