Paying Bills Online
Thank you for completing this form. If the question has an asterisk, it is required. When finished, please click the "submit" button. To protect your confidentiality under HIPAA, you will not receive an emailed copy. Feel free to print or screen shot a copy before submitting.
Patient Legal Name
*
First Name
Last Name
Patient Date of Birth
*
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Month
-
Day
Year
Date
Cell phone number of person completing form (If cell phone is not utilized, use your main number)
*
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Area Code
Phone Number
Account number on the statement we sent (if available)
Credit or Debit Card Information
Payment Amount
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( X )
USD
$
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
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