HealthePay One Payment Form

Pay Now: One-Time Payment Service

For those patients that have an outstanding balance with us, but do not desire to enroll in the HealthePay™ Program, select the pay now option to pay a one time bill with your credit card. You will be asked to provide the account number and amount due.

All credit card information is kept on a secure server in compliance with Federal Privacy and Security Standards. By using the pay now service, you agree to receive email confirmation of such payment from HealthePay™

Payment Form:

Patient Information	* Required
* Card Number
* Exp Month	* Exp Year
* Card Code
* Amount to Pay:
* Account Number:
* Patients First Name:
* Patients Last Name:
* Doctor or Practice Name:
Billing Information for Credit Card
* First Name
* Last Name
* Street
* City
* State/Providence	2-letter abbreviation
* Country
* Zip/Postal Code (No Spaces)
* Email
* Phone [xxx-xxx-xxxx]