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Pay Your Bill Online! - Feb, 24 2018
Merchant Services
 
Secure STEP 2 OF 3 Red Arrow  - Fill Out The Payment Form.

Patient Information

 - Select The Correct Hospital only if your Online Payment code is incorrect.  
Women and Infants |  Butler |  Kent Hospital |  Memorial Hospital |  Care New England

The Online Payment code on the bottom of your billing statement is WF. If this is not correct, please click on the hospital name above from which you have received a bill.

All patient information should match your billing statement.

* = Required


Patient Account Number: *
Where can I find the “Patient Account Number”?
 
Patient First Name: *
Patient Last Name: *
Patient Date of Birth: *      mm/dd/yyyy
 

Credit Card Billing Information

 
Credit Card Holder's Full Name: *
  (As it appears on your Credit Card.)
Street Address 1: *
  (As it appears on your Credit Card.)
Address 2:
City: *
State: *   
ZIP: *
Telephone Number: * - -
E-mail Address:

The credit card holder’s email address is not required, but if provided the credit card holder will receive an emailed copy of the payment receipt.
 
Amount To Be paid : *    $
Credit Card Type: *
Credit Card Number: *
Expiration Date:  Month*   Year* (yy)



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