Make a Payment Make a Payment Please enter the amount you would like applied to your account. Please keep in mind that most copays are auto-charged to the card on file in the patient portal account. Only use this form to charge amounts that were previously declined, unable to be processed, or need one-time payments with a different card. Patient Information Full Name* Date of Birth* 12345678910111213141516171819202122232425262728293031 DayJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Month2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Back Next Payment Information prevnext( X ) USDEnter Invoice Amount Credit Card Details First Name Last Name Credit Card Number Security Code Card Expiration Signature Clear Back Next Please verify that you are human* Submit Should be Empty:
