Online Patient Payment Center
Welcome to the Online Payment Center. You may pay your Dimmit Regional Hospital bills here by credit card or by check.
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 Dimmit Regional Hospital using your credit card information or by submitting your bank account routing number and checking account number in below fields. Please only supply one set of payment information: your credit card info or your online check information. All payments are via secure server. Thank you for allowing us to serve you.
Name Of Patient
Name of Patient Treated.
Invoice Number (optional)
Invoice Number. (Should Be Located On Your Bill, This is Optional)
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.
Method of Payment?
Please Check One.
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
Name Of Your Bank
If Paying By Online Check, Please List The Local Bank Hosting Your Checking Account.
Comments Or Messages Related To Your Payment