Pay Online : Overview

Pay Online

Submit Online Payment

To avoid duplicate charges in the event of an error message, please contact us at 704-343-7010 to confirm the status of your initial payment prior to reprocessing your card.

There was an issue submitting your information, please double-check the information below:

PATIENT INFORMATION

Patient First Name:
Patient Last Name:
Patient Date of Birth:
Patient Account #:
Patient Billing Address:
City:
State:
Zip:
Contact Phone Number:

CARD HOLDER INFORMATION

SAME AS PATIENT
Card Holder First Name:
Card Holder Last Name:
Card Holder Billing Address:
City:
State:
Zip:
Contact Phone Number:

REASON FOR PAYMENT

Payment on Account Balance
Pre Payment
Other

Enter Amount

 

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