Bill Pay

Pay Bill

First Name

Last Name

Email Address

Address

Address

Address

Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Carolina Arthritis Account Number

Last 4 Digits of Social #

Bill Total

Credit Card #

Credit Card #

Credit Card #

Credit Card #

Credit Card #

Credit Card #

Sending

Appointments

Please arrive 30 minutes prior to your first appointment and plan to be in the office for 2 hours.

Please bring the following items with you:

Insurance card(s)
Co-pay and/or coinsurance payment - cash, check, MasterCard, Visa, Discover
Completed System Review Form
Signed Payment Policy
Signed HIPAA Consent/Authorization
Signed Acknowledgement of Privacy Practices/Assignment of Benefits
Completed Patient Registration
Current medication bottles/ Medical Records from other physicians