paymentathena-health.com Open in urlscan Pro
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Form analysis
1 forms found in the DOM

Name: formId —

<form name="formId">
  <input class="form-control form-control-lg" name="clientId" id="clientId" data-mask="AAAA-AAAA-AAA-AAAA" placeholder="XXXX-XXXX-XXX-XXXX" type="text" aria-label=".form-control-lg example" style="width: 240px;" required="" autocomplete="off"
    maxlength="18"><br>
  <a href="" data-bs-toggle="modal" data-bs-target="#exampleModal" style="text-decoration: none; font-family:'PT Serif', serif; font-weight: 600; color:#4e2d82">Where can I find my code?</a>
  <div style="margin:20px 0px 0px 0px;text-align: left;width: 220px;border: 1px solid rgb(46, 46, 46);border-radius: 5px;">
    <h2 type="text" id="mainCaptcha">A G 4 M B S 9</h2>
    <p><button type="button" id="refresh" onclick="Captcha();"><i class="fas fa-redo-alt"></i></button></p>
    <input type="text" id="txtInput" placeholder="Enter above text" required="" style="width: 162px;">
  </div>
  <br>
  <br>
  <button type="submit" class="btn" id="submit-btn" style="background-color: #2d3482; border-radius: 20px; color:white; width: 250px; height: 50px;">Continue</button>
  <br>
  <br>
</form>

Text Content

FIND YOUR CODE

We'll need your statement code to identify you. You can find it on your
statement as shown below:

Welcome!
Let's pay your medical bill.



Enter your statement code to get started.


Where can I find my code?


A G 4 M B S 9





Continue





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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.

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