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BENEFIS HEALTH SYSTEM
500 15TH AVE S, PO BOX 5096, GREAT FALLS, MT 59405
(406) 455-3535
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Email
Patient Account #
Medical Record Number
Guarantor ID
Guarantor First Name
Guarantor Last Name
First Name
Last Name
Middle
Date of Birth
Patient's date of birth (MM/DD/YYYY).
Phone Number
ZIP Code
Statement Number
Statement Date
Amount Due
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Dynamic Field 3
Dynamic Field 4
ProviderAlias
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