Insurance Billing Assistance Escalation Form Full Name * (as it appears on your insurance card) First Name Last Name Date of Birth * MM DD YYYY Insurance Provider Name * Member ID or Policy Number * Is this an In-Network or Out-of-Network Claim? * In-Network Out-of-Network Date(s) of Service Affected If applicable, list any dates for which billing is in question Brief Description of Billing Issue * Previous Contact Details Date(s) When You Last Contacted Twin Oaks Billing or Rebel Heart Therapy Thank you for submitting your inquiry. Rebel Heart Therapy's Administrative Staff will respond to you via the Client Portal messaging system to ensure confidentiality. If we are unable to verify your information in our system, HIPAA regulations prevent us from reaching out directly. If you do not hear from us via the Client Portal within 3 business days (excluding holidays), please call our office directly at 971-350-1122 to confirm your details.
