Billing Questions/Concerns

This form is for general inquiries about billing concerns only. Please fill out the form below and one of our representatives will contact you within 48 hours. If you are in need of immediate assistance, please call us at (719) 538-2945.

Patient Information

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First Name:  
Last Name:  
Account Number:  
Date of birth: (ex:MM/DD/YYYY) 

WARNING: IF YOU HAVE AN EMERGENCY, PLEASE CONTACT YOUR PHYSICIAN'S OFFICE DIRECTLY BY PHONE OR CALL 911 FOR IMMEDIATE ASSISTANCE.
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