Customer Identification  
Instructions
List the call number and the name on the account to which you are making a payment. Additional billing information will be collected on the next page.
 
Call Number: (required)  
Customer Name:
Payment Amount: $

(More payment information will be collected on the next page)



Clear Form

LifeMed, Inc.
PO BOX 323
North Manchester , IN 46962
(260) 982-8363

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