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BCFC Patient Payment
INSTRUCTIONS
Please fill in the form below and click on Submit to Submit your Payment.
PATIENT INFORMATION
PATIENT INFORMATION
FirstName
LastName
DOB
AMOUNT
Balance
Amount
CC Charge:
0
CONTACT INFO FOR BILLING RECEIPT
-Select State-
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District Of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Puerto Rico
New
Payment Method
Payment Method
CREDIT OR DEBIT CARD
disclaimer
When you click "Submit" you are authorizing funding for a payment. Make sure you have adequate funds to cover the payment. Do not complete this transaction if you do not agree to these terms. REFUND POLICY: All sales are final and no refunds.
BCFC Payment
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Card Details
Card Holder Details
Charge Amount(css hidden)
Select Card
Card
-Select-
Add New Card
Charge
Token for card
Tokenized card number
Card bin
Card last4
Card type
Card expirymonth
Card expiryyear
Billingpaymentnum
Patientcardnumber
Is saved
Button to click
Total chargeable
Amount paid
Action
Heading action
Gatewaytransactionid
Cardnum inpaymentdet
Public key hl
Bpn amt string
Total payable
Total current payment
Is cards saved
Is show new card
Billingpaymentnums
Form patientnum
Form amount
Ret paymedetail row
Select payment config
Id num
Customer logo
Header text
Office name parm12
Contact number parm13
Enable entryinto ledger
Pat payment num
Diagnums
Enable partpay
if this is the version of the page where the bill feature is done
Is namedob edit
Cc charge
Submit medi page
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