Patient Notebook

DCH Encore Rehabilitation, LLC

For Billing Questions:

Phone: (256) 340 - 9708

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Error Summary

Please, correctly fill out all required fields.

1. Patient Information

First Name *

M.I.

Last Name *

Account Number *

Dates of Service

Cardholder Telephone Number *

This number will only be used to call if we have a question about your payment.

Patient Date of Birth *

This date will only be used to match payment to correct patient account.

Email Address

A receipt will be sent to this email address.

2. Payment Amount

Amount

3. Payment Method

Credit/Debit Card

Name on Card *

Card Number *

Expiration Date *

Security Code *

Zip Code *

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