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    Patient Billing Online Bill Pay

    		  
     
    		 
      Payment Plan by ECheck  
         
     

    I HEREBY AUTHORIZE Midlands Anesthesiology to initiate charges to my checking account in the amount specified below:

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

    f you would like to cancel your payment plan at any time, please call us at: 803-765-1838.

    		  
     
    Patient First Name: *
    Patient Last Name: *
    Account Number: *
    Re-enter Account Number: *
     
    PAYMENT PLAN INFORMATION:
    Select Payment Period:
    Amount to be drafted: *
    Number of payments: *
    OR  
    Pay until balance is $0.00:
       
    Routing Number: *
    Checking Account Number: *
    Check Number: *
    Account Holder Name: *
    Address: *
    City: *
    State: *
    Postal Code: *
    Email Address:
    Phone Number:
    Comments:
     
     
     
     
     
    		 
     


    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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