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Account Information
Locate your account number at the top of your statement.
Account Number*
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Patient's Date of Birth*
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Year
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Please continue to pay if your account is in collections.
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Acknowledgement/Attestation
(Optional)
I hereby attest, certify and acknowledge, under penalty of perjury, that my current gross household income is less than that set forth in the
Federal Poverty Guidelines
, as adjusted for my marital status and household size, and that I will send payment of the total billed charges minus 15% on or before:
XX/XX/20XX
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