Patient Notebook

Associates in Pediatric Therapy, LLC

ATTN: BILLING DEPT

90 Howard Drive

Shelbyville, KY 40065

Phone: (502) 633 - 1007

Fax: (502) 805 - 1511

Email: scott@kidtherapy.org

Website: www.kidtherapy.org

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Error Summary

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1. Patient Information

First Name *

M.I.

Last Name *

Patient Account Number *

Be sure you have selected the CORRECT Provider. This payment willbe made to Assoc in Pediatr Therapy

Date of Birth *

Email Address

A receipt will be sent to this email address.

2. Payment Amount

Amount

THIS PAYMENT WILL BE MADE TO ASSOCIATES IN PEDIATRIC THERAPY.

3. Payment Method

Credit/Debit Card

Bank Account

Name on Card *

Card Number *

Expiration Date *

Security Code *

Zip Code *

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ATTN: BILLING DEPT

P (502) 633 - 1007

F (502) 805 - 1511

W www.kidtherapy.org

90 Howard Drive

Shelbyville, KY 40065