Payments | Diakon Family Life Services

Diakon Behavioral Health Services Payment Form

For assistance completing this form please contact the hotline at 888-232-3015

Program Name:

Account #:

Client Name:

First Name:

Last Name:

Email Address:

Phone Number (xxx-xxx-xxxx):

Address:

Address Line 2

City:

State:

Zip Code:

Amount of Transaction:

Amount will be applied to the current statement unless the client has an outstanding balance, then the amount will be applied to any overdue balance.

Comments:

Payment

Card Number

Card CVC

LOCATIONS

Mechanicsburg

5000 Ritter Road
Mechanicsburg, PA 17055

Phone: (717) 795-0330
Toll-Free: 1-866-700-6868

Lancaster

163 W Fredrick Street
Lancaster, PA 17551

Phone: (717) 795-0330
Toll-Free: 1-866-700-6868

Lewisburg

1800 West Market Street
Lewisburg, PA 17837

Phone: (570) 524-9477
Toll-Free: 1-800-395-8327

Williamsport

435 West Fourth Street
Williamsport, PA 17701

Phone: (570) 322-7873
Toll-Free: 1-866-244-5760

Montoursville

241 Broad Street
Montoursville, PA 17754

Phone: (570) 433-7060
Toll-Free: 1-866-244-5760