Paysuite - One Mnet Health

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Build Payment Plan

Are you a patient or facility administrator?*

Patient Facility Administrator

Amount*

Provider Access Code*

{{pageState.patientOrFacility == 'Facility' ? 'Payment Plan Set Up' : 'View Payment Options'}}

Change Amount

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{{pageState.patientOrFacility == 'Facility' ? 'Administrator Payment Plan Setup' : 'Payment Plan Options'}}

Did you verify the patient's ID?* Yes No

Payment Plan Option

{{ option.Months }} month - No{{option.PercentageDown}}% down payment

Payment Details

Monthly Payment Amount - {{formData.selectedMonthPayment}} Month Plan*

Today's Down Payment - {{formData.selectedMonthPayment}} Month Plan*

Payment Details

Payment Amount*

Payment Frequency*

{{pageState.calculated ? 'Choose Your Monthly Payment Date' : 'First Payment Date'}}*

Override Approval By*

Administrator Email*

Facility Staff Signature for Approval of Payment Plan*

Use your mouse or finger to draw your signature above

[clear]

Account Details

Have you already had your procedure?*

Yes No

If either of these options do not meet your needs, please call {{ pageState.alreadyHadProc == 'true' ? 'the Patient Billing Department at: ' + pageState.PaymentBillingPhone : 'Financial Services at: ' + pageState.OFPaymentAgencyPhone}}

Balance {{formData.amount}}

Account Number*

Date of Service*

Patient Name

First Name*

Last Name*

Address Line 1*

Address Line 2

City*

State*

ZIP Code*

Patient's Date of Birth*

Parent/Guardian

First Name*

Last Name*

Email*
Your email is never shared with 3rd parties. It is used for confirmation and support

Cell Phone Number*

Home Phone Number

Payment Information and Signature Authorization

Name on Card

First*

Last*

Credit Card Information

Credit Card*

{{pageState.creditCardError}} Visa

Financial Agreement {{formData.financialAgreement}}

Patient signature on file at facility*

Yes No

Account holder signature*

Use your mouse or finger to draw your signature above

[clear]

Please update the following fields: {{pageState.errorString}}

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