Bill Pay

What type of payment will you be making today?*

How many physicians are you paying for today?

Your cost for physicians is $

How many allied health professionals are you paying for today?

Your cost for allied health professionals is $

Provider name(s)*

Please list all providers names

Practice name*

Amount listed on your quarterly statement $

Comments

Please indicate the statement period listed in your quarterly statement

Your cost for the vendor agreement is $

Organization name

Cardholder's name*

First Name

Last Name

Billing address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Email*

Credit Card*