Patient Account Information Request

Account Information Request
Patient Information
Name *

First Name Middle Name Last Name
Account number
If you do not have a Patient Account Number
Date of birth

Month Day Year
Date
Date of service

Month Day Year
Date
Facility
Do you need your account balance?
Email
example@example.com
If you are providing an e-mail address you are:

1. Attesting to the accuracy of the address, and
2. Authorizing children's to answer your inquiry via e-mail.

Be advised that e-mail is not an entirely secure and private means of communication. The e-mail provider you utilize may be vulnerable to intrusion. If you have strong concerns about the privacy of the information that might be contained in an e-mail to you from Children's Healthcare of Atlanta, you should not provide an e-mail address.
Do you have payment arrangement or general questions?

If you fill in your phone number, a customer service representative will call you to set up payment arrangements.
Select a best time to reach you
Phone Number
Please enter a valid phone number.
Do you need to change your address?

This will only change your mailing address, not the guarantor or responsible party.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Should be Empty:

Account Information Request