Please fill in the following from your statement:

Your Patient Account Number
(including the initial 3 character code)
Statement Date

Please fill in the following payment information:

Amount You Are Paying (Enter Amount Only - no dollar sign, e.g. 25.00)
Your Credit Card Number
Expiration Date (MM/YY) /
First Name (on card)
Last Name (on card)
Billing Address
City
State
Zip Code
 
Email Address (for receipt)