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*
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.
- Self Pay New Patient ($99)
- Self Pay Follow Up Visit ($69)
- Self Pay Home Sleep Test ($299)
- Insurance Co-Pay
- Other Amount
Insurance Provider
Insurance Group Number
Insurance Card Images
Please upload pictures of the front and back of your insurance card.
Drop files here or

Accepted file types: jpg, png, pdf.
Co-Payment Amount
Other Amount
Total
$0.00
Credit Card

Card Details

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

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