Secure Online Payment

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/Permit Number:

^* Name on Account:

First Name

Last Name

Patient Name:
(If Different)

^* Email Address:

^* Phone Number:

* A one-time verification code will be sent to the phone number or email address listed above in order to complete payment. Please make sure you have access to the provided email address or the phone number you entered accepts SMS (Text Messages).

^* 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 Name

Last Name

^* Card Number:

^* Card Verification (CVV):

3 digit security code listed on card

^* Expiration:


Month	Year

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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