Patient support forms (Billing, insurance, and appointment setting)

Patient Support Resources

If you have questions about scheduling an appointment, referrals, billing or insurance, or other support related to your care, we’re here to help. Please complete the form or call one of the contact numbers listed for assistance.

Helpful contact numbers:

New patient referral line: (765) 935-8934

Medical record requests: (765) 983-3174

General billing questions: (765) 983-3184

Financial assistance & insurance questions: (765) 983-3184

Request price estimate: (765) 983-3358

Please select from the following:

If you would like to schedule a new patient appointment, please call our Customer Contact Center, visit MyChart open scheduling or enter your question/request below.

I have a general question about my health recordsI would like to request my medical records online

BillingInsurance

Personal information

Full Name*

Email*

Phone Number*

Format: (000) 000-0000.

Please provide details about your question or request

Request your medical records here.

Your information is submitted through a secure online form and handled in line with our HIPAA obligations. View our privacy policy here.