Skip to content
Home
Secure Payment Portal
Step
1
of
2
50%
Hidden
Visit ID
Patient Lookup
– Fill Out Other Fields –
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.
Hidden
Insurance or Cashpay fees for Telemed Visit
(Required)
Telemedicine Visit Fee Increment
Price:
Total Charges to be Collected
Hidden
Credit card number
Secure Credit Card Payment
(Required)
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Expiration Date
Month
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
Year
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
Security Code
Cardholder Name
Hidden
end credit card number
