University Orthopedics Center

Payment Information

Account Information

First Name

First name of account to make payment on.

Last Name

Last name of account to make payment on.

Account Number

Account number appearing on the statement.

Home Phone Number

Home phone number to contact for additional information.

Payment Amount

Payment amount to be placed on account.

Payment Account Type

Master Card

Visa

Discover

Payment Account Types.

Credit Card Number

Credit card number on face of card.

Expiration Date

Credit card Expiration date on face of card.

Security Code

3 or 4 digit numeric value printed on the back of the credit card.

Billing Address

Same as patient information.

First Name

First name on payment account.

Last Name

Last name on payment account.

Address

Address on payment account.

City

Address City on payment account.

State

Address State on payment account.

Zip Code

Address Zip Code on payment account.

Phone Number

Phone Number on payment account.

Email on payment account.

Payment Notes

Notes to pass with payment.