Online Patient Payment Center
Welcome to the Online Payment Center. You may pay your hospital bills here by credit or debit 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 during working hours, Mon. - Fri. 7:30 - 4:00. (931) 289-4211 ext. 400
You may make payments to the Hospital using your credit card information in below fields. All payments are via secure server. Thank you for allowing us to serve you.
Name Of Patient
Name of Patient Treated.
Account Number. (Should Be Located On Your Bill)
Date of Service
Name of Payor
Payor's Name on Credit Card
Address Where Your Credit Card statement is mailed.
City, State, Zip
Please Include Your City, State, and Five Digit Zip Code.
Please include area 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 If You Are Paying By Credit Card.
Credit Card Number
Input The 16 Digit Number Just As It Appears On Card.
Credit Card Expiration Date
Comments Or Messages Related To Your Payment