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Memorial Hospital
633 3rd Ave., 4th Floor
New York,NY 10017
(646) 227-3228

STEP 1
Payment
       
STEP 2
Confirm
       
STEP 3
Receipt
Payment Type

           
Credit Card Bank Account

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
Patient Account Number
Patient Last Name
Patient First Name  Middle :
  (MM/DD/YYYY)
 -  - 
Card Holder Email Address
       Patient Zip    -

Payment Information

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Card :
Card Holder Name
Card Type
Card Number   Exp Date   (MM/YY)
CVN   What is this?
Amount            Current Balance  
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  Your credit card/bank account will not be charged
until all information is confirmed in the next step.
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