speedy5.world Open in urlscan Pro
162.241.122.185  Public Scan

Form analysis
1 forms found in the DOM

POST Pay

<form action="Pay" class="form-vertical" id="frmQuickPayAccount" method="post" novalidate="novalidate"><input id="TabSessionIdentifier" name="TabSessionIdentifier" type="hidden" value="80e1faef-abb2-4b65-b5b7-18dafdd7f19f"><input id="ProviderIdLabel"
    name="ProviderIdLabel" type="hidden" value="Client ID"><input id="AccountId1Label" name="AccountId1Label" type="hidden" value="Account Number"><input id="AccountId2Label" name="AccountId2Label" type="hidden" value="Five Digit Zip Code"><input
    id="AccountId3Label" name="AccountId3Label" type="hidden" value="Bill Pay ID"><input id="AccountId1Regex" name="AccountId1Regex" type="hidden" value=""><input id="AccountId1ErrorMessage" name="AccountId1ErrorMessage" type="hidden" value=""><input
    id="AccountId2Regex" name="AccountId2Regex" type="hidden" value=""><input id="AccountId2ErrorMessage" name="AccountId2ErrorMessage" type="hidden" value=""><input id="AccountId3Regex" name="AccountId3Regex" type="hidden" value=""><input
    id="AccountId3ErrorMessage" name="AccountId3ErrorMessage" type="hidden" value="">
  <div style="padding-bottom: 5px;">
    <h2>Quick Pay</h2>
    <span class="required">*</span> Required Field <p style="width: 500px;">Enter your account information below exactly as it appears on your statement.&nbsp; Refer to your most recent statement and then click 'Continue'.</p>
  </div>
  <input data-val="true" data-val-required="The DisplayProviderId field is required." id="DisplayProviderId" name="DisplayProviderId" type="hidden" value="True">
  <div style="width: 200px; float: left; padding-top: 10px;">
    <input id="ProviderIdLabel" name="ProviderIdLabel" type="hidden" value="Client ID">
    <label> Client ID <sup></sup>
      <span class="required">*</span>: </label>
  </div>
  <div style="width: 500px; float: left; padding-top: 10px;">
    <input class="input span4" type="text" value="">
    <div id="divProviderIdError" class="error"></div>
  </div>
  <div style="width: 200px; float: left; padding-bottom: 10px; padding-top: 10px; clear: both;">
    <input id="AccountId1Label" name="AccountId1Label" type="hidden" value="Account Number">
    <label> Account Number <sup>1</sup>
      <span class="required">*</span>: </label>
  </div>
  <div style="width: 500px; float: left; padding-bottom: 10px; padding-top: 10px">
    <input class="input span4" type="text" value=""> &nbsp;&nbsp;&nbsp;&nbsp; <a href="#" onclick="ViewLargeImage()">View larger image</a>
    <div id="divID1Error" class="error"></div>
  </div>
  <input data-val="true" type="hidden" value="True">
  <div style="width: 200px; float: left; padding-bottom: 10px; clear: both;">
    <input id="AccountId2Label" name="AccountId2Label" type="hidden" value="Five Digit Zip Code">
    <label> Five Digit Zip Code <sup>2</sup>
      <span class="required">*</span>: </label>
  </div>
  <div style="width: 500px; float: left; padding-bottom: 10px;">
    <input class="input span4" name="Id2" type="text" value="">
    <div id="divID2Error" class="error"></div>
  </div>
  <div style="width: 200px; float: left; padding-bottom: 10px; clear: both;">
    <input id="AccountId3Label" name="AccountId3Label" type="hidden" value="Bill Pay ID">
    <label> Bill Pay ID <sup></sup>
      <span class="required">*</span>: </label>
  </div>
  <div style="width: 500px; float: left; padding-bottom: 10px;">
    <input class="input span4" name="Id3" type="text" value="">
    <div id="divID3Error" class="error"></div>
  </div>
  <div class="control-group submit-section alignRight" style="width: 510px">
    <button type="submit" name="submit" class="btn btn-primary">Continue</button>
  </div>
  <div class="sample-statement" id="sample-statement-id" style="opacity: 0.8;">
    <img src="https://www.paymydoctor.com/images/BillPayID_help_doc2.jpg" alt="View larger image" title="View larger image" class="sample-statementimg" onmousedown="dragStart(event)" id="sample-image">
    <img src="https://www.paymydoctor.com/Images/icon-close.png" alt="Close" title="close" class="sample-statementimg-close" onclick="sampleStatementClose()">
  </div>
  <div style="width: 700px; float: left; padding-bottom: 10px;">
    <label>
      <sup></sup>
      <em>As displayed on the statement</em>
    </label>
  </div>
  <div style="width: 700px; float: left; padding-bottom: 10px; clear: both;">
    <label>
      <sup>1</sup>
      <em>As displayed on the statement</em>
    </label>
  </div>
  <div style="width: 700px; float: left; padding-bottom: 10px; clear: both;">
    <label>
      <sup>2</sup>
      <em>As displayed on the statement</em>
    </label>
  </div>
  <div style="width: 700px; float: left; padding-bottom: 10px; clear: both;">
    <label> *** <em>As displayed on the statement</em>
    </label>
  </div>
  <input data-val="true" data-val-required="The ValidateThirdElement field is required." id="ValidateThirdElement" name="ValidateThirdElement" type="hidden" value="False">
</form>

Text Content

QUICK PAY

* Required Field

Enter your account information below exactly as it appears on your statement. 
Refer to your most recent statement and then click 'Continue'.

Client ID *:

Account Number 1 *:
     View larger image

Five Digit Zip Code 2 *:

Bill Pay ID *:

Continue

As displayed on the statement
1 As displayed on the statement
2 As displayed on the statement
*** As displayed on the statement



Final Authentication

*:

Back    
 * Privacy Policy

  Having trouble viewing the site? This site is compatible with Chrome, Firefox,
IE 8 and IE 11   

© 2021 Change Healthcare LLC and/or one of its subsidiaries. All Rights
Reserved.