Meridian Patient Payment Form

After completing all required fields, click the "Submit" button only once. You will receive a confirmation notice thereafter. If you have any questions, please call the Billing Department at 352-374-5600 ext. 8323

Patient Information

{ binding firstError.message }
This is the person whose account will be credited.
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Payment Information

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Please enter any comments about your payment.
{ binding firstError.message }

{~ Payment_Block_Label}

{ binding firstError.message }
{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['payment-amount-due'] + ":" }} {binding displayValue}

Meridian Patient Payment Form

{{ Cognito.resources['order-transaction-details-header'] }}

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}
{{ Cognito.resources['order-date-label'] }}: {binding displayValue}
{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}

{{ Cognito.resources['order-billing-info-header'] }}

{binding BillingName}
{binding BillingAddress.FullInternationalAddress}
{binding EmailAddress}
{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:{binding displayValue}

Patient Information

Name
{binding displayValue}
Address
{binding displayValue}
Phone
{binding displayValue}
Email
{binding displayValue}
{ binding firstError.message }

Payment Information

Payment Amount
{binding displayValue}
Account Number (From Statement)
{binding displayValue}
Comments (Please note if this is a prepayment)
{ binding firstError.message }

Meridian Patient Payment Form

After completing all required fields, click the "Submit" button only once. You will receive a confirmation notice thereafter. If you have any questions, please call the Billing Department at 352-374-5600 ext. 8323

{{ Cognito.resources['order-transaction-details-header'] }}

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}
{{ Cognito.resources['order-date-label'] }}: {binding displayValue}
{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}

{{ Cognito.resources['order-billing-info-header'] }}

{binding BillingName}
{binding BillingAddress.FullInternationalAddress}
{binding EmailAddress}
{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:{binding displayValue}

Patient Information

Name
{binding displayValue}
Address
{binding displayValue}
Phone
{binding displayValue}
Email
{binding displayValue}
{ binding firstError.message }

Payment Information

Payment Amount
{binding displayValue}
Account Number (From Statement)
{binding displayValue}
Comments (Please note if this is a prepayment)
{ binding firstError.message }