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SAMCN WEB PMT
4300 E. Flamingo Avenue, Nampa, ID 83587-3138
(866) 626-7272
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Email
Account number
Medical Record Number
Guarantor ID
Guarantor First Name
Guarantor Last Name
First Name
Last Name
Middle Name
Date of Birth
Patient's date of birth (MM/DD/YYYY).
Phone Number
ZIP Code
Statement Number
Statement Date
Amount Due
Dynamic Field 1
Dynamic Field 2
Dynamic Field 3
Dynamic Field 4
ProviderAlias
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