Clinical Service Payments Use this form to make payment for clinical services only. Upload multiple/prefilled documents or statements. Name* First Last Phone* Submitting payment for service type* Public Health Nursing Services For Public Health Nursing Services, please enter Invoice or Medical Record Number (MRN) below.Description for Other EHSDescription for Other EHS Description for Other ServicesDescription for Other Services Facility Name Mailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Submitting payment(s) for which County:CASSVAN BURENBOTHHiddenDescription Invoice / MRN / /Statements Please provide if possibleAttach applications, supporting documents or images (optional) Drop files here or Select files Max. file size: 50 MB. Payment Amount Please Note: We no longer will be processing payments by PayPal. All payments are processed by AllPaid. See new fee schedule.CommentsThis field is for validation purposes and should be left unchanged.
