Quick Pay

Please do not refresh the page to avoid multiple transactions.

1. Account Info
2. Choose Payment Method
3. Payment Information
4. Confirmation

Account Information

Account Number:*

Account Number is required

Account Number located on statement

Guarantor Date of Birth:*

Date of birth is required to validate the account entered.

MM/DD/YYYY

PayPal currently is under review and construction. We apologize for the inconvenience. You may use one of the other convenient options available. Thank you.

Debit/Credit Card

eCheck

Invalid value

Account Information

Monthly Payment Amount:

Payment Amount:*

Amount is required.

Transaction Total:

Billing Information

First Name:*

First name is required.

Last Name:*

Last Name is required.

Billing Address:*

Address is required.

City:*

City is required.

State:*

State is required.

Zip Code:*

Zip code is required.

Email Address:*

Invalid value

Send Receipt Via Email:

Phone Number:

Invalid value

Card Number:*

Credit Card number is required.

Format 4111222233334444

CVV Code:*

CVV code is required

Located on the back of the card

Expiration Date:*

Expiration month is required.

Expiration Year:*

Expiration year is required.

Submit Payment

Bank Routing Number:*

Routing number is required.

Bank Account Number:*

Bank account is required.

Layout Item:

Submit Payment

Making a payment through paypal on the website will redirect you to Paypal.com so you can login
and choose your payment method. Second, you will be redirected back to confirm your payment where it will be processed and you will
receive a confirmation number.

Thank You!

You may print the receipt below, if you don't have access to a printer your credit card/bank statement statement will count as your receipt.

Receipt

Medical Services Extended Pay

PO BOX 22266

Chattanooga TN 37422

1-866-735-8812

Print Receipt

Invalid value

Send Receipt Via Email

Account Number :

First Name :

Last Name :

Billing Address :

City :

State :

Zip Code :

Amount :

Transaction ID :

Transaction Date :

Authorization Code :

Your transaction has been approved. Thank You for Your Payment !

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