Pay My Bill

NOTE: Payments on this site are for the hospital ONLY, not physicians.
* indicates required field
* patient first name:
* patient last name:
* patient SSN (Last 4):  
(ex: 1234)
* patient account number:
bill date (optional):
service from date (optional):
service to date (optional):
statement balance (optional):
* payment amount:
* credit/debit card selection:
* credit/debit card number:
* credit/debit card expiration date:  
* credit/debit card 3 digit security code:  (see example below)
* billing name:
* billing address 1:
billing address 2:
* billing city:
* billing state:
* billing zip:
billing phone:
May we contact you via email?
If so, email address:
* I have read and understood the ULH notice of privacy practices. (Click here)  (Initial to agree)
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