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Bakersfield Behavioral
5201 White Lane, Bakersfield, CA 93309
(661) 241-6201
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Email
Patient ID (PATIENT ACCOUNT #)
Medical Record Number
Guarantor ID
Guarantor First Name
Guarantor Last Name
First Name
Last Name
Middle Name
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 2
Dynamic Field 3
Dynamic Field 4
ProviderAlias
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