Patient Information

*  Responsible Party
Of The Account

*  Account Number
*  Medical Record Number (MRN)
*  Patient's First Name
*  Patient's Last Name
*  Patient's Date of Birth    

 

Cardholder/Payment Information

credit cards accepted: Mastercard / Visa / American Express / Discover
*  Name on Card
  
*  Address   
*  City   
*  State   
*  Zip Code   
  Email Address
 
  
(Optional: A verification of payment will be sent to the email address if entered. Your email address will not used for any other purpose than to send a payment confirmation.)
*  Daytime phone number
(area code first)
  
*  Amount of Payment $
*  Credit Card Number   
*  Card Security Number   
What is my card security number?
*  Credit Card Expiration     
*  Indicates a required field


Refund Policy: If a payment made on this site results in an overpayment of the patient's liability for servces rendered, UT Medicine San Antonio will issue a refund to the approprate payee by check.

Please contact (888) 410-2777 if you have any questions or concerns regarding your payment.

v0.2 (2014-03-25)