Pediatric Associates of Lawrenceville

Please complete and submit the following form and one of PAL's office staff will respond to your inquiry as soon as possible.

Fields marked with an asterisk (*) are optional. All other fields are required.

Contact PAL Regarding a Billing Inquiry

Parent’s full name
Child’s full name
Child's date of birth
Contact telephone number
Alternate telephone number*
Contact e-mail address
Contact preference	Respond by telephone Respond by e-mail
Date of service
Insurance company
Insurance policy number
Insurance telephone number
Description of billing problem

Payment Policy
PAL requests payment for all medical services provided at the time of your child’s visit, including all copays. Cash, check, and major credit cards are accepted.

Please allow our staff 1 to 3 business days to respond to your online inquiry. If you experience difficulty completing this form, or would rather contact PAL by telephone, please call 770.277.6725.
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