Patient Portal Refill Request Make Payment

Online Payment


  1. Go to this link:
  2. Click on the 'Guest Pay' button.
  3. Enter the 'Account Number' and 'Form ID' from the top right hand corner of your current billing statement (see sample statement below).
    • If you don't have a paper statement in hand give us a call at 815-986-1113 and we will look up your Account Number and Form ID for you over the phone.
  4. Use your credit card to complete the payment process.

Sample Statement

Sample billing statement