Patient Insurance Information
Please use the space below to send specific billing information through our secure form to the business office. We appreciate your assistance.
Patient Name
Gender
Social Security Number
Birthdate
Address
Address 2
City, State, ZIP
Daytime Phone
Evening Phone
Email
Insurance Company Name
Insurance Mailing Address
Subscriber Number
Group Number
Effective Date of Insurance Coverage
Additional Information
(972) 566-7866 (hospital and scheduling office phone) (972) 566-6290 (hospital and scheduling office fax) (972) 239-8902 (billing office phone) (972) 661-2551 (billing office fax) Email: info@rcnd.com
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