HealthePay One Payment Form

Rochester Gastroenterology Associates

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Pay Now: One-Time Payment Service

For those patients that have an outstanding balance with us, but do not desire to enroll in the HealthePay™ 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:

Patient Information	* Required
* Card Number
* Exp Month	* Exp Year
* Card Code
* Amount to Pay:
* Account Number:
* Patients First Name:
* Patients Last Name:
* Doctor or Practice Name:
Billing Information for Credit Card
* First Name
* Last Name
* Street
* City
* State/Providence	2-letter abbreviation
* Country
* Zip/Postal Code (No Spaces)
* Email
* Phone [xxx-xxx-xxxx]