Sample Page Type of Payment*Individual/FamilyCorporateName* First Last Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Corporation Account Name*Patient Account Number*Account Number*To make a payment, complete the form by entering the amount you want to pay, followed by your credit card information. Unsure of how much you need to pay on your account? Just give us a call at 417-450-4805 and we will be happy to assist you! Amount* Total $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Authorization* I am authorized to charge this card for the specified amount indicated above. I submitted my credit card information and payment amount in the above form. SignatureCAPTCHA