www.concentra.com
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URL:
https://www.concentra.com/patients/urgent-care/pay-bill/
Submission Tags: falconsandbox
Submission: On January 27 via api from US — Scanned from DE
Submission Tags: falconsandbox
Submission: On January 27 via api from US — Scanned from DE
Form analysis
1 forms found in the DOMPOST https://globalgatewaye4.firstdata.com/pay
<form action="https://globalgatewaye4.firstdata.com/pay" autocomplete="off" data-sid="{80ACDE1E-E2A5-456E-B19C-1C81A71F0C00}" data-vurl="/api/sitecore/PayBill/PrepareSubmissionData" id="pay-bill-form" method="post"><input
name="__RequestVerificationToken" type="hidden" value="TRHDqmXnr5tR1KRfhbCm8S2vIU1mNYhec_Xkfix3aTzup5WHm5vwXZQhfomVGPFAWVGcCUzKoDckQ6PEAZAl3GvQoQU1">
<div class="sweet-element" style="display: none;">
<label>Keep this field blank; it's intended for robots.</label>
<input type="text" name="sweet-text" id="sweet-text">
<input type="email" name="sweet-email" id="sweet-email">
</div>
<div class="form-section">
<input id="x_login" name="x_login" type="hidden" value="WSP-CONCE-EhBLqABDtQ">
<input id="x_test_request" name="x_test_request" type="hidden" value="FALSE">
<input id="x_fp_sequence" name="x_fp_sequence" type="hidden" value="">
<input id="x_fp_timestamp" name="x_fp_timestamp" type="hidden" value="">
<input id="x_fp_hash" name="x_fp_hash" type="hidden" value="">
<input id="x_show_form" name="x_show_form" type="hidden" value="PAYMENT_FORM">
<div class="form-field-wrapper small-12 large-9 form-field-wrapper-x_reference_3 required">
<label class="float" for="x_reference_3">Name (as shown on bill):</label><input class="text-box single-line" data-validation-message="Name can only contain letters, dots, apostrophes, and spaces." id="x_reference_3" name="x_reference_3"
pattern="^[a-zA-Z ,.'‘’-]+$" placeholder="Name (as shown on bill):" required="" title="Name can only contain letters, dots, apostrophes, and spaces." type="text" value="">
</div>
<div class="form-field-wrapper small-12 large-3 numbers-only form-field-wrapper-x_invoice_num">
<label class="float" for="x_invoice_num">Invoice/Voucher:</label><input class="text-box single-line" data-validation-message="Invoice Number is optional and requires 5 to 8 digits." id="x_invoice_num" maxlength="8" minlength="5"
name="x_invoice_num" pattern="^\d{5,8}$" placeholder="Invoice/Voucher:" title="Invoice Number is optional and requires 5 to 8 digits." type="text" value="">
</div>
<div class="form-field-wrapper numbers-only account-number form-field-wrapper-x_po_num required">
<label class="float" for="x_po_num">Account Number:</label><input class="text-box single-line" data-validation-message="Account is required. The first three digits should be between 100 and 500." id="x_po_num" maxlength="11" minlength="11"
name="x_po_num" pattern="^([1-4][0-9][0-9]|500)-\d{3}-\d{3}$" placeholder="Account Number:" required="" title="Account is required. The first three digits should be between 100 and 500." type="text" value="">
</div>
<div class="form-field-wrapper money form-field-wrapper-x_amount required">
<label class="float" for="x_amount">Payment Amount:</label><input class="text-box single-line" data-validation-message="Payment amount required." id="x_amount" max="99999" maxlength="14" min="0.01" minlength="1" name="x_amount"
pattern="^\d{1,5}(\.\d{2})?$" placeholder="Payment Amount:" required="" step="any" title="Payment amount required." type="number" value="">
</div>
<div class="form-field-wrapper form-field-wrapper-cbAgree required form-field-wrapper-checkbox">
<input class="check-box" data-val="true" data-val-required="The Acknowledge field is required." data-validation-message="I acknowledge that by checking this box I am aware that I am moving from Concentra’s website to the First Data website."
