Newman Regional Health
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Welcome to the Newman Regional Health Patient Payment Page
One Time Patient Payment Amount
Patient Payment Amount:    *
Reference / Invoice:       (If applicable)
Billing Address
Full Name:    *
Address:    *
Address 2:  
City:    *
State:    *
(only required for US and Canada addresses)
ZIP Code:    *
(all numbers without spaces or dashes)
Country:    *
Phone Number:    *
(any format without spaces)
Email Address:    *
Patient Name:   *
Patient Account Number:   *
Billing Information
              Pay with card
Account Number:    *
(all numbers without spaces or dashes)
Visa MasterCard Discover American Express
Expiration Date:       *
CSC:    *  What is CSC?
              Pay with checking account
Routing Number:    *
(all numbers without spaces or dashes, include leading zeros)
Checking Account:    *
(all numbers without spaces or dashes, include leading zeros)
Special Instructions:  
  I agree with the Payment Terms and Conditions. *
 Help?
(please click only once to prevent duplicate orders)
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