Patient Account Payment

This page is for use only in facilitating patient payments.
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Patient Account Number

Account Number Help

I don't know my account number

Your account number is located on the upper right of your patient statement (see example circled in red).

If you do not have your patient statement or cannot find your account number, please leave blank and we will match your payment to your account manually.

Patient First Name

Patient Last Name

Patient Birthdate

MM/DD/YYYY

Patient Contact Information

Patient Mailing Address

City

State

Zip Code

Country

Phone (incl. area code)

numbers only - no hyphens or parenthesis

Phone Type

Email Address

Hidden Fields

Lower Email

Mobile Phone

Home Phone

Work Phone

Select Payment Type

One-Time Payment or Automatic Monthly Payment?

About Automatic Monthly Payments: Your first payment will be made today, and will repeat on this date each month. If your initial payment was made on the 31st, subsequent payments will be made on the last day of the month. Payments will continue until you direct otherwise by contacting finance@lifeflighteagle.org. Note, payments will not automatically stop once a balance has been paid off. You must contact finance@lifeflighteagle.org to cancel or update automatic payments.

Payment Amount

Payment Method

Processing Fee

Today's Payment Total