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Mid-Valley Hospital & Clinic

Secure Payment Form

     
Account Number
First Name
Last Name
Address
City
State
Zip
Phone Number
Email Address

Required for receipt

Payment Amount
Name on Card
Card Number
Billing Zip
Expiration Date

MM/YYYY

CVV2/CID

3 digit number on back of card

*ATTENTION*

At Mid-Valley Hospital & Clinic we provide financial assistance to eligible low-income and uninsured patients, the application to apply can be printed directly from our website at www.mvhealth.org.

If you are unable to pay your bill, please contact a Patient Financial Counselor at (509) 826-7661, (509) 826-7647, or (509) 826-1760. We will review your financial situation to determine if you are eligible.

Your health insurance carrier may send you an EOB (Explanation of Benefits) explaining payments, adjustments, and any balance due by you. If you have not received an EOB within thirty days from the date of service, please contact your health insurance company.

Questions regarding non-covered charges or policy benefits (such as co-pays and deductibles) should be directed to your insurance company.


Privacy Policy: We are committed to protecting your privacy. We only collect information about the transactions you undertake including details of payment card. We will never pass your personal data to anyone else. The security of your personal information is very important to us. When you enter sensitive information (such as a credit card number) we encrypt that information using secure socket layer technology (SSL).