Patient Payment Form - Thank you for visiting one of our health centers!

 
Please enter the following information:
 
  * All fields are required
- Name, address, and account # must match your statement.
   Account #:   PPKM banner
First Name: 
Last Name: 
 
Address Line 1: 
Address Line 2: 
City: 
State: 
Zip: 
Phone:   (e.g. 913  312  5100)
Email: 
 
 
Enter your payment details:
 
Payment: Amount of your payment (without $ signs) to be applied to the account specified above.
Donation: Donations are used for family planning and education services unless indicated below.
Total:  (this is a calculated value)
Comments/
Suggestions:
 
 
 
Please provide your credit card information below. NOTE: After entering your payment information, please do not use your browser’s back button because it will affect the payment process.
 
NOTE: Credit card information is required to ensure your credit card is securely and properly processed. This information is solely used for the processing of the credit card and is not stored on our system.
   
Visa

  Visa
     Mastercard

 Mastercard
     AmEx

 American Express
     Discover

 Discover
        
Name on the card:    
Credit Card Number:
(No dashes or spaces)
  Exp. Date:
      
 
Billing address for card:         Same as above ?    Yes     No
   Address Line 1: 
Address Line 2: 
City: 
State: 
Zip: