Online Bill Pay

Take advantage of online bill pay by completing and submitting the following form. Please use your LifeSave billing statement as reference for your date of service and account numbers. If you have questions or need assistance, please contact a LifeSave billing advocate at 316.932.1414.

 

Account Information

Date of Call

Call # (if applicable)

Patient #

Total Payment Amount ($)

Number of Payments (maximum 12 mo.) 1 payment 2 payments 3 payments 4 payments 5 payments 6 payments 7 payments 8 payments 9 payments 10 payments 11 payments 12 payments

For assistance setting up your payment plan, please call us at 316.932.1414.

Contact Information

First Name

MI

Last Name

I am the patient.I am not the patient.

Patient First & Last Name

Email

Phone

Mailing Address

City

State

Zip