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CHS Eyeglass Payment Form

  1. Eyeglass Payment Form

    Please fill out form below to pay for eye glasses 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

    Once you submit the form, you will be sent an email with a transaction ID. You will be required to provide this 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.