* Required fields.

* Patient Name:
* Patient Account Number:	*Your account number is listed on your statement.
Patient Billing Address:
* Street:
* City:
* State:	-Select State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersy New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Varginia Wisconsin Wyoming
* Zip:
* Patient Phone Number (format: XXX-XXX-XXXX):
Patient Email:
Should you need to make payment arrangements and/or have any questions or comments regarding your statement or balance owed, please call 806-743-2898 or 1-800-872-2956.
* Payment Amount:

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For Business Office use only:		Email: