HAVE A QUESTION ABOUT YOUR BILL?

To send your question, please complete the following form in its entirety. 

Quick Collect Account Number
Patient's First Name
Patient's Last Name
Patient's Date of Birth
Your First Name
Your Last Name
Relationship to Patient
Address
City
State
Phone Number
Type of Phone
Email Address
Write your question about your bill

By clicking "SUBMIT QUESTION", I acknowledge that Quick Collect, Inc. is a collection agency and any information obtained will be used for the purpose of collecting a debt.