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Coffeyville Regional Medical Center

CRMC Online Patient Payment Center

Welcome to the CRMC Online Payment Center. You may pay your hospital bills here by credit card.
For your convenience please complete the payment form below. All information will be kept secure and confidential. For more information you may call our business office during working hours at 620-252-1530.

You may make payments to the Hospital using your credit card information in the fields below. All payments are via secure server. Thank you for allowing us to serve you.

* Name Of Patient
Name of Patient Treated.
* Account Number
Account Number. The account number(s) is located on the top of your statement. You may enter up to 3 account numbers. Example: V900506 for hospital payments and 3 or 4 digit number for Clinic payments
* Name of Payor
Payor's Name on Credit Card
* Billing Address
Address Where Your Credit Card Statements Are Mailed.
* City, State, Zip
Please Include Your City, State, and Five Digit Zip Code.
* Payor Phone Number
Please give us a phone number where you can be reached during the day.
  Your E-Mail Address
Please Provide An E-mail Address.
* Amount of Your Payment
Please Specify How Much You Are Paying. Please Use Dollars and Cents.
* Credit Card Type
Select If You Are Paying By Credit Card.
Visa     MasterCard     American Express     Discover    
* Credit Card Number
Input The 16 Digit Number Just As It Appears On Card.
* Credit Card Expiration Date
Example: 00/00
  Comments Or Messages Related To Your Payment