Online Billing Inquiries

For questions regarding your bill, please fill out the form below.

In compliance with Federal regulations regarding the disclosure of personal health information, the response to your inquiry will be sent via email in a secure format that requires you to create a username and password in order to view the response.

Account Number

Reference/Invoice Number

Patient First Name

Patient Last Name

Patient Date of Birth (MM/DD/YYYY)

Date of Service (MM/DD/YYYY)

Amount Billed

Relation to patient

Self Other

Your First Name

Your Last Name

Your Phone Number

A Montefiore representative will call you if additional information is needed to complete your request.

Your Email

What is the reason for your inquiry?

Are you providing insurance information different from what is shown on the back of the bill?

No Yes

Insurance Name

Policy Number

Address to Send Claims (see back of your health plan ID card)

Insurance Phone Number

Relation to Policy Holder

Self Other

Policy Holder First Name

Policy Holder Last Name

Policy Holder Date of Birth (MM/DD/YYYY)