Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Kimball Health Services

Kimball Health Services Secure Patient Payment Center

Welcome to Kimball Health Services Secure Payment Center. You may pay your hospital bills here by credit card.
For your convenience please fill out the below payment form. All information will be kept secure and confidential. For more information you may call our business office at (308) 235-1951 during regular business hours, 8am to 5pm, Monday thru Friday.

You may make payments to Kimball Health Services using your credit card information. All payments are via secure server. Thank you for allowing us to serve you.


* Name Of Patient
Name of Patient Treated.
  Invoice Number (optional)
Invoice Number. (Should Be Located On Your Bill, This is Optional)
* 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.
* 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 Credit Card.
Visa     MasterCard     Discover    
* Credit Card Number
Input The 16 Digit Number Just As It Appears On Card.
* Credit Card Expiration Date
Example: Exp Date 00/00
* V Code
Enter the 3 digit number that appears on the back of your card
  Comments Or Messages Related To Your Payment