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MaineHealth PFS-Patient Portal Payment Receipt
PFS-Patient Portal Payment Receipt, PO Box 360430, PITTSBURGH, PA 15251-6430
(866) 804-2499
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Email
Patient Account #
guarantor/Account/Invoice # including any letters or zeros
Enter the Account OR Invoice Number, including any leading letters, from the billing statement received.
Guarantor ID
Guarantor First Name
Guarantor Last Name
Patient's First Name
Enter the First Name of the PATIENT, not the credit card holder.
Patient's Last Name
Enter the Last Name of the PATIENT, not the credit card holder.
Middle
Date of Birth
Patient's date of birth (MM/DD/YYYY).
Phone Number
Not required but Credit Card Holder's phone number will be on the next page.
ZIP Code
5 or 9 digit postal code of the PATIENT'S mailing address.
Statement Number
Statement Date
Amount Due
Dynamic Field 1
Dynamic Field 2
Dynamic Field 3
Dynamic Field 4
ProviderAlias
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