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* Account #:
The account # is required.
The account # may not contain a credit card number.
* Patient's Name:
The patient's name is required.
The patient's name may not contain a credit card number.
* Patient's Date of Birth:
The patient's date of birth is required.
The patient's date of birth is not valid.
The patient's date of birth may not contain a credit card number.
Last 4 Digits of the Patients SSN:
The last 4 digits of the patients SSN is not valid.
The SSN may not contain a credit card number.
* Address:
The address is required.
The address may not contain a credit card number.
* Payment Amount:
The payment amount is required.
The payment amount is not valid.
The payment amount may not contain a credit card number.
Technical Support
If you need technical support for this online payment processing application, please send an email to
cavazpour@maryscenter.org
.