Health Services : Billing : West Central District Health Department

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Responsible Party:

Address

Country

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Address Line 2

City *

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Postal Code *

Patient Name

First Name *

Middle

Last Name *

Date of Birth:

/

/

Payment Amount

$

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Credit Card
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Cardholder Name

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Visa MasterCard American Express Discover

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Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged