Guest Payments

One-Time Payment by Credit or Debit Card

First Name*
Last Name*
Address*
Address 2
City*
State*
Zip*
Customer IP
Date
Account Number*

Enter a upper-case 'H' before the account number (acct # is referenced on your billing statement top right).

Confirm Account Number*

Enter a upper-case 'H' before the account number (incorrect or partial account number may cause delay or denial of payment).

Payment Amount*
Card Processing Fee
Total Charges
Name as on Card*
Card Billing Address*
Card Billing Zip*
Card Number*
Card Expiration Date*
CVV2/CID*
Phone Number*
Receive a Billing Receipt*

If you select 'Yes' be sure to enter a valid email address below (recommended).

Receipt Email Address

 

Payment Authorization*


Payment Authorization: You must be authorized to use the payment card. By selecting 'Yes' and submitting payment information through this Service I agree to the terms and conditions of this Agreement and any documents incorporated by reference. I further agree that this User Agreement forms a legally binding contract between me and AR Billing Services and that this Agreement constitutes "a writing signed by you" under any applicable law or regulation. Any rights not expressly granted herein are reserved by AR Billing Services. I understand today's payment has been subject to a $3.50 card processing fee. I understand where card processing fees are prohibited by State law or statute the fee will be waived and the 'Total Charge' reflected on this form will be applied towards my balance. I understand there are no fees to pay by check in the provided secure envelope with my billing statement, online or by phone. Please save or print this authorization for your records.


Please verify all information before submitting your payment. Incorrect or partial account information can cause denial or delay of payment. Refunds will be automatically submitted if payment intention is not clear and on over-payments by mailing a paper check. If you need to cancel your current payment arrangement or put a stop on a recent payment please contact the billing department for immediate assistance (877) 879-6613.


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