Berkshire Health Systems

Please note: If you are paying for more than one visit at Berkshire Health Systems you must list each visit

separately, using the appropriate account number and the amount you are paying on each account.

Required fields are marked with an (*).

Account Number	Amount to Pay
1.	$
2.	$
3.	$
4.	$
5.	$
Total Payment	$
* Patient Name:
* Credit Card Number:
* Expiration Date:
* CCV Code:
* Card Holder First Name:
* Card Holder Last Name:
* Card Street Address:
* Card Holder City:
* Card Holder State:
* Card Holder Zip Code:
* Contact Phone:

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Berkshire Health Systems is proud of its mission to provide excellent service to all our patients and their families. If you need assistance with your financial responsibility, our financial counselors are here to help. Please contact us to speak with one of our Certified Application Counselors.

Berkshire Health Systems 413-447-2505

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