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Account Information

Card Holder First Name

Card Holder Last Name

Account Number on Statement

Patient First & Last Name

Address 1

City

State

Zip

Email address

Phone number

Payment Information

Payment ($)

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

Payment type

Card Check

Card number

Expiration date

Card security code

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 $.

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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