paymybill.memorialhermann.org
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Submitted URL: http://click.simpleepay.com/?qs=aae249731dbcdccd15467a3bb8b531b8008b67fca5de283afdac9b3b5adf3836e3c2cb80b3bad91f4c9332121bff...
Effective URL: https://paymybill.memorialhermann.org/providers/mhhs/bills/new_session?id=6368677&token=tg7Ez2PYf4_S5C395FRS7mIJvA8O69mOCDbgvN_z&utm_c...
Submission: On August 10 via api from US — Scanned from DE
Effective URL: https://paymybill.memorialhermann.org/providers/mhhs/bills/new_session?id=6368677&token=tg7Ez2PYf4_S5C395FRS7mIJvA8O69mOCDbgvN_z&utm_c...
Submission: On August 10 via api from US — Scanned from DE
Form analysis 3 forms found in the DOM
POST https://vault2.simpleepay.com
<form id="new_credit_card_details" action="https://vault2.simpleepay.com" accept-charset="UTF-8" method="post"><input name="utf8" type="hidden" value="✓"><input type="hidden" name="authenticity_token"
value="ekvjmCfqJSWg+bnavTXC+di1KPeu53/lGi40mrschKHNTBOH8W8zP5ZR7DouqMJiDgxcUrPn+gqwpo5YHWem3A==">
<input type="hidden" name="vault_url" id="vault_url" value="https://vault2.simpleepay.com">
<input type="hidden" name="paypage" id="paypage" value="vault">
<input type="hidden" name="paypage_id" id="paypage_id">
<div class="card-details">
<div class="row new-card-row">
<label class="text-label" for="card_number">Card Number</label>
<div class="card_number text hosted-field focus" id="card_number"><iframe name="card_number_frame" title="card number. Required Field" id="card_number_frame" frameborder="0" scrolling="no" display="inline"
src="https://vault2.simpleepay.com/hosted_fields/new?style=quick_pay&mask=true&frame_type=card_number&paypage=vault&paypage_id=&devices=%5B%22regular%22%5D&disable_cc_fields=&pre_service=&label_content%5Bcvv%5D=&label_content%5Bcard_number%5D="
style="height: 100%; width: 100%;"></iframe></div>
</div>
<div class="row new-card-row">
<div class="relative-parent">
<label class="combo-title text-label short" for="month">Month</label>
<select name="credit_card_details[expiration_month]" id="credit_card_details_expiration_month" class="month-select no-conversion empty">
<option value="">Select</option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
</div>
<div class="relative-parent">
<label class="text-label combo-title" for="year">Year</label>
<select name="credit_card_details[expiration_year]" id="credit_card_details_expiration_year" class="no-conversion year-select empty">
<option value="">Select</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
<option value="2031">2031</option>
<option value="2032">2032</option>
</select>
</div>
<div class="relative-parent">
<label class="text-label short" for="cvv">CVV</label>
<div class="cvv text short hosted-field" id="cvv"><iframe name="cvv_frame" title="cvv. Required Field" id="cvv_frame" frameborder="0" scrolling="no" display="inline"
src="https://vault2.simpleepay.com/hosted_fields/new?style=quick_pay&mask=true&frame_type=cvv&paypage=vault&paypage_id=&devices=%5B%22regular%22%5D&disable_cc_fields=&pre_service=&label_content%5Bcvv%5D=&label_content%5Bcard_number%5D="
style="height: 100%; width: 100%;"></iframe></div>
</div>
</div>
<div class="row cards-desktop">
<ul class="cart-list" id="credit-cards-img-list">
<li>
<img alt="Visa" height="38" id="visa-img" src="/assets/visa.png">
<img alt="Visa" height="38" id="visa-gray-img" src="/assets/visa_gray.png" style="display:none;">
</li>
<li>
<img alt="Mastercard" height="38" id="mastercard-img" src="/assets/mastercard.png">
<img alt="Mastercard" height="38" id="mastercard-gray-img" src="/assets/mastercard_gray.png" style="display:none;">
</li>
<li>
<img alt="Discover" height="38" id="discover-img" src="/assets/discover.png">
<img alt="Discover" height="38" id="discover-gray-img" src="/assets/discover_gray.png" style="display:none;">
</li>
<li class="last">
<img alt="American Express" height="38" id="amex-img" src="/assets/american_express.png">
<img alt="American Express" height="38" id="amex-gray-img" src="/assets/american_express_gray.png" style="display:none;">
</li>
</ul>
</div>
</div>
<div class="guarantor-details">
