ENT and Allergy Associates, LLP-Pay Bill Online

If you wish to pay your bill by credit card, fill out the following form and press the “Submit” button when you’re finished. Please be aware that all information must be included to process the form successfully. Thank you!

***Important*** - Flexible Spending Credit Cards cannot be used as a source of payment through the website

Patient Full Name:
Patient Account Number:

Name as it appears on credit card:
Address:
Address 2:
City:
State:
Zip:
Daytime Phone Number:
E-Mail Address:

Type of Credit Card:
Credit Card Number:
Expiration Date:
Amount to be charged:	$