Payment Agreement Form

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Date(Required)

Patient Name(Required)

First Last

Account Number(Required)

Balance(Required)

Monthly Payment Amount(Required)

Payment Day of the Month(Required)

About Ancor

Ancor Pediatrics PA was started in 2004 and located at the Good Shepherd Medical Plaza. In 2011, Ancor expanded their services to provide care to adults and changed the clinic name to Ancor Health Center, PA.