Invoice Payment

Please enter the PATIENT’S name, date of birth, and Account Number, found on the statement you received in the mail. If you are paying for multiple patients, you must complete this process multiple times in order to ensure the payments are applied to the correct accounts. You will enter your own information during the payment checkout phase.

Amount you would like us to charge your card today ( $ )

Minimum price: $6.00

Patient’s First Name *

Patient’s Last Name *

If this is a PEDIATRICS payment, enter the guarantor’s name. Additionally, if you are paying for multiple children, you must complete this process individually for each child.

Patient’s Date of Birth (MM/DD/YYYY) *

Account # or Patient ID

Memo (optional)

Collections Accounts

If your account is in collections and you are paying on your collections balance, check this box.