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Submitted URL: https://gfapay.com/
Effective URL: https://api.payaconnect.com/hostedpaymentpage?id=11ec2d312bf504fc8f6f9ca4&data=U2FsdGVkX18xMWVjMmQzMc0QrIbjvZZNmB56FClEN%2B%...
Submission: On August 17 via api from US — Scanned from DE
Effective URL: https://api.payaconnect.com/hostedpaymentpage?id=11ec2d312bf504fc8f6f9ca4&data=U2FsdGVkX18xMWVjMmQzMc0QrIbjvZZNmB56FClEN%2B%...
Submission: On August 17 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: hppForm —
<form id="hpp_form" name="hppForm" class="hppForm">
<div id="hpp_header_container" class="row">
<div class="col-sm-6" id="hpp_header_col_0">
<div class="hppform_field" id="hppform_field_header_logo"><img class="hppform_field_image" src="https://marvel-b1-cdn.bc0a.com/f00000000113059/www.envisionphysicianservices.com/img/evps2/icons/evps-logo-aas-2x.png" alt="IMAGE"></div>
<div class="hppform_field" id="hppform_field_header_title">
<h1 class="hppform_field_heading">Welcome to Envision Physician Services</h1>
</div>
<div class="hppform_field" id="hppform_field_text_display_1">
<p class="hppform_field_text">Greater Florida Anesthesiologists LLC is an affiliated provider of Envision Physician Services. Please use this secure portal to make a payment in advance of your procedure. If you have any questions, please
contact our customer service team at 1-888-610-5651. Please note that this page is not supported by Internet Explorer. To complete your transaction, please use a different web browser.</p>
</div>
</div>
<div class="col-sm-6" id="hpp_header_col_1">
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_9umy9d3hf2k"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_cwp1of6b6cl"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_j6xxhjhns3f"></div>
</div>
</div>
<div id="hppform_errors" class="row"></div>
<div id="hppform_success" class="row"></div>
<div id="hppform_response_data" class="row"></div>
<div id="hpp_body_container" class="row">
<div class="col-sm-3" id="hpp_body_col_0">
<div class="hppform_field" id="hppform_field_account_holder_name"><label class="hppform_field_label">Patient Name (First & Last)<span class="hppform_field_required_indicator"> *</span></label><input class="hppform_field_input"
name="account_holder_name"></div>
<div class="hppform_field" id="hppform_field_billing_street"><label class="hppform_field_label">Patient Street<span class="hppform_field_required_indicator"> *</span></label><input class="hppform_field_input" name="billing_street"></div>
<div class="hppform_field" id="hppform_field_billing_state"><label class="hppform_field_label">Patient State<span class="hppform_field_required_indicator"> *</span></label><input class="hppform_field_input" name="billing_state"></div>
<div class="hppform_field" id="hppform_field_billing_phone"><label class="hppform_field_label">Patient Phone<span class="hppform_field_required_indicator"> *</span></label><input class="hppform_field_input" name="billing_phone"></div>
<div class="hppform_field" id="hppform_field_custom_data-Name_of_Facility"><label class="hppform_field_label">Name of Facility <span class="hppform_field_required_indicator"> *</span></label><select class="hppform_field_select"
name="custom_data-Name_of_Facility" id="hppform_field_select_custom_data-Name_of_Facility">
<option value="select_no_data" disabled="" class="hppform_field_select_option">Select...</option>
<option value="Advanced Surgical Care Clearwater" class="hppform_field_select_option">Advanced Surgical Care Clearwater</option>
<option value="Adventhealth Surgery Center Wellswood" class="hppform_field_select_option">Adventhealth Surgery Center Wellswood</option>
<option value="Carillon Surgery Center" class="hppform_field_select_option">Carillon Surgery Center</option>
<option value="Center for Special Surgery" class="hppform_field_select_option">Center for Special Surgery</option>
<option value="Cypress Creek Outpatient Surgery Center" class="hppform_field_select_option">Cypress Creek Outpatient Surgery Center</option>
<option value="Delray Ambulatory Surgical and Laser Center" class="hppform_field_select_option">Delray Ambulatory Surgical and Laser Center</option>
<option value="Palms Wellington Surgical Center" class="hppform_field_select_option">Palms Wellington Surgical Center</option>
<option value="ParkCreek Surgery Center" class="hppform_field_select_option">ParkCreek Surgery Center</option>
<option value="RMG/IVF Surgery Center" class="hppform_field_select_option">RMG/IVF Surgery Center</option>
<option value="Skyway Surgery Center" class="hppform_field_select_option">Skyway Surgery Center</option>
<option value="Surgcenter Dunedin" class="hppform_field_select_option">Surgcenter Dunedin</option>
<option value="Surgicare of Mirarmar" class="hppform_field_select_option">Surgicare of Mirarmar</option>
<option value="St Anthony’s Hospital" class="hppform_field_select_option">St Anthony’s Hospital</option>
