Text To Pay

Text To Pay Form

Text To Pay is an easy and convenient way to pay your balance. Instead of receiving a paper statement, you would receive a text message stating that you have a balance. The text will include a link to a secured website to pay your bill. You can save your credit card information on file for future balances. You would receive a text asking if you would like to use the credit card on file for easy payment. All you would need to do is respond with “Yes”, and the payment would be run. It is that easy!

Patient Name*
Any child is fine if you have multiple children.
Patient Date of Birth*
Date Format: MM slash DD slash YYYY
Phone
This is the phone number in which you wish for us to send the text message to.
Patient ID Listed on Statement
optional
Security Check

Please note that, by signing up for Text To Pay, you will not receive a paper copy of your statement. If you need a paper copy, please contact our office at 317-582-7238.

By submitting this form, you authorize Carmel Pediatrics, LLC to send you your statement via text (Text To Pay) once a month should you have a balance.