Secure Payment Portal

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Visit ID

Patient Lookup

Patient Name(Required)

First Last

Patient Phone(Required)

Patient Email(Required)

Should the Telemedicine Provider suggest your visit continue in-person today, all charges for this Telemedicine visit will be credited for a same-day in-clinic visit. Patient (or Parent for Minors) Consents to the payment and to communicate and receive care using virtual and other telecommunications tools. This patient has been explained the risks, if any, related to encounter and that care provided through video or audio communication cannot replace the need for physical examination or an in person visit for some disorders or urgent problems.

There are no payments due today for your telemed visit – please select “Completed” below to achnowledge.

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Insurance or Cashpay fees for Telemed Visit(Required)

Telemedicine Visit Fee Increment

Price:

Total Charges to be Collected

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Credit card number

Secure Credit Card Payment(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

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Credit card number

end credit card number