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Assistance Request
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* Indicates required question
Email
*
Your email
Name
Your answer
Priority
Choose
Urgent - Same day
High Priority - 1-2 days
Medium Priority - 3-5 Days
Not Urgent
What does it apply to?
1. Copays/Client Charges
2. Client Balances, Credits, or Invoices
3. Payroll Issue
4. Has lunch been ordered?
5. Claims Rejected or Unpaid
6. Credentialing
7. Client Insurance Issue
8. Credit Card Declined
9. Openings for new clients
10. Scheduling
11. Client needs contacted
12. Request for supplies or office issue
Other:
Client Name if applicable (form is encrypted)
Your answer
What specifically can we help with:
Your answer
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