Payment Information

How to Complete the Payment Form

1. 1

   Amount

   Enter the amount shown on your statement, or the amount you would like to pay today.

2. 2

   Contact Information

   Enter the patient's first and last name.

   Please enter the patient's name, even if someone else is making the payment.

3. 3

   Account Number — Required

   Enter the account number from your statement.

   Your account number is required to ensure your payment is applied to the correct patient account.