Medical Data Systems
 
PAYMENT INFORMATION

MEDICAL REVENUE SERVICE
Pursuant to Section 807 (11) Fair Debt Collection Practices Act, this communication is from a debt collector and is an attempt to collect a debt. Any further information obtained will be used for that purpose.
For your convenience, MDS accepts online payments by credit card and personal check.

Please complete the information below to make a payment.

* Indicates required fields.  
*Facility Name  *Reference Number 
*First Name  *Last Name 
*Mailing Address 1  Mailing Address 2 
*City  *State 
*Zip Code  *Email 
*Home Phone   Work Phone 
 Place of Employment    

Billing Information
My mailing address is the same as my billing address.
*Billing Address 1  Billing Address 2 
*City  *State 
*Zip Code 
***** Choose one of the following payment options ******
American Express| MasterCard| Visa| Discover| Personal Check
I would like to set up a Payment Plan
*Name on Credit Card
*Account Number
*Expiration Date
mm/yyyy
*CVC Number
What's This?
*Name on Check
*Routing Number
*Account Number
*Check Number
Remember to VOID this check number. RETURN CHECK CHARGE WILL BE THE MAXIMUM AMOUNT ALLOWED BY LAW
*Amount Paying $

If you are not paying your balance in full and wish to setup a payment plan
please check the "Payment Plan" box above and enter comments below.

Pursuant to Section 807 (11) Fair Debt Collection Practices Act, this communication is from a debt collector and is an attempt to collect a debt. Any further information obtained will be used for that purpose.