<div class="row new-card-row">
<label class="text-label" for="Name">Name</label>
<input type="text" name="credit_card_details[billing_name]" id="credit_card_details_billing_name" class="billing-name text">
</div>
<div class="row new-card-row">
<div class="relative-parent">
<label class="text-label short" for="Zip_Code">Zip Code</label>
<input type="text" name="credit_card_details[billing_zip]" id="credit_card_details_billing_zip" class="zipcode text short">
</div>
</div>
<div class="row new-card-row">
</div>
</div>
</form>POST /credit_card_transactions.json
<form class="new_payments_service_credit_card_transaction" id="new_payments_service_credit_card_transaction" action="/credit_card_transactions.json" accept-charset="UTF-8" data-remote="true" method="post"><input name="utf8" type="hidden"
value="✓"><input type="hidden" name="payments_attributes[0][payable_id]" id="payments_attributes_0_payable_id" value="7691711">
<input type="hidden" name="payments_attributes[0][amount]" id="payments_attributes_0_amount" value="44955">
<input type="hidden" name="provider_id" id="provider_id" value="mhhs">
<input type="hidden" name="card_type" id="card_type" value="new_card">
<input value="true" type="hidden" name="payments_service_credit_card_transaction[quick_pay]" id="payments_service_credit_card_transaction_quick_pay">
<input type="hidden" name="payments_service_credit_card_transaction[credit_card_id]" id="payments_service_credit_card_transaction_credit_card_id">
<input type="hidden" name="payments_service_credit_card_transaction[saved_credit_card_cvv]" id="payments_service_credit_card_transaction_saved_credit_card_cvv">
<div class="credit_card">
<input class="cc-field" type="hidden" name="payments_service_credit_card_transaction[credit_card_attributes][credit_card_token]" id="payments_service_credit_card_transaction_credit_card_attributes_credit_card_token">
<input class="cc-field" type="hidden" name="payments_service_credit_card_transaction[credit_card_attributes][credit_card_response_code]" id="payments_service_credit_card_transaction_credit_card_attributes_credit_card_response_code">
<input class="cc-field" type="hidden" name="payments_service_credit_card_transaction[credit_card_attributes][card_type]" id="payments_service_credit_card_transaction_credit_card_attributes_card_type">
<input class="cc-field" type="hidden" name="payments_service_credit_card_transaction[credit_card_attributes][last_4]" id="payments_service_credit_card_transaction_credit_card_attributes_last_4">
<input class="cc-field" type="hidden" name="payments_service_credit_card_transaction[credit_card_attributes][litle_response_message]" id="payments_service_credit_card_transaction_credit_card_attributes_litle_response_message">
<input class="cc-field" type="hidden" name="payments_service_credit_card_transaction[credit_card_attributes][litle_response_time]" id="payments_service_credit_card_transaction_credit_card_attributes_litle_response_time">
<input class="cc-field" type="hidden" name="payments_service_credit_card_transaction[credit_card_attributes][litle_transaction_id]" id="payments_service_credit_card_transaction_credit_card_attributes_litle_transaction_id">
<input class="cc-field" type="hidden" name="payments_service_credit_card_transaction[credit_card_attributes][litle_response_type]" id="payments_service_credit_card_transaction_credit_card_attributes_litle_response_type">
<input value="false" class="cc-field" type="hidden" name="payments_service_credit_card_transaction[credit_card_attributes][physically_swiped]" id="payments_service_credit_card_transaction_credit_card_attributes_physically_swiped">
<!-- / Copied from credit card details form -->
<input type="hidden" name="payments_service_credit_card_transaction[credit_card_attributes][expired_at]" id="payments_service_credit_card_transaction_credit_card_attributes_expired_at">
<input type="hidden" name="payments_service_credit_card_transaction[credit_card_attributes][billing_name]" id="payments_service_credit_card_transaction_credit_card_attributes_billing_name">
