Consumer Credit Inquiry

Fields marked with an asterisk (*) are required

Full Name (as it would have been filled out on a patient form)*

Street address line 1*

Street address line 2

City*

State*

Zip*

Phone number*

Email address*

Channel (Provider of the Credit Report)*

Inquiry ID (Alpha-Numeric code accompanying the Medlytix Line Item)*
Medlytix inquiries should read “AR ########## MEDLYTIX/XXXX“.
Enter the “XXXX” portion in this field.

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