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z1-ppw.phreesia.net Open in urlscan Pro
207.254.84.121  Public Scan

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Submitted URL: https://www.paymyentbill.com/
Effective URL: https://z1-ppw.phreesia.net/25/patient/Payment.aspx/IdentifyPatient
Submission: On August 12 via automatic, source certstream-suspicious — Scanned from DE

Form analysis 1 forms found in the DOM

POST /25/patient/Payment.aspx/IdentifyPatient

<form action="/25/patient/Payment.aspx/IdentifyPatient" id="form0" method="post"><input name="__RequestVerificationToken" type="hidden"
    value="O0aX7+yrOInk5uMKkpauudYct4Gnm/VYaoO8g4/dPlR/H+1aRMqNM+y1loNdtWgIST0/ZggoRCNuIpii0aWPTdSfpHOkURWXrH7G/ByIZUe3C1bT+7afTtMO4TZDIIK+RdT01w==">
  <div class="modBoxOut">
    <div class="modBoxIn">
      <div class="error validation-summary-errors" id="error-list" style="display: none;">
        <h2 class="hed">Oops.</h2>
      </div>
      <script type="text/javascript">
        $(function() {
          SetDateFieldValidation("#Dob", true, false, true);
          $("#PhoneNumber, #EmailAddress, #PatientIdOrChartNumber, #StatementNumber").change(function() {
            this.value = $.trim(this.value);
          });
        });
      </script>
      <style type="text/css">
        div.validationDiv {
          width: 280px;
        }
      </style>
      <span class="req floatRt"><span class="reqStarLrg">*</span>&nbsp;<span>Required</span></span>
      <h2 class="modBoxTitle">Patient Information</h2>
      <div class="formRow">
        <label class="lab">Patient First Name <span class="reqStar">*</span></label>
        <div class="inputs">
          <input class="txt wide focusField reqField" id="FirstName" name="FirstName" type="text" value="">
          <div class="validationDiv"><span class="field-validation-valid" id="FirstName_validationMessage"></span></div>
        </div>
        <div class="clear"></div>
      </div>
      <!--.formRow-->
      <div class="formRow">
        <label class="lab">Patient Last Name <span class="reqStar">*</span></label>
        <div class="inputs">
          <input class="txt wide reqField" id="LastName" name="LastName" type="text" value="">
          <div class="validationDiv"><span class="field-validation-valid" id="LastName_validationMessage"></span></div>
        </div>
        <div class="clear"></div>
      </div>
      <!--.formRow-->
      <div class="formRow">
        <label class="lab">Date of Birth <span class="reqStar">*</span></label>
        <div class="inputs dob">
          <select class="month" id="Dob_Month" name="Dob.Month">
            <option value="">Month...</option>
            <option value="1">January</option>
            <option value="2">February</option>
            <option value="3">March</option>
            <option value="4">April</option>
            <option value="5">May</option>
            <option value="6">June</option>
            <option value="7">July</option>
            <option value="8">August</option>
            <option value="9">September</option>
            <option value="10">October</option>
            <option value="11">November</option>
            <option value="12">December</option>
          </select>
          <select class="day" id="Dob_Day" name="Dob.Day">
            <option value="">Day...</option>
            <option value="1">1</option>
            <option value="2">2</option>
            <option value="3">3</option>
            <option value="4">4</option>
            <option value="5">5</option>
            <option value="6">6</option>
            <option value="7">7</option>
            <option value="8">8</option>
            <option value="9">9</option>
            <option value="10">10</option>
            <option value="11">11</option>
            <option value="12">12</option>
            <option value="13">13</option>
            <option value="14">14</option>
            <option value="15">15</option>
            <option value="16">16</option>
            <option value="17">17</option>
            <option value="18">18</option>
            <option value="19">19</option>
            <option value="20">20</option>
            <option value="21">21</option>
            <option value="22">22</option>
            <option value="23">23</option>
            <option value="24">24</option>
            <option value="25">25</option>
            <option value="26">26</option>
            <option value="27">27</option>
            <option value="28">28</option>
            <option value="29">29</option>
            <option value="30">30</option>
            <option value="31">31</option>
          </select>
          <select class="year" id="Dob_Year" name="Dob.Year">
            <option value="">Year...</option>
            <option value="2024">2024</option>
            <option value="2023">2023</option>
            <option value="2022">2022</option>