<input type="hidden" name="payments_service_credit_card_transaction[credit_card_attributes][billing_zip]" id="payments_service_credit_card_transaction_credit_card_attributes_billing_zip">
</div>
<input type="submit" name="commit" value="Pay $449.55" class="submit" data-disable-with="Pay $449.55">
</form>POST /providers/mhhs/bills/create_session
<form class="bill-form" id="new_account_session" novalidate="novalidate" data-providername="Memorial Hermann" action="/providers/mhhs/bills/create_session" accept-charset="UTF-8" method="post"><input name="utf8" type="hidden" value="✓"><input
type="hidden" name="authenticity_token" value="ekvjmCfqJSWg+bnavTXC+di1KPeu53/lGi40mrschKHNTBOH8W8zP5ZR7DouqMJiDgxcUrPn+gqwpo5YHWem3A==">
<fieldset>
<input type="hidden" name="term_accepted" id="term_accepted">
<input type="hidden" name="id" id="id" value="6368677">
<input type="hidden" name="notification" id="notification">
<input type="hidden" name="provider" id="provider">
<input type="hidden" name="referrer_url" id="referrer_url"
value="https://paymybill.memorialhermann.org/providers/mhhs/bills/6368677?token=tg7Ez2PYf4_S5C395FRS7mIJvA8O69mOCDbgvN_z&utm_campaign=mhhs&utm_content=ET&utm_medium=email&utm_source=AssistNewBillPathway2PayInFull&utm_term=View %26 Pay Bills">
<input type="hidden" name="source" id="source" value="email">
<input type="hidden" name="convert_auto_plan" id="convert_auto_plan">
<input type="hidden" name="convert_manual_plan" id="convert_manual_plan">
<input value="[7691711]" type="hidden" name="account_session[payable][ids]" id="account_session_payable_ids">
<input value="mhhs" type="hidden" name="account_session[payable][provider]" id="account_session_payable_provider">
<div class="frame">
<input type="hidden" name="auth_field" id="auth_field" value="zip">
<div class="row long underline">
<span class="text parent-active">
<label for="auth_field_input">Zip Code <span class="visuallyhidden on-error-text" style="display: none;">Please enter the Zip Code</span>
</label></span>
<div class="table">
<input type="text" name="account_session[password][zip]" id="auth_field_input" class="text-active login-field" autocomplete="off" required="required" oninput="if (true) onInputNumber(this)" maxlength="5" inputmode="numeric" tabindex="4">
<div class="error" id="err-account">
<span class="err-msg">Please enter the Zip Code</span>
</div>
</div>
</div>
<div class="row long underline">
<span class="text">
<label for="date_of_birth_input">Patient’s Date Of Birth <span class="visuallyhidden on-error-text" style="display: none;">A valid date is required</span>
</label></span>
<div class="table">
<input type="hidden" name="account_session[password][date_of_birth]" id="account_session_password_date_of_birth">
<div id="date-of-birth">
<label for="selectedMonth"><span class="visuallyhidden">Patient’s Date Of Birth</span>
<span class="visuallyhidden">Month</span>
<span class="visuallyhidden">, required</span>
</label>
<div class="month-part">
<div class="bootstrap month-change">
<select name="selectedMonth" id="selectedMonth" class="months selectpicker" onchange="onInputDOBField(this,2)" tabindex="5" style="display: none;">
<option selected="selected" value="0">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>
<div class="btn-group bootstrap-select months"><button aria-haspopup="true" type="button" class="btn dropdown-toggle btn-default" data-toggle="dropdown" data-id="selectedMonth" tabindex="5" title="Month"><span
class="visuallyhidden">Patient’s Date Of Birth Month , required </span><span aria-hidden="true" class="filter-option pull-left">Month</span> <span class="caret"></span></button>
<div class="dropdown-menu open">
<ul class="dropdown-menu inner" role="menu">
<li data-original-index="0" class="selected">
<a tabindex="0" class="" data-normalized-text="<span class="text">Month</span>" data-tokens="null" aria-selected="true"><span class="text">Month</span><span class="glyphicon glyphicon-ok check-mark"></span></a></li>
<li data-original-index="1">
<a tabindex="0" class="" data-normalized-text="<span class="text">January</span>" data-tokens="null" aria-selected="false"><span class="text">January</span><span class="glyphicon glyphicon-ok check-mark"></span></a>
