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Online Bill Pay

Patient Account Information
Patient Account Number*
Patient Name*
Payment Amount*
Credit Card Holder Information
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Email Address
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Acknowledgement*
- I understand and agree that a receipt will be sent to the email address I provide in an unencrypted manner.
* All indicated fields must be completed.
** Account number is on your statement
Comments
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Contact Us at 937-427-8900

89 Sylvania Drive, 2nd Floor
Dayton, OH 45440

Phone: 937.427.8900
Fax: 937.427.1710

1861 Towne Park Drive, Suite C
Troy, OH 45373

Phone: 937.427.8900
Fax: 937.427.1710

C. Patrick Carroll, M.D.
A. Marie Martinek, M.D.
Bruce M. Buerk, M.D.
Scott D. Schoenberger, M.D.
Martin F. Wilkes, M.D.