            <option value="2021">2021</option>
            <option value="2020">2020</option>
            <option value="2019">2019</option>
            <option value="2018">2018</option>
            <option value="2017">2017</option>
            <option value="2016">2016</option>
            <option value="2015">2015</option>
            <option value="2014">2014</option>
            <option value="2013">2013</option>
            <option value="2012">2012</option>
            <option value="2011">2011</option>
            <option value="2010">2010</option>
            <option value="2009">2009</option>
            <option value="2008">2008</option>
            <option value="2007">2007</option>
            <option value="2006">2006</option>
            <option value="2005">2005</option>
            <option value="2004">2004</option>
            <option value="2003">2003</option>
            <option value="2002">2002</option>
            <option value="2001">2001</option>
            <option value="2000">2000</option>
            <option value="1999">1999</option>
            <option value="1998">1998</option>
            <option value="1997">1997</option>
            <option value="1996">1996</option>
            <option value="1995">1995</option>
            <option value="1994">1994</option>
            <option value="1993">1993</option>
            <option value="1992">1992</option>
            <option value="1991">1991</option>
            <option value="1990">1990</option>
            <option value="1989">1989</option>
            <option value="1988">1988</option>
            <option value="1987">1987</option>
            <option value="1986">1986</option>
            <option value="1985">1985</option>
            <option value="1984">1984</option>
            <option value="1983">1983</option>
            <option value="1982">1982</option>
            <option value="1981">1981</option>
            <option value="1980">1980</option>
            <option value="1979">1979</option>
            <option value="1978">1978</option>
            <option value="1977">1977</option>
            <option value="1976">1976</option>
            <option value="1975">1975</option>
            <option value="1974">1974</option>
            <option value="1973">1973</option>
            <option value="1972">1972</option>
            <option value="1971">1971</option>
            <option value="1970">1970</option>
            <option value="1969">1969</option>
            <option value="1968">1968</option>
            <option value="1967">1967</option>
            <option value="1966">1966</option>
            <option value="1965">1965</option>
            <option value="1964">1964</option>
            <option value="1963">1963</option>
            <option value="1962">1962</option>
            <option value="1961">1961</option>
            <option value="1960">1960</option>
            <option value="1959">1959</option>
            <option value="1958">1958</option>
            <option value="1957">1957</option>
            <option value="1956">1956</option>
            <option value="1955">1955</option>
            <option value="1954">1954</option>
            <option value="1953">1953</option>
            <option value="1952">1952</option>
            <option value="1951">1951</option>
            <option value="1950">1950</option>
            <option value="1949">1949</option>
            <option value="1948">1948</option>
            <option value="1947">1947</option>
            <option value="1946">1946</option>
            <option value="1945">1945</option>
            <option value="1944">1944</option>
            <option value="1943">1943</option>
            <option value="1942">1942</option>
            <option value="1941">1941</option>
            <option value="1940">1940</option>
            <option value="1939">1939</option>
            <option value="1938">1938</option>
            <option value="1937">1937</option>
            <option value="1936">1936</option>
            <option value="1935">1935</option>
            <option value="1934">1934</option>
            <option value="1933">1933</option>
            <option value="1932">1932</option>
            <option value="1931">1931</option>
            <option value="1930">1930</option>
            <option value="1929">1929</option>
            <option value="1928">1928</option>
            <option value="1927">1927</option>
            <option value="1926">1926</option>
            <option value="1925">1925</option>
            <option value="1924">1924</option>
            <option value="1923">1923</option>
            <option value="1922">1922</option>
            <option value="1921">1921</option>
            <option value="1920">1920</option>
            <option value="1919">1919</option>
            <option value="1918">1918</option>
            <option value="1917">1917</option>
