Midlands Anesthesiology - Secure Portal

Patient Billing Online Bill Pay

Payment by Credit Card

I HEREBY AUTHORIZE Midlands Anesthesiology to initiate charges to my credit card in the amount specified below:

Please allow 3-5 days to process, your confirmation will be emailed to the email address you provide below.

Patient First Name:	*
Patient Last Name:	*
Account Number:	*
Re-enter Account Number:	*

PAYMENT INFORMATION:
Payment Amount:	*
Credit Card Type:
Credit Card Number:	*
Expiration Date:	Month: / Year: *
Security Code (CVV):	3 Digits (4 digits for AMEX) *
Cardholder Name:	*
Billing Address:	*
City:	*
State:	*
Postal Code:	*
Email Address:
Phone Number:
Comments:



Your credit card charge will appear on your bill as: Midlands Anesthesiology

If you have any questions please contact us:

Midlands Anesthesiology
Attn: Billing Department
PO Box 1427
Columbia, SC 29202

Phone: 803-765-1838