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Patient Information
*
Last Name
*
First Name
*
Billing Hospital
Jackson Health System(JHS)
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Account Number
*
Amount
Add More Accounts
Account Number 1:
Amount 1:$
Account Number 2:
Amount 2:$
Account Number 3:
Amount 3:$
Account Number 4:
Amount 4:$
Card Holder Information
*
Name (First Last)
Street Address
City
State
AL (Alabama)
AK (Alaska)
AZ (Arizona)
AR (Arkansas)
CA (California)
CO (Colorado)
CT (Connecticut)
DE (Delaware)
DC (District of Columbia)
FL (Florida)
GA (Georgia)
HI (Hawaii)
ID (Idaho)
IL (Illinois)
IN (Indiana)
IA (Iowa)
KS (Kansas)
KY (Kentucky)
LA (Louisiana)
ME (Maine)
MD (Maryland)
MA (Massachusetts)
MI (Michigan)
MN (Minnesota)
MS (Mississippi)
MO (Missouri)
MT (Montana)
NE (Nebraska)
NV (Nevada)
NH (New Hampshire)
NJ (New Jersey)
NM (New Mexico)
NY (New York)
NC (North Carolina)
ND (North Dakota)
OH (Ohio)
OK (Oklahoma)
OR (Oregon)
PA (Pennsylvania)
RI (Rhode Island)
SC (South Carolina)
SD (South Dakota)
TN (Tennessee)
TX (Texas)
UT (Utah)
VT (Vermont)
VA (Virginia)
WA (Washington)
WV (West Virginia)
WI (Wisconsin)
WY (Wyoming)
GM (Guam)
VI (Virgin Islands)
PR (Puerto Rico)
AS (American Samoa)
*
Card Holder Zip
Must match with Card Holder Billing Zip code
Phone(10-digit)
Email
Payment Information
Sale
Patient-Portal
*
Payment Total $
*
Payment Type
Master
Visa
Amex
Discover
*
Card Number
*
Expiration Date
January (01)
February (02)
March (03)
April (04)
May (05)
June (06)
July (07)
August (08)
September (09)
October (10)
November (11)
December (12)
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
*
CVV2
*
Bank Routing#
Date
(mm/dd/yyyy)
Bank Acct#
Check#
Payment Memo
Jackson Health System
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