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St Francis Health Center OL
8140 South Holly Street
Centennial,CO 80122
(888) 269-7001

STEP 1
Payment
       
STEP 2
Confirm
       
STEP 3
Receipt

Patient
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Patient ID PatientMedicalRecordNumber First Name Last Name Birth Date PatientServiceBeginDate PatientServiceEndDate AdditionalInfo1 Additional Info 2 Additional Info 3 Additional Info 4 Additional Info 5 Additional Info 6 Amount
Add Row Total $0.00
Enter Patient Account# characters up to the Dash
Unique Reference Number
Last Name
First Name  Middle Name :
Birth Date   (MM/DD/YYYY)
Phone #  -  - 
Email Address
Enter Patient Account# characters after the Dash, if applicable. Do not enter the dash
Address
Address
City
State        Zip    -
Zip    -
Country

Payment Information

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Card :
Card Holder Name
Card Type
Card Number   Exp Date   (MM/YY)
Amount            Current Balance  
Save this card for future use

Account Information

Address 1
Address 2
City
State        Zip    -
Zip    -
Country
 -  - 
  Your credit card/bank account will not be charged
until all information is confirmed in the next step.
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