ONLINE PATIENT PAYMENT

Welcome to our secure PAYPAL based patient payment page. Please be advised that only one payment transaction per patient will be accepted. You can pay using your Credit Card (MasterCard, Visa or American Express) or for your convenience, you can also pay using your PayPal account.

For your convenience this Online Patient Payment form is available 24 hours, and you may pay towards your copay, deductible, patient statements, etc. through this secure PayPal method.

Invoice or Statement Number:*

Patient Name:*

Address:*

Tel:*

Payment Amount:*

Payment Type:*

Copay Deductible Balance Other

SECURITY NOTE FOR CREDIT CARD USERS: Your Credit Card information is not saved on our website anywhere for security reasons - we use the secure PAYPAL services for processing your credit card.

Website designed by Rimage Solutions; your "one-stop shop for Healthcare software requirements".