Ebillling - Advanced Family Medicine

Patient Name
As a responsible party you are only able to receive e-statements for your legal dependents. Please specify their names above
Parent/Guardian Name
Patients SSN
Email
By opting in, you agree to receive statements through your personal email address above. You may opt out at any time by contacting our billing office at 866-822-8104.
Signature of Patient/ Responsible Party
(If Patient is a minor, Parent or Guardian signature is required)
Date
MM slash DD slash YYYY