Email Statements Form

Request Invoices and Statements To Be Emailed

Please fill out all required sections on this form and submit

MEDENT Account Number:*

Practice Name:*

By clicking yes, you are authorizing MEDENT to send you your billing invoices and monthly statements via email rather than USPS, to the email addresses listed below.

Yes, please email us our billing invoices and our monthly MEDENT statements*

Authorized Name:*

Signature (by checking this box you are signing this document)*

Email addresses to send billing invoices monthly statements to (enter up to five)

Note: We strongly recommend you use a business only email address that multiple employees have access to. Ex.( accountspayable@medicalpractice.com). If you do not have a business email, we recommend providing multiple email addresses in the event an employee leaves the practice to ensure your practice continues to receive your billing invoices and monthly statements.

Email #1:*

Email #2:

Email #3:

Email #4:

Email #5:

Additional Instructions: