mychart.atlantichealth.org
Open in
urlscan Pro
198.140.184.213
Public Scan
Submitted URL: https://mychart.atlantichealth.org/mychart/s/HMZ3J4AIHJKSQI77IOCDANARNE/BillPay
Effective URL: https://mychart.atlantichealth.org/MyChart/Billing/GuestPay/PayAsGuest?id=WP-24-2F6hvPjDLvE7l96d94q6VWA-3D-3D-24awAhfzKuEbJePmqmobR...
Submission: On December 04 via manual from US — Scanned from DE
Effective URL: https://mychart.atlantichealth.org/MyChart/Billing/GuestPay/PayAsGuest?id=WP-24-2F6hvPjDLvE7l96d94q6VWA-3D-3D-24awAhfzKuEbJePmqmobR...
Submission: On December 04 via manual from US — Scanned from DE
Form analysis 2 forms found in the DOM
<form id="guestPay-content" autocomplete="off">
<div id="videovisitbanner"></div>
<div class="subway noprint noFade hidden">
<div class="nav"><a class="scrollleft" href="#" role="button" aria-label="Show steps 1 to 4"></a><a class="scrollright" href="#" role="button" aria-label="Show steps 5 to 3"></a></div>
<div class="stopWrapper">
<div class="line dotnet extraWide" aria-hidden="true"></div>
<div class="stops dotnet extraWide"></div>
</div>
</div><span id="subwayStepFocusTarget" class="clearlabel" tabindex="-1">Step 1 of 3.</span>
<div class="subwayStep">
<div id="divPmtAmount" class="Step">
<div id="accountLookupContainer" class="Step">
<div aria-live="polite">
<div class="alert card jqHidden warningIconLeft ErrorBanner" id="errorNoPayments">
<div class="warningContainer"><img aria-hidden="true" src="/MyChart/en-US/images/warning.png" alt="">
<div id="errNoPaymentsMessage" class="errorMessages">We are unable to accept online payments for this account.</div>
</div>
<div><a class="button autowidth" id="btnStartOver-Link" title="Clear this page and start over." href="/MyChart/billing/guestpay/payasguest" role="button" aria-labelledby="btnStartOver-Title">Start over</a>
<div class="hidden" for="btnStartOver-Link" id="btnStartOver-Title">Clear this page and start over.</div>
</div>
</div>
</div>
<div aria-live="polite">
<div class="alert card jqHidden warningIconLeft ErrorBanner" id="errorLocked">
<div class="warningContainer"><img aria-hidden="true" src="/MyChart/en-US/images/warning.png" alt="">
<p id="errLockedMessage" class="errorMessages">This account has been locked due to too many failed attempts. </p>
</div>
<div><a class="button autowidth" id="btnStartOver2-Link" title="Clear this page and start over." href="/MyChart/billing/guestpay/payasguest" role="button" aria-labelledby="btnStartOver2-Title">Start over</a>
<div class="hidden" for="btnStartOver2-Link" id="btnStartOver2-Title">Clear this page and start over.</div>
</div>
</div>
</div>
<div aria-live="assertive">
<div class="alert card jqHidden warningIconLeft ErrorBanner" id="divMustContinueAsGuest">
<div class="warningContainer"><img aria-hidden="true" src="/MyChart/en-US/images/warning.png" alt="">
<p class="errorMessages" id="msgMustContinueAsGuest"></p>
</div>
</div>
</div>
<div id="divGuarLookup" class="Step">
<h2 class="header">Look up your account</h2>
<p>You may enter a guarantor account number or a specific visit account number.</p>
<div id="divLookupRegion">
<div id="divLookupWarnings" tabindex="-1" class="jqHidden alert card warningIconLeft ErrorBanner">
<div class="warningContainer"><img aria-hidden="true" src="/MyChart/en-US/images/warning.png" alt="">
<p class="errorMessages" id="errMatchFailed">We were unable to look up your account with the information you provided. Please ensure that there are no typos and try again.</p>
<p class="errorMessages" id="errAmbiguous">We need additional information to verify your account.</p>
</div>
<div>
<a id="btnTryName" class="button autowidth multi" tabindex="0" title="Try to match the account using the guarantor's last name." role="button" aria-labelledby="btnTryName-Title">Try last name</a><a id="btnTryDate" class="button autowidth multi" tabindex="0" title="Try to match the account using the guarantor's date of birth." role="button" aria-labelledby="btnTryDate-Title">Try date of birth</a><a id="btnTrySSN" class="button autowidth multi" tabindex="0" title="Try to match the account using the last four digits of the guarantor's social security number." role="button" aria-labelledby="btnTrySSN-Title">Try Social Security number</a><label
class="hidden" id="btnTryName-Title">Try to match the account using the guarantor's last name.</label><label class="hidden" id="btnTryDate-Title">Try to match the account using the guarantor's date of birth.</label><label
class="hidden" id="btnTrySSN-Title">Try to match the account using the last four digits of the guarantor's social security number.</label></div>
</div>
