Itemization request

Itemization Request

Use this form to request an itemized statement for an account you have in our office. We will request it from our client (your healthcare provider) and mail it to the address you have on file with us. If you feel we have the wrong address for you, please call our office and speak to a representative to update that address because we need to confirm your mailing address with you directly to ensure your health data privacy.

Please allow up to 4 weeks to receive your itemization documentation.

Note: If you want this information to be sent to anyone other than you, please complete the HIPAA Authorization Form and mail it to our office at PO Box 310, Scottsdale, AZ 85252-0310.
This communication is from a debt collector. This is an attempt to collect a debt and any information obtained will be used for that purpose.