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

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

This is the person whose account will be credited.

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Payment Information

Payment Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Account Number (From Statement) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Comments (Please note if this is a prepayment) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please enter any comments about your payment.

{~ 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-number-label'] }}: {binding displayValue}

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

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

{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 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Payment Information

Payment Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Account Number (From Statement) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Comments (Please note if this is a prepayment) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Meridian Patient Payment Form

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

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

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

{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 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Payment Information

Payment Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Account Number (From Statement) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Comments (Please note if this is a prepayment) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Meridian Patient Payment Form

Patient Information

Payment Information

{~ Payment_Block_Label}

Meridian Patient Payment Form

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

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

Patient Information

Payment Information

Meridian Patient Payment Form

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

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

Patient Information

Payment Information