eCheck Bill Payment

Please complete and submit the secure form below and follow the instructions to complete the payment process. Please see the eCheck Bill Payment Instructions provided.

eCheck Bill Payment Instructions

If you have questions or concerns, contact our office at 770-951-8427.

Note: This payment form is NOT for patients to pay medical bills.

You must be located inside the United States to use this electronic payment method, as we do not accept payments from international locations at this time.

Client Account Information

Client or Practice Name:
Invoice #: (6 digits)
Comments:
First Name:
Last Name:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Email Address:

Bank Acount Information

Name on Bank Account:
Bank Institution:
ABA Routing Number:
Account Number:
Check Number:
Bank Account Type:
Payment Amount:	$

By clicking the Submit Payment button below, I authorize Medical Management Associates, Inc. to debit my bank account per the information I entered on this form.