Pay My Home Medical Equipment Bill

* = required

Information about you, the payer

Title Select One Dr Miss Mr Mrs Ms

• First Name *
• Last Name *
• Address Line 1 *
• Address Line 2
• City *
• State * Please select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming
• Zip *
• Email Address *
• Phone *

Payment Information

Patient Name/Account Number: *

Payment Amount: *

• Name on Credit Card *
• Card Type * Select One VISA Mastercard Discover
• Credit Card Number *
• Expiration Month * Select Month (01) January (02) February (03) March (04) April (05) May (06) June (07) July (08) August (09) September (10) October (11) November (12) December
• Expiration Year * Select Year 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033
• Card Validation Code * Last 3 digits on back of card.

Billing Information

Check this box if billing information is the same as information entered above.

• First Name *
• Last Name *
• Address Line 1 *
• Address Line 2
• City *
• State * Please select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming
• Zip *
• Phone *

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