Please allow 1 to 2 business days for your payment to be processed. This transaction will appear as 'Goodman Campbell Brain and Spine' on your card statement.

Patient Financial Services
317-396-1300 x2998
toll-free: 888-225-5464 x2998

Chase Bank is a global leader in secure payment processing and merchant acquiring, capable of authorizing transactions in over 130 currencies. The company currently processes more than 50 percent of all Internet transactions.

PATIENT PAYMENT CENTER

Welcome to our secure patient payment center. Please complete all of the fields in the following sections.

  1. Patient Information
  2. Payment Amount
  3. Billing Information
  4. Method of Payment

Once you submit your payment, you will receive a confirmation e-mail.
Thank you.

PATIENT INFORMATION



PATIENT ACCOUNT #:  
What's This?

PATIENT FIRST NAME:  

PATIENT LAST NAME:  

PHONE:  

TYPE:  
home  
work  
cell  

OPTIONAL BILLING COMMENTS: