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    •      
     

    Patient Billing Online Bill Pay

    		  
     
    		 
      Deposit 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 for AMEX) *
    Cardholder Name: *
    Cardholder Signature: *
    Billing Address: *
    City: *
    State: *
    Postal Code: *
    ADDITIONAL INFORMATION:
    Email Address:
    Phone Number:
    Surgeon Name:
    Surgery Date:
       
     
     

    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

    MA@patient-billing.com

    		  
     

     

     

     

     

     

     
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