Jay County Cancer Society

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Medical Bills Examples: CO-Pays, Surgery, Treatment, Scans, X-Rays, Labs, Anesthesia, etc.

PATIENT INFORMATION

Patient Name: *

Patient's Date of Birth: *

Address: *

City: *

Zip Code: *

County: *

Complete the form and attach receipts or EOB

Attach EOB or Receipts (photos or PDF): Multiple files allowed

Snap a photo (mobile)

Upload files (you can select multiple at once)

Date

Medical Bills

Out of Pocket Expenses (after Insurance has paid)

EOB/Receipt Included

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LET'S TALK

MAILING ADDRESS:
PO BOX 614
Portland, IN 47371

MESSAGE LINE:
(260)726-8110

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