PHA Billing Information Request

Physicians Health Alliance, Inc.
Billing Information Request

The purpose of this on-line service is to provide you with the capability to submit billing inquiries, allowing us time to research your account prior to returning your call, so we may better address your needs.

You can expect to be called back at the phone number you provide in this form within three (3) hours. If your request is submitted after 4:00 PM, you will be called the following morning. If your request is submitted after 4:00 PM on a Friday, you will be called by Noon the following Monday.

You will view a confirmation notice after you submit your request.

**This is NOT a secure link, if you are not comfortable sending this information over the internet please call our office**

PATIENT INFORMATION
Last Name:
First Name:
Date Of Birth: (mm/dd/yyyy)
Account #:
Date of Service:
SUBSCRIBER INFORMATION
Insurance Company:
Policy #:
Policy Holder(name):
Telephone:	Work Home
Please state the nature of the problem:(please be as specific as possible)

PATIENT INFORMATION

SUBSCRIBER INFORMATION