            <option value="1916">1916</option>
            <option value="1915">1915</option>
            <option value="1914">1914</option>
            <option value="1913">1913</option>
            <option value="1912">1912</option>
            <option value="1911">1911</option>
            <option value="1910">1910</option>
            <option value="1909">1909</option>
            <option value="1908">1908</option>
            <option value="1907">1907</option>
            <option value="1906">1906</option>
            <option value="1905">1905</option>
            <option value="1904">1904</option>
            <option value="1903">1903</option>
            <option value="1902">1902</option>
            <option value="1901">1901</option>
            <option value="1900">1900</option>
          </select>
          <div><input id="Dob" name="Dob" type="hidden" value=""></div>
          <div><span class="field-validation-valid" id="Dob_validationMessage"></span></div>
        </div>
        <div class="clear"></div>
      </div>
      <!--.formRow-->
      <div class="formRow">
        <label class="lab">Gender <span class="reqStar">*</span></label>
        <div class="inputs">
          <label class="chkOpt"><input id="Gender" name="Gender" style="margin-right: 5px" type="radio" value="Male">Male</label>
          <br>
          <label class="chkOpt"><input id="Gender" name="Gender" style="margin-right: 5px" type="radio" value="Female">Female</label>
          <div class="validationDiv"><span class="field-validation-valid" id="Gender_validationMessage"></span></div>
        </div>
        <div class="clear"></div>
        <input id="GenderRequired" name="GenderRequired" type="hidden" value="True">
      </div>
      <!--.formRow-->
      <div class="formRow">
        <label class="lab">Address <span class="reqStar">*</span></label>
        <div class="inputs">
          <input class="txt wide" id="Address" name="Address" type="text" value="">
          <p class="fieldCaption">Include apartment or unit number on address line.</p>
          <div class="validationDiv"><span class="field-validation-valid" id="Address_validationMessage"></span></div>
        </div>
        <div class="clear"></div>
      </div>
      <!--.formRow-->
      <div class="formRow">
        <label class="lab">City <span class="reqStar">*</span></label>
        <div class="inputs">
          <input class="txt wide" id="City" name="City" type="text" value="">
          <div class="validationDiv"><span class="field-validation-valid" id="City_validationMessage"></span></div>
        </div>
        <div class="clear"></div>
      </div>
      <!--.formRow-->
      <div class="formRow">
        <label class="lab">State <span class="reqStar">*</span></label>
        <div class="inputs">
          <select class="txt state" data-state="" id="State" name="State">
            <option value="" class="null">State...</option>
            <option value="AL">Alabama</option>
            <option value="AK">Alaska</option>
            <option value="AZ">Arizona</option>
            <option value="AR">Arkansas</option>
            <option value="CA">California</option>
            <option value="CO">Colorado</option>
            <option value="CT">Connecticut</option>
            <option value="DE">Delaware</option>
            <option value="DC">District Of Columbia</option>
            <option value="FL">Florida</option>
            <option value="GA">Georgia</option>
            <option value="HI">Hawaii</option>
            <option value="ID">Idaho</option>
            <option value="IL">Illinois</option>
            <option value="IN">Indiana</option>
            <option value="IA">Iowa</option>
            <option value="KS">Kansas</option>
            <option value="KY">Kentucky</option>
            <option value="LA">Louisiana</option>
            <option value="ME">Maine</option>
            <option value="MD">Maryland</option>
            <option value="MA">Massachusetts</option>
            <option value="MI">Michigan</option>
            <option value="MN">Minnesota</option>
            <option value="MS">Mississippi</option>
            <option value="MO">Missouri</option>
            <option value="MT">Montana</option>
            <option value="NE">Nebraska</option>
            <option value="NV">Nevada</option>
            <option value="NH">New Hampshire</option>
            <option value="NJ">New Jersey</option>
            <option value="NM">New Mexico</option>
            <option value="NY">New York</option>
            <option value="NC">North Carolina</option>
            <option value="ND">North Dakota</option>
            <option value="OH">Ohio</option>
            <option value="OK">Oklahoma</option>
            <option value="OR">Oregon</option>
            <option value="PA">Pennsylvania</option>
            <option value="RI">Rhode Island</option>
