Patient Notebook

Community Health Care

PO Box 250

Brunswick, TN 38014

Phone: (901) 425 - 9600

Fax: (901) 432 - 2277

Website: www.chc901.com

Make a Payment

Need to make a payment? Please fill out the information below and hit continue.

Error Summary

Please, correctly fill out all required fields.

1. Patient Payment Information

First Name *

M.I.

Last Name *

Provide Patients Full Name

Date of Service *

Run Number *

Date of Service

Run 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 *

Cancel

P (901) 425 - 9600

F (901) 432 - 2277

W www.chc901.com

PO Box 250

Brunswick, TN 38014