BAYSTATE EYECARE GROUP

BAYSTATE EYE CARE GROUP

413-783-3100 X 210

Date

Patient Account Number

Patient Name

Name on Credit Card

Payment Amount

Credit Card number

Expiration Date

3 Digit Security Code (4 Digit for American Express)

Billing address associated with credit card

Request a Receipt You will not receive a confirmation when you submit your payment. The billing office will process all payments submitted within 24 to 48hrs.

Yes

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