Patient Payment

Please complete the following form to make a payment related to the care of a hospice or palliative care patient. If you have any questions, please call the Business Office at 336.889.8446.

Patient and Billing Information
Patient Name*
First Last Suffix
Billing from:*
- Hospice of the Piedmont
- Piedmont Palliative Care Services
Hospice Patient ID*
Group Code*
Account Number*
Payment Information
Payer Name*
First Last
Phone Number*
Email*
Credit Card Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Payment Amount*
Total
$0.00
Hidden
I would like this to be a recurring monthly payment.*
- Yes
- No
This recurring payment will be processed each month. The first payment will be deducted today.
Billing Information*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Comments or special Instructions:
CAPTCHA
Thank you for your payment. If you have additional questions please contact the Business Office at 336.889.8446.
Name
This field is for validation purposes and should be left unchanged.

Patient Payment

Patient and Billing Information

Payment Information