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: Patient name, date of birth, and address must be the patient's. Your email can be different — you can be the point of contact even if you're not the patient. If you're signing for someone else, we'll guide you through what's needed.

Are you the patient? *

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

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

2Patient Information

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

3Provider Information

Provider/Hospital Name *

City *

State *

How many days was this service? *

Service Date

4Bill Details

Did the patient have insurance during dates of service? *

Amount You Owe (USD) *

Bill Status *

Upload Your Documents *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 we should know?

How did you find us?

5What You're Agreeing To

Authorize CareRoute to pursue bill reduction with your provider, insurer, or other parties as needed

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

6Signature

Signature *

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

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