Physique Medical Clinic – Billing Inquiry Form

Before submitting a billing inquiry, please review your Explanation of Benefits (EOB) from your insurance company. Many patient balances are related to deductibles, coinsurance, copays, or non-covered services as determined by your insurance plan.

Common reasons for patient balances include:

Annual deductible not yet met
Coinsurance responsibility
Copayment responsibility
Non-covered services
Out-of-network benefits
Insurance processing delays

If your Explanation of Benefits (EOB) indicates that the balance is your responsibility, payment may still be due even if you have insurance coverage.

Name

Date of Birth

Phone Number

Invoice Number

Date of Service in Question

Select all that apply: Select all that apply: I have reviewed my Explanation of Benefits (EOB) from my insurance company. I understand that deductibles, coinsurance, copays, and non-covered services are determined by my insurance plan. If my question relates to insurance payment or claim processing, I have contacted my insurance company for clarification. I understand that Physique Medical Clinic cannot change insurance plan benefits or payment determinations made by my insurance company.

What Best Describes Your Concern?

Please Describe Your Billing Question

Acknowledgement Acknowledgement I understand billing inquiries are reviewed in the order received and responses may take up to 5–7 business days. I certify that the information provided above is accurate to the best of my knowledge.

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