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(Guarantor is the Person financially responsible for your bill)

   * Required Field

Account Number *
   The account number is the 10 digit number located in box 15 on the left hand side of your statement.
   
Patient Date of Birth * format: mm/dd/yyyy
Guarantor Email Address format: yourname@yourdomain.com
  
   You may be required to supply legal documentation regarding a name change.
Patient Name Change
Incorrect Information
Current Last Name:
Current First Name:
Current Middle Intital:
   
Corrected Information
New Last Name:
New First Name:
New Middle Initial:
Guarantor Name Change (person financially responsible)
Legal documentation required.  Please send to attention:  Customer Service Unit - 99 Delaware Ave., Delmar, NY 12054
Incorrect Information
Guarantor Last Name:
Guarantor First Name:
Guarantor Middle Initial:
Guarantor Date of Birth:
   
Corrected Information
New Guarantor Last Name:
New Guarantor First Name:
New Guarantor Middle Initial:
New Guarantor Date of Birth:
   
   
   Reason for Change:
 

What you need to send to our Customer Service Unit:
     Marriage
- Marriage certificate
     Divorce - Divorce decree
     Name Change - Legal Documentation
     Adoption - Legal Documentation
     Spelling Error - No Document needed

   Select a Preferred Contact Method: