Billing Information  
 
  
Your Account Number
   Patient Name
  
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

 
 
Important Information

If you are paying on more than one account, please enter "Guarantor" in the "Your Account Number" box. Then enter the total amount that you are paying in the "Payment Amount" box. In the "Notes" section, please list the 6 digit account number just above the name of each encounter on you statement.

You can pay with either your checking, savings or credit card. If you would like to set up recurring payments please call 620-873-2141 and someone from our business can assist you.


This is a secure site. All of your information is secure and confidential.