DoctorPayments

Call Us

Toll-Free at 855-691-9890

Monday-Thursday: 8am-9pm ET

Friday: 8am-8pm ET

Use the form below to send us an email.

Patient's Name

As seen on statement

Patient's Date of Birth

Account Number

Locate your account number at the top of your statement.

Date of Service

Can be found on statement

Are you the patient?

Yes No

What is your relationship to the patient?

Phone Number

Address Line 1

Address Line 2 (Optional)

City

State

Zip Code

How can we help you?

Please do not provide insurance information in this field

Attachment (Optional)

Such as proof of payment, copy of identification, etc.

(File Type: .jpg, .png, .pdf, or .doc. Max file size: 25MB)