PAY BILL

Patient Name *

First

Last

Date of Birth *//

Invoice Number

(This is optional. If the invoice entered here matches with an outstanding invoice on file, the payment will be applied to that invoice. If nothing is entered here, the payment will be applied to the oldest outstanding balance on the patient's file)

Amount to charge now: *

Email *

For emailed receipt of payment

Therapists Email

If you want your therapist to receive an instantaneous notification of your payment, select their email address above, otherwise don't make a selection.

Your Name *

First

Last

Individual filling out this form

Authorizations *

I authorize the payment of this amount for the patient listed above. (You will be taken to PayPal to complete your transaction).
I also authorize IPG to store on file the card that I enter (payment form will open below), and to charge to it all past and future assigned fees, copays, coinsurance amounts, deductibles, Scheduling Fees for appointments not kept, or any amounts due as may be determined by insurance, for the patient listed above.

Cardholder's Name

(if different from above)

Dropdown *

Card Number *

Visa/MC/Disc/Amex Accepted

Expiration Date *

CVV2 Code *

Card Notes (optional)

If any clarifications are needed, i.e. when to use this card versus the previous cards on file, or in combination with the prior cards...

Phone

If we have any questions

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Signature *

With my signature above, I authorize IPG to store the above card on file and to charge to it all past and future assigned fees, copays, coinsurance amounts, deductibles, Scheduling Fees for appointments not kept, or any amounts due as may be determined by insurance, for the patient listed above.

Below is a simple way to pay some or all of your bill. You may also use this form to store a card on file for future use.

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