Please complete the following form to submit your payment.   Please complete all required fields which are marked with an asterisk (*).

Payment Form

Location of treatment*
Patient First Name*
Patient Last Name*
Amount I am paying today*
Statement Number
Statement Date
Account Number
Zip Code*
Email Address*
Payment Method*
Credit Card Number*
Expiration Date (MM/YY)*
Security Code*

Questions regarding your statement?  Please contact Tx:Team Accounting at 317-756-9712. enables secure bill payment on your behalf and is not an affiliate of Tx:Team.