On-Line Payments

Rolling Plains Memorial Hospital is proud to offer on-line bill payment. You may process your payment with Visa, Master Card, American Express or Discover.

To pay online via Visa, Master Card, American Express or Discover utilize the form below:

Personal Information

Title Home address*

First name*

Last name* City*

Daytime phone State/Province*

Evening phone Postal code*

Fax Country*

Email address*

Confirm email*

ACCOUNT NUMBER*

Credit Card Information

Card number*

Card security number* (found on the back of the card)

Credit Card*

Exp.date* / mm/yy

Payment Amount*