TeleVisit & Other Payment Options

Patient 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*
Payment Options (as of 03/02/2021)*
- New Patient (Self Pay) $169.99
- Follow Up Visit (Self Pay) $99.00
- Home Sleep Test (Self Pay) $299.00
- Insurance Co-Pay
- Other Amount
Please select your payment option. If you are paying using insurance, 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.
Co-Payment Amount
Other Amount
Total
$0.00
Notes
Credit Card*

Card Details

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

Sign Up Now and Get All Three of Dr. Patel’s eBooks Free!