Description | Account # | Claim Number | Date of Service | Discount Amount | Amount | |
---|---|---|---|---|---|---|
- |
Description | Account # | Claim Number | Date of Service | Amount |
---|---|---|---|---|
- |
Payment Type: | {{'ACH'==confirm.paymentRecords.CardData.PaymentType?'Electronic Check':'CC'==confirm.paymentRecords.CardData.PaymentType?'Credit Card':confirm.paymentRecords.CardData.PaymentType}} Payment |
Account Holder's Name: | |
Account Number: | |
Account Type: | |
Email Address: |