Park Nicollet corporate logo
Please have your Park Nicollet Health Care Products billing statement in front of you, as it contains information necessary to fill out this form.

Payments will be processed within three business days of receipt. Check and credit card payments may still be sent by mail to the address listed on your billing statement.
Park Nicollet Health Care Products includes:
• Park Nicollet Health and Care Stores
• Park Nicollet Orthotics and Prosthetics
• Park Nicollet Hearing Center
• Park Nicollet CPAP Services
• Park Nicollet and HealthPartners Point of Care Durable Medical Equipment

All fields in bold are required.

Remittance Mailing Address on Statement.