Medical Laboratory Billing Address Update Form

Medical Laboratory Billing Address Update Form
Please complete this form to update the billing address for your medical laboratory. Accurate and complete information will ensure prompt processing of your request.
Laboratory Name
Laboratory Identification Number (if applicable)
Current Billing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
New Billing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Effective Date for New Billing Address
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Person Full Name
First NameLast Name
Contact Person Email Address
example@example.com
Contact Person Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Relationship to the Laboratory
Reason for Billing Address Update
Additional Comments or Instructions (optional)
Should be Empty: