Patient Identification  
Instructions
Specify the appropriate Pediatrician, using the drop down box, then input your 7 or 8 digit account # as shown on your bill. Next, enter the amount you would like to pay. Additional billing information will be collected on the next page.

 
   
  Pediatrician:
  Account #:
  Amount: $
 

  (More payment information will be collected on the next page)

  

  Clear Form

 

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