New Payment Request

Patient Identifiers
Find this patient by CSN or SSN
*
Note: To use a SSN to locate the patient, provide the value in dashed format (###-##-####)
Patient Last Name
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Patient Date of Birth
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Use the calendar or enter the date in the following format (MM/DD/YYYY)
Provider Identifiers
Prescriber's NPI
*
Treatment Name or NDC
*

After typing in the first three characters, you may select your entry from the list using your arrow keys or mouse.