Make A Payment

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Patient Information

This form requires four steps for completion: Patient Information, Account Information, Payment and Payment Preview. When you have completed all the steps, click the SUBMIT button on the last page of the form and print a copy of the confirmation page for your records. Your payment will be processed within 24 hours of submission, Monday through Friday.

If you have any questions about completing the secure online payment form, please call the number listed on your bill or click here for a directory.

All Fields are Required!

Patient’s First Name:
Patient’s Last Name:
Street Address:
City:
State:
Zip:
Phone Number:
Best time to call:	Morning  Afternoon  Evening
Email:
Date of Birth (mm/dd/yyyy):