* Required fields.

* Patient Name:  
* Patient Account Number:   *Your account number is listed on your statement.

Patient Billing Address:

* Street:    
* City:  
* State:  
* Zip:  
* Patient Phone Number:  
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:     

 
For Business Office use only:   Email: