How Can We Assist You?
Please fill out this form for any Financial/Billing inquiries so that our Patient Account Specialist will be able to assist you.
Today's Date:
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Month
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Day
Year
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Patient's Name:
Parent's Name
First Name
Last Name
Phone Number
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Area Code
Phone Number
E-mail
What can we assist you with?
Deductible/Out-Of-Pocket Max Met
GSR's Billing Protocol
Charges Invoiced
GSR's Payment Collection Protocol
Monthly Statement/Balance
Claims Processing Incorrectly
Incorrect Benefits Quoted
Change in Insurance
Other
If your Deductible or Out-Of-Pocket Max has been met for the year, please provide us with the date that it was met so that we can adjust accordingly.
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Month
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Day
Year
Date
Please explain your inquiry:
Please explain the steps you have taken towards this inquiry so far:
Please provide the insurance's call reference # (if obtained).
Please upload any documents that we might need in order to resolve your inquiry.
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Please allow up to 7 business days for us to look in to your inquiry and respond back. Thank you for choosing Great Strides Rehabilitation and we look forward to speaking with you soon.
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