Payment - Bitterroot Health

To ensure your payment is posted correctly, please complete the fields below and click Add Account. You can add multiple accounts to split your payment. When you have finished, click Next.

Once an account has been added, you may click the icon to remove it from the list, or click on the icon to edit the row information.

		Account Number	Patient Name	Payment Amount
			Total	$ 0.00

Account Number

Patient Name

Payment Amount

How would you like to pay? Please select a payment method below and complete the required fields. When you have finished, click Next.

Credit Card
Check

Card Number

Card Holder's Name

Expiration Date

Card Verification Code CVC Code

Name on Check

Bank Name

Bank Routing Number

Account Number

Check Number

Please confirm the address below matches your credit card billing address.

BILLING ADDRESS

Street Address

Unit Number

Country

City

State / Region

ZIP Code

CONTACT INFORMATION

Phone

Email

Please confirm that the information below is correct, then click Submit Payment. If you need to make any changes, select the Previous button to go back.

BILLING ADDRESS

Address

State / Region

City

ZIP Code

Country

Phone

Email

PAYMENT METHOD (Credit Card)

XXXX-XXXX-XXXX-1234

Total Payment

$0.00

BILLING ADDRESS

CONTACT INFORMATION

BILLING ADDRESS

PAYMENT METHOD (Credit Card)

REFERENCE NUMBER