Payment Details
*Please fill in all of the fields below before clicking the "PAY NOW" button in step 4.

1
Patient Details
2
Patient Address
3
Credit Card Billing Information
4
Payment Details
Please enter your account number exactly as it appears in the top right hand corner of your statement INCLUDING the last three letters.
Example:
1xxxxxRES
1xxxxxOAS
1xxxxxCAA
1xxxxxSSA