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LUKASIEWICZ & BELLAVANCE

    
Statement Information Ensures Account is Linked to Online Payment
Payment Amount

Enter the Dollar Amount Listed on your Statement

Account Number

Enter Account Number Located on Upper Right of Statement

Patient's Name

Or Family Name on Account

Phone Number

If Additional Information is Needed

Name as on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date
CVV2/CID
First Name
Last Name
Address
Address 2
City
State
Zip
Email Address