*
Required fields
Personal Information
*
Patient Last Name
*
Patient First Name
*
Billing Hospital Code
Roane General Clinic( RGC )
Roane General Hospital( RGH )
*
Account Number
*
Payment Amount $
Add More Accounts
Account Number 1
:
Payment Amount 1: $
Account Number 2
:
Payment Amount 2: $
Account Number 3
:
Payment Amount 3: $
Account Number 4
:
Payment Amount 4: $
Card Holder Information
*
Name (First Last)
Street Address
City
State
AL (Alabama)
AK (Alaska)
AZ (Arizona)
AR (Arkansas)
CA (California)
CO (Colorado)
CT (Connecticut)
DE (Delaware)
DC (District of Columbia)
FL (Florida)
GA (Georgia)
HI (Hawaii)
ID (Idaho)
IL (Illinois)
IN (Indiana)
IA (Iowa)
KS (Kansas)
KY (Kentucky)
LA (Louisiana)
ME (Maine)
MD (Maryland)
MA (Massachusetts)
MI (Michigan)
MN (Minnesota)
MS (Mississippi)
MO (Missouri)
MT (Montana)
NE (Nebraska)
NV (Nevada)
NH (New Hampshire)
NJ (New Jersey)
NM (New Mexico)
NY (New York)
NC (North Carolina)
ND (North Dakota)
OH (Ohio)
OK (Oklahoma)
OR (Oregon)
PA (Pennsylvania)
RI (Rhode Island)
SC (South Carolina)
SD (South Dakota)
TN (Tennessee)
TX (Texas)
UT (Utah)
VT (Vermont)
VA (Virginia)
WA (Washington)
WV (West Virginia)
WI (Wisconsin)
WY (Wyoming)
GM (Guam)
VI (Virgin Islands)
PR (Puerto Rico)
AS (American Samoa)
*
Zip
Phone (Eg:1234567890)
Email
Payment Information
Sale
Patient-Portal
*
Payment Total $
*
Payment Type
Mastercard
Visa
Amex
Discover
*
Card Number
*
Expiration Date
January (01)
February (02)
March (03)
April (04)
May (05)
June (06)
July (07)
August (08)
September (09)
October (10)
November (11)
December (12)
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
*
CVV2
*
Bank Routing#
Date
(mm/dd/yyyy)
Bank Acct#
Check#
ABC
Payment Memo