</div>
<div id="divEditLookupInfo" class="LookupInfo grid ">
<div class="row">
<div class="PaymentEntryField col-3"><label for="AccountIDEntry" id="AccountID-Label-1">Account #</label><input id="AccountIDEntry" aria-invalid="false" class="AccountIDInput" required="true" maxlength="25" type="text"
autocomplete="off" aria-describedby="AccountIDEntry-Error">
<div id="AccountIDEntry-Error" aria-live="polite"><span id="AccountBlankError" class="alert hidden">Account field is required</span><span id="AccountNumericError" class="alert hidden">Account field must be numeric</span></div>
</div>
<div id="divEnterLastName" class="PaymentEntryField col-3"><label for="LastNameEntry" id="SecondAuth-Label-1">Guarantor last name</label><input id="LastNameEntry" aria-invalid="false" class="GuarantorNameInput GuestPayInput"
required="true" maxlength="50" type="text" autocomplete="off"><span id="NameBlankError" class="alert hidden">Account field is required</span></div>
<div id="divEnterDOB" class="PaymentEntryField hidden col-3">
<div class="label" id="SecondAuth-Label-2">Date of birth</div>
<fieldset class="formsection" id="dobFormSection">
<legend class="hidden">Date of birth</legend><label for="DateOfBirthEntry-Month" class="clearlabel inlinelabel">Month</label>
<div class="segment2"><input id="DateOfBirthEntry-Month" aria-invalid="false" class="DateOfBirthInput2digit GuestPayInput" required="true" maxlength="2" type="text" autocomplete="off">
<div class="helptext accessibleLabel" aria-hidden="true">mm</div>
</div><span class="separator subtle">/</span><label for="DateOfBirthEntry-Day" class="clearlabel inlinelabel">Day</label>
<div class="segment2"><input id="DateOfBirthEntry-Day" aria-invalid="false" class="DateOfBirthInput2digit GuestPayInput" required="true" maxlength="2" type="text" autocomplete="off">
<div class="helptext accessibleLabel" aria-hidden="true">dd</div>
</div><span class="separator subtle">/</span><label for="DateOfBirthEntry-Year" class="clearlabel inlinelabel">Year</label>
<div class="segment4"><input id="DateOfBirthEntry-Year" aria-invalid="false" class="DateOfBirthInput4digit GuestPayInput" required="true" maxlength="4" type="text" autocomplete="off">
<div class="helptext accessibleLabel" aria-hidden="true">yyyy</div>
</div>
</fieldset><span id="DateFormatError" class="alert hidden">Please enter a valid date</span>
</div>
<div id="divEnterSSN" class="PaymentEntryField hidden col-3"><label for="SSNEntry" id="SecondAuth-Label-3">Last four of SSN</label><input id="SSNEntry" aria-invalid="false" class="GuarantorNameInput GuestPayInput" required="true"
maxlength="4" type="text" autocomplete="off"><span id="SSNBlankError" class="alert hidden">Account field is required</span><span id="SSNNumericError" class="alert hidden">Account field must be numeric</span></div>
<div class="captchaContainer">
<div class="visuallabel">As a spam prevention measure, complete the CAPTCHA below.</div><label class="clearlabel" for="g-recaptcha-response" id="captcha-label-1701702446420">This field is machine-generated content. Please
ignore.</label>
<div class="__captchaCore">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-dfnqpqhv2bs8" 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/api2/anchor?ar=1&k=6Lc4CxIUAAAAAIEmqP9LNTTI05xE21oCheYN8pal&co=aHR0cHM6Ly9teWNoYXJ0LmF0bGFudGljaGVhbHRoLm9yZzo0NDM.&hl=en&v=-QbJqHfGOUB8nuVRLvzFLVed&size=normal&cb=l1me59so7ibl"></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 class="__captchaMessage messagedisplay" aria-live="polite"></div>
</div>
<div id="divQuickPayVerify" aria-hidden="false" class="VerifyButton col-3"><input type="button" id="btnVerify" tabindex="0" class="button autowidth completeworkflow disabled" role="button" aria-disabled="true" value="Look up"
aria-label="Look up your account with the information you provided."><span class="blocklabel sm-hide"> </span></div>
</div>
</div>
<div aria-live="polite" id="divVerifiedInfoRegion">
<div id="divVerifiedInfo" class="LookupInfo grid hidden">
<div class="row">
<div class="col-3"><span id="AccountId-Label-2" class="label">Guarantor account #</span>
<p id="txtAccountId"></p>
</div>
<div class="col-3"><span id="SecondAuth-Readonly-Label-1" class="label">Guarantor last name</span><span id="SecondAuth-Readonly-Label-2" class="hidden label">Date of birth</span><span id="SecondAuth-Readonly-Label-3"
class="hidden label">Last four of SSN</span>
<p id="txtSecondAuth"></p>
</div>
<div id="divQuickPayVerified" class="VerifyIcon green col-3"><label class="blocklabel sm-hide"> </label><img aria-hidden="true" src="/MyChart/en-US/images/requirement_met.svg" alt="Complete"><span>Account found</span></div>
