Indianapolis Independent Pediatricians, P.C. Online Payments


Patient Identification		Instructions Please provide the name of the patient, name of the guarantor, and the account number if you have it. Additional billing information will be collected on the next page.

Guarantor Name:
Patient Name:
Account Number:	(optional)

Amount:	$

(More payment information will be collected on the next page) Clear Form

3850 Shore Drive Suite #315 Indianapolis, IN 46254 Phone: (317) 293-7177