• Before You Begin
  • Complete Agency Form
  • Enter Payment Info
  • Review & Submit
  • Confirmation

About this form

Use this form to pay your Uniform Business Office bill for services received at the 21st Medical Group.

Please fill out all required fields as annotated by (*). In the IEN/Accounts Number(s) field, input the Patient IEN code located below the patients name and address on the AF Form 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.

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Contact:
21 MDG UBO
Email:
Phone:
719-556-3940