Pre-Payment for Tubal Reversal

Complete this form, print it out, and send a copy with each payment you mail in for your pre-payment account. No Personal Checks Accepted. Please mail in only Money Orders or Cashier's Checks made payable to: Chapel Hill Tubal Reversal Center

Mail this form with your payment to:
Chapel Hill Tubal Reversal Center
Attn: Pre-Payment Plan
109 Conner Drive Suite 2200
Chapel Hill, NC 27514

Doctor performing my tubal reversal:
Last name:
First name:
Middle Initial:
Date of birth:
SS#:
Address:
Address line 2:
City:
State:	Zip:
Home phone:
Cell phone:
Work phone:	Ext:
Email

Amount of Payment: $
Check if you would like to be notified upon receipt of your payment:
This is a payment for a new or existing account

Participation in the pre-payment account will guarantee fees for one year from the date the first payment is received. Accounts are considered inactive if payments are not made for a period of 12 months or more. In this case, patients are no longer locked into the fees that were in place at the time they began the plan and current fees will apply. If you have general questions or would like to request a refund please call 919-968-4656, Monday - Friday, 8:00 am to 5:00 pm Eastern Time and ask for the business office.

In the event that a refund is requested all money in your pre-payment account will be refunded less a $250 processing fee. Please note that refunds may take up to 30 days to process.