WWWP Billing Issue Form / Formulario para Problemas de Facturación

2. ¿Cuál es su nombre? *This question is required.

2. What is your name? *This question is required.

2. ¿Cuál es su fecha de nacimiento?
(mes/día/año) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. What is your date of birth? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. What health care system is the bill from? *This question is required.

2. ¿De qué sistema de salud es la factura? *This question is required.

2. Please write the health care system the bill is from in the textbox below. *This question is required.

2. Por favor, escriba el sistema de salud del que proviene la factura en el cuadro de texto a continuación. *This question is required.

2. What was the date of your appointment that you received the bill for? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. ¿Cuál fue la fecha de la cita por la que recibió la factura?
(mes/día/año) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. What is the balance of the bill you received? *This question is required.

2. ¿Cuál es el saldo de la factura que recibió? *This question is required.

2. Please write what covered service(s) you received the bill for in the textbox below. *This question is required.

2. Por favor, escriba en el recuadro de texto de abajo el(los) servicio(s) cubierto(s) por WWWP por los cuales se le está facturando. *This question is required.

2. Please attach a photo of your bill from your device by clicking on the "Browse..." button below and selecting the photo you want to add to this form for our staff to review.

Our staff can better assist you with the bill when they have a copy to review.

Please note that the Wisconsin Well Woman Program can only cover a specific list of medical services and visits for breast and cervical cancer screenings. If you received a service that is not covered by the program, your bill will not be paid for by the program.

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2. Por favor, adjunte una foto de su factura desde su dispositivo presionando el botón de abajo "Browse..." y seleccione imagen que desea agregar a este formulario para que nuestro personal la revise y pueda asistirle mejor.

Tenga en cuenta que el Programa Mujer Sana de Wisconsin solo cubre ciertos servicios y visitas para exámenes de cáncer de mama y cuello uterino. Si recibió un servicio que no está cubierto, el programa no pagará su factura.

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2. What is your phone number? *This question is required.

2. ¿Cuál es su número de teléfono? *This question is required.

2. What is your email address? *This question is required. This question requires a valid email address.

2. ¿Cuál es su correo electrónico? *This question is required. This question requires a valid email address.

WWWP Billing Issue Form / Formulario para Problemas de Facturación

Wisconsin Well Woman Program (WWWP) Billing Issue Form / Formulario para Problemas de Facturación del Programa Mujer Sana de Wisconsin