Patient Payment

To make a payment, please enter the information below & hit "Continue" to enter the credit card information. Fields labeled in bold are required fields. The information entered here is sent with maximum security.

Account Number
Please enter the 3 character prefix in the first box and the rest of the account number in the second box. Show me an example
Patient Information
Origin Rep
Origin Users Only

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(First, MI, Last)
  
Birth Date

Daytime Area Code/Telephone

Evening Area Code/Telephone

Patient's Relationship to Primary Insured
 
Check here if you need to update the "Patient Address" shown on the statement. (This information will be collected on the next page)