Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Glendive Medical Center

Online Patient Payment Center

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 at 406-345-3350 Monday-Friday between 8am - 5 pm.

You may make payments to the Hospital or Clinic using 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.
* Name of Guarantor/Addressee
The name of responsible person on statement.
  Account Number (optional)
Account Number. (Should Be Located On Your Bill, This is Optional)
* Name on Credit Card
Name as it appears on Credit Card.
* Billing Address
Address Where Your Credit Card Statement is Mailed.
* City, State, Zip
Please Include Your City, State, and Five Digit Zip Code.
* Your E-Mail Address
Please Provide An E-mail Address.
Payment Information
Please Specify How Much You Are Paying In Dollars and Cents.
  Hospital Portion
Please indicate amount of payment to go toward your hospital bill.
  Clinic Portion
Please indicate amount of payment to go toward your clinic bill.
* Amount of Your Total Payment
Please Indicate The Portion You Would Like To Go To The Hospital And/Or Clinic Above. The Total Amount should be the sum of the Hospital and Clinic portions above.
* 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
mm/yy
  Comments Or Messages Related To Your Payment