Patient NameAs a responsible party you are only able to receive e-statements for your legal dependents. Please specify their names aboveParent/Guardian NamePatients SSNEmail 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 Δ
