Enrollment Service for Rochester Gastroenterology Associates HealthePayTM Program

Payment is due at the time of service. If a patient is unsure of their covered benefits, Rochester Gastroenterology Associates will accommodate requests for a delay of payment until such time that Rochester Gastroenterology Associates sends the claim to the insurance company and receives an explanation of benefits, so long as the patient or their guarantor, agrees to enroll in our HealthePayTM Program. The patient or their guarantor must provide a current credit card and agree to allow Rochester Gastroenterology Associates to charge that card for all charges deemed to be the patient’s responsibility. This includes payment in full for the visit if the insurance card information is invalid or not current.

All credit card information is kept on a secure server in compliance with Federal Privacy and Security Standards. By enrolling in this program, you agree to receive email confirmation of your enrollment in the Rochester Gastroenterology Associates HealthePayTM Program. You also agree to an email confirmation when your credit card is charged. The information that may be sent will be the date of service and total fees due. There will be no diagnosis codes or visit details on that receipt but are available by request. This is to maintain your or your child’s health information confidential.

Enrollment Form:

First Name: (on credit card)
Last Name: (on credit card)
Patient Name(s):
Doctor or Practice Name:
* located in the top left corner of your statement

Billing Address:


Credit Card Information:

Credit Card Type:
Credit Card:
Expiration:   /  
CCV Code:
User Agreement  (View User Agreement)
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