Pay Now: One-Time Payment Service

For those patients that have an outstanding balance with us, but do not desire to enroll in the HealthePayTM Program, select the pay now option to pay a one time bill with your credit card. You will be asked to provide the account number and amount due.

All credit card information is kept on a secure server in compliance with Federal Privacy and Security Standards. By using the pay now service, you agree to receive email confirmation of such payment from Rochester Gastroenterology Associates.

Payment Form:

First Name: (on credit card)
Last Name: (on credit card)
Email:
Phone:

Billing Address:
Address:
City:
State:
Postal/Zip:

Patient Information:
Patient Name(s):
Doctor or Practice Name:
* located in the top left corner of your statement

Payment Information:
Statement Date:
Account #:
Amount:
Notes/Comments:

Credit Card Information
Credit Card Type:
Credit Card:
Expiration:   /  
CCV Code:
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