OMS of Utah | Balance Collect

Required Field *

Additional Information

Patient First Name

Patient Last Name

Patient Account Number

Patient Date of Birth

Billing Information

Credit Card Number *

Expiration *

CVV *

First Name *

Last Name *

Street Address

City

State

Zip Code *

Email Address(For a copy of your receipt enter your email address. )

Payment Amount

Amount (Max $100,000.00)*

Return to Home

Merchant

Date/Time

Transaction ID

Transaction Type

Credit Card

Amount

Type

Number

Name

Street Address

City, State, Zip Code