</li>
<li data-original-index="2">
<a tabindex="0" class="" data-normalized-text="<span class="text">February</span>" data-tokens="null" aria-selected="false"><span class="text">February</span><span class="glyphicon glyphicon-ok check-mark"></span></a>
</li>
<li data-original-index="3">
<a tabindex="0" class="" data-normalized-text="<span class="text">March</span>" data-tokens="null" aria-selected="false"><span class="text">March</span><span class="glyphicon glyphicon-ok check-mark"></span></a></li>
<li data-original-index="4">
<a tabindex="0" class="" data-normalized-text="<span class="text">April</span>" data-tokens="null" aria-selected="false"><span class="text">April</span><span class="glyphicon glyphicon-ok check-mark"></span></a></li>
<li data-original-index="5">
<a tabindex="0" class="" data-normalized-text="<span class="text">May</span>" data-tokens="null" aria-selected="false"><span class="text">May</span><span class="glyphicon glyphicon-ok check-mark"></span></a></li>
<li data-original-index="6">
<a tabindex="0" class="" data-normalized-text="<span class="text">June</span>" data-tokens="null" aria-selected="false"><span class="text">June</span><span class="glyphicon glyphicon-ok check-mark"></span></a></li>
<li data-original-index="7">
<a tabindex="0" class="" data-normalized-text="<span class="text">July</span>" data-tokens="null" aria-selected="false"><span class="text">July</span><span class="glyphicon glyphicon-ok check-mark"></span></a></li>
<li data-original-index="8">
<a tabindex="0" class="" data-normalized-text="<span class="text">August</span>" data-tokens="null" aria-selected="false"><span class="text">August</span><span class="glyphicon glyphicon-ok check-mark"></span></a>
</li>
<li data-original-index="9">
<a tabindex="0" class="" data-normalized-text="<span class="text">September</span>" data-tokens="null" aria-selected="false"><span class="text">September</span><span class="glyphicon glyphicon-ok check-mark"></span></a>
</li>
<li data-original-index="10">
<a tabindex="0" class="" data-normalized-text="<span class="text">October</span>" data-tokens="null" aria-selected="false"><span class="text">October</span><span class="glyphicon glyphicon-ok check-mark"></span></a>
</li>
<li data-original-index="11">
<a tabindex="0" class="" data-normalized-text="<span class="text">November</span>" data-tokens="null" aria-selected="false"><span class="text">November</span><span class="glyphicon glyphicon-ok check-mark"></span></a>
</li>
<li data-original-index="12">
<a tabindex="0" class="" data-normalized-text="<span class="text">December</span>" data-tokens="null" aria-selected="false"><span class="text">December</span><span class="glyphicon glyphicon-ok check-mark"></span></a>
</li>
</ul>
</div>
</div>
</div>
</div>
<label for="day"><span class="visuallyhidden">Patient’s Date Of Birth</span>
<span class="visuallyhidden error normal-error" style="display: none;">Please enter the Patient’s Date Of Birth</span>
<span class="visuallyhidden error date-error" style="display: none;">Please verify the Patient’s Date Of Birth entered is correct.</span>
<span class="visuallyhidden error day-error" style="display: none;">Please enter a valid day of the month.</span>
<span class="visuallyhidden">, required</span>
</label>
<input autocomplete="off" class="text-active login-field DOB-input" id="day" inputmode="numeric" oninput="onInputDOBField(this,2)" placeholder="Day" tabindex="6" type="text">
<label for="year"><span class="visuallyhidden">Patient’s Date Of Birth</span>
<span class="visuallyhidden error normal-error" style="display: none;">Please enter the Patient’s Date Of Birth</span>
<span class="visuallyhidden error date-error" style="display: none;">Please verify the Patient’s Date Of Birth entered is correct.</span>
<span class="visuallyhidden error year-error" style="display: none;">Year must be in format YYYY e.g. 1983</span>
<span class="visuallyhidden">, required</span>
</label>
<input autocomplete="off" class="text-active login-field DOB-input" id="year" inputmode="numeric" oninput="onInputDOBField(this,4)" placeholder="Year (YYYY)" tabindex="7" type="text">
