TeleVisit & Other Payment Options


  • Date Format: MM slash DD slash YYYY
    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.
  • Drop files here or
    Accepted file types: jpg, png, pdf.
    Please upload pictures of the front and back of your insurance card.
  • $0.00
  • This field is for validation purposes and should be left unchanged.