Make a Payment on Account

* Indicates required field

Patient Name *

First

Last

Credit Card Number *

Card Expiration *

Card Verification Code (3 digit code on back of card) *

Amount to be Applied to the Account Balance *

Information on this form will be submitted via email to our office and processed.
We will mail a receipt to the patient's billing address.
If you have questions or would like to us to set up an auto pay for your account please call our
billing department at 785-742-7495 and ask to speak to Tressa.
Thank you!

Submit