Patient Inquiry Form

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Patient Inquiry

Please use this form to provide the information needed for the team at Innovative to respond quickly and with excellence.

Innovative Healthcare Systems, Inc. (www.ihsi.com) provides professional services for healthcare service providers across the United States; www.paymybill.healthcare is one of our platforms.

Type

Priority

Patient Date of Birth

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Patient Information

Innovative is committed to the security of every patient's Protected Health Information (PHI). The information in this form will be encrypted upon submission, so please ONLY include the information requested.

Your attention allows us to serve you with excellence and efficiency.

Relationship to Patient*

Self Spouse Legal Parent Step Parent Employer

Other:

First Three (3) Letters of Patient LAST Name*

In an effort to guard the Protected Health Information (PHI) of the patient, please ONLY share THREE characters.

Account Number or Medical Record Number (MRN)*

Available on your statement.

Did you receive a statement?*

YES NO

Treatment Facility/Location Name*

Available on Statement

Date of Treatment/Service*

Available on Statement

Inquiry Details

Reason for Inquiry*

Insurance Question Statement Question Please Update My Information

Other:

Additional Notes

Notes SHOULD NOT include information that would identify yourself or services rendered.

Updated Insurance Information Detail

Please use this section to provide your updated insurance information.

Insurance Name

Insurance Address Provided

Address Line 1

Address Line 2

City

State

ZIP Code

ID or Policy Number

Group

Subscriber

If self-pay, just enter "SELF"

Contact Information

Innovative knows that the security of personal contact information is incredibly important. We request the following information to allow our team to quickly serve your inquiry.

We do not share your contact information with any third parties.

Name*

Prefix

First Name

Last Name

Contact Email*

Preferred Communication*

Email Telephone Mail

Preferred Return Call Time*

Early: 7:30 a.m. - 9:00 a.m. Morning: 9:00 a.m. - 11:00 a.m. Afternoon: 1:00 p.m. - 3:30 p.m. Late: 3:30 p.m. - 5:30 p.m.

Times are in Central Time. We will make every effort to honor your request.

Phone*