Patient Billing Online Bill Pay
DEPOSIT PAYMENT BY ECHECK:

I HEREBY AUTHORIZE MEDcare Urgent Care 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.
Location: *
Date of Service: *
Patient First Name: *
Patient Last Name: *
Account Number: *
Re-enter Account Number: *
 
PAYMENT INFORMATION:
Payment Amount: *
Routing Number: *
Checking Account Number: *
Check Number: *
Account Holder Name: *
Billing Address: *
City: *
State: *
Postal Code: *
ADDITIONAL INFORMATION:
Email Address:
Phone Number:
Doctor Name:
Appointment Date: