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City of Rio Rancho Please complete all the (City of Rio Rancho)

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BROWSE CITY OF RIO RANCHO (NM) FORMS

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Section I - Customer Information Date:
Zip
Date Received:
Please return this completed and signed form to: Attn: Steve Perkins, Ambulance Billing, 3200
Civic Center Circle NE, Rio Rancho, NM 87144, or fax to (505) 891-5762.
Date
For Internal Use Only
Date Responded:
Street City/State
Customer Signature
Section II - Dispute Information
Please describe the nature of your billing dispute in the space provided below. If more space is
required, please attach additional sheets with this form. Many questions may be answered by
visiting the City's Web site at http://www.rrnm.gov/index.aspx?NID=1448.
Phone #: E-Mail:
City of Rio Rancho
Department of Finance - Ambulance Billing
Customer Dispute Form
Please complete all the information on this form as completely and accurately as possible by typing or using blue or
black ink. Please contact us at (505) 891-5021 with any questions.
Last Name First Name
Patient Name:
Address:
Call #
v10.09.20
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City of Rio Rancho Please complete all the (City of Rio Rancho)

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Completed 10 February 2021

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