Logged in as ebpp
InstaMed
Accounting Department
1880 John F Kennedy Blvd. 12th Floor
Philadelphia, PA 19103
(215) 789-3684

STEP 1
Payment
       
STEP 2
Confirm
       
STEP 3
Receipt


*Bold fields are required



Patient ID PatientMedicalRecordNumber First Name Last Name Birth Date PatientServiceBeginDate PatientServiceEndDate AdditionalInfo1 Additional Info 2 Additional Info 3 Additional Info 4 Additional Info 5 Additional Info 6 Amount
Add Row Total $0.00
Invoice #
Account Name
Contact First Name  Last :
  (MM/DD/YYYY)
Phone #  -  - 
       Zip    -

Payment Information

Need to pay over time? Create a Payment Plan

Card :
Card Holder Name
Card Type
Card Number   Exp Date   (MM/YY)
CVN   What is this?
Amount            Current Balance  
Save this card for future use

Account Information

       Zip Code    -
Zip Code    -
 -  - 
  Your credit card/bank account will not be charged
until all information is confirmed in the next step.