About this form

Use the form to make payments for your 81st Medical Group Medical Services

Fill our fields as annotated by asterisk.  Patient IEN which is ***(***** AF From 1127

Accepted Payment Methods:

• Bank account (ACH)
• Amazon account
• PayPal account
• Debit or credit card

With an account you can:

• See the payments you made since you created an account.
• Store payment information so you don't have to re-enter it.
• Copy a form you already submitted the next time you need to make a payment.

To take advantage of these benefits, you can Sign In . If you don't have an existing account, you will have the option to create an account on the sign-in page. To continue as a guest user, click the 'Continue to the Form' button.