Start Your Bill Reduction

Start reducing your medical bills today. Our expert team negotiates directly with hospitals on your behalf. Only pay us if we save you money.

1Patient Information

Full Legal Name *

Date of Birth *Required for hospital to release billing records to CareRoute

Street Address *Required for hospital to release billing records to CareRoute

City *

State *

ZIP Code *

Phone *Required for hospital to release billing records. Used for updates.

Email *

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

Upload bill or statement

PDF, JPG, or PNG

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

Authorize CareRoute to pursue bill reduction with your provider

Pay 18% of savings achieved (no savings = no fee)

Signature may also be used for financial aid applications we submit on your behalf, with your approval.

Signature *

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

Anything else? (optional)

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