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RADIOLOGY ALLIANCE PC
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      Mar 1, 2009  $40.00
     

      Feb 1, 2009  $100.00
     

      Jan 1, 2009  $7.00
     
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RADIOLOGY ALLIANCE PC
210 25TH AVE N.
SUITE 602
NASHVILLE,TN 37203
(615) 312-0600

STEP 1
Payment
       
STEP 2
Confirm
       
STEP 3
Receipt

Patient
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Patient ID PatientMedicalRecordNumber First Name Last Name Birth Date PatientServiceBeginDate PatientServiceEndDate AdditionalInfo1 Additional Info 2 Additional Info 3 Additional Info 4 Additional Info 5 Additional Info 6 Amount
Add Row Total $0.00
Account No.
Last Name
First Name  Middle :
  (MM/DD/YYYY)
 -  - 
Email Address
       Zip    -

Payment Information

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Card :
Card Holder Name
Card Type
Card Number   Exp Date   (MM/YY)
CVN   What is this?
Amount            Current Balance  
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Account Information

Street 1
Street 2
City
State        Zip    -
Zip    -
Country
Phone #  -  - 
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until all information is confirmed in the next step.