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.

Encounter Number Patient Name Payment Amount
Total $ 0.00
How would you like to pay? Please select a payment method below and complete the required fields. When you have finished, click Next.

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

  BILLING ADDRESS

  CONTACT INFORMATION

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
Name on check
Check Number
Bank Name
Routing Number
Total Payment
$0.00
  REFERENCE NUMBER