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).

Liberty Regional Medical Center

Online Patient Payment Center

Welcome to Liberty Regional Medical Center Online Payment Center. You may pay your hospital bills here by credit or debit card.
For your convenience please fill out the payment form below. All information will be kept secure and confidential. For more information you may call our business office during working hours.

You may make payments to Liberty Regional Medical Center using your credit or debit 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. (Should Be Located On Your Bill, This information is helpful to us but not required.)
* 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.
* Phone Number
Number where you can be reached.
  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
Please select the correct credit or debit card.
Visa     MasterCard     AMEX     Discover    
* Credit Card Number
Input The 16 Digit Number Just As It Appears On Card.
* Security Code
* Credit Card Expiration Date
Example: 00/00
  Comments Or Messages Related To Your Payment
Click the Submit button one time only. Do not double-click.