Patient Notebook

Barnes Healthcare Services

P O Box 1187

Valdosta, GA 31603

Phone: (800) 422 - 5059

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Error Summary

Please, correctly fill out all required fields.

1. Patient Information

First Name *

M.I.

Last Name *

MRN or Pharmacy Account Number *

MRN as shown on the top right corner of patient statement.

Invoice #

Invoice # as shown on patient statement. Payment applied to most outstanding invoice if is blank.

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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