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This application is used to sign up for services with Patient Payment Solutions.

IMPORTANT:  Before filling out this application, please have ready to upload:

  • A PDF/JPG copy of a utility bill (water, sewage, electric)
  • A PDF/JPG copy of a voided check

Save for later: If you need to save this application for later, their is a link at the bottom that will allow you to do this.  Be sure to keep the link safe as this is how you will access the form at a later time.

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