Bill Pay

1 Start 2 Review Your Payment Info 3 Complete
Patient Info
Name of Patient Treated
Guarantor Number. (Should be located on your bill. This is optional.)
Payor Info
Enter the info about the person making the payment
Address where your credit card statements are mailed.
Please provide an E-mail address.
Payment Info
Please specify how much you are paying. Please use dollars and cents.
Input the 16 digit number just as it appears on card. ie: 1234 1234 1234 1234
Example: 00/00