<option value="The Orthopedic Center of Palm Beach County" class="hppform_field_select_option">The Orthopedic Center of Palm Beach County</option>
<option value="USF Endoscopy & Surgery Center" class="hppform_field_select_option">USF Endoscopy & Surgery Center</option>
<option value="Weston Outpatient Surgical Center" class="hppform_field_select_option">Weston Outpatient Surgical Center</option>
</select></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_u598jzb6vgm"></div>
<div class="hppform_field" id="hppform_field_heading_payment_info">
<h3 class="hppform_field_heading">Payment Information</h3>
</div>
<div class="hppform_field" id="hppform_field_transaction_amount"><label class="hppform_field_label">Transaction Amount<span class="hppform_field_required_indicator"> *</span></label><input class="hppform_field_input" name="transaction_amount">
</div>
<div class="hppform_field" id="hppform_field_exp_date"><label class="hppform_field_label">Exp Date<span class="hppform_field_required_indicator"> *</span></label>
<div>
<div class="exp_date_select_container months"><select class="hppform_field_select exp_date_select" name="exp_month" id="exp_month">
<option value="select_no_data" disabled="" class="hppform_field_select_option">Month</option>
<option value="01" class="hppform_field_select_option">01 - January</option>
<option value="02" class="hppform_field_select_option">02 - February</option>
<option value="03" class="hppform_field_select_option">03 - March</option>
<option value="04" class="hppform_field_select_option">04 - April</option>
<option value="05" class="hppform_field_select_option">05 - May</option>
<option value="06" class="hppform_field_select_option">06 - June</option>
<option value="07" class="hppform_field_select_option">07 - July</option>
<option value="08" class="hppform_field_select_option">08 - August</option>
<option value="09" class="hppform_field_select_option">09 - September</option>
<option value="10" class="hppform_field_select_option">10 - October</option>
<option value="11" class="hppform_field_select_option">11 - November</option>
<option value="12" class="hppform_field_select_option">12 - December</option>
</select></div>
<div class="exp_date_select_container"><select class="hppform_field_select exp_date_select" name="exp_year" id="exp_year">
<option value="select_no_data" disabled="" class="hppform_field_select_option">Year</option>
<option value="24" class="hppform_field_select_option">2024</option>
<option value="25" class="hppform_field_select_option">2025</option>
<option value="26" class="hppform_field_select_option">2026</option>
<option value="27" class="hppform_field_select_option">2027</option>
<option value="28" class="hppform_field_select_option">2028</option>
<option value="29" class="hppform_field_select_option">2029</option>
<option value="30" class="hppform_field_select_option">2030</option>
<option value="31" class="hppform_field_select_option">2031</option>
<option value="32" class="hppform_field_select_option">2032</option>
<option value="33" class="hppform_field_select_option">2033</option>
<option value="34" class="hppform_field_select_option">2034</option>
<option value="35" class="hppform_field_select_option">2035</option>
<option value="36" class="hppform_field_select_option">2036</option>
<option value="37" class="hppform_field_select_option">2037</option>
<option value="38" class="hppform_field_select_option">2038</option>
<option value="39" class="hppform_field_select_option">2039</option>
<option value="40" class="hppform_field_select_option">2040</option>
</select></div>
</div>
</div>
<div class="hppform_field" id="hppform_field_custom_data-Date_of_Payment"><label class="hppform_field_label">Date of Payment<span class="hppform_field_required_indicator"> *</span></label><input class="hppform_field_input"
name="custom_data-Date_of_Payment" type="date"></div>
<div class="hppform_field g-recaptcha" id="hppform_field_captcha">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-6q7qlq9z60m5" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation"
src="https://www.google.com/recaptcha/enterprise/anchor?ar=1&k=6Lf04jsiAAAAAPMsKKbqPRBtoq0zoOZkbSmPZswc&co=aHR0cHM6Ly9hcGkucGF5YWNvbm5lY3QuY29tOjQ0Mw..&hl=de&v=hfUfsXWZFeg83qqxrK27GB8P&size=normal&cb=8pm60lqz4a4d"></iframe>
</div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
</div>
<div class="col-sm-3" id="hpp_body_col_1">
<div class="hppform_field" id="hppform_field_custom_data-Date_of_Birth"><label class="hppform_field_label">Patient Date of Birth<span class="hppform_field_required_indicator"> *</span></label><input class="hppform_field_input"
name="custom_data-Date_of_Birth" type="date"></div>
<div class="hppform_field" id="hppform_field_billing_city"><label class="hppform_field_label">Patient City<span class="hppform_field_required_indicator"> *</span></label><input class="hppform_field_input" name="billing_city"></div>
<div class="hppform_field" id="hppform_field_billing_zip"><label class="hppform_field_label">Patient Zip<span class="hppform_field_required_indicator"> *</span></label><input class="hppform_field_input" name="billing_zip"></div>
