payment.patient.athenahealth.com
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54.192.51.85
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Submitted URL: http://ahmsg.us/3TdpkTW
Effective URL: https://payment.patient.athenahealth.com/notification/?token=9e8ZUW5Obqc6_CN29DpG
Submission: On March 10 via manual from US — Scanned from US
Effective URL: https://payment.patient.athenahealth.com/notification/?token=9e8ZUW5Obqc6_CN29DpG
Submission: On March 10 via manual from US — Scanned from US
Form analysis 1 forms found in the DOM
<form class="form-container">
<p class="instructions-copy">Please verify Brian’s information for security purposes.</p>
<div class="fe_c_form-field fe_c_form-field--medium">
<div class="fe_l_grid-row fe_l_grid-row--align-stretch fe_l_grid-row--nested">
<div class="fe_l_grid-row__col fe_l_grid-row__col--align-stretch fe_l_grid-row__col--small-12 fe_l_grid-row__col--medium-12 fe_l_grid-row__col--large-12 fe_c_form-field__label fe_c_form-field__label--forced-above"><label for="last-name-input"
id="last-name-input-label" class="fe_c_label"><span class="form-label">Patient last name</span></label></div>
<div class="fe_l_grid-row__col fe_l_grid-row__col--align-stretch fe_l_grid-row__col--small-12 fe_l_grid-row__col--medium-12 fe_l_grid-row__col--large-12 fe_c_form-field__right fe_c_form-field__right--label-forced-above">
<div class="fe_c_form-field__input-slot">
<div class="fe_c_input__wrapper">
<div class="fe_c_input fe_c_form-field__input"><input autocomplete="off" id="last-name-input" name="last-name-input" label="[object Object]" aria-labelledby="last-name-input-label" aria-describedby="last-name-input-error"
class="fe_c_input__input" type="text" value=""></div><svg xmlns="http://www.w3.org/2000/svg" class="fe_c_icon fe_c_icon--success-solid" viewBox="0 0 25 25" aria-hidden="true" role="img">
<title>Success</title>
<g>
<g class="fe_c_icon__icon fe_c_icon__icon--secondary">
<path d="M12.6 23.2C18.4542 23.2 23.2 18.4542 23.2 12.6C23.2 6.74578 18.4542 2 12.6 2C6.74578 2 2 6.74578 2 12.6C2 18.4542 6.74578 23.2 12.6 23.2Z"></path>
<path d="M7 13.448L10.465 17L18 9"></path>
<path d="M7 13.448L10.465 17L18 9" stroke="white" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"></path>
</g>
</g>
</svg>
</div>
</div>
<div class="fe_c_form-field__status"></div>
</div>
</div>
</div>
<div class="fe_c_form-field fe_c_form-field--medium form-label">
<div class="fe_l_grid-row fe_l_grid-row--align-stretch fe_l_grid-row--nested">
<div class="fe_l_grid-row__col fe_l_grid-row__col--align-stretch fe_l_grid-row__col--small-12 fe_l_grid-row__col--medium-12 fe_l_grid-row__col--large-12 fe_c_form-field__label fe_c_form-field__label--forced-above"><label for="dob-input"
id="dob-input-label" class="fe_c_label"><span class="form-label"><span>Patient date of birth <span aria-hidden="true" class="fe_u_font-weight--semibold">(MM-DD-YYYY)</span></span></span></label></div>
<div class="fe_l_grid-row__col fe_l_grid-row__col--align-stretch fe_l_grid-row__col--small-12 fe_l_grid-row__col--medium-12 fe_l_grid-row__col--large-12 fe_c_form-field__right fe_c_form-field__right--label-forced-above">
<div class="fe_c_form-field__input-slot">
<div class="fe_c_input__wrapper">
<div class="fe_c_input fe_c_form-field__input"><input autocomplete="off" maxlength="10" placeholder="MM-DD-YYYY" id="dob-input" name="dob-input" label="[object Object]" aria-labelledby="dob-input-label" aria-describedby="dob-input-error"
class="fe_c_input__input" type="tel" value=""></div><svg xmlns="http://www.w3.org/2000/svg" class="fe_c_icon fe_c_icon--success-solid" viewBox="0 0 25 25" aria-hidden="true" role="img">
<title>Success</title>
<g>
<g class="fe_c_icon__icon fe_c_icon__icon--secondary">
<path d="M12.6 23.2C18.4542 23.2 23.2 18.4542 23.2 12.6C23.2 6.74578 18.4542 2 12.6 2C6.74578 2 2 6.74578 2 12.6C2 18.4542 6.74578 23.2 12.6 23.2Z"></path>
<path d="M7 13.448L10.465 17L18 9"></path>
<path d="M7 13.448L10.465 17L18 9" stroke="white" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"></path>
</g>
</g>
</svg>
</div>
</div>
<div class="fe_c_form-field__status"></div>
</div>
</div>
</div><button class="fe_c_fpbutton fe_c_fpbutton--solid-dark fe_c_fpbutton--large fe_c_fpbutton--full-width continue-button" type="submit" aria-label="Continue"> <span>Continue</span></button>
</form>Text Content
WELCOME! Please verify Brian’s information for security purposes. Patient last name Success Patient date of birth (MM-DD-YYYY) Success Continue -------------------------------------------------------------------------------- Go to Patient Portal powered by Opens in a new window ¿Prefieres español? Privacy Policy Terms & Conditions Accessibility Statement Note: This page should only be accessed by the patient or those authorized by the patient (e.g. guarantor). By continuing, you represent that you are authorized to address the patient's billing matters. Note: This page should only be accessed by the patient or those authorized by the patient (e.g. guarantor). By continuing, you represent that you are authorized to address the patient's billing matters. powered by Note: This page should only be accessed by the patient or those authorized by the patient (e.g. guarantor). By continuing, you represent that you are authorized to address the patient's billing matters.