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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)
$USD
Amount
Billing Address
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country
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.
Consent


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