Online Payment

You may pay an outstanding balance with a secure transaction online. After submitting this form, you will be forwarded to our payment partner NMI.com to complete your secure transaction. If you have any questions or need help, please email us or call 404-351-2008.

Asterisks (*) indicate required fields

Patient Information

Patient Name *

Account Number

Statement Number

Payment Details

Person who will be submitting payment

First Name *

Last Name *

Address *

Address 2

City *

State *

Postal Code *

Phone *

A phone number where we can reach you if there is a problem or question.

Email *

An email where we can reach you if there is a problem or question.

Payment Amount *

The amount you will be paying.

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Online Payment