Submit Your Bill

Fill out your bill details below. We'll review it and start negotiating. You only pay if we save you money.

1Person Completing This Form

Important: Only the patient or their legally authorized representative can complete and sign this form.

Are you the patient? *

Yes, I am the patientNo, signing on behalf of patient

Your Email *We'll send case updates to this email

Full Legal Name *Must match the name on file with your provider

Date of Birth *Must match your provider's records so they can release billing info to us

Street Address *Must match your provider's records so they can release billing info to us

City *

State *

ZIP Code *

Phone *Must match your provider's records so they can release billing info to us

Household Size *

Annual Household Income (USD) *Used only to qualify you for maximum financial assistance and discounts

Provider/Hospital Name *

City *

State *

How many days was this service? *

Service Date

Did the patient have insurance during dates of service? *

Bill Amount (USD) *

Bill Status *

Upload Your Bill and/or EOB *Upload all documents related to this provider visit - bills, EOBs, statements

Upload bills, EOBs, or statements

PDF, JPG, or PNG - select multiple files at once

Anything else? (optional)

How did you find us? *

Authorize CareRoute to pursue bill reduction with your provider

Pay 25% of savings, or just 18% if you're a CareRoute app Premium member. No savings = no fee.

Signature *

Sign as it appears on your ID (driver's license, etc.)

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