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Bill Pay


 
* Required fields        
 

Patient Information

 
   
* Last Name
* First Name  
* Billing Hospital
* Account   Number  11 Digit Account Number  
* Amount    
    Add More Accounts
   

Card Holder Information

 
   
* Name (First Last)    
  Street Address    
  City    
  State
 
* Card Holder Zip      
Must match with Card Holder Billing Zip code    
 
  Phone(10-digit)      
  Email    
   

Payment Information

 
   
 
* Payment Total $        
* Payment Type Master Card   Visa   AmericanExpress   Discover  
* Card Number        
 * Expiration Date                     
 * CVV2        
   Payment Memo
 
 
      
 

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