Bill Payment

Please fill out your information below to pay your bill online by credit card. This form is strictly for paying your bill. If you have questions regarding a bill, please complete the "Billing Questions" form.

Fields marked with the red asterisk (*) are required fields and must be filled out.

Patient's Last Name* Patient's First Name* Street Address* City* State* Zip Code* Home Phone* -- Work Phone -- ext. E-mail* Date of Birth* (ex. mm/dd/yyyy) Insurance Select an Insurance Aetna US Healthcare CareFirst BC/BS HMO CareFirst BC/BS non HMO Trigon BC/BS of VA Blue Cross/Blue Shield Cigna Healthcare of Mid-Atlantic Mamsi Medicaid Medicare NCPPO One Health United Healthcare of Mid-Atlantic HMO United Healthcare of Mid-Atlantic non HMO Humana PHCS No insurance Member ID Group Number Credit Card Type*  MasterCard  Visa Payment Amount* $ Account Number* Expiration Date* ex. mm/yy Send My Balance Additional Comments or Questions