RBH Patient Account Balance Payment Form

My RBH Patient Account Balance

USDPlease enter the full amount of your RBH Patient Account Balance into the payment window above.

My signature below provides the authorization for Restore Behavioral Health, PLLC to keep on file the credit card below for charges of the patient responsibility copay/deductible/balance payments for services received.
Cardholder Name:

First NameLast Name
Date:
Should be Empty:

RBH Credit Card Authorization