</div>
<div class="error normal-error" id="err-dob">
<span class="err-msg">Please enter the Patient’s Date Of Birth</span>
</div>
<div class="error year-error" id="err-dob">
<span class="err-msg year-error">Year must be in format YYYY e.g. 1983</span>
</div>
<div class="error day-error" id="err-dob">
<span class="err-msg day-error">Please enter a valid day of the month.</span>
</div>
<div class="error date-error" id="err-dob">
<span class="err-msg date-error">Please verify the Patient’s Date Of Birth entered is correct.</span>
</div>
<label class="dob-message"></label>
</div>
</div>
<div class="row long assist">
<div class="assist-container">
<label>
<div class="error" id="err-account">
<span class="err-msg">Legal agreement must be accepted before continuing</span>
</div>
<input type="checkbox" name="assist_communication_agreement" id="assist_communication_agreement" value="agree" required="required" class="checkbox not-custom required agreement-checkbox" tabindex="8">
<div class="terms-privacy">
<span class="text"> Your use of this site is governed by the documents linked below. By checking the box at the beginning of this paragraph and clicking the “View My Bill” button below, you confirm you have received, read and agree by
electronic signature to Simplee’s <a target="_blank" class="terms_link" tabindex="9" href="https://www.flywire.com/legal/terms-of-use">Terms of Service<span class="visuallyhidden">open in a new window</span></a> ,
<a target="_blank" class="privacy_policy" tabindex="10" href="https://www.flywire.com/legal/privacy-policy">Privacy Policy<span class="visuallyhidden">open in a new window</span></a> , <a class="popup-link simple-popup-Confidentiality_Notice normal-text-link" data-backdrop="true" data-target="#simple-popup-Confidentiality_Notice" data-toggle="modal" href="#" tabindex="11">
Confidentiality Notice
</a>
<div class="bootstrap">
<div class="modal fade selector-popup" id="simple-popup-Confidentiality_Notice">
<div class="modal-body">
<div class="section print-only">
<img id="logo-img" alt="Memorial Hermann" src="https://dxql1etc638wm.cloudfront.net/settings_service_assets/20171130101006_patient_logo_provider_mhhs-image.png">
<p>
<b>Time:</b> 09:26pm UTC
</p>
</div>
<div class="section">
<div class="modal-content">
<div class="modal-header">
<button class="close" data-dismiss="modal" type="button">
<div class="mobile-view">x</div>
<a class="close-popup not-printable" href="#" onclick="">
<img class="close-popup-icon" alt="Close popup" src="/assets/icon-close.png">
<img class="close-popup-icon-hover" alt="Close popup" src="/assets/icon-close_hover.png">
</a>
</button>
</div>
<div class="modal-header">
<h3 class="modal-title">Confidentiality Notice</h3>
</div>
<div class="modal-body"> The information that will be accessed beyond this point is privileged and confidential and/or protected health information (PHI) and may be subject to protection under the law, including the Health
Insurance Portability and Accountability Act of 1996, as amended (HIPAA). This information is intended for the sole use of the patient or authorized party. If you are not the patient, legal guardian or have express
consent, you are notified that any use, viewing, dissemination, distribution, printing or copying of this information is strictly prohibited and may subject you to criminal or civil penalties. Access should not be
attempted or accepted beyond this point if these requirements are not met and acknowledged. </div>
<div class="modal-footer not-printable">
<div class="buttons print-mail-container">
<a class="print-btn print-icon" href="#" onclick="" target="">
<img alt="Print" class="print-img not-printable" src="/assets/print_icon.png">
<img alt="Print" class="print-img-hover not-printable" src="/assets/print_icon_hover.png">
</a>
</div>
</div>
</div>
</div>
</div>
</div>
</div> and <a class="popup-link simple-popup-Electronic_Communications normal-text-link" data-backdrop="true" data-target="#simple-popup-Electronic_Communications" data-toggle="modal" href="#" tabindex="12">
Consent to Electronic Communications.