<div class="hppform_field" id="hppform_field_notification_email_address"><label class="hppform_field_label">Patient Email<span class="hppform_field_required_indicator"> *</span></label><input class="hppform_field_input"
name="notification_email_address"></div>
<div class="hppform_field" id="hppform_field_custom_data-Procedure_Scheduled_Date"><label class="hppform_field_label">Procedure Scheduled Date<span class="hppform_field_required_indicator"> *</span></label><input class="hppform_field_input"
name="custom_data-Procedure_Scheduled_Date" type="date"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_wxtwx2eibfo"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_mxgrnb1t0d"></div>
<div class="hppform_field" id="hppform_field_account_number"><label class="hppform_field_label">Card Number<span class="hppform_field_required_indicator"> *</span></label><input class="hppform_field_input" name="account_number"
id="hppform_account_number"></div>
<div class="hppform_field" id="hppform_field_cvv"><label class="hppform_field_label">CVV</label><input class="hppform_field_input" name="cvv"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_a38157sbap9"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_ph6cxd94gat"></div>
</div>
<div class="col-sm-3" id="hpp_body_col_2">
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_yxd2xk3nbmm"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_2dtdb8zvv0l"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_ucy78u85pv9"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_1bklar05hrb"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_hgdjfx5r1ca"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_5ff5in4er15"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_smxcuj2sls"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_33we5vov968"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_ap0zbhkard"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_lgzbn29p85"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_gupkkn2jzq"></div>
</div>
<div class="col-sm-3" id="hpp_body_col_3">
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_xkr59rsrwdk"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_lqsr1ibxgp"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_w4ss1fig8q"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_bb9ocow9qm"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_5f2pv0yga2n"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_6pp7yxl6s5g"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_q74gbww4ex"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_x8074oxq6v"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_mf27v16bg9q"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_exwxi6a5fw"></div>
<div class="hppform_field hppform_field_blank" id="hppform_field_blank_zzmr2jddz7"></div>
</div>
</div>
<div id="hpp_footer_container" class="row">
<div class="col-sm-12" id="hpp_footer_col_0">
<div class="hppform_field" id="hppform_field_terms_agree"><input class="hppform_field_checkbox" name="terms_agree" type="checkbox" value="i agree to pay the above total according to my card issuer agreement.">I agree to pay the above total
according to my card issuer agreement.</div>
<div class="hppform_field" id="hppform_field_submit_button"><button class="hppform_field_button" name="submit_button" id="hppform_submit_button">
<span class="hppform_submit_button_text">Submit Payment</span>
</button></div>
</div>
</div>
</form>Text Content
WELCOME TO ENVISION PHYSICIAN SERVICES Greater Florida Anesthesiologists LLC is an affiliated provider of Envision Physician Services. Please use this secure portal to make a payment in advance of your procedure. If you have any questions, please contact our customer service team at 1-888-610-5651. Please note that this page is not supported by Internet Explorer. To complete your transaction, please use a different web browser. Patient Name (First & Last) * Patient Street * Patient State * Patient Phone * Name of Facility *Select...Advanced Surgical Care ClearwaterAdventhealth Surgery Center WellswoodCarillon Surgery CenterCenter for Special SurgeryCypress Creek Outpatient Surgery CenterDelray Ambulatory Surgical and Laser CenterPalms Wellington Surgical CenterParkCreek Surgery CenterRMG/IVF Surgery CenterSkyway Surgery CenterSurgcenter DunedinSurgicare of MirarmarSt Anthony’s HospitalThe Orthopedic Center of Palm Beach CountyUSF Endoscopy & Surgery CenterWeston Outpatient Surgical Center PAYMENT INFORMATION Transaction Amount * Exp Date * Month01 - January02 - February03 - March04 - April05 - May06 - June07 - July08 - August09 - September10 - October11 - November12 - December Year20242025202620272028202920302031203220332034203520362037203820392040 Date of Payment * Patient Date of Birth * Patient City * Patient Zip * Patient Email * Procedure Scheduled Date * Card Number * CVV I agree to pay the above total according to my card issuer agreement. Submit Payment