Patient Billing Online Bill Pay

PAYMENT PLAN 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.

If you would like to cancel your payment plan at any time, please call us at: (843) 576-5246.

Location: *
Date of Service: *
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: