Pay Suite

Short-Term Payment Plan

No Cost or Credit Check

You can set up a short-term payment plan at no additional charge. This payment plan option is ideal for patients who have an open credit card or checking account and need to break up their balance over a few payments, using a check, a major credit card, or your Flex Spending Account or Health Savings Account. Your provider has worked to offer you payment plans that may meet your needs.

Paysuite - One Mnet Health

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Build Payment Plan

Are you a patient or facility administrator?*

Patient Facility Administrator

Amount*

Provider Access Code*

{{pageState.patientOrFacility == 'Facility' ? 'Payment Plan Set Up' : 'View Payment Options'}}

Change Amount

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{{pageState.patientOrFacility == 'Facility' ? 'Administrator Payment Plan Setup' : 'Payment Plan Options'}}

Did you verify the patient's ID?* Yes No

Payment Plan Option

{{ option.Months }} month - No{{option.PercentageDown}}% down payment

Payment Details

Monthly Payment Amount - {{formData.selectedMonthPayment}} Month Plan*

Today's Down Payment - {{formData.selectedMonthPayment}} Month Plan*

Payment Details

Today's Down Payment*

Payment Amount*

Payment Frequency*

{{pageState.calculated ? 'Choose Your Monthly Payment Date' : 'First Payment Date'}}*

Override Approval By*

Administrator Email*

Facility Staff Signature for Approval of Payment Plan*

Use your mouse or finger to draw your signature above

[clear]

Account Details

Have you already had your procedure?*

Yes No

If either of these options do not meet your needs, please call {{ pageState.alreadyHadProc == 'false' ? 'the Patient Billing Department at: ' + pageState.PaymentBillingPhone : 'Financial Services at: ' + pageState.OFPaymentAgencyPhone}}

Balance {{formData.amount}}

Account Number*

Date of Service*

Patient Name

First Name*

Last Name*

Address Line 1*

Address Line 2

City*

State*

ZIP Code*

Patient's Date of Birth*

Parent/Guardian

First Name*

Last Name*

Email*
Your email is never shared with 3rd parties. It is used for confirmation and support

Cell Phone Number*

Home Phone Number

Payment Information and Signature Authorization

Name on Card

First*

Last*

Credit Card Information

Credit Card*

{{pageState.creditCardError}} Visa

Financial Agreement {{formData.financialAgreement}}

Patient signature on file at facility*

Yes No

Account holder signature*

Use your mouse or finger to draw your signature above

[clear]

Please update the following fields: {{pageState.errorString}}

Save

Payment Suite

Make A Payment

Apply For Extension

INTERESTED IN FINANCING OPTIONS?

Short-Term Payment Plan

No Cost or Credit Check

Get In Touch!