Patient Notebook

Outpatient CareCenter

2720 University Boulevard

Birmingham, AL 35233

Phone: (205) 933 - 0050

Fax: (888) 290 - 6998

Website: www.outpatientcc.com/

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Error Summary

Please, correctly fill out all required fields.

1. Patient Information

First Name *

M.I.

Last Name *

Patient Account Number *

Date of Service *

Visit Number *

Email Address

A receipt will be sent to this email address.

2. Payment Amount

Amount

3. Payment Method

Credit/Debit Card

Bank Account

Name on Card *

Card Number *

Expiration Date *

Security Code *

Zip Code *

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P (205) 933 - 0050

F (888) 290 - 6998

W www.outpatientcc.com/

2720 University Boulevard

Birmingham, AL 35233