Request for Visit Refund - Virtual Care for Families

Request for Visit Refund

If you need to request a visit refund, please submit the form below

For billing-related questions/concerns, click here or call us at (682) 267-0452

Request for Visit Refund Submission Form

Request for Visit Refund
Patient First Name
Patient Last Name
Patient ID
Visit Date(s)
Clinic/Virtual Visit
Best Contact Phone Number
Valid Secure Email Address (for expedited communication)
Detailed Reason for Visit Refund Request
Additional Requests

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