</div>
</div>
<div id="msgNoBalance" class="successMessage hidden"><img aria-hidden="true" src="/MyChart/en-US/images/requirement_met.svg" alt="Complete">
<p>Your account does not have any outstanding balances.</p>
</div>
</div>
</div>
</div>
<div id="divMyChartPrompt" class="MyChartPromptBox hidden">
<div>Want to save your credit card or bank account for next time? You can also learn more about your bill, sign up for a payment plan, and review your payment history. Sign up for MyChart today!</div>
<div class="MyChartPromptButtonBox">
<a id="btnCreateAccount" class="button autowidth multi otherbutton" title="Leave this page and create a MyChart account before paying." aria-describedby="btnCreateAccount-Title">Sign up now</a><a id="btnContinueWithoutAccount" class="button multi completeworkflow autowidth" tabindex="0" title="Continue paying as a guest and skip creating an account." aria-describedby="btnContinueWithoutAccount-Title">Continue as guest</a>
<div class="hidden" id="btnCreateAccount-Title">Leave this page and create a MyChart account before paying.</div>
<div class="hidden" id="btnContinueWithoutAccount-Title">Continue paying as a guest and skip creating an account.</div>
</div>
</div>
<div id="divSigninPrompt" class="MyChartPromptBox hidden">
<div>Want to use a saved credit card or bank account? Log in to your MyChart account!</div>
<div class="MyChartPromptButtonBox">
<a id="btnSignIn" class="button autowidth multi" title="Leave this page and sign in to your MyChart account before paying." href="#" aria-describedby="btnSignIn-Title">Sign in</a><a id="btnContinueWithoutSignIn" class="button autowidth multi completeworkflow" tabindex="0" title="Continue paying as a guest and skip signing in." aria-describedby="btnContinueWithoutSignIn-Title">Continue as guest</a>
<div class="hidden" id="btnSignIn-Title">Leave this page and sign in to your MyChart account before paying.</div>
<div class="hidden" id="btnContinueWithoutSignIn-Title">Continue paying as a guest and skip signing in.</div>
</div>
</div>
<div id="paymentInfoContainer" class="hidden">
<div id="divChooseAccount" class="Step hidden">
<fieldset>
<div class="grid">
<div class="row">
<div class="col-12">
<div class="GuarantorInfo" id="GuarantorBalanceInfoToggle"><span id="serviceAreaExplanationToggle"></span></div>
<h2 class="header">Which balance do you want to pay?</h2>
</div>
</div>
<div class="row">
<div class="col-3"><span class="tbContainer accountSelectOptionContainer"><input type="radio" class="clearradio togglebutton" id="accountSelectHB" name="accountSelect"><label for="accountSelectHB"
class="togglebutton accountSelectLabel"><img src="/MyChart/en-US/images/hospital.png" alt="Hospital Billing" aria-hidden="true"><span>Hospital</span></label></span></div>
<div class="col-3"><span class="tbContainer accountSelectOptionContainer"><input type="radio" class="clearradio togglebutton" id="accountSelectPB" name="accountSelect"><label for="accountSelectPB"
class="togglebutton accountSelectLabel"><img src="/MyChart/en-US/images/provider.png" alt="Professional Billing" aria-hidden="true"><span>Physician</span></label></span></div>
</div>
</div>
</fieldset>
</div>
<div class="section" id="divPaymentAmounts">
<div class="content">
<div class="StepPreTextSection"></div>
<div id="GuarantorBalanceInfo" class="GuarantorInfo"><span id="serviceAreaExplanation"></span></div>
<div id="newActivityContainer" class="BillingWarningBox softwarning">
<p id="newActivity"></p>
</div>
<h2 id="AmountSectionHeader" class="header">How much would you like to pay today?</h2>
<div class="grid">
<div class="row">
<div class="col-6" id="paymentAmountContainer"></div>
</div>
</div>
<div aria-live="polite">
<div tabindex="0" id="divOverpaymentWarning" class="BillingWarningBox softwarning hidden">
<p>The payment amount that you have entered is more than your total outstanding balance for the account.</p>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="subwayNavButtons">
<p class="button buttoncheck pullback hidden unchecked" id="subway-verify-container" aria-checked="false"><input type="checkbox" class="buttoncheck" id="subway-verify-checkbox"><label for="subway-verify-checkbox"
class="buttoncheck required"><span>This information is correct</span><span class="requiredStar" aria-hidden="true"> </span></label></p>
<div id="VerifyCheckbox_message" class="messagedisplay hidden">
<div class="alert validationmessage hidden" id="subway-verify-warning"><img src="/MyChart/en-US/images/warning.png" class="yield" alt=""><span>This is required</span></div>
</div>
