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Pay Your Bill Online
Please contact our billing specialists at 844-721-6901 for any billing inquiries you may have.
Pay Bill Online
Account Number
*
Ex: WX1234
Patient Legal First Name
*
Patient Legal Last Name
*
Date of Service
*
Please list the first date of service to which the payment should be applied. Provide the year as applicable. Or use the statement date.
Cardholder First Name
*
As it appears on card.
Cardholder Last Name
*
As it appears on card.
Enter Cardholder's Billing Address
*
Enter Cardholder's Billing Address
Enter Street Address
Enter Street Address
Enter Apt/Suite Number
Enter Apt/Suite Number
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Email Address
*
Enter your email address to receive an emailed receipt. (Will be delivered within an hour.)
Phone
*
Please list your best callback number without dashes or parentheses, should we have any follow-up questions.
Credit Card Payment Information
*
Credit Card Payment Information
Enter entire card number as it appears on the card.
Enter entire card number as it appears on the card.
Credit Card Payment Information
Month
1
2
3
4
5
6
7
8
9
10
11
12
Credit Card Payment Information
Year
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
Enter CSV
Enter CSV
Payment Amount
*
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