Online Patient Payment Center (new)
Welcome to the Online Payment Center. You may pay your hospital or clinic bills here by credit 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 using your credit card information. All payments are via secure server. Thank you for allowing us to serve you.
Name Of Patient
Name of Patient Treated.
Account Number. (Should Be Located On Your Bill, or you can indicate hospital or clinic.)
Name of Payor
Payor's Name on Credit Card or Checking Account.
Address Where Your Credit Card or Bank Account 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 Just As It Appears On Card.
Credit Card Expiration Date
Comments Or Messages Related To Your Payment