Patient Notebook

The Ambulatory Surgery Center of Westchester

34 South Bedford Road

Mount Kisco, NY 10549

Phone: (914) 244 - 6776

Fax: (914) 244 - 6750

Website: ambulatorysurgerywestchester.com/

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Error Summary

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1. Patient Information

First Name *

M.I.

Last Name *

Full Legal Name

Account Number

Patient MRN located on Statement.

Dates of Service

The Date of the Procedure.

Email Address

A Receipt will be sent to this E-Mail

2. Payment Amount

Amount

The Balance on the Statement received.

3. Payment Method

Credit/Debit Card

Name on Card *

Card Number *

Expiration Date *

Security Code *

Zip Code *

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P (914) 244 - 6776

F (914) 244 - 6750

W ambulatorysurgerywestchester.com/

34 South Bedford Road

Mount Kisco, NY 10549