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

About this form

Please use this form to pay your copy charges for your medical records and outstanding out patient bills using your mobile device.

Accepted Payment Methods:

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

By creating an account you can:

  • See the payments you made since you created an account.
  • Store payment information, such as credit card numbers, so that you do not have to reenter it each time you make a payment.
  • Copy a form you already submitted so that you do not have to reenter you information next time.
  • Set up automatic recurring payments (from a bank account, debit card, or credit card).

To take advantage of these benefits, you can Sign In or Create an Account . To continue as a guest user, click the 'Continue to the Form' button.

This is a secure service provided by United States Department of the Treasury. The information you will enter will remain private. Please review our privacy policy for more information.

Need Help?

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Contact: William Condon
Email: Click to email
Phone: (757) 458-2998 x 74077

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