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

About this form

Please use this form to pay for Copy Record Charges with Evans Army Community Hospital


If you have any questions regarding this form, please contact the Patient Administration Division, Release of Information/Correspondence Office at 719-526-0890, 719-526-7293, 719-526-7840, or 719-526-7276

Accepted Payment Methods:

  • Bank account (ACH)
  • Debit or credit card

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.

Contact:
Elizabeth Burlingame
Phone:
719-526-7769