Set Payment on Account
This payment option will allow you to make a payment on your account. If you want to pay the FULL AMOUNT of your statement and you do not see that option on this form please call 888-558-3188 x3. An account specialist will take your payment information to process.
Patients Name
*
First Name
Last Name
Email of contact for this patient
*
example@example.com
Phone of contact for this patient
*
Please enter a valid phone number.
Date of Birth of this patient
*
-
Month
-
Day
Year
Date
Chart Number
*
Person making this payment
*
First Name
Last Name
Signature of person making this payment.
*
Person making payment.
Payment Options
prev
next
( X )
Payment On Account of $5.00
You are paying $5.00 on your account.
$
5.00
Payment On Account of $10.00
You are paying $10.00 on your account.
$
10.00
Payment On Account of $20.00
You are paying $20.00 on your account.
$
20.00
Payment On Account of $50.00
You are paying $50.00 on your account.
$
50.00
Payment On Account of $75.00
You are paying $75.00 on your account.
$
75.00
Payment On Account of $100.00
You are paying $100.00 on your account.
$
100.00
Payment On Account of $150.00
You are paying $150.00 on your account.
$
150.00
Online Payment Fee
This is a convenience fee for online processing
$
1.00
Quantity
1
2
3
4
5
6
7
8
9
10
Submit
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
Should be Empty: