Diakon Family Life 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

960 Century Drive
Mechanicsburg, PA 17055

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

New Bloomfield

25 East McClure Street
New Bloomfield, PA 17068

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

Diakon does not discriminate in admissions, the provision of services, or referrals of clients on the basis of race, color, creed, religion, sex,
national origin, sexual orientation, age, marital status, veteran status, disability or any other classes protected by law.