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Welcome to the Online Payment Center. You may pay your hospital bills here by credit card or debit card. |
For your convenience please fill out the below payment form. All information will be kept secure and confidential. For more information you may call our business office during working hours.
You may make payments to the Hospital by entering your credit card or debit card information in the fields below. All payments are via secure server. Thank you for allowing us to serve you.
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Name Of Patient Name of Patient Treated. |
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Patient or Admission Number (optional) Patient or Admission Number. (Should Be Located On Your Bill) |
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Billing Address Address Where Your Credit Card or Bank Account Statements Are Mailed. |
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City, State, Zip Please Include Your City, State, and Five Digit Zip Code. |
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Phone Number Please provide phone number including area code |
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Your E-Mail Address Please Provide An E-mail Address. |
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Name of Payor Payor's Name on Credit Card or Checking Account. |
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Amount of Your Payment Please Specify How Much You Are Paying. Please Use Dollars and Cents. |
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Credit Card Type Select If You Are Paying By Credit Card. |
Visa MasterCard Discover American Express |
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Credit Card Number Input The 16 Digit Number Just As It Appears On Card. |
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Credit Card Expiration Date Example: 00/00 |
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Comments Or Messages Related To Your Payment |
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