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Please select the name of the facility as it appears in Google Maps
You can upload a document (PDF), a photo of the bill, or an Explaination of Benefits from your insurer
You can add up the total costs of estimates or bills received
This will help us recommend experienced care provided to other patients
We request that you omit sensitives data from bills, including your name, address and other personal information, before submitted By submitted your mediacal records, you are choosing to publicly share your protected health information, which is otherwise protected from disclosure by you health care provider under the Health insurance Probability and Accountability Act.
This picture will be used in your fundraiser. You can preview it before starting your fundraiser.
Why are you fundraising? The more detail the better to attract funders
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