Billing Support Request - SAGE Counseling, Inc

FOR CLIENTS

Billing Department Request

Name(Required)

First Last

Client ID

Date of Birth(Required)

Phone

Email(Required)

Enter Email Confirm Email

How can we help?(Required)

Request a billing statement

Request a billing summary

Request a payment summary

Billing Statement: a summary of all billed services. Requests will be processed within 1 business day.

Billing Summary: a summary of all billed services and payments made. Requests will be processed within 1 business day.

Payment Summary: a summary of all payments made. Requests will be processed within 1 business day.

Purpose of the request:(Required)

For personal review

Submitting to private insurance for reimbursement

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FOR CLIENTS

Billing Department Request

NOTICE