Online Patient Payment Center
Welcome to the Online Payment Center. You may pay your hospital bills here by credit/debit card.
For your convenience please fill out the below payment form. All information will be kept secure and confidential. For more information you may call our business office during working hours.
You may make payments to the Hospital submitting your credit card information in below fields.
All payments are via secure server. Thank you for allowing us to serve you.
Name Of Patient
Name of Patient Treated.
Patient Account Number
Account Number. (Should Be Located On Your Bill)
Name on Credit Card.
Address Where Your Credit Card Statements Are Mailed.
City, State, Zip
Please Include Your City, State, and Five Digit Zip Code.
Your E-Mail Address
Please Provide An E-mail Address.
Amount of Your Payment
Please Specify How Much You Are Paying. Please Use Dollars and Cents.
Credit Card Type
Select If You Are Paying By Credit Card.
Credit Card Number
Input The 16 Digit Number Exactly As It Appears On Card.
Credit Card Expiration Date
3-digit code located on the back of your credit card.
Comments Or Messages Related To Your Payment