JOINT TOWNSHIP DISTRICT M
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Welcome to the JOINT TOWNSHIP DISTRICT M  Payment Page
One Time Payment Amount
Payment Amount:    *
Reference / Invoice:       (If applicable)
Billing Address
Full Name:    *
Address:    *
Address 2:  
City:    *
State:    *
(only required for US and Canada addresses)
ZIP Code:    *
(all numbers without spaces or dashes)
Country:    *
Phone Number:    *
(any format without spaces)
Email Address:    *
Patient Account Number:   *
Chip Card Presented:   *
Billing Information
Account Number:    *
(all numbers without spaces or dashes)
Visa MasterCard Discover American Express
Expiration Date:       *
CSC:    *  What is CSC?
Special Instructions:  
  I agree with the Payment Terms and Conditions. *
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(please click only once to prevent duplicate orders)
www.grandlakehealth.org/ | patientaccounts2@JTDMH.ORG | JOINT TOWNSHIP DISTRICT M Terms | Copyright 2004-2017 PayTrace, Inc. All Rights Reserved.
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