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Fort Madison Community Hospital

FMCH Online Patient Payment Center

Welcome to Fort Madison Community Hospital Online Payment Center. You may pay your bill to the hospital or to the Fort Madison Physicians & Surgeons clinic here by filling out the fields below.
For your convenience please fill out the payment form below. All information will be kept secure and confidential. All payments are processed via secure server. For more information you may call our Business Office at 319-376-2114.

* Name Of Patient
Name of Patient Treated.
* Payment is For Fort Madison Community Hospital     Fort Madison Physicians & Surgeons    
* Visit or Account Number
Visit Number. (For FMCH, this number should be located on your bill and begins with a V followed by several zeros. For Fort Madison Physicians & Surgeons clinic, you will need to enter the "account number" printed on the top, middle portion of your statement.)
* Name of Payor
Payor's Name on Credit Card Account.
* Billing Address
Address Where Your Credit Card Statements Are Mailed.
* City, State, Zip
Please Include Your City, State, and Five Digit Zip Code.
* 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
  Card Identification Number
This is the 3-digit code located on the back of your Credit Card.
  Comments Or Messages Related To Your Payment
  Your E-Mail Address
Please Provide An E-mail Address.