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Mt. San Rafael Hospital

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.

You may make payments by submitting your payment details below. All payments are via secure server. Thank you for allowing us to serve you.

For more information you may call our business office at 719-845-4208. Business office is open Monday through Friday from 8:00 am to 4:00 pm.
* Name Of Patient
Name of Patient Treated.
* Patient Account Number
Account Number. (Should Be Located On Your Bill)
* Your E-Mail Address
Please Provide An E-mail Address.
Billing Information
* Billing Name
Name on 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