ACCOUNT AUDIT/REFUND REQUEST

If you have not been contacted by our office and feel there is a refund due to you and would like an audit be made on your account, please complete the form below and submit it.  A member of our team will acknowledge the form and an audit will be processed.

 

Be advised that the audit and refund will take up to 30 business days from the day it is received. In some cases, the auditor may need to speak with you to gather additional information. Failure to communicate with the auditor or failure to provide the accurate information needed will result in additional delays in the process.

 

THE ACCOUNTS DEPARTMENT WILL NOT BE AVAILABLE TO TAKE ANY INBOUND CALLS REQUESTING UPDATES ON THE PROCESS UNTIL IT IS FINALIZED.

Account Audit/Refund Request

I hereby request and audit be done on my child's account.

Patient's Full Name*

 

Guardian's Signature*

I understand that my name entered in the box above stands for my signature and grants authorization to look into my child's account.

 

Patient's DOB*

 

Email*

 

Phone*

 

Reason for Request*

 

Once complete, a representative will reach out to you and inform you of the details regarding your account. If a refund is due, the necessary information will be collected from you and a refund will be processed. Please note, the account audit can take up to 30 days to ensure accuracy, and the funds are available approximately 7 days after the audit is complete. If the account reflects a balance due after the audit, payment in full of this balance will need to be paid upon receipt of electronic statement.
 

I understand that all information I hereby authorize to be obtained will be held strictly confidential and cannot be released without my written consent. I understand that this authorization will remain in effect until revoked by me in writing. I understand that unless otherwise limited by state or federal regulations, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time by submitting my request in writing.

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