Billing Information  
 
  
Patient Visit ID
  
Company Name (optional)
  
First Name
 
MI
 
Last Name
   Address
  
  
City
  
State
  
Zip Code
  
Phone
  
Work Phone
  
E-mail (required for an emailed receipt)
  
 
   Payment Information  
  

Payment Amount
 
  Please select a payment method
Checking Savings Credit/Debit Card
  Notes

 
 
Notice

Please enter your patient visit ID off your bill to ensure the payment is posted to the proper account.

Please call the Marengo Memorial Hospital Business Office at 319-642-5543 with any questions

Thank you for your Payment


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