AZ Max | Balance Collect | Payment

Required Field *

Additional Information

Dr. and Office

Patient Name *

Patient ID

Additional info

Patient Date of Birth *

Billing Information

Credit Card Number *

Expiration *

CVV *

First Name *

Last Name *

Street Address

City

State

Zip Code *

Email Address(For a copy of your receipt enter your email address. )

Payment Amount

Amount (Max $100,000.00)*

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Transaction Receipt

Merchant Information

Merchant

Date/Time

Transaction ID

Transaction Type

Credit Card

Amount

Credit Card Information

Type

Number

Billing Information

Name

Street Address

City, State, Zip Code

Additional Information