Online Patient Payment Center

Online Patient Payment Center

Welcome to the Online Payment Center. You may pay your hospital bills here by credit/debit card.
For your convenience, please fill out the payment form below. All information will be kept secure and confidential. For more information, you may call our business office during working hours. You may make payments to the hospital submitting your credit card information in below fields. All payments are via secure server. Thank you for allowing us to serve you.
Name of Patient Treated*

First NameLast Name
Patient Account Number*
This number should be located on your bill.
Your Email Address*
example@example.com
Comments or Messages Related to Your Payment

Amount of Payment*

USDFormat: 45.67 (Include decimal and cents. Do not use a dollar sign.)

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country