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Account Information

Account Number on Statement

Patient First & Last Name

Payment Information

Card Holder First Name

Card Holder Last Name

Pay with card Pay with check

Card number

Expiration date

Card security code

Address 1

City

State

Zip

Email address

Phone number

Payment ($)

You are agreeing to pay $ plus a 0.00 of $ (%) for a Total of $.

Confirmation

Are you human?

By checking the box to the left, you are indicating that you give Fedko Emer Phys New Mexico, LLC authorization to process the above payment of $.

By checking the box to the left, you are indicating that you give Fedko Emer Phys New Mexico, LLC your authorization to process the payments as outlined in the payment schedule above using the payment method listed above. To revoke your authorization you must contact Fedko Emer Phys New Mexico, LLC.

Please include your patient account number which is on your billing statement, when submitting your payment. If you have any questions please contact our office at 1-800-225-0953. Thank you for using our online convenient payment center.

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