Patient Billing Online Bill Pay

PAYMENT BY CREDIT CARD:

I HEREBY AUTHORIZE MEDcare Urgent Care to initiate charges to my credit card in the amount specified below:

Please allow 3-5 days to process, your confirmation will be emailed to the email address you provide below.

Location: *
Date of Service: *
Patient First Name: *
Patient Last Name: *
Account Number: *
Re-enter Account Number: *
 
PAYMENT INFORMATION:
Payment Amount: *
Credit Card Type:

Credit Card Number: *
Expiration Date: Month: / Year: *
Security Code (CVV): 3 Digits (4 digits for AMEX) *
Cardholder Name: *
Billing Address: *
City: *
State: *
Postal Code: *
Email Address:
Phone Number:
Comments:
 
 
 
 

Your credit card charge will appear on your bill as:

MEDcare Urgent Care