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Chestatee Regional Hospital

Online Patient Payment Center

Welcome to Chestatee Regional Hospital Online Payment Center. You may pay your hospital 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 Chestatee Regional 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.
  Patient Account Number (optional)
Patient Account Number is located on your statement/bill. This field is optional but will ensure prompt and accurate posting of your payment.
* Your E-Mail Address
Please Provide An E-mail Address.
  Comments Or Messages Related To Your Payment
* Cardholder First Name
The first name of the account holder as it appears on the credit card.
* Cardholder Last Name
The last name of the account holder as it appears on the credit card.
* Amount of Payment
Format: 45.67 (Include decimal and cents. Do not use a dollar sign.)		 $
* Card Number
* Expiration Date
* Card Code Verification Number
The three digit number on the back of your card. (Four digit code on the front of American Express.)
* Billing Postal or Street Address
* Billing City
* Billing State
* Billing Zip Code
5 digit zip code

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