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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.
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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 Email on payment account.
Payment Notes Notes to pass with payment.
814.231.2101 • 800.505.2101 • 814.949.4050 • 717.248.5200
State College   |   Altoona   |   Tyrone   |   Huntingdon   |   Lewistown
University Orthopedics Center and affiliated companies provide diagnostic, surgical and rehabilitation
services for patients with musculo-skeletal injuries or chronic/degenerative orthopedic disorders.
© 2014, University Orthopedics Center. All Rights Reserved.