You have received this secure form because we are missing insurance information for billing on behalf of the physician who treated you. Although you may have already provided this information to the hospital, your physician is not a hospital employee, so we bill from a different system and sometimes the information we receive is incomplete. Completion of this form allows us to quickly update your account. If you have any questions or do not have insurance and need a selfpay rate, you may call our billing office at 855-666-4956 or send an email to Info@blitzmedical.com
