Children's Health System - bill payment All fields are required

	Patient Name:	(As it appears on your bill)
	CHS Account Number:
	To ensure your account is appropriately credited, select location below as indicated on your statement.
	Location Where Service Provided:	--- Please Make a Selection --- After Hours Clinic Behavioral Health Clinic The Children's Hospital ER Physician Billing
	Amount to Pay:	(ex. 9999.99)

	Payments are allowed via credit card transactions only.
	You will be directed to a subsequent screen to enter credit card details.