YOUR PAYMENT INFORMATION
Patient First Name
Patient Last Name
Patient Account Number
Date of Birth
Last 4 of Social
First Name on Bank Card
Last Name on Bank Card
Bank Account Billing Address
Confirm Email Address
Please provide your email address for payment confirmation.
By checking this box, you signify you have reviewed, understand, meet and agree to the
Online Payment Terms and Conditions
By checking this box, you agree that this is your personal email address and you authorize us to send you emails, including confirmation of payment receipt.
If you are experiencing a problem, trouble making a payment, have a question or wish to make a payment over the phone, please call 888.323.0811 to speak with a Patient Advocate.
THIS COMMUNICATION IS FROM A DEBT COLLECTOR. THIS IS AN ATTEMPT TO COLLECT A DEBT, AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.