Advanced Foot & Ankle Care, LLC. - Where we take it one step at a time!
Patient Name {Last, First}
Date of Birth
Primary Insurance Carrier
Policy Number
Relationship to the Subscriber
Self
Spouse
Child
Other
Date of Service you are inquiring about?
Billing Questions:
Why do I have a balance?
Why were the charges applied to my deductible?
Is AFAC "in-network" with my insurance carrier?
Other
Briefly describe your billing question:
What is the best time to reach you?
Hours
 
 : 
Minutes
 
What is the best way to reach you?
Email
Phone (home,work,cell)
Mail
Email address:
telephone number
Cell Phone