Secure Online Payments

You will need the bill that was mailed to you for your recent ARHS service.

Please complete the form below and submit to process your payment. All fields are required. Your account number and bill type is located on your bill. Thank you.


Account Information

* Bill Type:
* Account Number:
* Name on Account:
First NameLast Name
Patient Name:
(If Different)
* Email Address:
* Phone Number:
--
* Mailing Address:
Mailing Address 2:
* City:
* State:
* Zipcode:
* Amount to be Paid:
$
* minimum amount of $3.00
Comments:
 

Payment Information

 
* Card Type:
* Name on Card:
First NameLast Name
* Card Number:
* Expiration:
MonthYear
 

Billing Address

Use My Mailing Address for Billing
 
Please enter the address associated with the card that will be processed for the payment.
* Address:
Address 2:
* City:
* State:
* Zipcode:


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