SEDGWICK COUNTY HOSPITAL
Secure Payment Form
Payment Summary
Payment Date
Payment Amount
Account Number
Account Name
Name as it appears on account
Description
Billing Summary
Email Addresss
Phone Number
Credit Card Information
Name as on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date
CVV2/CID
Recurring Payments
Schedule
Disabled
Daily
Weekly
Biweekly
Monthly
Bimonthly
Quarterly
Biannually
Annually
Billing Amount
Total transactions of recurring billing
Enable Recurring
No
Yes
Date of Payments
Add Customer
Yes
No
Submit
