TeleVisit & Other Payment Options

Name*
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Billing Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
TeleVisit Payment Options*
- Self Pay New Patient ($99)
- Self Pay Follow Up Visit ($69)
- Self Pay Home Sleep Test ($299)
- Insurance Co-Pay
- Other Amount
Please select your payment option. If you a paying using Insurance Co-pay please fill out the Insurance Company, Group Number and Co-payment Amount fields. If you are paying another amount please fill out the Other Amount field.
Insurance Provider
Insurance Group Number
Insurance Card Images
Drop files here or

Accepted file types: jpg, png, pdf.
Please upload pictures of the front and back of your insurance card.
Co-Payment Amount
Other Amount
Total
$0.00
Credit Card

Card Details

Cardholder Name
Phone
This field is for validation purposes and should be left unchanged.

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