Online Payment – John Naus, MD PA

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Phone: 817-545-9100 Fax: 817-545-9134

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Office Phone: 817-545-9100
Office Fax: 817-545-9134

Welcome
- About Us
- Education Center
WAITING ROOM
- Online Payment Form
Messages
- Announcements and News
New Patients
Current Patients

Fill out the form below and submit it to make a payment today or to update your payment method.

Payment Form

Name (Patient's Name) *

First

Last

Phone *

Do you consent to receive text reminders and to receive communication via text message. *

Yes
No

I authorize John Naus MD PA to charge my credit card for the charges due at this time. All charges will be billed and collected as dictated by the agreed upon treatment contract. *

I have read and agree with this statement.

Please check all that apply, but at least one to be charged/updated. (Itemized receipts are available upon request...see below) *

Charges due for my upcoming visit. (Please enter your appointment time and date below or click "I don't know it")
Charges for my outstanding balance. (Options below)
Update my card on file. (This will be charged 24 hrs. before your apt. or on the Thursday before your Monday apt. It can be updated anytime just return here and fill out this form)
Charges for my New Patient Visit.
OTHER. (Example: paperwork / documents / ect.- anything not listed above)

Is this related to any paperwork you are requesting? (letters / FMLA ect.) *

No.
Yes.

Do you know your appointment date and time that you are making a payment for? *

Yes. (see below)
No. I don't know it but I know it is soon so just charge me 24hrs. before it and send me reminders as always the day or so before my apt.
No. I don't know it. (We send 2 reminders, but additional reminders can be requsted at johnnausmdpa.com)

Please enter your appointment date and time that we are charging. *

Please explain "OTHER" here.

Please check one that applies to your outstanding balance. *

I have been contacted about, or I know I have an outstanding balance that I would like to pay with the card I am submitting today.
I am not sure if I have an outstanding balance and I would like to inquire about it.

Were you contacted by our office and asked to URGENTLY update your card information? *

YES - I need to make an expedited card update. (Ex.: to keep a scheduled appointment or pay an overdue balance)
No

Name as it appears on your card *

Card type (VISA/Master Card/ect.) - We do not accept AMEX at this time. *

Credit Card Number *

Expiration Date *

Security Code *

Would you like a receipt? *

Yes.
No.

We can send you a receipt through the patient portal. Would you like to enroll in "Patient Ally?" *

Yes.
Not today, I will message if I need anything in the future.
I am already enrolled.

Email - this is required to enroll in Patient Ally. Check your email we will send you and email allowing you to complete the enrollment process. *

Email

Confirm Email

Message

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