Health Services : Billing : West Central District Health Department

Responsible Party:

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Patient Name

First Name *

Middle

Last Name *

Date of Birth:

Month

/

Day

/

Year

Payment Amount

$

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Select a Payment Method

Credit Card
Bank Account

Cardholder Name

Credit Card #

Expiration Date

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Account Holder

First Name

Last Name

Account Type

Checking
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Account Number

Routing Number

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged