AISC Billing Complaint/Grievance

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AISC Billing Complaint/Grievance

If you believe there are discrepancies in your bill and have concerns, please initiate a billing complaint/grievance, and we will respond to you within 7 business days.

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Contact Information

First Name*

Last Name*

Phone*

Email Address*

Relationship to Patient:

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Patient Information

Patient First Name*

Patient Last Name*

Patient Phone*

Patient Email Address*

Additional Information

Date of Visit

Details of your Complaint/Grievance

Amount / Items Disputing

Describe your Complaint/Grievance

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AISC Billing Complaint/Grievance

AISC Billing Complaint/Grievance

Contact Information

Patient Information

Additional Information

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