Patient Name1 - Required
 
Payment Amount - Required

(ex: 94.25)
 
Payer Phone # - Required
 
Payer Name - Required
 
Payer Email Address - Optional, to receive a payment confirmation email.
 
Card Information & Zipcode - Required
 
 
Secure Online Billpay
 
1A confirmation of this payment is sent to our billing department via email, and includes the patient's name.
If you do not wish to have that information included out of privacy concerns, you may omit it and use the account number instead.
Email is not considered a 100% secure form of communication.