Update Contact & Billing Information
We request that contact and billing information be updated annually and when any changes to this information occur.
If you are a current client and need to update your contact or billing information, please download and complete the form below. Return the completed form to your clinician at our office address or fax. You may also scan or take a photo of your form and send it via email*.
USPS: 250 Commercial Street, Suite 3004, Manchester, NH 03101Fax: 1-603-668-8666Email*: Click Here
*NOTE: Although our email system is protected by encryption, there are possible risks associated with sending your personal health information (PHI) through any email system that is not encrypted. Please consider using password protection or another encryption application to send PHI via email.
*NOTE: Although our email system is protected by encryption, there are possible risks associated with sending your personal health information (PHI) through any email system that is not encrypted. Please consider using password protection or another encryption application to send PHI via email.
Credit Card Information
If you would like to make a payment to your credit card, you may provide credit card information to be entered into our encrypted system, by talking with your clinician at your next appointment or calling Susan in the billing office. Please provide the following information:
* Client Name, Cardholder Name, Account Number, Expiration Date, 3-digit Security Code (on the back of the card), and Billing Zip Code.
* Amount to be charged and frequency (e.g., one-time payment or recurring copays)
You may also submit the form (below) to our office with Attention to: Susan Peoples:
USPS: 250 Commercial Street, Suite 3004, Manchester, NH 03101Fax: 1-603-668-8666
NOTE: For your security, we do not recommend sending your credit card information by email.