            <option value="SC">South Carolina</option>
            <option value="SD">South Dakota</option>
            <option value="TN">Tennessee</option>
            <option value="TX">Texas</option>
            <option value="UT">Utah</option>
            <option value="VT">Vermont</option>
            <option value="VA">Virginia</option>
            <option value="WA">Washington</option>
            <option value="WV">West Virginia</option>
            <option value="WI">Wisconsin</option>
            <option value="WY">Wyoming</option>
          </select>
          <div class="validationDiv"><span class="field-validation-valid" id="State_validationMessage"></span></div>
        </div>
        <div class="clear"></div>
      </div>
      <!--.formRow-->
      <div class="formRow">
        <label class="lab">Zip Code <span class="reqStar">*</span></label>
        <div class="inputs">
          <input class="txt wide" id="ZipCode" maxlength="5" name="ZipCode" type="text" value="">
          <div class="validationDiv"><span class="field-validation-valid" id="ZipCode_validationMessage"></span></div>
        </div>
        <div class="clear"></div>
      </div>
      <!--.formRow-->
      <div class="formRow">
        <label class="lab">Phone Number <span class="reqStar">*</span></label>
        <div class="inputs">
          <input class="txt wide" id="PhoneNumber" name="PhoneNumber" type="text" value="">
          <div class="validationDiv"><span class="field-validation-valid" id="PhoneNumber_validationMessage"></span></div>
        </div>
        <div class="clear"></div>
        <input id="PhoneNumberRequired" name="PhoneNumberRequired" type="hidden" value="True">
      </div>
      <!--.formRow-->
      <div class="formRow">
        <label class="lab">Email Address <span class="reqStar">*</span></label>
        <div class="inputs">
          <input class="txt wide" id="EmailAddress" name="EmailAddress" type="text" value="">
          <div class="validationDiv"><span class="field-validation-valid" id="EmailAddress_validationMessage"></span></div>
        </div>
        <div class="clear"></div>
        <input id="EmailAddressRequired" name="EmailAddressRequired" type="hidden" value="True">
      </div>
      <!--.formRow-->
      <div class="formRow">
        <label class="lab">Patient ID / Chart # </label>
        <div class="inputs">
          <input class="txt wide" id="PatientIdOrChartNumber" name="PatientIdOrChartNumber" type="text" value="">
          <div class="validationDiv"><span class="field-validation-valid" id="PatientIdOrChartNumber_validationMessage"></span></div>
        </div>
        <div class="clear"></div>
        <input id="PatientIdOrChartNumberRequired" name="PatientIdOrChartNumberRequired" type="hidden" value="False">
      </div>
      <!--.formRow-->
    </div>
    <!--.modBoxIn-->
    <div class="modBoxShad"></div>
  </div>
  <!--.modBoxOut-->
  <div class="butsBackForth">
    <a id="continue" class="butNext butProcessing" href="javascript:void(0);"><span class="butArrow"></span>
                    Continue</a>
  </div>
  <input type="hidden" name="action" value="next">
  <p class="butCaption hide">Your credit card will <strong>not</strong> be charged yet.</p>
</form>

Text Content

FLORIDA ENT ASSOCIATES

15280 NW 79th Court
Suite 200
Miami Lakes, FL 33016
Office Phone:
305-558-3724



MAKE A PAYMENT

Learn more about Phreesia's secure payments

 * 1Patient Info
 * 2Payment
 * 3Confirmation


OOPS.

* Required


PATIENT INFORMATION

Patient First Name *


Patient Last Name *


Date of Birth *
Month... January February March April May June July August September October
November December Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
22 23 24 25 26 27 28 29 30 31 Year... 2024 2023 2022 2021 2020 2019 2018 2017
2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001
2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985
1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969
1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953
1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937
1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921
1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905
1904 1903 1902 1901 1900



Gender *
Male
Female


Address *

Include apartment or unit number on address line.



City *


State *
State... Alabama Alaska Arizona Arkansas California Colorado Connecticut
Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa
Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota
Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico
New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode
Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia
Washington West Virginia Wisconsin Wyoming


Zip Code *


Phone Number *


Email Address *


Patient ID / Chart #



Continue

Your credit card will not be charged yet.




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