Payments HealthePay

Gastroenterology Group Of Rochester

Installment Payments
(Secure Form)
Please provide your Credit Card information for verification.
You will proceed to calculate your monthly amounts.

Billing information (All* fields are required)*
First Name:	(on Card)
Last Name:	(on Card)
Address:
City:
State:
Zip:
Phone Number:	xxx-xxx-xxxx
Email Address:

This will become a RECURRING MONTHLY PAYMENT METHOD.
Please proceed the next page to select monthly charges and patient information.

Credit Card Number:

Month / Year :

Card Code :

(3 digits on the back of your card)

Please click only once