Bill Payment Form

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Bill Pay Form

Information for Patient Receiving Care

First name
Last name
(If Known Or Listed On Invoice)

Payment Information

(If Known)
Billing Address
Billing Address
Street Address
Street Address Line 2
State / Province
Postal / Zip Code
Credit Card
Credit Card

Authorization To Charge Payment To Card

I Agree by checking "Yes" below, I agree that Assisted Home Health & Hospice is hereby authorized to charge the card described above for the payment described above, and that I have the proper authority to grant that authorization.

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