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.