id="cbAgree" name="cbAgree" required="" title="I acknowledge that by checking this box I am aware that I am moving from Concentra’s website to the First Data website." type="checkbox" value="true"><input name="cbAgree" type="hidden"
value="false">
<label for="cbAgree">I acknowledge that by checking this box I am aware that I am moving from Concentra’s website to the First Data website.</label>
</div>
<div class="form-field-wrapper">
<button id="pay-bill-form-submit" type="submit" class="submit-button">Pay Bill</button>
</div>
</div>
</form>
Text Content
Skip to ContentClick to view our Accessibility Policy and contact us with accessibility-related questions. Concentra - Urgent Care. Open in the Concentra app. * EMPLOYERS * Patients * CAREERS * HUB Login * Locations * Pay Bill * Locations * Forms Search the Concentra Site Go Concentra HUB provides employers, workers’ compensation payors, and third-party administrators (TPAs) quick access to account information and visit results through a single automated system. Login Learn about the HUB * Workplace Injuries * Physical Therapy * Physicals * Work Health Screenings * Vaccinations * Urgent Care * Pay Bill * Contact Us * Employers * Occupational Health * Physical Therapy Services * Physical Exams * Tests & Screenings * Workers Comp Essentials * Onsite Clinics * Resource Center * Portal Login * go to Employers * Create New Account * PATIENTS * Workplace Injuries * Physical Therapy * Physicals * Work Health Screenings * Vaccinations * Urgent Care * go to PATIENTS * Pay Bill * Contact Us * CAREERS * Who We Are * Medical * Therapy * Medical Center * Sales * Corporate * go to CAREERS * Search Careers * HUB Login * Concentra HUB provides employers, workers’ compensation payors, and third-party administrators (TPAs) quick access to account information and visit results through a single automated system. Login Learn about the HUB * Your Visit * Treating Your Injuries * Telemedicine for Injury Care * Getting You Back to Work * What to Expect * Medical Specialist Care * Related Resources * Patient FAQ * Find a location * Forms for Your Visit * * > They really listened to me and immediately set me on the road to > recovery. DanielColorado Patient * Therapy Visit * Home Exercise Programs * Therapy Services * About Your Physical Therapy Visit * Related Resources * Patient FAQ * Forms for Your Visit * Find a Location * * > One of your physical therapists saved my life. She is the BEST! DoreenNorth Carolina patient * Physicals for You * DOT Physical Requirements * School Sports and Camp * Immigration Physical * Pre-Placement Physical * Police and Firefighter Physical * Return To Work Physicals * Related Resources * Patient FAQ * Find a Location * Forms for Your Visit * * > Your staff put me right at ease and explained everything. MarkVirginia patient * Screening Services * Drug Testing * Work Related * Diagnostic and Preventative * Related Resources * Patient FAQ * Forms for Your Visit * Find a Drug Test Location * Immigration Physicals * * > Usually clinics are busy and impersonal, but everyone was so nice! PaulaTexas patient * Walk-In Services * Services Provided * Your Walk-in Visit * Online Billpay * Related Resources * Patient FAQ * Forms for Your Visit * Insurance Accepted * Find a Location * * > Everyone was professional, helpful, and friendly. Great experience! Carey Michigan patient Concentra has acquired the Connecticut occupational health business of PhysicianOne and the Bethlehem/Allentown occupational health business of Lehigh Valley Health Network in Pennsylvania. Dismiss URGENT CARE BILL PAY ONLINE PAYMENT PAYING YOUR BILL MADE SIMPLE Concentra now offers online bill pay for urgent care services. We accept Visa, MasterCard, Discover, and American Express. Payments are normally processed within 24 hours. Please have your printed invoice ready to reference before you begin. To start the online payment process, enter your invoice and account number. You can find these numbers at the top right-hand corner of your Concentra urgent care bill. For any questions paying your bill, please call us at 877-427-8801. Keep this field blank; it's intended for robots. Name (as shown on bill): Invoice/Voucher: Account Number: Payment Amount: I acknowledge that by checking this box I am aware that I am moving from Concentra’s website to the First Data website. Pay Bill * Pay Bill * Contact Us ABOUT CONCENTRA * About Us * Key Leadership * Concentra Ventures * Selling Your Practice * HIPAA & Privacy * Accessibility Policy * CA Consumer Privacy Requests * Internet Privacy Policy * EEO and Accommodation * Cures Act Request * No Surprises Act RESOURCES * Resource Center * Articles * White Papers * Media Kit * Glossary * * * * * * Get the Concentra mobile app: ©2023 Concentra, Inc. All rights reserved.