</a>
<div class="bootstrap">
<div class="modal fade selector-popup" id="simple-popup-Electronic_Communications">
<div class="modal-body">
<div class="section print-only">
<img id="logo-img" alt="Memorial Hermann" src="https://dxql1etc638wm.cloudfront.net/settings_service_assets/20171130101006_patient_logo_provider_mhhs-image.png">
<p>
<b>Time:</b> 09:26pm UTC
</p>
</div>
<div class="section">
<div class="modal-content">
<div class="modal-header">
<button class="close" data-dismiss="modal" type="button">
<div class="mobile-view">x</div>
<a class="close-popup not-printable" href="#" onclick="">
<img class="close-popup-icon" alt="Close popup" src="/assets/icon-close.png">
<img class="close-popup-icon-hover" alt="Close popup" src="/assets/icon-close_hover.png">
</a>
</button>
</div>
<div class="modal-header">
<h3 class="modal-title">Consent to Electronic Communications.</h3>
</div>
<div class="modal-body"> You consent to receive disclosures from us electronically through this web site, by email, or by text message. By consenting to the electronic delivery of disclosures, you agree that we may provide
electronically any and all communications concerning any payments you make to us or any payment plan agreements you enter into with us now or in the future, including disclosures required by state or federal law (the
“Disclosures”). To electronically receive and view and electronically save or print the Disclosures, you must have: a personal computer or device with Internet access; a widely-used, recent-generation web browser; a
widely-used, recent-generation portable document file reader; the email address you have provided us (or a new email address you subsequently provide us); and a printer, hard drive or other storage device. If the
information you have supplied us for contacting you electronically changes, please notify us of your new contact information. You may withdraw your consent to receipt of electronic disclosures by calling
<b>(713) 338-5502</b>. Any such request will only be effective as to communications we send after the date of withdrawal. If you withdraw your consent, you may no longer be eligible for certain services we only offer
electronically and you will not be able to receive disclosures from us electronically or do business with us electronically. You have the option to receive any information that we have provided electronically in paper form
at no cost to you by calling us at <b>(713) 338-5502</b>. </div>
<div class="modal-footer not-printable">
<div class="buttons print-mail-container">
<a class="print-btn print-icon" href="#" onclick="" target="">
<img alt="Print" class="print-img not-printable" src="/assets/print_icon.png">
<img alt="Print" class="print-img-hover not-printable" src="/assets/print_icon_hover.png">
</a>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</span>
</div>
</label>
</div>
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<div class="row">
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Your browser is no longer supported and may affect the performance of this site. For a better experience we recommend updating your browser. Google Chrome Microsoft Edge Mozilla Firefox Apple Safari Skip to Main Content English Español English * English * Español Feedback English Español English * English * Español Feedback You have a $449.55 total balance due for your visits to Memorial Hermann. Enter your payment information to quick pay now. Card Number Month Select01 02 03 04 05 06 07 08 09 10 11 12 Year Select2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 CVV * * * * Name Zip Code View My Bill WELCOME TO MEMORIAL HERMANN ENTER YOUR INFORMATION TO SEE WHAT YOU OWE OR MAKE A PAYMENT Zip Code Please enter the Zip Code Please enter the Zip Code Patient’s Date Of Birth A valid date is required Patient’s Date Of Birth Month , required Month January February March April May June July August September October November December Patient’s Date Of Birth Month , required Month * Month * January * February * March * April * May * June * July * August * September * October * November * December Patient’s Date Of Birth Please enter the Patient’s Date Of Birth Please verify the Patient’s Date Of Birth entered is correct. Please enter a valid day of the month. , required Patient’s Date Of Birth Please enter the Patient’s Date Of Birth Please verify the Patient’s Date Of Birth entered is correct. Year must be in format YYYY e.g. 1983 , required Please enter the Patient’s Date Of Birth Year must be in format YYYY e.g. 1983 Please enter a valid day of the month. Please verify the Patient’s Date Of Birth entered is correct. Legal agreement must be accepted before continuing Your use of this site is governed by the documents linked below. By checking the box at the beginning of this paragraph and clicking the “View My Bill” button below, you confirm you have received, read and agree by electronic signature to Simplee’s Terms of Serviceopen in a new window , Privacy Policyopen in a new window , Confidentiality Notice Time: 09:26pm UTC x CONFIDENTIALITY NOTICE The information that will be accessed beyond this point is privileged and confidential and/or protected health information (PHI) and may be subject to protection under the law, including the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA). This