tet

**Please complete the following form to contact your billing department. Only submit your information once. Duplicate entries will be removed automatically by our system. If you would like to follow up on your submission, please call our billing department, do not submit another entry. Thank you.
FOR ALL REFUND REQUESTS PLEASE ALLOW 60 DAYS FROM THE DATE OF SERVICE TO REQUEST STATUS UPDATE.**

I need to contact the billing department regarding:

—Please choose an option—RefundItemized ReceiptOther

[group Refund]

Full Name:

Date of Birth:

Phone:

Best Contacting Email:

Date of Visit:

I allow Xpress Urgent Care to contact me via phone or email.

[/group]

[group ItemizedReceipt]

Date of Birth:

Phone:

Best Contacting Email:

Date of Visit:

I allow Xpress Urgent Care to contact me via phone or email.

[/group]

[group Others]

Date of Birth:

Phone:

Best Contacting Email:

Date of Visit:

Other:

I allow Xpress Urgent Care to contact me via phone or email.

[/group]