Submit a Payment

Important: Please note that there is no additional fee for submitting a payment through our web site.

After making a payment, you will receive a confirmation number, please print or write this number down for future reference. If you do not receive a confirmation number, the payment was not processed.

Information being transmitted is secured for your protection.
Please look for the lock icon in your browser window.

Please note: Fields with an * must be completed for your information to be processed.

Patient Information
First Name * MI Last Name *
Account Number * (No dashes or spaces)
- -  


Accepted Credit Cards
Payment Information
Amount* $
Credit Card Type*
Credit Card Number *
(No dashes or spaces)
Expiration Date *
Card Verification Value (CVV2) *  What's this?
Cardholder's Name *
(Exactly as it appears on the card)

Cardholder's Billing Address
Address 1 *
Address 2
City *
State *
Zip *  
E-mail Address  
Comments
(1000 Character Limit)