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CHCO Medical Records
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      Mar 1, 2009  $40.00
     

      Feb 1, 2009  $100.00
     

      Jan 1, 2009  $7.00
     
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CHCO Medical Records
13123 East Colfax Ave, B150
Aurora,CO 80045
(720) 777-6658

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STEP 3
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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
Medical Record #
Invoice #
Patient Last Name
Patient First Name  Middle :
  (MM/DD/YYYY)
Contact Phone Number  -  - 
       Zip    -

Payment Information

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Card :
Card Holder Name
Card Type
Card Number   Exp Date   (MM/YY)
Amount            Current Balance  
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until all information is confirmed in the next step.