Refund Request Form

Request a Refund*

Please complete the form below to request a refund from Kentucky Urgent Care.

DISCLAIMER: If you are experiencing a medical emergency, please call 9-1-1. This form is for appointment requests only.

*Request must be within two years of the insurance claim filing date

Patient Contact Information

Name(Required)

First Middle Last Suffix

Date of birth(Required)

Gender(Required)

Male

Female

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

No Email

Phone(Required)

Phone type(Required)

Patient Insurance

Insurance Company(Required)

Policy ID Number(Required)

Group Number. It may also be referred to as the "GRP" number

Is the patient the insurance holder?

Yes

Name

First Middle Last Suffix

Policy Holder's date of birth

Policy Holder's Gender

Male

Female

Relationship to the primary holder

Payment Information for Refund Request

What is the reason for the refund request?

Please indicate the other reason.

Was your payment taken over a year ago? (If so, please upload an image of voided check)

Please upload an image of a voided check.(Required)

Max. file size: 512 MB.

Date of Appointment(Required)

By submitting this form, I confirm that the information provides is accurate and that I am requesting a refund according to the terms and conditions of the purchase.(Required)

If you have a billing question, feel free to contact us by one of the methods below!

Photo of lady on the phone with billing questions

Call us at (859) 868-1025

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Email us at billing@urgentcareofky.com

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