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).

Perry County Memorial Hospital

Online Patient Payment Center

1 Hospital Road
TELL CITY, IN 47586
(812)547-7011

Welcome to Perry County Memorial Hospital Online Payment Center! Credit card payments can now be made online fast and easy!!
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.

You may make payments to Perry County Memorial Hospital, Tell City, IN, using your credit card number in below fields. All payments are via secure server. Thank you for allowing us to serve you.

Perry County Memorial Hospital's Refund Policy: Overpayments on accounts will be refunded within two weeks of the overpayment being identified. Refunds to patients are not issued for less than $5.00.

To review Perry County Memorial Hospital's Notice of Privacy Practices, please click here.
* Name Of Patient
Name of Patient Treated.
  Account Number (optional)
Account Number. (Should Be Located On Your Bill, This is Optional)
* Name of Payor
Payor's Name on Credit Card or Checking Account.
  Your E-Mail Address
Please Provide An E-mail Address.
  Comments Or Messages Related To Your Payment
* Amount of Payment
Format: 45.67 (Include decimal and cents. Do not use a dollar sign.)
$
* Card Number
* Expiration Date
* Card Code Verification Number
The three digit number on the back of your card. (Four digit code on the front of American Express.)
* Billing Postal or Street Address
* Billing City
* Billing State
* Billing Zip Code
5 digit zip code