information is intended for the sole use of the patient or authorized party. If you are not the patient, legal guardian or have express consent, you are notified that any use, viewing, dissemination, distribution, printing or copying of this information is strictly prohibited and may subject you to criminal or civil penalties. Access should not be attempted or accepted beyond this point if these requirements are not met and acknowledged. and Consent to Electronic Communications. Time: 09:26pm UTC x CONSENT TO ELECTRONIC COMMUNICATIONS. You consent to receive disclosures from us electronically through this web site, by email, or by text message. By consenting to the electronic delivery of disclosures, you agree that we may provide electronically any and all communications concerning any payments you make to us or any payment plan agreements you enter into with us now or in the future, including disclosures required by state or federal law (the “Disclosures”). To electronically receive and view and electronically save or print the Disclosures, you must have: a personal computer or device with Internet access; a widely-used, recent-generation web browser; a widely-used, recent-generation portable document file reader; the email address you have provided us (or a new email address you subsequently provide us); and a printer, hard drive or other storage device. If the information you have supplied us for contacting you electronically changes, please notify us of your new contact information. You may withdraw your consent to receipt of electronic disclosures by calling (713) 338-5502. Any such request will only be effective as to communications we send after the date of withdrawal. If you withdraw your consent, you may no longer be eligible for certain services we only offer electronically and you will not be able to receive disclosures from us electronically or do business with us electronically. You have the option to receive any information that we have provided electronically in paper form at no cost to you by calling us at (713) 338-5502. CONSENT TO ELECTRONIC COMMUNICATIONS. You consent to receive disclosures from us electronically through this web site, by email, or by text message. By consenting to the electronic delivery of disclosures, you agree that we may provide electronically any and all communications concerning any payments you make to us or any payment plan agreements you enter into with us now or in the future, including disclosures required by state or federal law (the “Disclosures”). To electronically receive and view and electronically save or print the Disclosures, you must have: a personal computer or device with Internet access; a widely-used, recent-generation web browser; a widely-used, recent-generation portable document file reader; the email address you have provided us (or a new email address you subsequently provide us); and a printer, hard drive or other storage device. If the information you have supplied us for contacting you electronically changes, please notify us of your new contact information. You may withdraw your consent to receipt of electronic disclosures by calling (713) 338-5502. Any such request will only be effective as to communications we send after the date of withdrawal. If you withdraw your consent, you may no longer be eligible for certain services we only offer electronically and you will not be able to receive disclosures from us electronically or do business with us electronically. You have the option to receive any information that we have provided electronically in paper form at no cost to you by calling us at (713) 338-5502. I Agree I Don't Agree CONSENT TO ELECTRONIC COMMUNICATIONS. You consent to receive disclosures from us electronically through this web site, by email, or by text message. By consenting to the electronic delivery of disclosures, you agree that we may provide electronically any and all communications concerning any payments you make to us or any payment plan agreements you enter into with us now or in the future, including disclosures required by state or federal law (the “Disclosures”). To electronically receive and view and electronically save or print the Disclosures, you must have: a personal computer or device with Internet access; a widely-used, recent-generation web browser; a widely-used, recent-generation portable document file reader; the email address you have provided us (or a new email address you subsequently provide us); and a printer, hard drive or other storage device. If the information you have supplied us for contacting you electronically changes, please notify us of your new contact information. You may withdraw your consent to receipt of electronic disclosures by calling (713) 338-5502. Any such request will only be effective as to communications we send after the date of withdrawal. If you withdraw your consent, you may no longer be eligible for certain services we only offer electronically and you will not be able to receive disclosures from us electronically or do business with us electronically. You have the option to receive any information that we have provided electronically in paper form at no cost to you by calling us at (713) 338-5502. I Agree I Don't Agree © Simplee. 2011-2022 All Rights Reserved.