Pay Your Bill Online - UrgentCare Indy

Thank you for using our online bill pay! Please enter your invoice number below as well as the amount that you would like to pay (up to the full amount of your invoice balance) so that we can credit payment to the balance on your account.

Your Payment: ( $ )

Patient Name *

Enter the full name of the patient as it is written on the account invoice.

Patient Name:

Patient Date of Birth:

Optional – Chart Number

Enter your Chart # (located at the top left port of your statement above the due date):

Chart #

Billing Details

First Name *

Last Name *

Email Address *

Phone *

Address *

City *

State *

ZIP *

Country *

Your order

Product Quantity	Total
Cart Subtotal	$0.00
Order Total	$0.00

Credit Card

Pay securely using your credit card.
Card Number *
Expiration (MM/YY) *
Card Security Code *
Securely Save to Account
TeleCheck

Pay securely using your checking account.

By entering my account number below and clicking Place Order, I authorize my payment to be processed as an electronic funds transfer or draft drawn from my account. If my full order is not available at the same time, I authorize partial debits to my account, not to exceed the total authorized amount. The partial debits will take place upon each shipment of partial goods for amounts corresponding to the value of each shipment. If any of my payments are returned unpaid, I authorize you or your service provider to collect the payment and my state’s return item fee for each payment by electronic fund transfer(s) or draft(s) drawn from my account. Click here to view your state’s returned item fee and other costs associated with the transaction. If this payment is from a corporate account, I make these authorizations as an authorized corporate representative and agree that the entity will be bound by the NACHA operating rules. This authorization shall remain in full force and effect until revoked. Any payment authorized for today’s date will initiate at end-of-business, Central Time. I understand that for orders shipped in full, my account will be debited within 1-2 banking days from this Authorization. In the event payments are authorized for initiation at a future date, those payments may be revoked by providing written notice to this merchant at the contact information found on this merchant's website and providing the merchant reasonable opportunity to act upon it.

Please use your browser’s print feature to print this disclosure for your records.

Routing Number *
Account Number *
Check Number *
Check Type *
ID Type *
ID Number *

Update Totals

I’ve read and accept the terms & conditions *