Bay Medical Center

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Patient Accounting

* Marked fields are required

Card Number:

Security or CCV Code:

What is this?

Expiration Date:

Type of card:

Name on Card:

Billing Address:

City:

State:

Zip:

Name of Patient:

Account Number:

Amount:
Format: 1000.00
(dollars.cents
no commas)

.

Requested By:
(Your name)

Do you want a receipt?:

Email:

Daytime Phone Number:

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For assistance, please call customer service at (850)747-6076.

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