AR Payments
Email Us
with any questions/comments or call us at
(937) 762-1629
(8-4:30pm, M-F)
.
THIS IS NOT TO BE USED TO PAY PERSONAL MEDICAL EXPENSES OCCURRED AT HOSPITAL OR PHYSICIAN OFFICES.
This area is for Bill Payment of Finance Accounts Receivable.
Fill out this form to successfully process your payment.
Note that the address must match the credit card's account holder's billing address.
Billing Information
* Your First Name:
* Your Last Name:
* Company Name:
* Address:
* City:
* State:
AK
AL
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
* Zip Code:
* Phone:
* Email Address:
Account Information
* Invoice/Badge #:
(No 'K' if badge #)
* Payment Amount $:
(No Commas)
Comments:
Please notate if you are paying on multiple invoices in detail here
Payment Information
* Credit Card Number:
(No spaces or dashes)
* Expiration:
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2024
2025
2026
2027
2028
2029
2030
* Security Code:
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