Bill Pay

Complete the form below to pay your bill. Your submission is confidential and we use the latest technology (SSL) to encrypt your responses.

Your credit card information is kept confidential and secure. Payments to your card are processed only after the claim has been filed and processed by your insurer, and the insurance portion of the claim has been paid and posted to the account.

"*" indicates required fields

Patient Name*

Email Address*

To receive your payment receipt.

Who is your physician?*

Are you making a payment for a telemedicine appointment?*

Yes

Payment options*

What are you paying for?

Account Number

Optional. Your account number can be found on your invoice.

Invoice Amount*

This is the amount we will charge your credit card.

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

I authorize Los Angeles Colon & Rectal Surgical Associates (Norman N. Hoffman MD Inc.) to charge my credit or debit card listed above for the amount that I have entered. This represents payment for services rendered to me for balances due as my financial responsibility.

I agree to the Payment Terms of Service