<div class="formbuttons multiStep right">
<div class="alert validationmessage" id="subwayFinishAboveWarning" hidden=""><img src="/MyChart/en-US/images/warning.png" class="yield" alt=""><span></span></div><button type="button" class="button primary positive jqHidden" id="subway-submit"
data-disable-if-invalid="true" style="display: none;">Submit</button><button type="button" class="button primary positive jqHidden disabled" id="subway-next" data-disable-if-invalid="true" disabled="">Next</button><button type="button"
class="button secondary neutral jqHidden" id="subway-back" style="display: none;">Back</button><button type="button" class="button secondary negative jqHidden" id="subway-cancel">Cancel</button>
</div>
</div>
</form>POST /MyChart/Billing/GuestPay/Verify
<form action="/MyChart/Billing/GuestPay/Verify" autocomplete="off" method="post"><input name="__RequestVerificationToken" type="hidden" value="YMu190JXRxYAlrv8RL2SVbJ6GlrvLyd25AsWXUl6ZVftUXdZ51S60aiC8pO9TI6_amTdxb4ltmbjNM7z6AO3wbp-L9Q1"
autocomplete="off"><input id="SignInSidebar-id" name="guarantorID" type="hidden" value="" autocomplete="off"><input id="SignInSidebar-context" name="context" type="hidden" value="" autocomplete="off"><input id="SignInSidebar-relay"
name="relaystate" type="hidden" value="" autocomplete="off">
<div><input class="button autowidth" type="submit" title="Leave this page and sign in to your MyChart account before paying." value="Sign in" autocomplete="off"></div>
</form>Text Content
Error: Please enable JavaScript in your browser before using this site. PAY AS GUEST Step 1 of 3. We are unable to accept online payments for this account. Start over Clear this page and start over. This account has been locked due to too many failed attempts. Start over Clear this page and start over. LOOK UP YOUR ACCOUNT You may enter a guarantor account number or a specific visit account number. We were unable to look up your account with the information you provided. Please ensure that there are no typos and try again. We need additional information to verify your account. Try last nameTry date of birthTry Social Security numberTry to match the account using the guarantor's last name.Try to match the account using the guarantor's date of birth.Try to match the account using the last four digits of the guarantor's social security number. Account # Account field is requiredAccount field must be numeric Guarantor last nameAccount field is required Date of birth Date of birthMonth mm /Day dd /Year yyyy Please enter a valid date Last four of SSNAccount field is requiredAccount field must be numeric As a spam prevention measure, complete the CAPTCHA below. This field is machine-generated content. Please ignore. Guarantor account # Guarantor last nameDate of birthLast four of SSN Account found Your account does not have any outstanding balances. Want to save your credit card or bank account for next time? You can also learn more about your bill, sign up for a payment plan, and review your payment history. Sign up for MyChart today! Sign up nowContinue as guest Leave this page and create a MyChart account before paying. Continue paying as a guest and skip creating an account. Want to use a saved credit card or bank account? Log in to your MyChart account! Sign inContinue as guest Leave this page and sign in to your MyChart account before paying. Continue paying as a guest and skip signing in. WHICH BALANCE DO YOU WANT TO PAY? Hospital Physician HOW MUCH WOULD YOU LIKE TO PAY TODAY? The payment amount that you have entered is more than your total outstanding balance for the account. This information is correct This is required SubmitNextBackCancel What is a guarantor?The guarantor is the person responsible for paying the bill. You can find the guarantor name and account number on your statement. What is a visit account?A visit account is how your charges are grouped together to bill insurance, and usually represents your billing activity for a single visit. You may have multiple visit accounts, each with their own balance. Need help? Sign in to MyChartWant to use a saved credit card or bank account? Log in to your MyChart account! Sign up for MyChartWant to save your credit card or bank account for next time? You can also learn more about your bill, sign up for a payment plan, and review your payment history. Sign up for MyChart today! Sign up now Connect Third-Party AppTerms and ConditionsDefault ThemeHigh Contrast Theme Notice of Privacy Practices Code of Ethics Disclaimer Language Assistance Accessibility MyChart® licensed from Epic Systems Corporation© 1999 - 2023 Loading...