Employee Badge Replacement Fee Payment (Currently $10.00) may be made using the secure form below.


FULL Name: *
Date of Birth: *
Last 4 digits of your Social Security Number: *
Phone: *
Email: *
Employee Badge Replacement Fee: $10.00


Credit card number:

Exp Month/Year/

CVV (3 digit verification number on card):




Please only press the payment link/button below *ONCE* and allow time to process!!!
Pressing a second time MAY cause a double charge!

Pikeville Medical Center