Health Services : Billing : West Central District Health Department

Responsible Party:

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

mc25l1072jpc

Patient Name

First Name *

Middle

Last Name *

Date of Birth:

Month

/

Day

/

Year

Payment Amount

$

Select a Payment Method

Credit Card
Bank Account

Cardholder Name

Credit Card #

Expiration Date

Security Code

Account Holder

First Name

Last Name

Account Type

Checking
Savings

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