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Please complete this form in its entirety. Your itemized billing statement cannot be generated until 72 hours after your last date of service. If you do not know your date of service please see an Insurance Advisor in the Student Health lobby. UCSB Permanent Name Identification No. Last First M Non-Student Local Telephone Number Email address Dates of Service From period of time this summary will cover to Month/ day/ year I specifically want my itemized billing statement to include Please check each box that applies Medical Information Women s Health Information Date Mental Health Information Men s Health Information Patient s Signature Please drop off form in the container provided at the Information Desk in Student Health or mail to Or fax to 805-893-5340 IMPORTANT NOTICE If this will be mailed to anyone other than yourself or an insurance agency you must sign an Authorization for Release of Medical Information. This form is available at the Information Desk or on the Student Health Service website. University of California Santa Barbara Student Health Service REQUEST FOR ITEMIZED BILLING STATEMENT Your itemized billing statement will be mailed to you within one week of this request. Please complete this form in its entirety. Your itemized billing statement cannot be generated until 72 hours after your last date of service. If you do not know your date of service please see an Insurance Advisor in the Student Health lobby. UCSB Permanent Name Identification No* Last First M Non-Student Local Telephone Number Email address Dates of Service From period of time this summary will cover to Month/ day/ year I specifically want my itemized billing statement to include Please check each box that applies Medical Information Women s Health Information Date Mental Health Information Men s Health Information Patient s Signature Please drop off form in the container provided at the Information Desk in Student Health or mail to Or fax to 805-893-5340 IMPORTANT NOTICE If this will be mailed to anyone other than yourself or an insurance agency you must sign an Authorization for Release of Medical Information* This form is available at the Information Desk or on the Student Health Service website. If you do not provide one this summary will be sent to your local address. See an Please print name and address to send your records to. University of California Santa Barbara Student Health Service REQUEST FOR ITEMIZED BILLING STATEMENT Your itemized billing statement will be mailed to you within one week of this request. Please complete this form in its entirety. Your itemized billing statement cannot be generated until 72 hours after your last date of service. Please complete this form in its entirety. Your itemized billing statement cannot be generated until 72 hours after your last date of service. If you do not know your date of service please see an Insurance Advisor in the Student Health lobby. If you do not know your date of service please see an Insurance Advisor in the Student Health lobby. UCSB Permanent Name Identification No* Last First M Non-Student Local Telephone Number Email address Dates of Service From period of time this summary will cover to Month/ day/ year I specifically want my itemized billing statement to include Please check each box that applies Medical Information Women s Health Information Date Mental Health Information Men s Health Information Patient s Signature Please drop off form in the container provided at the Information Desk in Student Health or mail to Or fax to 805-893-5340 IMPORTANT NOTICE If this will be mailed to anyone other than yourself or an insurance agency you must sign an Authorization for Release of Medical Information* This form is available at the Information Desk or on the Student Health Service website.

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