Online Patient Payment Center - Checks & Credit Cards
Welcome to Buena Vista Regional Medical Center Online Payment Center. You may pay your hospital bills here by credit card, debit card or by check. Please only supply one type of payment information.
For your convenience please fill out the payment form below. All information will be kept secure and confidential.
For more information or if you have questions you may call our billing department at 712.213.8688 Monday-Friday 8 am - 5 pm
It may be helpful to have a copy of your statement and/or letter in front of you as it contains necessary information to complete the form.
Name Of Patient
Name of Patient Treated.
Patient account number. This is a 6 digit number located on your statement and/or letter. (If no account number is supplied, we will apply the payment to the oldest date of service.) You can list one or more account numbers here.
Patient Account 1
Patient Account 2
Patient Account 3
Patient Account 4
Patient Account 5
Your E-Mail Address
Please Provide An E-mail Address.
Comments Or Messages Related To Your Payment
Payor's Name on Credit Card or Bank Statements
Please select from the available payment methods.
Amount of Payment
Format: 45.67 (Include decimal and cents. Do not use a dollar sign.)
Cardholder First Name
The first name of the account holder as it appears on the credit card.
Cardholder Last Name
The last name of the account holder as it appears on the credit card.
Bank Routing Number
Nine (9) digit bank routing number
Bank Account Number
Your account number is typcially six (6) to ten (10) digits.
Confirm Bank Account Number
Bank Account Type
The name of the bank your check belongs to.
Account Holder's Name
The name of a person who is authorized on this account (Listed in the top, left corner of the check in most cases).
Card Code Verification Number
The three digit number on the back of your card.
Billing Postal or Street Address
District Of Columbia
Billing Zip Code
5 digit zip code
Contact Phone Number
Please provide a phone number where we may reach you regarding this payment