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CHS Eyeglass Payment Information Form

  1. CHS Eyeglass Payment Information Form
    Please fill out the form below to pay for eyeglasses for a patient at Maricopa County Correctional Health Services.
  2. Today's Date
  3. Requestor Information
    Please fill out below as the person paying for patient.
  4. Patient/Self Information
    Please fill out patient information below.
  5. Additional Information
    Within 24 hours of submitting this form, you will be sent an email with a transaction ID and an online payment link. You will be required to provide the transaction ID when submitting payment. An eye exam will be scheduled once payment is received.
  6. Please NOTE:
    For safety concerns the patient will not be notified in advance of the appointment date/time.
  7. Leave This Blank:

  8. This field is not part of the form submission.