Pay My Bill

Patient Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Please check all that apply to you:
- My address has changed
- My Primary Insurance has changed
- My Secondary Insurance has changed
Patient Address*
Street Address Address Line 2 City State ZIP Code
Insurance
New Insurance Information*

Name of New Primary Insurance Carrier
New Policy Number*

Policy # of your new Primary Insurer
Insurance Company Phone Number*

Include area code
Secondary Insurance Information*

Name of Secondary Insurance Carrier
New Secondary Policy Number*

Policy # of your Secondary Insurer
Insurance Company Phone Number*

Include area code
Case Number
Located on the upper right side of your statement
Payment Amount*
Check a box ONLY if the reason for your payment is listed below:
Do not check any of the boxes if you are making a client invoice payment
- Missed or Cancellation Appointment Fee
- Rent Payment - MHC Residence
- Medical Records Fee
Card Holder Information
Billing Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
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Name
This field is for validation purposes and should be left unchanged.

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