PaymentBanc Help Request

Please complete and submit the form below. A Customer Service Representative will contact you as soon as possible regarding your request.

Bold fields are required.

Provider Name

Your Name

Address

State

PB Acct #

Phone Number

City

Zip

Confirm Email

How may we assist you?

Account Inquiry

eSign

Pay In Full

Payment Arrangements

Payment Method Change

Other

Note: Changes to your account must be requested four (4) business days prior to your draft date.

Enter a brief description below.

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