One-time payment by Check

Date
Customer IP
Account Number*

Account Number will be referenced on your billing statements.

Confirm Account Number*

Incorrect or partial account number may cause delay or denial of payment.

Payment Amount*
Pay By Credit Card
Name as on Check*
Bank Routing Number*
Bank Account Number*
Check Number*
First Name*
Last Name*
Address*
Address 2
City*
State*
Zip*
Phone Number*

 

Receive a Billing Receipt*

If you selected 'Yes' be sure to enter a valid email address below in order to recieve a payment confirmation.

Email Address

 

Check Authorization*

Check Authorization: You must be authorized to sign the check. By selecting 'Yes' and submitting payment information through this Service you agree to the terms and conditions of this Agreement and any documents incorporated by reference. You further agree that this User Agreement forms a legally binding contract between you 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. By selecting 'Yes" and 'Submit Paymnet' I understand that my check will be presented to my bank electronically. After you Submit Payment the check will be submitted to AR Billing Services and you will not be able to make changes without contacting AR Billing Services. I understand unless prohibited by State law or statute a return check fee of $30.00 will be charged to your account for not sufficent funds (NSF). Please save or print this authorization for your records.

Please verify all information before submitting your payment. Incorrect account information can cause denial or delay of payment. Refunds will be automatically submitted on over-payments by mailing a paper check. If you need to cancel a current payment arrangement or put a stop on a recent payment please contact the billing department for immediate assistance (877) 879-6613. Older versions of Internet Explorer may expereince issues with use of this form, we recommend using the most recent version of Google Chome.

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